Deepak Acharya

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Scholarly Contributions

Chapters

• Acharya, D., & Rajapreyar, I. (2020). Pathophysiology of Right Heart disease in chronic lung disease. In Cardiovascular Disease in Chronic Lung Disease. Springer.

Journals/Publications

• Kelty, C. E., Dickinson, M. G., Leacche, M., Jani, M., Shrestha, N. K., Lee, S., Acharya, D., Rajapreyar, I., Sadler, R. C., McNeely, E., & Loyaga-Rendon, R. Y. (2024). Increased disparities in waitlist and post-heart transplantation outcomes according to socioeconomic status with the new heart transplant allocation system. The Journal of heart and lung transplantation : the official publication of the International Society for Heart Transplantation, 43(1), 134-147.
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  The study objective was to assess disparities in outcomes in the waitlist and post-heart transplantation (HT) according to socioeconomic status (SES) in the old and new U.S. HT allocation systems.
• Loyaga-Rendon, R. Y., Acharya, D., Jani, M., Lee, S., Trachtenberg, B., Manandhar-Shrestha, N., Leacche, M., & Jovinge, S. (2024). Predicting Survival of End-Stage Heart Failure Patients Receiving HeartMate-3: Comparing Machine Learning Methods. ASAIO journal (American Society for Artificial Internal Organs : 1992), 70(1), 22-30.
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  HeartMate 3 is the only durable left ventricular assist devices (LVAD) currently implanted in the United States. The purpose of this study was to develop a predictive model for 1 year mortality of HeartMate 3 implanted patients, comparing standard statistical techniques and machine learning algorithms. Adult patients registered in the Society of Thoracic Surgeons, Interagency Registry for Mechanically Assisted Circulatory Support (STS-INTERMACS) database, who received primary implant with a HeartMate 3 between January 1, 2017, and December 31, 2019, were included. Epidemiological, clinical, hemodynamic, and echocardiographic characteristics were analyzed. Standard logistic regression and machine learning (elastic net and neural network) were used to predict 1 year survival. A total of 3,853 patients were included. Of these, 493 (12.8%) died within 1 year after implantation. Standard logistic regression identified age, Model End Stage Liver Disease (MELD)-XI score, right arterial (RA) pressure, INTERMACS profile, heart rate, and etiology of heart failure (HF), as important predictor factors for 1 year mortality with an area under the curve (AUC): 0.72 (0.66-0.77). This predictive model was noninferior to the ones developed using the elastic net or neural network. Standard statistical techniques were noninferior to neural networks and elastic net in predicting 1 year survival after HeartMate 3 implantation. The benefit of using machine-learning algorithms in the prediction of outcomes may depend on the type of dataset used for analysis.
• Acharya, D., Kazui, T., Al Rameni, D., Acharya, T., Betterton, E., Juneman, E., Loyaga-Rendon, R., Lotun, K., Shetty, R., & Chatterjee, A. (2023). Aortic valve disorders and left ventricular assist devices. Frontiers in cardiovascular medicine, 10, 1098348.
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  Aortic valve disorders are important considerations in advanced heart failure patients being evaluated for left ventricular assist devices (LVAD) and those on LVAD support. Aortic insufficiency (AI) can be present prior to LVAD implantation or develop during LVAD support. It is usually a progressive disorder and can lead to impaired LVAD effectiveness and heart failure symptoms. Severe AI is associated with worsening hemodynamics, increased hospitalizations, and decreased survival in LVAD patients. Diagnosis is made with echocardiographic, device assessment, and/or catheterization studies. Standard echocardiographic criteria for AI are insufficient for accurate diagnosis of AI severity. Management of pre-existing AI includes aortic repair or replacement at the time of LVAD implant. Management of AI on LVAD support is challenging with increased risks of repeat surgical intervention, and percutaneous techniques including transcatheter aortic valve replacement are assuming greater importance. In this manuscript, we provide a comprehensive approach to contemporary diagnosis and management of aortic valve disorders in the setting of LVAD therapy.
• Acharya, D., Manandhar-Shrestha, N., Leacche, M., Rajapreyar, I., William, P., Kazui, T., Hooker, R., Tonna, J., Jovinge, S., & Loyaga-Rendon, R. (2023). Extracorporeal membrane oxygenation as a bridge to advanced heart failure therapies. The Journal of heart and lung transplantation : the official publication of the International Society for Heart Transplantation, 42(8), 1059-1071.
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  Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is a key support modality for cardiogenic shock. The 2018 United Network for Organ Sharing (UNOS) heart transplant allocation algorithm prioritizes VA-ECMO patients.
• Chatterjee, A., Kazui, T., & Acharya, D. (2023). Growing prevalence of aortic stenosis - Question of age or better recognition?. International journal of cardiology, 388, 131155.
• Guddeti, R. R., Sanina, C., Jauhar, R., Henry, T. D., Dehghani, P., Garberich, R., Schmidt, C. W., Nayak, K. R., Shavadia, J. S., Bagai, A., Alraies, C., Mehra, A., Bagur, R., Grines, C., Singh, A., Patel, R. A., Htun, W. W., Ghasemzadeh, N., Davidson, L., , Acharya, D., et al. (2023). Mechanical Circulatory Support in Patients With COVID-19 Presenting With Myocardial Infarction. The American journal of cardiology, 187, 76-83.
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  ST-segment elevation myocardial infarction (STEMI) complicating COVID-19 is associated with an increased risk of cardiogenic shock and mortality. However, little is known about the frequency of use and clinical impact of mechanical circulatory support (MCS) in these patients. We sought to define patterns of MCS utilization, patient characteristics, and outcomes in patients with COVID-19 with STEMI. The NACMI (North American COVID-19 Myocardial Infarction) is an ongoing prospective, observational registry of patients with COVID-19 positive (COVID-19+) with STEMI with a contemporary control group of persons under investigation who subsequently tested negative for COVID-19 (COVID-19-). We compared the baseline characteristics and in-hospital outcomes of COVID-19+ and patients with COVID-19- according to the use of MCS. The primary outcome was a composite of in-hospital mortality, stroke, recurrent MI, and repeat unplanned revascularization. A total of 1,379 patients (586 COVID-19+ and 793 COVID-19-) enrolled in the NACMI registry between January 2020 and November 2021 were included in this analysis; overall, MCS use was 12.3% (12.1% [n = 71] COVID-19+/MCS positive [MCS+] vs 12.4% [n = 98] COVID-19-/MCS+). Baseline characteristics were similar between the 2 groups. The use of percutaneous coronary intervention was similar between the groups (84% vs 78%; p = 0.404). Intra-aortic balloon pump was the most frequently used MCS device in both groups (53% in COVID-19+/MCS+ and 75% in COVID-19-/MCS+). The primary outcome was significantly higher in COVID-19+/MCS+ patients (60% vs 30%; p = 0.001) because of very high in-hospital mortality (59% vs 28%; p = 0.001). In conclusion, patients with COVID-19+ with STEMI requiring MCS have very high in-hospital mortality, likely related to the significantly higher pulmonary involvement compared with patients with COVID-19- with STEMI requiring MCS.
• Hernandez, A., Andres, B., Jagadish, P. S., Oskouie, S., Acharya, T., Juneman, E., & Acharya, D. (2023). Steroid-Responsive Fulminant Lymphocytic Myocarditis Mimicking Giant-Cell Myocarditis. The American journal of medicine, 136(11), e220-e221.
• Acharya, D., & Haas, G. (2022). Bereavement and Mortality in Heart Failure. JACC. Heart failure, 10(10), 765-767.
• Ajmal, M., Chatterjee, A., & Acharya, D. (2022). Persistent or Recurrent Angina Following Percutaneous Coronary Revascularization. Current cardiology reports, 24(12), 1837-1848.
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  Persistent or recurrent angina after percutaneous coronary intervention (PCI) has substantial patient morbidity and economic impact. As knowledge of the pathophysiology of this condition has evolved, new tools for accurate diagnosis and treatment have become available. We provide a current, comprehensive review of mechanisms of post-PCI angina, diagnostic strategies, and therapeutic options.
• Bisural, R., Acharya, D., Adhikari, S., Chaulagai, B., Mainali, A., Chowdhury, T., & Gousy, N. (2022). Unprovoked Isolated Pulmonary Embolism and Graves' Disease in a Patient With Dyspnea: A Case Report. Cureus, 14(5), e24972.
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  Graves' disease is a commonly diagnosed disease with a plethora of manifestations that can lead to its diagnosis. One of the rarer presentations of Graves' disease is hypercoagulability with the development of spontaneous venous thrombosis. In patients presenting with unprovoked pulmonary embolism, we suggest evaluating the patient's thyroid function tests as a potential underlying cause. To bring this issue to attention, we are presenting a rare case of isolated spontaneous pulmonary embolism development secondarily to underlying Graves' disease.
• Bull, D. A., Bull, D. A., Chatterjee, A., Chatterjee, A., Lee, K., Lee, K., Shanmugasundaram, M., Shanmugasundaram, M., Acharya, D., Acharya, D., Hamidi, M., Hamidi, M., Hsu, C., Hsu, C., Kazui, T., & Kazui, T. (2021). Pre-transcatheter aortic valve replacement 5-meter-walk test score and 1-year noncardiac mortality. Journal of Thoracic and Cardiovascular Surgery.
• Chang, Y., Antonescu, C., Ravindranath, S., Dong, J., Lu, M., Vicario, F., Wondrely, L., Thompson, P., Swearingen, D., & Acharya, D. (2022). Early Prediction of Cardiogenic Shock Using Machine Learning. Frontiers in cardiovascular medicine, 9, 862424.
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  Cardiogenic shock (CS) is a severe condition with in-hospital mortality of up to 50%. Patients who develop CS may have previous cardiac history, but that may not always be the case, adding to the challenges in optimally identifying and managing these patients. Patients may present to a medical facility with CS or develop CS while in the emergency department (ED), in a general inpatient ward (WARD) or in the critical care unit (CC). While different clinical pathways for management exist once CS is recognized, there are challenges in identifying the patients in a timely manner, in all settings, in a timeframe that will allow proper management. We therefore developed and evaluated retrospectively a machine learning model based on the XGBoost (XGB) algorithm which runs automatically on patient data from the electronic health record (EHR). The algorithm was trained on 8 years of de-identified data (from 2010 to 2017) collected from a large regional healthcare system. The input variables include demographics, vital signs, laboratory values, some orders, and specific pre-existing diagnoses. The model was designed to make predictions 2 h prior to the need of first CS intervention (inotrope, vasopressor, or mechanical circulatory support). The algorithm achieves an overall area under curve (AUC) of 0.87 (0.81 in CC, 0.84 in ED, 0.97 in WARD), which is considered useful for clinical use. The algorithm can be refined based on specific elements defining patient subpopulations, for example presence of acute myocardial infarction (AMI) or congestive heart failure (CHF), further increasing its precision when a patient has these conditions. The top-contributing risk factors learned by the model are consistent with existing clinical findings. Our conclusion is that a useful machine learning model can be used to predict the development of CS. This manuscript describes the main steps of the development process and our results.
• Dehghani, P., Schmidt, C. W., Garcia, S., Okeson, B., Grines, C. L., Singh, A., Patel, R. A., Wiley, J., Htun, W. W., Nayak, K. R., Alraies, M. C., Ghasemzadeh, N., Davidson, L. J., Acharya, D., Stone, J., Alyousef, T., Case, B. C., Dai, X., Hafiz, A. M., , Madan, M., et al. (2022). North American COVID-19 Myocardial Infarction (NACMI) Risk Score for Prediction of In-Hospital Mortality. Journal of the Society for Cardiovascular Angiography & Interventions, 1(5), 100404.
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  In-hospital mortality in patients with ST-segment elevation myocardial infarction (STEMI) is higher in those with COVID-19 than in those without COVID-19. The factors that predispose to this mortality rate and their relative contribution are poorly understood. This study developed a risk score inclusive of clinical variables to predict in-hospital mortality in patients with COVID-19 and STEMI.
• Garcia, S., Dehghani, P., Stanberry, L., Grines, C., Patel, R. A., Nayak, K. R., Singh, A., Htun, W. W., Kabour, A., Ghasemzadeh, N., Sanina, C., Aragon, J., Alraies, M. C., Benziger, C., Okeson, B., Garberich, R., Welt, F. G., Davidson, L., Hafiz, A. M., , Acharya, D., et al. (2022). Trends in Clinical Presentation, Management, and Outcomes of STEMI in Patients With COVID-19. Journal of the American College of Cardiology, 79(22), 2236-2244.
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  We previously reported high in-hospital mortality for ST-segment elevation myocardial infarction (STEMI) patients with COVID-19 treated in the early phase of the pandemic.
• Kazui, T., Hsu, C. H., Hamidi, M., Acharya, D., Shanmugasundaram, M., Lee, K., Chatterjee, A., & Bull, D. (2022). Five-meter walk test before transcatheter aortic valve replacement and 1-year noncardiac mortality. JTCVS open, 12, 103-117.
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  The purpose of this study is to assess whether the 5-m walk test is associated with 1-year mortality after transcatheter aortic valve replacement.
• Lee, K. S., Natarajan, B., Wong, W. X., Yousman, W., Koester, S., Nyotowidjojo, I., Lee, J. Z., Kern, K. B., Acharya, D., Fortuin, D., Hung, O., Voelker, W., & Indik, J. H. (2022). A randomized controlled trial of simulation training in teaching coronary angiographic views. BMC medical education, 22(1), 644.
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  Simulation technology has an established role in teaching technical skills to cardiology fellows, but its impact on teaching trainees to interpret coronary angiographic (CA) images has not been systematically studied. The aim of this randomized controlled study was to test whether structured simulation training, in addition to traditional methods would improve CA image interpretation skills in a heterogeneous group of medical trainees.
• Pullela, N. K., Acharya, D., Shanmugasundaram, M., Acharya, T., Ajmal, M., Truong, H. T., Shetty, R., & Lotun, K. D. (2022). Transcatheter Closure of Complex Left Circumflex to Coronary Sinus Fistula. JACC. Case reports, 4(9), 559-563.
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  Coronary artery fistulae connecting the left circumflex to the coronary sinus are rare. Surgical closure of coronary sinus connections is technically challenging because of the location, especially in high-risk surgical patients. We used multimodality imaging to delineate the drainage site and successfully closed a left circumflex to coronary sinus fistula using a transcatheter closure technique. ().
• Acharya, D., Loyaga-Rendon, R. Y., Chatterjee, A., Rajapreyar, I., & Lee, K. (2021). Optical Coherence Tomography in Cardiac Allograft Vasculopathy: State-of-the-Art Review. Circulation. Heart failure, 14(9), e008416.
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  Cardiac allograft vasculopathy (CAV) is a challenging complication of heart transplantation. CAV pathophysiology is incompletely understood, standard screening modalities such as angiography have significant limitations, and currently available therapies have only modest efficacy in preventing progression. Optical coherence tomography is a light-based technique that provides microscopic level catheter-based intravascular imaging and has dramatically expanded our understanding of CAV, demonstrating it to be a complex, heterogeneous, and dynamic process. This review covers characteristics and uses of optical coherence tomography, including vessel characterization, serial use to assess progression of disease, guiding percutaneous intervention, and monitoring response to CAV therapies. We also discuss the potential of optical coherence tomography in providing individualized assessment and enable customized CAV therapies, which may lead to improvements in long-term transplant outcomes.
• Acharya, D., Rajapreyar, I., & Kern, K. (2021). Editorial: Cardiogenic Shock: Basic and Clinical Considerations. Frontiers in cardiovascular medicine, 8, 797527.
• Cruz Rodriguez, J. B., Chatterjee, A., Pamboukian, S. V., Tallaj, J. A., Joly, J., Lenneman, A., Aryal, S., Hoopes, C. W., Acharya, D., & Rajapreyar, I. (2021). Persistent mitral regurgitation after left ventricular assist device: a clinical conundrum. ESC heart failure, 8(2), 1039-1046.
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  Persistent mitral valve regurgitation (MR) after continuous flow left ventricular assist device implantation (cfLVAD) is associated with pulmonary hypertension and right ventricular failure with variable effects on survival across published studies. The aim of this study is to determine the incidence and predictors of persistent MR at 6-month follow-up after cfLVAD implantation and its impact on survival, haemodynamics, right ventricular function, and morbidity.
• Garcia, S., Dehghani, P., Grines, C., Davidson, L., Nayak, K. R., Saw, J., Waksman, R., Blair, J., Akshay, B., Garberich, R., Schmidt, C., Ly, H. Q., Sharkey, S., Mercado, N., Alfonso, C. E., Misumida, N., Acharya, D., Madan, M., Hafiz, A. M., , Javed, N., et al. (2021). Initial Findings From the North American COVID-19 Myocardial Infarction Registry. Journal of the American College of Cardiology, 77(16), 1994-2003.
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  The coronavirus disease 2019 (COVID-19) pandemic has impacted many aspects of ST-segment elevation myocardial infarction (STEMI) care, including timely access to primary percutaneous coronary intervention (PPCI).
• Gonzalez, M. H., Acharya, D., Lee, S., Leacche, M., Boeve, T., Manandhar-Shrestha, N., Jovinge, S., & Loyaga-Rendon, R. Y. (2021). Improved survival after heart transplantation in patients bridged with extracorporeal membrane oxygenation in the new allocation system. The Journal of heart and lung transplantation : the official publication of the International Society for Heart Transplantation, 40(2), 149-157.
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  Historically, patients bridged on extracorporeal membrane oxygenation (ECMO) to heart transplantation (HT) have very high post-transplant mortality. In the new heart transplant allocation system, ECMO-supported patients have the highest priority for HT. However, data are lacking on the outcomes of these critically ill patients. We compared the waitlist and post-transplant outcomes of ECMO-supported patients in the new and old allocation systems.
• Jani, M., Lee, S., Acharya, D., Hoeksema, S., Boeve, T., Leacche, M., Manandhar-Shrestha, N. K., Jovinge, S. V., & Loyaga-Rendon, R. Y. (2021). Decreased frequency of transplantation and lower post-transplant survival free of re-transplantation in LVAD patients with the new heart transplant allocation system. Clinical transplantation, e14493.
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  To evaluate the effect of the new heart transplant (HT) allocation system in left ventricular assist device (LVAD) supported patients listed as bridge to transplantation (BTT).
• Lee, K. S., Chatterjee, A., & Acharya, D. (2021). De-Escalation of DAPT After ACS: Escalating the Odds of Getting It Right. Journal of the American College of Cardiology, 78(8), 778-780.
• Loyaga-Rendon, R. Y., Kazui, T., & Acharya, D. (2021). Antiplatelet and anticoagulation strategies for left ventricular assist devices. Annals of translational medicine, 9(6), 521.
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  Left ventricular assist devices (LVAD) have revolutionized the management of advanced heart failure. However, complications rates remain high, among which hemorrhagic and thrombotic complications are the most important. Antiplatelet and anticoagulation strategies form a cornerstone of LVAD management and may directly affect LVAD complications. Concurrently, LVAD complications influence anticoagulation and anticoagulation management. A thorough understanding of device, patient, and management, including anticoagulation and antiplatelet therapies, are important in optimizing LVAD outcomes. This article provides a comprehensive state of the art review of issues related to antiplatelet and anticoagulation management in LVADs. We start with a historical overview, the epidemiology and pathophysiology of bleeding and thrombotic complications in LVADs. We then discuss platelet and anticoagulation biology followed by considerations prior to, during, and after LVAD implantation. This is followed by discussion of anticoagulation and the management of thrombotic and hemorrhagic complications. Specific problems, including management of heparin-induced thrombocytopenia, anticoagulant reversal, novel oral anticoagulants, artificial heart valves, and noncardiac surgeries are covered in detail.
• Acharya, D. (2020). Predictors of Outcomes in Myocardial Infarction and Cardiogenic Shock. Cardiology in review, 26(5), 255-266.
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  Myocardial infarction (MI) complicated by cardiogenic shock (MI-CS) is a major cause of cardiovascular morbidity and mortality. Predictors of outcomes in MI-CS include clinical, laboratory, radiologic variables, and management strategies. This article reviews the existing literature on short- and long-term predictors and risk stratification in MI complicated by CS.
• Acharya, D. (2020). Unloading and Reperfusion in Myocardial Infarction: A Matter of Time. Circulation. Heart failure, 13(1), e006718.
• Acharya, D., Torabi, M., Borgstrom, M., Rajapreyar, I., Lee, K., Kern, K., Rycus, P., Tonna, J. E., Alexander, P., & Lotun, K. (2020). Extracorporeal Membrane Oxygenation in Myocardial Infarction Complicated by Cardiogenic Shock: Analysis of the ELSO Registry. Journal of the American College of Cardiology, 76(8), 1001-1002.
• Aryal, S. R., Moussa, H., Sinkey, R., Dhungana, R., Tallaj, J. A., Pamboukian, S. V., Patarroyo-Aponte, M., Acharya, D., Bajaj, N. S., Bhattarai, S., Lenneman, A., Joly, J. M., Sibai, B. M., & Rajapreyar, I. N. (2020). Management of reproductive health in patients with pulmonary hypertension. American journal of obstetrics & gynecology MFM, 2(2), 100087.
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  Pulmonary hypertension is characterized by elevated pulmonary artery pressure caused by several clinical conditions that affect pulmonary vasculature. Morbidity and death in this condition are related to the development of right ventricular failure. Normal physiologic changes that occur in pregnancy to support the growing fetus can pose hemodynamic challenges to the pregnant patient with pulmonary hypertension that results in increased morbidity and mortality rates. Current guidelines recommend that patients with known pulmonary hypertension be counseled against pregnancy. This review aims to provide clinicians with guidelines for preconception counseling, medication management, and delivery planning.
• Cruz Rodriguez, J. B., Stewart, G. C., Pamboukian, S. V., Tallaj, J. A., Rajapreyar, I., Kirklin, J. K., Holman, W. L., Hoopes, C. W., Mukherjee, D., Mallawaarachchi, I., Dwivedi, A., & Acharya, D. (2020). Clinical characteristics and outcomes of patients requiring prolonged inotropes after left ventricular assist device implantation. Artificial organs.
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  Limited data exist regarding patients with continuous-flow left ventricular assist device (LVAD) support who require long-term inotropes. Our primary objective was to evaluate the clinical characteristics and all-cause mortality of LVAD recipients with prolonged inotrope use (PIU). Secondary endpoints were to compare predictors of PIU, mortality, risk of late re-initiation of inotropes, time to gastrointestinal bleed (GIB), infection, and arrhythmias. Retrospective cohort study was conducted on adult patients with primary continuous-flow LVADs implanted from January 2008 to February 2017 and the patients were followed up through February 2018. We defined PIU as ≥14 days of inotrope support. Kaplan-Meier method, competing risk models and Cox proportional hazard models were used. Final analytic sample was 203 patients, 58% required PIU, and 10% were discharged on inotropes. There was no difference in preimplant characteristics. One-year survival rate was 87% if no PIU required, 74% if PIU required, and 72% if discharged on inotropes. PIU was associated with longer length of stay and higher incidence of GIB. We found no association between PIU and late re-initiation of inotropes, infection or arrhythmias. Adjusted hazard risk of death was increased in patients with PIU (HR = 1.66, P = .046), older age (HR = 1.28, P = .031), and higher creatinine levels (HR = 1.60, P = .007). Prolonged inotrope use is frequently encountered following LVAD implantation and is associated with adverse prognosis but remains a therapeutic option. Inability to wean inotropes prior to hospital discharge is a marker of patients at particularly higher risk of mortality following LVAD implantation.
• Dhakal, B. P., Sweitzer, N. K., Indik, J. H., Acharya, D., & William, P. (2020). SARS-CoV-2 Infection and Cardiovascular Disease: COVID-19 Heart. Heart, lung & circulation, 29(7), 973-987.
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  Coronavirus disease (COVID-19) is a serious illness caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The symptoms of the disease range from asymptomatic to mild respiratory symptoms and even potentially life-threatening cardiovascular and pulmonary complications. Cardiac complications include acute myocardial injury, arrhythmias, cardiogenic shock and even sudden death. Furthermore, drug interactions with COVID-19 therapies may place the patient at risk for arrhythmias, cardiomyopathy and sudden death. In this review, we summarise the cardiac manifestations of COVID-19 infection and propose a simplified algorithm for patient management during the COVID-19 pandemic.
• Kendall, M. R., Reddy, S. M., Meinke, L. E., & Acharya, D. (2020). COVID-19 and ST elevations-keep an open mind: a case report. European heart journal. Case reports, 4(6), 1-4.
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  Coronavirus disease 2019 (COVID-19) has been associated with a range of cardiovascular manifestations, including myocardial injury and thrombo-embolism. Pulmonary embolism (PE) causing anteroseptal/anterior ST elevations that mimic myocardial infarction have previously been described. This phenomenon is thought to be related to right ventricular injury from large emboli.
• Kumar, K., Reddy, S., Acharya, D., & Lotun, K. (2020). Novel technique of performing multivessel PCI through an Impella sheath. Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions, 96(1), 117-120.
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  A 69-year-old woman with diabetes was found to have multi-vessel coronary artery disease and underwent 5-vessel coronary artery bypass grafting. Patient had persistent cardiogenic shock postoperatively despite intra-aortic balloon pump and escalating pressor requirements. Electrocardiogram showed new ischemic changes and the patient was urgently taken to the catheterization lab for coronary angiography and placement of an Impella CP for higher degree of hemodynamic support via the left femoral artery. Due to limitations in vascular access the Impella CP sheath was utilized for vascular access for diagnostic angiography and coronary intervention concurrently with ongoing Impella CP support. The first obtuse marginal had severe proximal disease and was treated with percutaneous coronary intervention (PCI) with a drug eluting stent. To our knowledge, this case is the first in which successful diagnostic angiography as well as multi-vessel PCI was performed via an Impella sheath while concurrently using the percutaneous mechanical circulatory support system of the Impella CP. Multiple guide catheters and a pigtail catheter were successfully passed via the Impella CP sheath to perform PCI. This novel method of vascular access could be an important tool to use in high-risk patients with limitations in access sites and decrease potential bleeding complications by limiting the number of arterial punctures.
• Loyaga-Rendon, R. Y., Acharya, D., & Kazui, T. (2020). Antiplatelet and anticoagulation strategies for left ventricular assist devices. Annals of Translational Medicine, 1-17.
• Loyaga-Rendon, R. Y., Acharya, D., & Kirklin, J. K. (2020). LVAD Implantation or Heart Transplantation for ECMO-Supported Patients. Journal of the American College of Cardiology, 76(21), 2575-2576.
• Loyaga-Rendon, R. Y., Boeve, T., Tallaj, J., Lee, S., Leacche, M., Lotun, K., Koehl, D. A., Cantor, R. S., Kirklin, J. K., & Acharya, D. (2020). Extracorporeal Membrane Oxygenation as a Bridge to Durable Mechanical Circulatory Support: An Analysis of the STS-INTERMACS Database. Circulation. Heart failure, 13(3), e006387.
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  Limited data are available regarding the outcomes of patients supported by extracorporeal membrane oxygenation (ECMO) who undergo durable mechanical circulatory support implantation (dMCS). We analyzed the clinical characteristics, outcomes, and risk factors for mortality in patients who were bridged with ECMO to dMCS.
• Loyaga-Rendon, R. Y., Boeve, T., Tallaj, J., Lee, S., Leacche, M., Lotun, K., Koehl, D. A., Cantor, R. S., Kirklin, J. K., & Acharya, D. (2020). Response by Loyaga-Rendon et al to Letter Regarding Article, "Extracorporeal Membrane Oxygenation as a Bridge to Durable Mechanical Circulatory Support: An Analysis of the STS INTERMACS Database". Circulation. Heart failure, 13(7), e007194.
• Acharya, D., & Rajapreyar, I. (2019). Myocardial perfusion imaging for cardiac allograft vasculopathy assessment: Evidence grows, but questions remain. Journal of nuclear cardiology : official publication of the American Society of Nuclear Cardiology, 26(3), 853-856.
• Acharya, D., Aryal, S., Loyaga-Rendon, R., Pamboukian, S. V., Tallaj, J., Kirklin, J. K., Holman, W. L., & Singh, S. (2019). Use of Computed Tomography in Preoperative Planning for Heartware Left Ventricular Assist Device Placement. ASAIO journal (American Society for Artificial Internal Organs : 1992), 65(1), 70-76.
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  Optimal left ventricular assist device (LVAD) cannula position is important for adequate ventricular unloading and LVAD function. Poor inflow cannula position predisposes to pump thrombosis, inotrope dependence, and mortality. We describe a novel technique of preoperative left ventricular apex marking using CT guidance and demonstrate in three cases the use of this method to achieve optimal inflow cannula positioning for lateral thoracotomy Heartware LVAD implantation.
• El-Dabh, A., & Acharya, D. (2019). EXPRESS: Pulmonary hypertension with dasatinib and other tyrosine kinase inhibitors. Pulmonary circulation, 2045894019865704.
• Joly, J. M., El-Dabh, A., Marshell, R., Chatterjee, A., Smith, M. G., Tresler, M., Kirklin, J. K., Acharya, D., Rajapreyar, I. N., Tallaj, J. A., & Pamboukian, S. V. (2019). Performance of Noninvasive Assessment in the Diagnosis of Right Heart Failure After Left Ventricular Assist Device. ASAIO journal (American Society for Artificial Internal Organs : 1992), 65(5), 449-455.
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  Right heart failure (RHF) after left ventricular assist device (LVAD) is associated with poor outcomes. Interagency Registry for Mechanically Assisted Circulatory Support (Intermacs) defines RHF as elevated right atrial pressure (RAP) plus venous congestion. The purpose of this study was to examine the diagnostic performance of the noninvasive Intermacs criteria using RAP as the gold standard. We analyzed 108 patients with LVAD who underwent 341 right heart catheterizations (RHC) between January 1, 2006, and December 31, 2013. Physical exam, echocardiography, and laboratory data at the time of RHC were collected. Conventional two-by-two tables were used and missing data were excluded. The noninvasive Intermacs definition of RHF is 32% sensitive (95% cardiac index (CI), 0.21-0.44) and 97% specific (95% CI, 0.95-0.99) for identifying elevated RAP. Clinical assessment failed to identify two-thirds of LVAD patients with RAP > 16 mm Hg. More than half of patients with elevated RAP did not have venous congestion, which may represent a physiologic opportunity to mitigate the progression of disease before end-organ damage occurs. One-quarter of patients who met the noninvasive definition of RHF did not actually have elevated RAP, potentially exposing patients to unnecessary therapies. In practice, if any component of the Intermacs definition is present or equivocal, our data suggest RHC is warranted to establish the diagnosis.
• Kumar, K., Reddy, S., Dhakal, B., Acharya, D., Shetty, R., & Lotun, K. (2019). Prophylactic Left Ventricular Outflow Tract Septal Ablation Before Transcatheter Mitral Valve Replacement. JACC. Case reports, 1(5), 823-831.
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  An 82-year-old woman with severe respiratory distress and limitations in functional status was found to have severe mitral valve stenosis with annular calcification and referred for transcatheter mitral valve replacement. Prophylactic alcohol septal ablation was used pre-procedurally to minimize mortality risk due to obstruction of the left ventricular outflow tract. ().
• Rajapreyar, I. N., Sinkey, R. G., Joly, J. M., Pamboukian, S. V., Lenneman, A., Hoopes, C. W., Kopf, S., Hayes, A., Moussa, H., Acharya, D., Aryal, S., Weeks, P., Cribbs, M., Wetta, L., & Tallaj, J. (2019). Management of reproductive health after cardiac transplantation. The journal of maternal-fetal & neonatal medicine : the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians, 1-10.
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  Pregnancy after cardiac transplantation poses immense challenges. Maternal risks include hypertensive disorders of pregnancy, rejection, and failure of the cardiac allograft that may lead to death. Fetal risks include potential teratogenic effects of immunosuppression and prematurity. Because of the high-risk nature of pregnancy in a heart transplant patient, management of reproductive health after cardiac transplantation should include preconception counseling to all women in the reproductive age group before and after cardiac transplantation. Reliable contraception is vital as nearly half of the pregnancies in this population are unintended. Despite the associated risks, successful pregnancies after cardiac transplantation have been reported. A multidisciplinary approach proposed in this review is essential for successful outcomes. A checklist for providers to guide management is provided.
• Rajapreyar, I., Acharya, D., Tallaj, J., Hornbuckle, L., Sharpton, J., Joly, J., & Pamboukian, S. (2019). Left Ventricular Assist Device Thrombosis-Amiodarone-Induced Hyperthyroidism: Causal Link?. ASAIO journal (American Society for Artificial Internal Organs : 1992), 65(2), e18-e20.
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  Ventricular arrhythmias occurs in 20-50% of patients supported with left ventricular assist devices (LVAD). Ventricular arrhythmias are well tolerated with LVAD support but long-term consequences include worsening right ventricular function. Management of ventricular arrhythmias in LVAD patients includes use of antiarrhythmic agents or ablation. Amiodarone has been used a first-line agent to treat ventricular arrhythmias post-LVAD implantation. Chronic treatment with amiodarone for arrhythmias can result in hyperthyroidism and hypothyroidism in 5-10% of patients. Hyperthyroidism is known to cause endothelial dysfunction, alterations in coagulation, and fibrinolytic pathways favoring hypercoagulable state. We describe two cases of left ventricular assist device (LVAD) thrombosis potentiated by amiodarone-induced hyperthyroidism (AIT) and discuss pathophysiological mechanisms for hypercoagulable state induced by hyperthyroidism.
• Sedhai, Y. R., Basnyat, S., Dar, T., & Acharya, D. (2019). Endovascular Treatment of Ruptured Renal Artery Aneurysm: A Case-Based Literature Review. Case reports in medicine, 2019, 3738910.
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  Renal artery aneurysms are extremely uncommon with a reported incidence of less than one percent in general population. They are being more frequently detected due to increasing availability and use of abdominal imaging. Renal artery aneurysm rupture is an extremely unusual cause of acute flank pain with hemodynamic instability. Given the rarity of diagnoses, clinicians may not consider and address this ruptured renal artery aneurysm early which can potentially lead to adverse clinical outcomes. We report the case of a 55-year-old male who presented with retroperitoneal bleeding from a ruptured aneurysm of the interlobular branch of renal artery. He was endovascularly treated with coil embolization. We have also reviewed the inherent literature.
• Chatterjee, A., Jackson, A. E., Acharya, D., & Law, M. A. (2018). Transcatheter Closure of Pulmonary Arteriovenous Malformation to Facilitate Treatment of Pulmonary Arterial Hypertension. JACC. Cardiovascular interventions, 11(6), e45-e46.
• Cox, M. L., Gulack, B. C., Thibault, D. P., He, X., Williams, M. L., Thourani, V. H., Jacobs, J. P., Brennan, J. M., Daneshmand, M. A., & Acharya, D. (2018). Outcomes after coronary artery bypass grafting in patients with myocardial infarction, cardiogenic shock and unresponsive neurological state: analysis of the Society of Thoracic Surgeons Database. European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery, 54(4), 710-716.
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  Previous studies have demonstrated a 20% mortality rate among patients undergoing isolated coronary artery bypass grafting (CABG) for cardiogenic shock. However, outcomes following CABG for cardiogenic shock in patients who are neurologically unresponsive preoperatively are unknown.
• Joly, J. M., Acharya, D., Doppalapudi, H., Kay, G. N., Lin, C. P., Maddox, W. R., McElderry, H. T., Pamboukian, S. V., Plumb, V. J., Rajapreyar, I. N., Tallaj, J. A., Yamada, T., & Kumar, V. (2018). Acute Hemodynamic Effects of Biventricular Pacing After Left Ventricular Assist Device. Journal of cardiac failure, 24(10), 716-718.
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  Despite cardiac resynchronization therapy (CRT), some patients with heart failure progress and undergo left ventricular assist device (LVAD) implantation. Management of CRT after LVAD implantation has not been well studied. The purpose of this study was to determine whether RV pacing or biventricular pacing measurably affects acute hemodynamics in patients with an LVAD and a CRT device.
• Joly, J. M., El-Dabh, A., Kirklin, J. K., Marshell, R., Smith, M. G., Acharya, D., Rajapreyar, I. N., Tallaj, J. A., Tresler, M., & Pamboukian, S. V. (2018). High Right Atrial Pressure and Low Pulse Pressure Predict Gastrointestinal Bleeding in Patients With Left Ventricular Assist Device. Journal of cardiac failure, 24(8), 487-493.
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  Gastrointestinal bleeding (GIB) remains a major morbid event during continuous flow left ventricular assist device (LVAD) support. This study investigated whether a common hemodynamic profile is associated with GIB in patients with LVADs.
• Maurer, M. S., Schwartz, J. H., Gundapaneni, B., Elliott, P. M., Merlini, G., Waddington-Cruz, M., Kristen, A. V., Grogan, M., Witteles, R., Damy, T., Drachman, B. M., Shah, S. J., Hanna, M., Judge, D. P., Barsdorf, A. I., Huber, P., Patterson, T. A., Riley, S., Schumacher, J., , Stewart, M., et al. (2018). Tafamidis Treatment for Patients with Transthyretin Amyloid Cardiomyopathy. The New England journal of medicine, 379(11), 1007-1016.
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  Transthyretin amyloid cardiomyopathy is caused by the deposition of transthyretin amyloid fibrils in the myocardium. The deposition occurs when wild-type or variant transthyretin becomes unstable and misfolds. Tafamidis binds to transthyretin, preventing tetramer dissociation and amyloidogenesis.
• Acharya, D., Loyaga-Rendon, R., Morgan, C. J., Sands, K. A., Pamboukian, S. V., Rajapreyar, I., Holman, W. L., Kirklin, J. K., & Tallaj, J. A. (2017). INTERMACS Analysis of Stroke During Support With Continuous-Flow Left Ventricular Assist Devices: Risk Factors and Outcomes. JACC. Heart failure, 5(10), 703-711.
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  This study sought to evaluate predictors of stroke during left ventricular assist device (LVAD) support from data available prior to implantation, and quantify stroke-related morbidity and mortality.
• Acharya, D., & Uyeki, T. M. (2016). The PARADIGM of Influenza Vaccination in Heart Failure Patients. JACC. Heart failure, 4(2), 159-161.
• Acharya, D., Gulack, B. C., Loyaga-Rendon, R. Y., Davies, J. E., He, X., Brennan, J. M., Thourani, V. H., & Williams, M. L. (2016). Clinical Characteristics and Outcomes of Patients With Myocardial Infarction and Cardiogenic Shock Undergoing Coronary Artery Bypass Surgery: Data From The Society of Thoracic Surgeons National Database. The Annals of thoracic surgery, 101(2), 558-66.
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  Acute myocardial infarction complicated by cardiogenic shock (AMI-CS) is associated with substantial mortality. We evaluated outcomes of patients in The Society of Thoracic Surgeons Adult Cardiac Surgery Database who underwent coronary artery bypass graft surgery (CABG) in the setting of AMI-CS.
• Acharya, D., Loyaga-Rendon, R. Y., Pamboukian, S. V., Tallaj, J. A., Holman, W. L., Cantor, R. S., Naftel, D. C., & Kirklin, J. K. (2016). Ventricular Assist Device in Acute Myocardial Infarction. Journal of the American College of Cardiology, 67(16), 1871-80.
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  Patients with acute myocardial infarction (AMI) complicated by acute heart failure or cardiogenic shock have high mortality with conventional management.
• Acharya, D., Sanam, K., Revilla-Martinez, M., Hashim, T., Morgan, C. J., Pamboukian, S. V., Loyaga-Rendon, R. Y., & Tallaj, J. A. (2016). Infections, Arrhythmias, and Hospitalizations on Home Intravenous Inotropic Therapy. The American journal of cardiology, 117(6), 952-6.
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  Inotropes improve symptoms in advanced heart failure (HF) but were associated with higher mortality in clinical trials. Recurrent hospitalizations, arrhythmias, and infections contribute to morbidity and mortality, but the risks of these complications with modern HF therapies are not well known. We collected arrhythmia, infection, and hospitalization data on 197 patients discharged from our institution from January 2007 to March 2013 on intravenous inotropes. Patients were followed until they died, received a transplant or left ventricular assist device, were weaned off inotropes, or remained on inotropes at the end of the study. All patients had stage D HF. At baseline, 30% had a history of ventricular tachycardia, 7.1% had a history of cardiac arrest, and 39% had a history of atrial fibrillation. During follow-up, 33 patients (17%) had one or more implantable cardioverter-defibrillator shocks. Of patients who had shocks, 27 patients (82%) had appropriate shocks for ventricular tachycardia/ventricular fibrillation, 3 patients (9%) had inappropriate shocks, and 3 patients (9%) had both appropriate and inappropriate shocks. The risk of implantable cardioverter-defibrillator shock was not related to dose of inotrope (p = 0.605). Fifty-seven patients (29%) had one or more infections during follow-up. Bacteremia was the most common type of infection. Implanted electrophysiology devices did not confer an increased risk of infection. One hundred twelve patients (57%) had one or more hospitalizations during follow-up. Common causes of hospitalizations were worsening HF symptoms (41%), infections (20%), and arrhythmias (12%). In conclusion, arrhythmias, infections, and rehospitalizations are important complications of inotropic therapy.
• Acharya, D., Doppalapudi, H., & Tallaj, J. A. (2015). Arrhythmias in Fabry cardiomyopathy. Cardiac electrophysiology clinics, 7(2), 283-91.
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  Fabry disease is an X-linked multisystem disorder caused by deficiency of the α-galactosidase A enzyme. Cardiovascular manifestations include hypertension, coronary disease, arrhythmias, valvular abnormalities, heart failure, and sudden death. Bradycardia and conduction system abnormalities are related initially to abnormal accumulation of glycolipids in the lysosomes of conduction tissues. Hypertrophy and eventual fibrosis provides a substrate for persistent conduction abnormalities and ventricular arrhythmias. Sudden cardiac death can be related to bradyarrhythmias or tachycardias. Enzyme replacement therapy can improve cardiac function and clinical outcomes. Pacemakers or defibrillators are important in the treatment of patients with Fabry disease who are at risk for arrhythmias.
• Takahashi, M., Arai, H., Kokubo, T., Furukawa, F., Kurata, Y., & Ito, N. (1980). An ultrastructural study of precancerous and cancerous lesions of the pancreas in Syrian golden hamsters induced by N-nitrosobis(2-oxopropyl)amine. Gan, 71(6), 825-31.
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  Transmission electron microscopic studies of precancerous and cancerous lesions in the pancreas of hamsters induced by N-nitrosobis(2-oxopropyl)amine (BOP) are presented. BOP was injected subcutaneously once weekly for 10 weeks and hamsters were sacrificed every 5 weeks after initiation of the experiment. The ultrastructural findings indicated that serial changes occurred in the epithelium of the pancreatic duct. The epithelial cells became cuboidal and showed increased secretions at 5 weeks. Probably precancerous cells with prominent nucleoli and irregular rough endoplasmic reticulum were found in the main duct at 10 weeks. At 15 weeks, pancreatic tumors forming a duct arrangement were seen, in good accord with the histological appearance. Well differentiated adenocarcinoma cells showing a tubular pattern had oval nuclei with granular chromatin. Poorly developed rough endoplasmic reticulum was irregularly distributed throughout the cytoplasm and the cell surface was covered with microvilli. Poorly differentiated adenocarcinoma showed poor gland formation and had distorted nuclei with prominent nucleoli. These cells were loosely joined. Mitochondria and rough endoplasmic reticulum were poorly developed, and the tumor cells were devoid of secretory granules. The most characteristic and common change of the precancerous and cancerous lesions in this experiment was the appearance of numerous microvilli on the luminal surface and loss of cytodifferentiation. These findings were obviously different from those of normal epithelial cells or those seen in inflammation. The findings in this study confirm that the pancreatic carcinoma induced by N-nitrosobis(2-oxopropyl)amine in Syrian hamsters is of duct cell origin. No evidence of acinar cells was obtained.