Deepak Acharya

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Scholarly Contributions

Books

• Rai, M., Acharya, D., & Rı́os, J. L. (2011). Ethnomedicinal Plants. doi:10.1201/b10495

Chapters

• Acharya, D., & Rajapreyar, I. (2020). Pathophysiology of Right Heart disease in chronic lung disease. In Cardiovascular Disease in Chronic Lung Disease. Springer.
• Rai, M., Acharya, D., & Rı́os, J. L. (2011). Brazilian Ethnomedicinal Plants with Anti-inflammatory Action. In Ethnomedicinal Plants. doi:10.1201/b10495-6
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  The use of flora as a source of therapeutic material is as ancient as therapy itself. Most, if not all, botanical species appear to have a rudimentary immune system (Sarti 1995) that favored the development of means of chemical defense against the attack of bacteria, fungi, protozoa, insects, birds and other animals. The substances that constitute this barrier-the natural products, frequently evidence hormonal toxic activity against parasites, insects that transmit disease and other live organisms that afflict humans and could therefore constitute useful therapeutic and/or prophylactic agents.
• Rai, M., Acharya, D., & Rı́os, J. L. (2011). Combining Ethnobotany and Informatics to Discover Knowledge from Data. In Ethnomedicinal Plants. doi:10.1201/b10495-19
• Rai, M., Acharya, D., & Rı́os, J. L. (2011). Ethnomedicine of Quassia and Related Plants in Tropical America. In Ethnomedicinal Plants. doi:10.1201/b10495-14
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  Quassi3 was the name of a Negro slave, a medicine man of Surinam, who acquired a great reputation in the treatment of fevers with a secret bitterplant remedy. His secret was made public by the Swedes Daniel Rolander and Carl G. Dahlberg in 1756 (Felter and Lloyd 1898) and his name was honored by Linné (Linaeus) in naming the plant Quassia amara in 1762.4 The term ‘amara’ refers to the bitterness of the plant and its extracts.
• Acharya, D., Gade, A., & Rai, M. (2006). Chapter 6 Bioactivity of fabaceous plants against food-borne and plant pathogens: potentials and limitations. In Advances in Phytomedicine. doi:10.1016/s1572-557x(06)03006-6
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  Family Fabaceae is known for its antimicrobial potential since time immemorial. Plants like Pongamia pinnata, Cassia tora, Psoralea corylifolia, Caesalpinia sapan, and Mucuna pruriens are described in ancient literature for their antimicrobial uses. There is a pressing need to search for new antimicrobial agents for the control of pathogenic enemies of crops for the sustainable future. Although, a significant contribution has been made in the field of search for fabaceous-derived natural drugs against human pathogenic fungi, phytopathogens are woefully neglected. Therefore, the pathogens causing diseases in economic plants should be given priority. The peptides play an important role in inhibition of the microbial growth. The structural, biochemical, and functional diversity of the proteins found in nature provide an opportunity for future research. This chapter focuses mainly on antimicrobial potential of plants of family Fabaceae, their bioactive compounds, and their role in sustainable plant disease management.

Journals/Publications

• Chatterjee, A., Shanmugasundaram, M., Lee, K. S., Kazui, T., Rajapreyar, I. N., & Acharya, D. (2024). Optical Coherence Tomography in the Assessment and Management of Cardiac Allograft Vasculopathy. Current cardiology reports, 26(8), 777-782.
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  Cardiac Allograft vasculopathy (CAV) is a major barrier to improving outcomes after heart transplantation. Coronary angiography has very low sensitivity to detect early CAV and intravascular ultrasound (IVUS) only improves it to some extent. In this article, we detail the current evidence surrounding use of Optical Coherence tomography (OCT) in patients with CAV.
• Dehghani, P., Singh, J., Mancini, G. B., Stanberry, L., Bergstedt, S., Madan, M., Benziger, C. P., Ghasemzadeh, N., Bortnick, A., Kankaria, R., Grines, C. L., Nayak, K., Yildiz, M., Alraies, M. C., Bagai, A., Patel, R. A., Amlani, S., Case, B. C., Waksman, R., , Shavadia, J. S., et al. (2024). Angiographic characteristics of patients with STEMI and COVID-19: Insights from NACMI registry. American heart journal, 271, 112-122.
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  To date, there has been no independent core lab angiographic analysis of patients with COVID-19 and STEMI. The study characterized the angiographic parameters of patients with COVID-19 and STEMI.
• Dehghani, P., Singh, J., Mancini, G., Stanberry, L., Bergstedt, S., Madan, M., Benziger, C., Ghasemzadeh, N., Bortnick, A., Kankaria, R., Grines, C., Nayak, K., Yildiz, M., Alraies, M., Bagai, A., Patel, R., Amlani, S., Case, B., Waksman, R., , Shavadia, J., et al. (2024). Angiographic characteristics of patients with STEMI and COVID-19: Insights from NACMI registry. American Heart Journal, 271. doi:10.1016/j.ahj.2024.02.012
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  Background: To date, there has been no independent core lab angiographic analysis of patients with COVID-19 and STEMI. The study characterized the angiographic parameters of patients with COVID-19 and STEMI. Methods: Angiograms of patients with COVID-19 and STEMI from the North American COVID-19 Myocardial Infarction (NACMI) Registry were sent to a Core Laboratory in Vancouver, Canada. Culprit lesion(s), Thrombolysis In Myocardial Infarction (TIMI) flow, Thrombus Grade Burden (TGB), and percutaneous coronary intervention (PCI) outcome were assessed. Results: From 234 patients, 74% had one culprit lesion, 14% had multiple culprits and 12% had no culprit identified. Multivessel thrombotic disease and multivessel CAD were found in 27% and 53% of patients, respectively. Stent thrombosis accounted for 12% of the presentations and occurred in 55% of patients with previous coronary stents. Of the 182 who underwent PCI, 60 (33%) had unsuccessful PCI due to post-PCI TIMI flow
• Echieh, C. P., Hamidi, M., Rogers, M. P., Acharya, D., Kazui, T., & Hooker, R. L. (2024). Survival trends in heart transplant patients supported on ECMO and IABP: A 10-year UNOS database analysis. International journal of cardiology. Heart & vasculature, 54, 101486.
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  The United Network for Organ Sharing (UNOS) heart transplant allocation policy was changed in 2018. This study examines the impact of the change in UNOS heart transplant allocation policy on the use of temporary mechanical circulatory support (MCS) devices and post-transplant survival. The analysis included a total of 26,481 patients listed and transplanted between January 2013 and June 2022. The results showed a decrease in waiting time for transplant after the policy change, indicating a successful reduction in waitlist time for high-priority status patients. However, the length of hospital stays from transplant to discharge increased following the policy change. The study also found an increase in the frequency of ECMO and IABP use both at the time of listing and at the time of transplant following the policy change. Cumulative patient and graft survival at 1000 days decreased following the policy change (86.1 per cent versus 83.7 per cent at 1000 days, p = 0.002). However, the survival curves showed similar survival trends in the first 2 years, with late divergence in survival occurring after 2 years. In conclusion the latest UNOS heart transplant allocation policy change led to a decrease in waiting times and an increase in the use of temporary MCS devices. There was a decrease in cummulative survival at 1000 days following the policy change.
• 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.
• Peled, Y., Ducharme, A., Kittleson, M., Bansal, N., Stehlik, J., Amdani, S., Saeed, D., Cheng, R., Clarke, B., Dobbels, F., Farr, M., Lindenfeld, J., Nikolaidis, L., Patel, J., Acharya, D., Albert, D., Aslam, S., Bertolotti, A., Chan, M., , Chih, S., et al. (2024). International Society for Heart and Lung Transplantation Guidelines for the Evaluation and Care of Cardiac Transplant Candidates-2024. The Journal of heart and lung transplantation : the official publication of the International Society for Heart Transplantation, 43(10), 1529-1628.e54.
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  The "International Society for Heart and Lung Transplantation Guidelines for the Evaluation and Care of Cardiac Transplant Candidates-2024" updates and replaces the "Listing Criteria for Heart Transplantation: International Society for Heart and Lung Transplantation Guidelines for the Care of Cardiac Transplant Candidates-2006" and the "2016 International Society for Heart Lung Transplantation Listing Criteria for Heart Transplantation: A 10-year Update." The document aims to provide tools to help integrate the numerous variables involved in evaluating patients for transplantation, emphasizing updating the collaborative treatment while waiting for a transplant. There have been significant practice-changing developments in the care of heart transplant recipients since the publication of the International Society for Heart and Lung Transplantation (ISHLT) guidelines in 2006 and the 10-year update in 2016. The changes pertain to 3 aspects of heart transplantation: (1) patient selection criteria, (2) care of selected patient populations, and (3) durable mechanical support. To address these issues, 3 task forces were assembled. Each task force was cochaired by a pediatric heart transplant physician with the specific mandate to highlight issues unique to the pediatric heart transplant population and ensure their adequate representation. This guideline was harmonized with other ISHLT guidelines published through November 2023. The 2024 ISHLT guidelines for the evaluation and care of cardiac transplant candidates provide recommendations based on contemporary scientific evidence and patient management flow diagrams. The American College of Cardiology and American Heart Association modular knowledge chunk format has been implemented, allowing guideline information to be grouped into discrete packages (or modules) of information on a disease-specific topic or management issue. Aiming to improve the quality of care for heart transplant candidates, the recommendations present an evidence-based approach.
• Acharya, D. (2023). Clinical Indications of Rasnadi Guggulu – An Experiential and Scientific View. INTERNATIONAL JOURNAL OF RESEARCH IN MEDICAL SCIENCES & TECHNOLOGY. doi:10.37648/ijrmst.v16i01.006
• Acharya, D., Acharya, D., Fitzpatrick, M., & Fitzpatrick, M. (2023). A CASE OF MISSED AORTIC DISSECTION. CHEST Journal. doi:10.1016/j.chest.2023.07.2674
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  SESSION TITLE: Imaging Case Report Posters 1 SESSION TYPE: Case Report Posters PRESENTED ON: 10/09/2023 02:10 pm - 02:55 pm INTRODUCTION: Type A Aortic dissection is a life-threatening surgical emergency with high morbidity and mortality. Presenting symptoms can be nonspecific.We present a unique case of a missed type A aortic dissection on CTA chest PE protocol, confirmed on Chest MRA in a 53-year-old female presenting with unwitnessed seizure and non-resolving lactic acidosis. CASE PRESENTATION: 53-year-old female presented to ED after a period of unresponsiveness, immediately following witnessed agitation and seizure-like activity. Medics found patient incontinent of urine and stool suspecting seizure. Presenting labs showed elevated lactate and elevated creatinine. Troponin negative, EKG demonstrated sinus tachycardia, Head CT negative for bleed; MRI brain demonstrated watershed infarct. Lab abnormalities and tachycardia were initially attributed to seizure but lactate remained elevated following fluid boluses and patient was persistently tachycardic. CTA of the chest timed for PE (pulmonary embolism) was negative for acute PE but demonstrated reflux of contrast in hepatic vein and small pericardial effusion. Bedside POCUS disclosed approximately 1 cm anterior pericardial effusion with underfilled RA/RV, LVH, normal LVEF, IVC 2.5 cm with no respiratory variability concerning for hemodynamically significant pericardial effusion. Additional labs revealed LFTs > 3000, HS Troponin >3000. D-dimer> 20. Stat Chest MR Angiography to rule out aortic dissection was done, revealing Type A aortic dissection with moderate-sized hemopericardium. The patient underwent surgical repair of the ascending aorta and made full recovery. DISCUSSION: Due to the variability of presenting symptoms the diagnosis of aortic dissection is often missed at time of presentation, particularly in absence of chest pain which is present in about 90% of cases. 20% of patients with Type A Aortic dissection present as syncope with no neurological signs. CTA chest PE is the preferred modality due to accessibility and high accuracy but its limitations include false negative results from inadequate opacification of aorta and false positives when performed without ECG gating. In our case, the CTA obtained early in the course was timed for PE, decreasing sensitivity for dissection, though retrospectively dissection flap was faintly visible. The physiological processes identified on CTA chest is noteworthy. Reflux of contrast into hepatic veins suggesting right heart strain, in the absence of RV dilation; concomitant presence of pericardial effusion raised concern for acute increase in pericardial pressure, important findings aiding in diagnosis. Further supported by imaging through POCUS in acute setting. Point of care ultrasound can be useful in diagnosis of acute aortic dissection with pooled specificity of 96% and pooled sensitivity of 86%.Contrast enhanced MR angiography was shown to have 96% post-test probability in high-risk pre-test probability thoracic aortic dissections versus 93% with helical CT in comprehensive meta-analysis. Limitations include longer acquisition time but cases of high clinical suspicion with a negative CTA chest, MR angiography aids in prompt diagnosis. CONCLUSIONS: Type-A Aortic Dissection is a life-threatening emergency. While CT angiography of the aorta and TEE are tests of choice, diagnosis can be supported with other modalities including CTPA and bedside POCUS or TTE. Findings of elevated right-sided pressures in absence of a dilated RV should raise concern for tamponade. REFERENCE #1: Aortic Dissection: New Frontiers in Diagnosis and Management Nienaber,Christoph A.doi: 10.1161/01.CIR.0000087009.16755.E4 REFERENCE #2: McMahon MA, Squirrell CA. Multidetector CT of Aortic Dissection: A Pictorial Review. Radiographics. 2010 Mar;30(2):445-60. doi: 10.1148/rg.302095104. PMID: 20228328. REFERENCE #3: Morello F, Santoro M, Fargion AT, Grifoni S, Nazerian P. Diagnosis and management of acute aortic syndromes in the emergency department. Intern Emerg Med. 2021 Jan;16(1):171-181. doi: 10.1007/s11739-020-02354-8. Epub 2020 May 1. PMID: 32358680. DISCLOSURES: No relevant relationships by Deeksha Acharya No disclosure on file for Meghan Fitzpatrick
• 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.
• Gonzalez, M., Jani, M., Lee, S., Watson, E. B., VandeWalker, R., Acharya, D., Shrestha, N. M., Leacche, M., & Loyaga‐Rendon, R. Y. (2023). Characteristics And Outcomes Of Patients Bridged To Transplant With Iabps Under Exception Status During New Allocation Era. Journal of Cardiac Failure. doi:10.1016/j.cardfail.2022.10.164
• 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.
• Ibrahim, R., Ferng, J., Shanmugasundaram, M., Acharya, D., Acharya, T., Pineda, J., & Lee, K. S. (2023). A CASE OF PERICARDIAL RUB TINNITUS. JACC. doi:10.1016/s0735-1097(23)03199-6
• Acharya, D., & Haas, G. (2022). Bereavement and Mortality in Heart Failure. JACC. Heart failure, 10(10), 765-767.
• Acharya, D., Boeve, T., Hoeksema, S., Jani, M., Jovinge, S. V., Leacche, M., Lee, S., Loyaga-rendon, R. Y., & Manandhar-shrestha, N. K. (2022). 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, 36(1), e14493. doi:10.1111/ctr.14493
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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)..Adult patients who were listed for HT between October 18, 2016 and October 17, 2019, and were supported with an LVAD, enrolled in the UNOS database were included in this study. Patients were classified in the old or new system if they were listed or transplanted before or after October 18, 2018, respectively..A total of 3261 LVAD patients were listed for transplant. Of these, 2257 were classified in the old and 1004 in the new system. The cumulative incidence of death or removal from the transplant list due to worsening clinical status at 360-days after listing was lower in the new system (4% vs. 7%, P = .011). LVAD Patients listed in the new system had a lower frequency of transplantation within 360-days of listing (52% vs. 61%, P < .001). A total of 1843 LVAD patients were transplanted, 1004 patients in the old system and 839 patients in the new system. The post-transplant survival at 360 days was similar between old and new systems (92.3% vs. 90%, P = .08). However, LVAD patients transplanted in the new system had lower frequency of the combined endpoint, freedom of death or re-transplantation at 360 days (92.2% vs. 89.6%, P = .046)..The new HT allocation system has affected the LVAD-BTT population significantly. On the waitlist, LVAD patients have a decreased cumulative frequency of transplantation and a concomitant decrease in death or delisting due to worsening status. In the new system, LVAD patients have a decreased survival free of re-transplantation at 360 days post-transplant.
• 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., Boeve, T., Hoeksema, S., Jani, M., Jovinge, S., Leacche, M., Lee, S., Loyaga-rendon, R. Y., Manandhar-shrestha, N., & Manandharshrestha, N. (2021). Changes in Wait List Mortality, Transplantation Rates and Early Post-Transplant Outcomes in LVAD BTT with New Heart Transplant Allocation Score. A UNOS Database Analysis. Journal of Heart and Lung Transplantation, 40(4), S17. doi:10.1016/j.healun.2021.01.1776
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  Purpose To evaluate the effect of the new heart transplant allocation system on LVAD supported patients listed as bridge to transplantation (BTT). Methods Adult patients, who were listed for heart transplant between October 1,2016 and September 30, 2019, and were supported with an LVAD, enrolled in the UNOS database were enrolled in this study. Patients were classified according in the old or new system if they were listed or transplanted before or after October 18, 2018. Results A total of 2184 LVAD patients were listed for transplant. Of these, 1229 were classified in the old and 955 in the new system. The cumulative incidence of death or removal from the transplant list due to worsening clinical status, 1 year after listing, was lower in the new system (5% vs. 9%, p Conclusion With the implementation of the new HT allocation system, LVAD-BTT patients have a lower frequency of transplantation and similar short-term post-transplant survival. LVAD-BTT patients are more likely to receive Hep C (+) donor hearts.
• Acharya, D., Fortuin, D., Hung, O., Indik, J. H., Kern, K. B., Koester, S., Lee, K. S., Lee, J. Z., Natarajan, B., Nyotowidjojo, I., Voelker, W., Wong, W. X., & Yousman, W. (2021). A Randomized Controlled Trial of Simulation Training in Teaching Coronary Angiographic Views. Research Square. doi:10.21203/rs.3.rs-1031601/v1
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  Abstract Introduction Simulation technology has an established role in teaching technical skills to cardiology fellows, but their 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 group of novices to advanced medical trainees. Methods We prospectively randomized 105 subjects comprising of medical students (N=20), residents (N=68) and fellows (N=17) from the University of Arizona. Subjects were randomized into a simulation training group which received simulation training in addition to didactic teaching (n=53) and a control training group which received didactic teaching alone (n=52). The change in pre and post-test score (delta score) was analyzed by a two-way ANOVA for education status and training arm. Results Subjects improved in their post-test scores with a mean change of 4.6 ± 4.0 points. Subjects in the simulation training arm had a higher delta score compared to control (5.4 ± 4.2 versus 3.8 ± 3.7, p=0.04), with greatest impact for residents (6.6 ± 4.0 versus 3.5 ± 3.4) with a p=0.02 for interaction of training arm and education status. Conclusions Simulation training complements traditional methods to improve CA interpretation skill, with greatest impact on novice trainees. This highlights the importance of incorporating high-fidelity simulation training early in cardiovascular fellowship curricula.
• 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., Alexander, P., Borgstrom, M., Kern, K. B., Lee, K. S., Lotun, K., Rajapreyar, I., Rycus, P., Shetty, R., Tonna, J. E., & Torabi, M. (2020). CLINICAL CHARACTERISTICS AND OUTCOMES OF PATIENTS WITH MYOCARDIAL INFARCTION AND CARDIOGENIC SHOCK RECEIVING EXTRACORPOREAL LIFE SUPPORT. Journal of the American College of Cardiology, 75(11), 1231. doi:10.1016/s0735-1097(20)31858-1
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  Refractory cardiogenic shock requiring venoarterial extracorporeal membrane oxygenation (VA-ECMO) has high mortality. The underlying cardiovascular diagnosis may influence outcomes and have implications for patient selection and management on ECMO. This study evaluated outcomes of patients with
• 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.
• Kassier, A., Kort, E. J., Shrestha, N. M., Acharya, D., Lee, S., Jovinge, S., Dickinson, M. G., & Loyaga-rendon, R. Y. (2019). Serum sST2 and Gal-3 Levels in Patients on Veno-Arterial Extracorporeal Life Support. Journal of Cardiac Failure, 25(8), S22. doi:10.1016/j.cardfail.2019.07.064
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  Objectives Patients with cardiogenic shock (CS) supported by Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) have a high mortality. The role of biomarkers in prediction of survival of these patients has not been clearly examined. Soluble Suppression of Tumorigenicity 2 (sST2) and Galactin-3 (Gal-3) are two well-acknowledged prognostic biomarkers in heart failure. Our objective was to analyze the levels of sST2 and Gal-3 in patients with cardiogenic shock supported by VA-ECMO. Methods Sixty five patients with CS supported by VA-ECMO were included in this study. Blood samples were collected prior to VA-ECMO support (t0) and 2 (t2) and 8 (t8) days after. sST2 and gal-3 where assayed by sandwich ELISA technique. Patients were grouped in those who recovered from CS (recovered group) and those received LVAD, heart transplant or died (not recovered group). Results In the recovered group the sST2 levels were statistically different at various time points, whereas in the not recovered group sST2 levels did not change over time. The absolute sST2 concentration was different between groups at t2 of VA-ECMO support. The gal-3 levels changed over time in both the recovered and not-recovered groups and was significantly different at t0-t2. Conclusion In patients with cardiogenic shock supported by VA-ECMO sST2 trend was significantly different between patients who recovered and those who did not. Also, sST2 levels at t2 were higher in the recovered group. Further studies are needed to assess the role of those two prognostic biomarkers in this population.
• 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.
• Joly, J. M., Andrikopoulou, E., Lin, C. P., Acharya, D., Pamboukian, S. V., Prabhu, S. D., Rajapreyar, I. N., Tallaj, J. A., & Kumar, V. (2017). (1059) - Acute Hemodynamic Effects of Cardiac Resynchronization Therapy in Patients with Left Ventricular Assist Device. Journal of Heart and Lung Transplantation, 36(4), S346. doi:10.1016/j.healun.2017.01.971
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  Cardiac resynchronization therapy (CRT) improves hemodynamics and long term outcomes in appropriately selected heart failure patients. Some have progressive symptoms despite CRT, and may require durable mechanical circulatory support. CRT management after left ventricular assist device (LVAD) has not been well studied. We sought to determine whether CRT measurably impacts the acute hemodynamic profile in patients with continuous flow LVAD.
• 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. (2017). (1286) – Dissecting the INTERMACS Definition of Right Heart Failure: Can We Really Predict Central Venous Pressure?. Journal of Heart and Lung Transplantation, 36(4), S418-S419. doi:10.1016/j.healun.2017.01.1198
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  Right heart failure (RHF) after left ventricular assist device (LVAD) is associated with adverse events and poor outcomes. INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) defines RHF as elevated right atrial pressure (RAP) >16 mmHg measured directly by right heart catheterization (RHC) or indirectly by jugular venous distension or dilated inferior vena cava (Criterion 1), plus clinical or laboratory evidence of venous congestion (Criterion 2). The purpose of this study was to examine how noninvasive diagnosis of RHF by INTERMACS criteria correlated with direct measurement of RAP by RHC.
• Sedhai, Y. R., Golamari, R., Basnyat, S., Dar, T., Acharya, D., & Missri, J. (2017). Contrast Volume to Creatinine Clearance Ratio Can be Used to Predict Contrast-Induced Nephropathy After Cardiac Catheterization. CHEST Journal. doi:10.1016/j.chest.2017.08.088
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  SESSION TITLE: Cardio-Pulmonary Interactions SESSION TYPE: Original Investigation Slide PRESENTED ON: Monday, October 30, 2017 at 01:30 PM - 02:30 PM PURPOSE: We sought to develop a simple risk prediction score to identify patients at risk of contrast-induced nephropathy (CIN) after cardiac catheterization. METHODS: A retrospective chart review of 513 patients who underwent cardiac catheterization from June to December 2014 was performed. Patients with end-stage renal disease (n=38) & without pre-procedural serum creatinine (n=57) were excluded. Serum creatinine before the procedure & each day for three days after the procedure was recorded. CIN was defined as an increase in serum creatinine by >25% or 0.5mg/dl from a pre-procedural value within 72 hours of contrast exposure. Pre-procedural creatinine clearance (CCr) was calculated using modification of diet in renal disease (MDRD) equation. Mehran score & Contrast Volume: Creatinine clearance ratio (CV/CCr ratio) were calculated for each patient. Receiver operating characteristic (ROC) curve was obtained & area under the curve (AUC) was calculated for both scores to see the predictive ability for CIN. RESULTS: A total of 418 patients (mean age 69.1 ± 13.8, 55% male & 45% female) were included in the study. Percutaneous coronary intervention (PCI) was performed in 29% (n=121) patients. 81% (n=98) were primary PCI. 16 patients developed CIN with a mean incidence of 3.8%. Contrast volume in CIN group was 150 ml, [95% confidence interval (CI)=36-400ml] Vs. 109.5 ml (95% CI=25ml-160 ml) in the non-CIN group, p=0.06. Mean contrast volume: creatinine clearance ratio (CV:CCr ratio) in CIN group was 3.25, (95% CI=0.70-10.60) Vs. 1.4, (95% CI 0.2-5.4), p=0.03. AUC for CV:CCr ratio was 0.735 (95% CI= 0.602- 0.867), P=0.001, optimal cut-off was 2.25, sensitivity 72.2 % & specificity 72.7%. AUC Mehran score was 0.793 (95% CI 0.646- 0.940), P=0.01, optimal cut-off was 9.5, sensitivity 85.7 % & specificity 71.0%. When compared to Mehran score, CV:Ccr ratio had similar AUC & speicificity. Mehran score had a superior sensitivity. CONCLUSIONS: Contrast volume: Creatinine Clearance ratio (CV:CCr ratio) can be used clinically to identify patients at risk of contrast-induced nephropathy (CIN) after cardiac catheterization. It requires few data, is based on a linear equation & is easy to calculate. CLINICAL IMPLICATIONS: Contrast-induced nephropathy (CIN) is independently associated with higher morbidity and mortality following cardiac catheterization. Identifying patients at risk is an important preventive step. Popular scoring systems like Mehran score uses both patients related and procedural data making it complicated to calculate and use. CV: CCr ratio can be clinically useful as it requires only two variables, easy to calculate and use. DISCLOSURE: The following authors have nothing to disclose: Yub Raj Sedhai, Reshma Golamari, Soney Basnyat, Tawseef Dar, Deepak Acharya, Jose Missri No Product/Research Disclosure Information
• Sedhai, Y. R., Golamari, R., Konda, P., Basnyat, S., Goud, S., Timalsina, S., & Acharya, D. (2017). 128 - Use of Chest Ct Angiography Derived Left Atrial Size as a Predictor of Diastolic Dysfunction. Journal of Cardiac Failure, 23(8), S49. doi:10.1016/j.cardfail.2017.07.137
• Sedhai, Y. R., Ochasi, A., Basnyat, S., Acharya, D., & Clark, P. (2017). Cadaveric Donation and Post-mortem Reuse of Pacemakers and Defibrillators in Nepal: Medical, Legal and Ethical Challenges. Journal of Advances in Internal Medicine. doi:10.3126/jaim.v6i1.18314
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  Cardiovascular diseases (CVDs) are the number one cause of death globally. An estimated 17.5 million people died from CVDs in 2012, representing 31% of all global deaths. Over three quarters of all deaths related CVDs take place in low- and middle-income countries (LMICs). Studies have estimated that 1 to 2 million people worldwide die each year due to lack of access to cardiac rhythm management devices (CRMDs) i.e. implantable cardiac defibrillator (ICD) or a pacemaker. The principal challenge is the high cost of these devices and the resource constraint in LMICs. A growing body of literature, mostly single center, uncontrolled and retrospective studies has suggested reuse of CRMDs from deceased donors as a safe and effective alternative. This paper seeks to propose the concept of post-mortem CRMD donation and reutilization program within Nepal as a life-saving initiative. Though the spirit of the program is in line with the ethical principles of respect for persons, beneficence, justice, and the common good, it is challenged with several logistical barriers and legal concerns. In this paper we have discussed the clinical, legal and ethical perspectives with a literature review on similar programs.
• 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., Holman, W. L., Kirklin, J. K., Loyaga-rendon, R. Y., Morgan, C. J., Pamboukian, S. V., & Tallaj, J. A. (2016). Stroke with Continuous-Flow LVADs. Journal of Heart and Lung Transplantation, 35(4), S9-S10. doi:10.1016/j.healun.2016.01.026
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  We sought to evaluate predictors of stroke during LVAD support and quantify stroke-related morbidity and mortality. We evaluated all patients in the INTERMACS registry who underwent continuous-flow LVADs. For patients with multiple devices, only the events that occurred while patient had the first device were considered. Baseline characteristics and stroke incidence were analyzed using standard summary statistics. Kaplan-Meier curves evaluated survival, Competing risk analysis was used to predict probability of patient outcomes, and Cox Proportional Hazards method was used to evaluate pre-implant predictors of developing stroke. During the study period, 12,375 patients underwent CF LVAD placement. Median follow-up was 11.43 months (range 0.02-81.87 months). Of all patients, 1185 (9.58%) had at least one stroke, with incidence rate of 0.082 strokes per patient-year. Six hundred ninety-six (50.58%) strokes were ischemic and 680 (49.42%) were hemorrhagic. Patients with strokes had higher rates of death during followup than those without (58.98% vs. 23.18%, p
• Acharya, D., Kirklin, K., Singh, S., Holman, W. L., Loyaga-rendon, R. Y., Pamboukian, S. V., & Tallaj, J. A. (2016). Computed-Tomography Guided Apex Marking for Lateral Thoracotomy LVAD Implantation. Journal of Heart and Lung Transplantation, 35(4), S320. doi:10.1016/j.healun.2016.01.915
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  A lateral thoracotomy approach for LVAD implant decreases postoperative recovery time and preserves the sternum for transplant. However, a limited viewing field may create challenges in obtaining optimal inflow cannula position. We describe a novel technique of multi-detector CT using a biopsy grid to determine the site on the skin surface that corresponds to the LV apex position and its use for preoperative planning for LVAD. Chest CT is performed without or with 10cc IV contrast and a CT biopsy grid (Webb Medical) over the left thorax. Contiguous 2mm images are acquired in supine position. Window and level are adjusted to optimize visualization of the ventricular septum and define the apex. Using the CT table position and laser guidance light the skin surface over the apex is marked with a marker (Figure 1). Axial and coronal reformatted images are used to determine the orientation of the LV apex and the distance and angle from the skin surface to the mid-point of the mitral valve. We exhibit the utility of this method in a representative series of five complicated surgical candidates, including ideal cannula position in a morbidly obese man with poor anatomical landmarks (Figure 2), a patient with very limited respiratory reserve, a man with extensive radiation fibrosis and limited site for chest access, a patient with massive cardiomegaly and posterolateral apex position, and a 90-pound man with a small chest diameter and requirement for biventricular support. CT provides anatomical and relational data not available by echo or catheterization, and can play an important role in preoperative planning for LVAD placement.
• 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.
• Joly, J. M., El-dabh, A., Brown, R. N., Kirklin, J. K., Marshell, R., Chatterjee, A., Smith, M., Tresler, M., Tallaj, J. A., Acharya, D., & Pamboukian, S. V. (2016). Abstract 17042: Unique Hemodynamic Parameters Predict GI Bleeding in Patients With Continuous Flow Ventricular Assist Devices. Circulation, 134.
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  Introduction: Gastrointestinal (GI) bleeding remains a major morbid event during continuous flow left ventricular assist device (LVAD) support. Hypothesis: This study investigated whether a common ...
• Loyaga-rendon, R. Y., Kumar, R., Acharya, D., Pamboukian, S. V., Siric, F., Holman, W. L., Hoopes, C. W., Kirklin, J. K., Morrow, C. D., & Tallaj, J. A. (2016). Intestinal Microbiota Changes in Left Ventricular Assist Device Supported Patients with Gastrointestinal Bleeding. Journal of Heart and Lung Transplantation, 35(4), S249-S250. doi:10.1016/j.healun.2016.01.708
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  s S249 and 113 (47.1%) as destination therapy (DT). Effect of reoperation for bleeding on outcomes was assessed. Results: Bleeding requiring reoperation occurred in 33 (13.8%) patients, 42.4% had a prior sternotomy, and 30.3% had previous temporary mechanical support. Survival was 95.2%, 85.7%, 84.5%, and 66.2%, respectively, at 30-days, 6-months, 12-months, and 24-months for patients who required reoperation, versus 92.1%, 88.0%, 80.4%, and 76.1%, respectively, for patients who did not (p= 0.237). The incidence of postoperative infection, stroke, right ventricular failure, renal failure, and/or device thrombosis was similar (p= NS). Conclusion: Reoperation for bleeding did not adversely impact survival or development of other LVAD-related complications. It therefore may be prudent to re-explore a bleeding patient early to limit transfusions and avoid potential consequences, such as right ventricular failure and prolonged ventilation. Patient Demographics and Comorbidities Variable Total (n= 240) Reop For bleeding (n= 33) No Reop For bleeding (n= 207) p-value Age 54.5 ± 12.1 yrs 55.9 ± 13.0 yrs 54.3 ± 12.0 yrs 0.279 Female 25.0% 24.2% 25.1% 0.914 African American 44.6% 50.0% 43.8% 0.510 NIDCM 62.1% 57.6% 62.8% 0.516 DM 46.7% 51.5% 45.9% 0.548 HTN 84.6% 84.9% 84.5% 0.961 CRI 43.3% 48.5% 42.5% 0.520 COPD 19.6% 12.1% 20.8% 0.245 PVD 10.8% 6.1% 11.6% 0.546 AFib 32.5% 27.3% 33.3% 0.490 Vented 4.6% 9.1% 3.9% 0.180 Liver Biopsy 5.0% 0% 5.8% 0.381 Previous Cardiac Surgery 34.2% 42.4% 32.9% 0.282 MCS at Time of VAD 24.6% 30.3% 23.7% 0.411 Creatinine 1.41 ± 0.59 1.39 ± 0.41 1.41 ± 0.62 0.344 AST 47.8 ± 76.5 35.5 ± 17.3 49.8 ± 82.0 0.680 Bilirubin 1.47 ± 1.45 1.28 ± 0.76 1.50 ± 1.53 0.815 Pre VAD CVP 10.1 ± 5.7 8.7 ± 4.8 10.4 ± 5.8 0.178 Pre VAD PAPs 51.3 ± 13.8 47.3 ± 15.2 51.9 ± 13.5 0.122
• Payne, G. A., Hage, F. G., & Acharya, D. (2016). Transplant allograft vasculopathy: Role of multimodality imaging in surveillance and diagnosis.. Journal of nuclear cardiology : official publication of the American Society of Nuclear Cardiology, 23(4), 713-27. doi:10.1007/s12350-015-0373-3
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  Cardiac allograft vasculopathy (CAV) is a challenging long-term complication of cardiac transplantation and remains a leading long-term cause of graft failure, re-transplantation, and death. CAV is an inflammatory vasculopathy distinct from traditional atherosclerotic coronary artery disease. Historically, the surveillance and diagnosis of CAV has been dependent on serial invasive coronary angiography with intravascular imaging. Although commonly practiced, angiography is not without significant limitations. Technological advances have provided sophisticated imaging techniques for CAV assessment. It is now possible to assess the vascular lumen, vessel wall characteristics, absolute blood flow, perfusion reserve, myocardial contractile function, and myocardial metabolism and injury in a noninvasive, expeditious manner with little risk. The current article will review key imaging modalities for the surveillance, diagnosis, and prognosis of CAV and discuss coronary physiology of transplanted hearts with emphasis on the clinical implications for provocative and vasodilator stress testing.
• 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.
• Acharya, D., Loyaga-rendon, R. Y., Tallaj, J. A., Pamboukian, S. V., Holman, W. L., George, J. F., Cantor, R. S., Naftel, D. C., & Kirklin, J. K. (2015). Ventricular Assist Device in Acute Myocardial Infarction-Findings From INTERMACS. Journal of Heart and Lung Transplantation, 34(4), S28-S29. doi:10.1016/j.healun.2015.01.065
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  PurposePatients with acute myocardial infarction (AMI) complicated by acute heart failure or cardiogenic shock have high mortality with conventional management. The purpose of this study was to evaluate outcomes with long-term mechanical circulatory support in this population.MethodsPatients in the INTERMACS registry who underwent continuous flow LVAD, BI-VAD, or TAH in the setting of AMI were included. Patients had AMI as the admitting diagnosis, or major MI as a complication during hospitalization that resulted in VAD implantation. Clinical characteristics and outcomes were evaluated, and compared to those in patients who received VADs for non-AMI indications.Results502 patients with AMI had VAD implantation: 443 LVAD, 33 BIVAD, and 26 TAH. The mean age was 57.1 (+/- 10.1) and 77.1% were male. Sixty-six percent were INTERMACS level 1 and 19% were INTERMACS level 2. Compared to patients receiving VADs for non-AMI indications, a higher proportion of AMI patients had IABP (57.6% vs. 25.3%, p
• Hashim, T., Sanam, K., Revilla-martinez, M., Morgan, C. J., Tallaj, J. A., Pamboukian, S. V., Loyaga-rendon, R. Y., George, J. F., & Acharya, D. (2015). Clinical Characteristics and Outcomes of Intravenous Inotropic Therapy in Advanced Heart Failure.. Circulation. Heart failure, 8(5), 880-6. doi:10.1161/circheartfailure.114.001778
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  Inotrope use in heart failure treatment was associated with improved symptoms, but worse survival in clinical trials. However, these studies predated use of modern heart failure therapies. This study evaluates contemporary outcomes on long-term inotropes..We collected baseline and postinotrope data on 197 patients discharged on inotropes between January 2007 and March 2013. Baseline characteristics, hemodynamic and clinical changes on inotropes, and survival were evaluated. Patients initiated on inotropes had refractory heart failure, with median baseline New York Heart Association class IV, cardiac index of 1.7 L/min per m(2), pulmonary capillary wedge pressure of 25.6 mm Hg, and left ventricular ejection fraction of 18.7%. Inotropes were used in patients listed for transplant or scheduled for left ventricular assist device (LVAD; 60 patients), in patients being evaluated for LVAD/transplant (20 patients), for stabilization pending cardiac resynchronization therapy/percutaneous coronary intervention (4 patients), in patients who were offered LVAD but chose inotropes (15 patients), and for palliation (98 patients). Milrinone was used in 84.8% and dobutamine in 15.2%. At the end of the study, 68 patients had died, 24 were weaned off inotropes, 23 were transplanted, 32 received LVADs, and 50 remained on inotropes. Patients who received inotropes for palliation or those who preferred inotropes over LVAD had median survival of 9.0 months (interquartile range, 3.1-37.1 months), actuarial 1-year survival of 47.6%, and 2-year survival of 38.4%. Of 60 patients who were placed on inotropes as a bridge to transplant/LVAD, 55 were successfully maintained on inotropes until transplant/LVAD..Survival on inotropes for patients who are not candidates for transplant/LVAD is modestly better than previously reported, but remains poor. Inotropes are effective as a bridge to transplant/LVAD.
• Holman, W. L., Acharya, D., Siric, F., & Loyaga-rendon, R. Y. (2015). Assessment and management of right ventricular failure in left ventricular assist device patients.. Circulation journal : official journal of the Japanese Circulation Society, 79(3), 478-86. doi:10.1253/circj.cj-15-0093
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  Mechanical circulatory support devices, including ventricular assist devices (VADs) and the total artificial heart, have evolved to become accepted therapeutic options for patients with severe congestive heart failure. Continuous-flow left VADs are the most prevalent option for mechanical circulatory assistance and reliably provide years of support. However, problems related to acute and chronic right heart failure in patients with left VADs continue to cause important mortality and morbidity. This review discusses the assessment and management of right ventricular failure in left VAD patients. The goal is to summarize current knowledge and suggest new approaches to managing this problem.
• Acharya, D., George, J. F., Hashim, T., Loyaga-rendon, R. Y., Martinez, M. I., Morgan, C. J., Pamboukian, S. V., Sanam, K., & Tallaj, J. A. (2014). Abstract 12776: Outcomes and Survival With Home Intravenous Inotrope Therapy in Contemporary Heart Failure Management. Circulation, 130(suppl_2). doi:10.1161/circ.130.suppl_2.12776
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  Introduction: Inotrope use in decompensated congestive heart failure (CHF) is associated with improved hemodynamics, but did not improve outcomes in previous trials, with 50% 6-month mortality. However, many of these studies predated modern CHF therapies, including aldosterone antagonists, implantable cardioverter-defibrillators (ICDs), and resynchronization. We evaluated contemporary survival and outcomes on long-term inotropes in advanced CHF. Methods: We collected baseline and post-inotrope data on 197 consecutive patients discharged from our hospital between January 2007 and March 2013 on intravenous inotropes. Clinical, hemodynamic, catheterization, and survival data were collected. T-tests and Chi-square tests were used to compare outcomes, and Kaplan-Meier curves to evaluate survival. Results: Among the 197 patients, 25.8% were women, 40% had ischemic etiology and mean age was 54.4 years (standard deviation [SD] 14.6 years). Patients started on inotropes had CHF refractory to standard management, with mean baseline NYHA 3.7, cardiac index (CI) 1.7 L/min/m2, pulmonary capillary wedge pressure (PCWP) 25.6 mmHg, and left ventricular ejection fraction 17%. Milrinone was used in 85% and dobutamine in 15% of patients. Sixty-eight patients died, 24 were weaned off inotropes, 23 were transplanted, 32 received a LVAD, and 50 remained on inotropes. Mean NYHA class decreased from 3.7 to 2.7 (p
• Acharya, D., Loyaga-rendon, R. Y., Tallaj, J. A., Pamboukian, S. V., & Sasse, M. F. (2014). Circulatory support for shock complicating myocardial infarction.. The Journal of invasive cardiology, 26(8), E109-14.
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  We discuss a patient with acute myocardial infarction complicated by cardiogenic shock (AMI-CS) who underwent percutaneous coronary intervention and hemodynamic support with a new short-term percutaneously inserted device, the Impella CP (Abiomed). We also review the evidence for mechanical circulatory support and management strategies in patients with AMI-CS.
• Hashim, T., Acharya, D., Tallaj, J. A., Kirklin, J. K., Holman, W. L., Pamboukian, S. V., & Loyaga-rendon, R. Y. (2014). Utility of Octreotide for Treatment of Recurrent Gastrointestinal Bleeding in Continuous-Flow Left Ventricular Assist Device Patients. Journal of Heart and Lung Transplantation, 33(4), S245. doi:10.1016/j.healun.2014.01.638
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  Gastrointestinal bleeding (GIB) is a common cause of morbidity in patients supported by continuous flow left ventricular assist devices (CF-LVAD). We describe our experience in the off-label use of octreotide in the management of recurrent GI bleed in patients with CF-LVAD. Seven of 116 CF-LVAD patients had recurrent GIB unresponsive to conventional management and were started on chronic octreotide injections. Hospitalizations due to GIB, red blood cell transfusions (RBC), and number of endoscopies were compared 3 months before and after octreotide using a paired t-test. All 7 were males, mean age 63.6 + 5.6 years and 5 received CF-LVAD as destination therapy. Patients received conventional therapy for a mean of 12 +10 months prior to initiation of octreotide. Two patients experienced cramps or diarrhea but none discontinued therapy. Table 1 compares outcome before and after treatment in all 7 patients. One patient did not respond to octreotide. When this patient was removed from the analysis, significant reductions were seen in the measured outcomes (Table 2). Octreotide decreased morbidity in most CF-LVAD patients with GIB. This may be a promising option for CF-LVAD patients with GIB unresponsive to conventional therapy and requires prospective study.
• Loyaga-rendon, R. Y., Inampudi, C., Tallaj, J. A., Acharya, D., & Pamboukian, S. V. (2014). Cancer in end-stage heart failure patients supported by left ventricular assist devices.. ASAIO journal (American Society for Artificial Internal Organs : 1992), 60(5), 609-12. doi:10.1097/mat.0000000000000116
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  The percentage of elderly patients receiving left ventricular assist devices (LVADs) has increased; thus, a rise in the frequency of elderly prevalent diseases would be expected in LVAD-supported patients. Cancer is the second leading cause of death in the United States, and the frequency of cancer and the mortality rate of malignancies increase with age. We describe the clinical characteristics of eight patients who were diagnosed of cancer after LVAD implantation. Skin, esophageal, central nervous system (CNS), hematological and renal malignancies were observed. After careful consideration, these patients underwent surgical resections, radiotherapy, radiofrequency ablation, and chemotherapy with variable results. Patients who developed cancer were older males who received LVAD predominantly as destination therapy. Skin cancer and hematological malignancy were managed with standard oncologic treatment. Renal cell carcinoma was monitored, and a CNS tumor was treated aggressively but as expected had a poor outcome. Esophageal cancer, although localized, represented a serious therapeutic challenge, as patients were unable to undergo a potentially curative surgical procedure because of the anatomic location of malignancy. More information is needed regarding the outcomes and best treatment strategies for this newly identified population.
• Sanam, K., Martinez, M. I., Hashim, T., Morgan, C. J., Tallaj, J. A., Pamboukian, S. V., Loyaga-rendon, R. Y., George, J. F., & Acharya, D. (2014). Abstract 12820: Arrhythmias on Home Intravenous Inotropic Therapy in Advanced Heart Failure. Circulation, 130.
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  Introduction: Although home inotropes improve hemodynamics and symptoms in low-output congestive heart failure (CHF), they were associated with arrhythmias in prior trials. However, these studies were performed before routine use of implantable cardioverter defibrillators (ICDs), cardiac resynchronization, beta blockers, and aldosterone antagonists in CHF. Although concern for arrhythmias limits inotrope use, arrhythmia risks with inotropes on modern therapies are not well known. Methods: We collected arrhythmia data at baseline and post-inotrope on 197 consecutive patients discharged from our institution between January 2007 and 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. Results: All patients had advanced CHF, with mean baseline NYHA 3.7, cardiac index 1.7 L/min/m2, left ventricular ejection fraction (LVEF) 17%. At baseline, 39% had a hist...
• Tallaj, J. A., Pamboukian, S. V., George, J. F., Kirklin, J. K., Brown, R. N., Mcgiffin, D. C., Acharya, D., Melby, S. J., Bourge, R. C., Naftel, D. C., & Loyaga-rendon, R. Y. (2014). Have risk factors for mortality after heart transplantation changed over time? Insights from 19 years of Cardiac Transplant Research Database study.. The Journal of heart and lung transplantation : the official publication of the International Society for Heart Transplantation, 33(12), 1304-11. doi:10.1016/j.healun.2014.08.014
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  The Cardiac Transplant Research Database (CTRD) collected data from 26 U.S. institutions from January 1, 1990 to December 31, 2008 providing the opportunity for construction of a comprehensive multivariable model of risk for death after transplantation. We analyzed risk factors for death over 19 years of experience to determine how risk profiles have changed over time and how they interact with age..A multivariable parametric hazard model for death was created for 7,015 patients entered into the CTRD. Variables collected over 19 years of experience were examined as potential risk factors and tested for interaction with date of transplantation to determine if their relative risk (RR) changed over time..The hazard for death post-transplant occurred in 2 phases: an early phase of acute risk lasting
• Wille, K. M., Bellot, S. C., Acharya, D., Madani, M. M., Singh, S. P., & Mcgiffin, D. C. (2014). Thromboendarterectomy for chronic thromboembolic pulmonary hypertension in hereditary hemorrhagic telangiectasia.. American journal of respiratory and critical care medicine, 189(1), 112-4. doi:10.1164/rccm.201310-1839le
• Acharya, D., & Mcgiffin, D. C. (2013). Hemolysis after mitral valve repair.. Journal of cardiac surgery, 28(2), 129-32. doi:10.1111/jocs.12060
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  Hemolysis is a potential complication of mitral valve repair. We report a case of hemolytic anemia after mitral valve repair successfully treated with re-repair, and review the literature on reoperation after failure of mitral valve repair with associated hemolysis.
• Acharya, D., Hashim, T., Kirklin, J. K., Holman, W. L., Pamboukian, S. V., Tallaj, J. A., Loyaga-rendon, R. Y., & Singh, S. P. (2013). Use of retrospectively gated CT angiography to diagnose systolic LVAD inflow obstruction.. ASAIO journal (American Society for Artificial Internal Organs : 1992), 59(5), 542-6. doi:10.1097/mat.0b013e3182a0d367
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  Assessment of patients with left ventricular assist devices (LVADs) can be challenging, and multiple modalities are sometimes necessary to arrive at the accurate diagnosis. We describe two patients with persistent heart failure symptoms after HeartMate II LVAD placement. After initial evaluation was unrevealing, retrospectively gated computed tomographic angiography (CTA) was used to diagnose partial inflow obstruction, leading to important changes in management. We describe the techniques and role of retrospective gating and discuss functional assessment by CT as well as future applications.
• Acharya, D., Kay, G. N., Jackson, L., Warnock, D. G., Plumb, V. J., Tallaj, J. A., & Robertson, P. G. (2012). Arrhythmias in Fabry cardiomyopathy.. Clinical cardiology, 35(12), 738-40. doi:10.1002/clc.22047
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  Prior studies suggest that the incidence of ventricular arrhythmias is high in patients with Fabry cardiomyopathy. This study evaluated the incidence of significant arrhythmias in a series of patients with Fabry cardiomyopathy..Arrhythmias are important causes of morbidity and mortality in Fabry Cardiomyopathy..This study was a retrospective chart review of 19 patients with known Fabry cardiomyopathy. Device interrogation reports were reviewed for those who had implantable devices. Electrocardiogram, Holter monitor, and event monitors were reviewed in those who did not have implantable devices..Eighteen of nineteen patients were on enzyme replacement therapy (ERT). Nine (47%) out of 19 patients had implantable devices. Implant indications included symptomatic bradycardia, nonsustained ventricular tachycardia, conduction abnormalities, palpitations, and syncope. Mean follow-up in the patients with devices was 50 ± 23 months. Two patients received implantable cardioverter-defibrillator (ICD) shocks, 1 of which was inappropriate for atrial fibrillation. Patients were paced in the atrium 71% ± 37% of the time and paced in the ventricle 49% ± 52% of the time. Four patients with devices were paced more than 95% of the time. Patients with an ICD had lower heart rates prior to ICD implant than the group that did not have devices (60 ± 10 vs 78 ± 16, P = 0.03). Of the patients without devices, only 1 had sudden cardiac death. Patients with implanted devices had higher left ventricular (LV) mass indices compared to patients without implanted devices (136 ± 40 g/m(2) vs 93 ± 19 g/m(2), P = 0.008)..Significant ventricular arrhythmias are uncommon in patients with Fabry cardiomyopathy on ERT, but utilization of pacing is high. Sudden cardiac death in Fabry cardiomyopathy may be related to bradycardia.
• Acharya, D., Nagaraj, H., & Misra, V. K. (2012). Transcatheter closure of left ventricular pseudoaneurysm.. The Journal of invasive cardiology, 24(6), E111-4.
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  Left ventricular pseudoaneurysm is a rare complication of myocardial infarction, cardiovascular surgery, trauma, or infection. Untreated left ventricular pseudoaneurysm can have significant morbidity and mortality. Surgical treatment has generally been the standard of care. However, with a sicker and older population, surgical risks can sometimes be significant. We report a case of successful percutaneous closure of left ventricular pseudoaneurysm using coils and a vascular plug. We emphasize the role and importance of multimodality imaging for accurate diagnosis and therapy, and briefly review the literature on the various approaches used for percutaneous closure of left ventricular pseudoaneurysms.
• Acharya, D., Papapietro, S. E., Pamboukian, S. V., Tallaj, J. A., & Litovsky, S. H. (2012). Coronary artery fistula after cardiac transplantation.. Circulation, 126(17), 2144-5. doi:10.1161/circulationaha.112.115519
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  A 68-year-old man with ischemic cardiomyopathy underwent heart transplantation in 2007. A routine endomyocardial biopsy done 4 weeks after transplantation reported 2 arterial branches (Figure 1). Physical examination did not reveal a murmur. Echocardiogram did not show a pericardial effusion. Coronary arteriogram 4 months later showed a left anterior descending artery-to-right ventricle fistula (Figure 2 and Movie I in the online-only Data …
• Acharya, D., Singh, S., Tallaj, J. A., Holman, W. L., George, J. F., Kirklin, J. K., & Pamboukian, S. V. (2011). Use of gated cardiac computed tomography angiography in the assessment of left ventricular assist device dysfunction.. ASAIO journal (American Society for Artificial Internal Organs : 1992), 57(1), 32-7. doi:10.1097/mat.0b013e3181fd3405
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  The purpose of this study is to describe the utility and limitations of gated contrast-enhanced cardiac computed tomography angiography in assessing left ventricular assist device function. Computed tomography angiography (CTA) was used in 14 patients with left ventricular assist devices (LVADs) who had persistent heart failure symptoms, hemodynamic instability, or potential problems with LVAD flows. Retrospectively gated contrast-enhanced CTA was performed on 64-detector scanner, and the CTA images were postprocessed in multiple curved projections on TeraRecon workstation. This study describes the use of CTA to identify LVAD-related issues that altered clinical management and explores the role of CTA and other techniques in evaluating LVAD function. Six of 14 LVAD patients who demonstrated no abnormality on CTA remained stable with medical management. In the remaining eight patients, CTA was abnormal, including abnormalities specifically related to the LVAD cannula. As a result of findings detected by CTA, six patients underwent surgical intervention, including device exchange and heart transplant. Computed tomography angiography is a noninvasive method that enhances diagnostic evaluation of patients with suspected LVAD dysfunction and can lead to changes in patient management.
• Acharya, D., Tallaj, J. A., Holman, W. L., Kirklin, J. K., George, J. F., Brown, R. M., Cadeiras, M., & Pamboukian, S. V. (2011). 622 The Use of Intravenous Warfarin after Heartmate II Ventricular Assist Device Implantation Does Not Affect 30 Day Neurologic or Bleeding Outcomes. Journal of Heart and Lung Transplantation, 30(4), S208. doi:10.1016/j.healun.2011.01.635
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  etiology and incidence in our single-center experience of GIB following rotary blood pump insertion. Methods and Materials: In a retrospective review from February 2007 through September 2010, 62 patients, ages 28-77 years, were implanted with rotary blood pumps (54 Thoratec HeartMate II and 8 HeartWare), at our center. GIB rates and etiologies were analyzed. GIB was defined as one guiac – positive stool with the requirement of blood transfusion of two units or more. Results: A total of 62 patients had a mean duration of mechanical support of 316 301 days. The mean age was 59 11 years with 40 bridge to transplant patients (BTT) and 22 destination therapy (DT) patients. 23 GIB, 0.39 events per patient year, were documented in 14 patients, four female and ten male with an onset of 11-405 days with a median of 31 days. Of those fourteen patients, 7 patients were DT and 7 were BTT. 4 of the 14 patients had prior history of GIB prior to pump implant. GIB etiologies varied with 8 incidences of AVMs in 5 patients, 3 incidents of radiation proctitis in 1 patient, 8 incidents of erosive or ulcerative disease in 6 patients, 3 incidents of intestinal polyps or tumors in 3 patients, and 1 incident of diverticulitis in 1 patient. Some patients had greater than one GI bleeding event with varied etiologies. Conclusions: Although GI bleeding was found in 14 patients post rotary pump implant, greater than 60% were non-AVM related. Further investigation needs to be done to evaluate the impact of LVAD and acquired VWB and how that contributes to GIB.
• Acharya, D., & Falik, R. (2009). Cardiovascular Effects of Thiazolidinediones: A Review of the Literature. PubMed. doi:10.1097/smj.0b013e318189879f
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  Type 2 diabetes is a common problem with serious complications. Optimal glycemic control is a major challenge in diabetes, and inadequate control can lead to acute complications as well as end-organ damage. Cardiovascular disease is the primary cause of death in diabetes. Thiazolidinediones (TZDs), one of the newer classes of diabetes medications, are an important part of diabetes care and have recently been implicated in increased cardiovascular morbidity and mortality. There is convincing evidence that these drugs can cause fluid retention, but whether they are indeed precipitating agents for myocardial infarction and death is less clear. The multiple studies addressing these issues are the focus of this review.
• Locker, J., Prenter, P. M., Anderson, D., Coppel, W. A., Cullen, D. A., Mishra, M., Nanda, S., Acharya, D., McKellar, B. H., Davi, B., Moore, E., Grjmshaw, R., Murtagh, B., Hill, J., Osborne, M. A., Hurst, C., Sloan, I. H., McNabb, A., Thompson, C., , Pearce, C. E., et al. (1985). ANZ volume 27 issue 2 Cover and Front matter. The Anziam Journal. doi:10.1017/s0334270000004811
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• 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.