Madhan Sundaram

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Scholarly Contributions

Chapters

• Shanmugasundaram, M. (2017). Drug Coated Therapies. In Peripheral vascular disease: A Clinical Approach. Wolters Kluwer.
• Shanmugasundaram, M., Shanmugasundaram, M., Kazui, T., & Kazui, T. (2022). Elderly and Heart Disease. In Cardiovascular Medicine and Surgery(pp Chapter 20). Philadelphia, PA: Wolters Klewer.
• Shanmugasundaram, M. (2019). Manual Compression and Assisted Manual Compression for Large Bore Access Closure. In Vascular Access, Management and Closure: Best Practices eBook, SCAI. Society for Cardiovascular Angiography and Interventions.
• Shanmugasundaram, M. (2017). Percutaneous Coronary Intervention in Acute Coronary Syndrome. In 1003 Questions: An Interventional Cardiology Board Review. Interventional Cardiology Board Review.
• Shanmugasundaram, M., & Moliterno, D. J. (2016). Glycoprotein IIb/IIIa antagonists. In Platelets in Thrombotic and Non-thrombotic Disorders - Pathophysiology, Pharmacology and Therapeutics. Springer.

Journals/Publications

• Kazui, T., Hsu, C., Hamidi, M., Acharya, D., Shanmugasundaram, M., Lee, K., Chatterjee, A., & Bull, D. A. (2022). Pre-transcatheter aortic valve replacement 5-meter-walk test score and 1-year noncardiac mortality. Journal of Thoracic and Cardiovascular Surgery.
• Kazui, T., Kazui, T., Hsu, C., Hsu, C., Hamidi, M., Hamidi, M., Acharya, D., Acharya, D., Shanmugasundaram, M., Shanmugasundaram, M., Lee, K., Lee, K., Chatterjee, A., Chatterjee, A., Bull, D. A., & Bull, D. A. (2021). Pre-transcatheter aortic valve replacement 5-meter-walk test score and 1-year noncardiac mortality. Journal of Thoracic and Cardiovascular Surgery.
• 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. ().
• Shanmugasundaram, M., Chatterjee, A., & Lee, K. (2022). Percutaneous Large Thrombus and Vegetation Evacuation in the Catheterization Laboratory. Interventional cardiology clinics, 11(3), 349-358.
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  Intracardiac and intravascular thrombi are associated with significant morbidity and mortality. Although surgery remains the gold standard treatment option, these patients often have multiple comorbidities that can make surgical options challenging. With advancements in catheter-based technologies, there are now percutaneous treatment options for these patients. The AngioVac is a percutaneous vacuum-assisted thrombectomy device FDA-approved for removal of intravascular debris that uses a venovenous extracorporeal membranous oxygenation circuit with a filter. Use of this device has now been reported in the removal of right atrial or iliocaval thrombi, debulking tricuspid vegetations, removal of vegetations from implantable cardiac devices, and pulmonary embolism.
• Shanmugasundaram, M., Pineda, J. E., & Murugapandian, S. (2021). Glucose-Lowering Medications and Cardiovascular outcomes. Current Cardiology Reports.
• Shanmugasundaram, M., Pineda, J. R., & Murugapandian, S. (2021). Glucose-Lowering Medications and Cardiovascular Outcomes. Current cardiology reports, 23(4), 24.
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  The purpose of this review is to examine recent evidence supporting CV safety profile and improvement of CV outcomes of some of the newer classes of diabetic medications.
• Truong, H. T., Tran, A., Smith, N., Shanmugasundaram, M., Noc, M., Kern, K. B., Hsu, P., Ho, D., Harhash, A., & Ciurlino, B. (2021). Extending Time to Reperfusion with Mild Therapeutic Hypothermia: A New Paradigm for Providing Primary Percutaneous Coronary Intervention to Remote ST Segment Elevation Myocardial Infarction Patients.. Therapeutic hypothermia and temperature management, 11(1), 45-52. doi:10.1089/ther.2019.0039
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  Primary percutaneous coronary intervention (PPCI) is the preferred treatment for acute ST segment elevation myocardial infarction (STEMI). The goal is reperfusion within 90 minutes of first medical contact (FMC) or 120 minutes if transfer is needed. Otherwise, fibrinolytic therapy is recommended. Mild therapeutic hypothermia (MTH) (≤35°C) before coronary reperfusion decreases myocardial infarct size. If applied before reperfusion, hypothermia could potentially lengthen the FMC-reperfusion time without increasing infarct size. Thirty-six swine had their mid left anterior descending coronary artery acutely occluded. All animals had an initial 30 minutes of occlusion to simulate typical delay before seeking medical attention. Eighteen animals were studied under normothermic conditions with reperfusion after an additional 40 minutes (the porcine equivalent of a 120-minute clinical FMC to reperfusion time) and 18 were treated with hypothermia but not reperfused until another 80 minutes (clinical equivalent of 240 minutes). Primary outcome was myocardial infarct size (infarct/area at risk [AAR]) at 24 hours. The two groups differed in systemic temperature at the time of reperfusion (39.1°C ± 1.0°C vs. 35.5°C ± 0.7°C; p < 0.0001). Myocardial infarct size was not significantly different despite the longer time to reperfusion in those treated with hypothermia (60.6% ± 12% of the AAR [normothermic] vs. 65.8% ± 11.8% of the AAR [hypothermic]; p = 0.39). Rapid induction of MTH during an anterior STEMI made it possible to extend the FMC to reperfusion time by the equivalent of an extra two clinical hours (120-240 minutes) without increasing the myocardial infarct size. This strategy could allow more STEMI patients to receive PPCI rather than the less effective intravenous fibrinolysis.
• White, C. J., Shanmugasundaram, M., Paul, T. K., Ojha, C. P., Nagarajarao, H. S., Mamas, M. A., Kumar, G., & Jneid, H. (2021). Medical Therapy Versus Revascularization in Patients with Stable Ischemic Heart Disease and Advanced Chronic Kidney Disease.. Current cardiology reports, 23(4), 23. doi:10.1007/s11886-021-01453-y
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  This article reviews the evidence on optimal medical therapy (OMT) versus coronary revascularization in patients with stable ischemic heart disease (SIHD) and advanced chronic kidney disease (CKD)..A post hoc analysis of the COURAGE trial in patients with SIHD and CKD showed no difference in freedom from angina, death, and nonfatal myocardial infarction (MI) between OMT and percutaneous intervention plus OMT compared with patients without CKD. The ISCHEMIA-CKD trial of 777 patients with advanced CKD revealed no difference in cumulative incidence of death or nonfatal MI at 3 years between OMT and revascularization but the composite of death or new dialysis was higher in the invasive arm. Additionally, there were no significant or sustained benefits in related to angina-related health status in invasive versus conservative strategy. An initial revascularization strategy does not reduce mortality or MI or relieve angina symptoms in patients with SIHD and advanced CKD.
• Khan, A. A., Murtaza, G., Khalid, M. F., White, C. J., Mamas, M. A., Mukherjee, D., Jneid, H., Shanmugasundaram, M., Nagarajarao, H. S., & Paul, T. K. (2020). Outcomes of rotational atherectomy versus orbital atherectomy for the treatment of heavily calcified coronary stenosis: A systematic review and meta-analysis. Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions.
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  The optimal approach to deal with severe coronary artery calcification (CAC) during percutaneous coronary intervention (PCI) remains ill-defined.
• Murtaza, G., Mukherjee, D., Gharacholou, S. M., Nanjundappa, A., Lavie, C. J., Khan, A. A., Shanmugasundaram, M., & Paul, T. K. (2020). An Updated Review on Myocardial Bridging. Cardiovascular revascularization medicine : including molecular interventions, 21(9), 1169-1179.
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  Myocardial bridging is a congenital coronary anomaly with normal epicardial coronary artery taking an intra-myocardial course also described as tunneled artery. The majority of patients with this coronary anomaly are asymptomatic and generally it is a benign condition. However, it is an important cause of myocardial ischemia, which may lead to anginal symptoms, acute coronary syndrome, cardiac arrhythmias and rarely sudden cardiac death. There are numerous studies published in the recent past on understanding the pathophysiology, diagnostic and management strategies of myocardial bridging. This review highlights some of the recent updates in the diagnosis and management of patients with myocardial bridging. We discuss the role of various non-invasive and invasive diagnostic methods to evaluate functional significance of bridging. In addition, role of medical therapy such as beta-blockers, percutaneous coronary intervention with stents/bioresorbable scaffolds and surgical unroofing in patients unresponsive to medical therapy is highlighted as well.
• Shanmugasundaram, M., Paul, T. K., Murtaza, G., Khan, A. A., Khalid, M. F., & Bagai, J. (2020). CRT-100.84 Complete Versus Culprit-Vessel-Only Percutaneous Coronary Intervention in ST Segment Elevation Myocardial Infarction and Multi-Vessel Disease: An Updated Meta-Analysis of Randomized Trials. Jacc-cardiovascular Interventions, 13(4), S22. doi:10.1016/j.jcin.2020.01.067
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  Studies comparing outcomes between complete revascularization (CR) versus culprit-vessel-only percutaneous coronary intervention (CV-PCI) in patients with multi-vessel coronary artery disease (MVCAD) without cardiogenic shock in the setting of acute ST segment elevation myocardial infarction (STEMI
• Shanmugasundaram, M., Paul, T. K., Murtaza, G., Kohli, V., Khalid, M. F., Bagai, J., & Ayub, M. T. (2020). CRT-600.21 Clinical Outcomes of Transcatheter Aortic-Valve Replacement Versus Surgical Aortic-Valve Replacement in Low- to Intermediate-Risk Patients With Severe Aortic Stenosis. Jacc-cardiovascular Interventions, 13(4), S53-S54. doi:10.1016/j.jcin.2020.01.166
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  Studies have shown similar outcomes of transcatheter aortic-valve replacement (TAVR) and surgical aortic-valve replacement (SAVR) in high-risk patients with severe aortic stenosis (AS). This meta-analysis of randomized controlled trials (RCTs) aims to compare outcomes in low- to intermediate-risk
• Shanmugasundaram, M., Paul, T., Hashemzadeh, M., & Movahed, M. R. (2020). Outcomes of Percutaneous Coronary Intervention in Atrial Fibrillation Patients Presenting With Acute Myocardial Infarction: Analysis of Nationwide Inpatient Sample Database. Cardiovascular revascularization medicine : including molecular interventions, 21(7), 851-854.
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  Atrial fibrillation (AF) is common in patients presenting with myocardial infarction (MI). Percutaneous coronary intervention (PCI) has been shown to improve cardiovascular outcomes in MI. However, outcomes of PCI in AF patients presenting with MI remains largely unknown.
• Shenoy, S., Shanmugasundaram, M., Paul, T. K., Murtaza, G., & Khalid, F. (2020). EXTENDED DURATION ANTICOAGULATION WITH DIRECT ORAL ANTICOAGULANTS FOR UNPROVOKED VENOUS THROMBOEMBOLISM TO PREVENT RECURRENT VENOUS THROMBOEMBOLISM EVENTS: A META-ANALYSIS OF RANDOMIZED TRIALS. Journal of the American College of Cardiology, 75(11), 2257. doi:10.1016/s0735-1097(20)32884-9
• Skinner, K., Shanmugasundaram, M., Paul, T. K., Movahed, M. R., Kumar, S., & Hashemzadeh, M. (2020). CRT-100.65 In-Hospital Outcomes Following Coronary Atherectomy During Percutaneous Coronary Intervention. Jacc-cardiovascular Interventions, 13(4), S16-S17. doi:10.1016/j.jcin.2020.01.046
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  Coronary atherectomy (CA) is used to modify calcified lesions before stent implantation. Percutaneous coronary intervention (PCI) in calcified lesions can be technically challenging and is associated with increased procedural complications. Despite increased prevalence of moderate to severe calcific
• Skinner, K., Shanmugasundaram, M., Paul, T. K., Murugapandian, S., Movahed, M. R., Kumar, S., & Hashemzadeh, M. (2020). CRT-100.05 Outcomes of Percutaneous Coronary Intervention in Acute Myocardial Infarction With Advanced Chronic Kidney Disease. Jacc-cardiovascular Interventions, 13(4), S2-S3. doi:10.1016/j.jcin.2020.01.007
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  Advanced chronic kidney disease (ACKD) is common in patients with acute myocardial infarction (AMI) and is associated with poor long-term outcomes. Patients with ACKD are less likely to receive evidence based pharmacologic or interventional therapies. Outcomes of percutaneous-coronary intervention (
• Murtaza, G., Virk, H. U., Khalid, M., Lavie, C. J., Ventura, H., Mukherjee, D., Ramu, V., Bhogal, S., Kumar, G., Shanmugasundaram, M., & Paul, T. K. (2019). Diabetic cardiomyopathy - A comprehensive updated review. Progress in cardiovascular diseases, 62(4), 315-326.
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  Diabetes causes cardiomyopathy and increases the risk of heart failure independent of hypertension and coronary heart disease. This condition called "Diabetic Cardiomyopathy" (DCM) is becoming a well- known clinical entity. Recently, there has been substantial research exploring its molecular mechanisms, structural and functional changes, and possible development of therapeutic approaches for the prevention and treatment of DCM. This review summarizes the recent advancements to better understand fundamental molecular abnormalities that promote this cardiomyopathy and novel therapies for future research. Additionally, different diagnostic modalities, up to date screening tests to guide clinicians with early diagnosis and available current treatment options has been outlined.
• Shanmugasundaram, M. (2019). Outcomes of Percutaneous Coronary Intervention In Patients With Peripheral Artery Disease Presenting with Acute Myocardial Infarction. Cardiovascular Revasc Med.
• Shanmugasundaram, M., Dhakal, B. P., Murugapandian, S., Hashemzadeh, M., Paul, T., & Movahed, M. R. (2019). Outcomes of patients with atrial fibrillation undergoing percutaneous coronary intervention analysis of national inpatient sample. Cardiovascular revascularization medicine : including molecular interventions.
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  Atrial fibrillation (AF) is the most common cardiac arrhythmia with a prevalence of 15% of patients over 80 years. Coronary artery disease co-exists in 20-30% of patients with atrial fibrillation. The need for triple anticoagulation therapy makes the management of these patients challenging following PCI.
• Truong, H. T., Shanmugasundaram, M., Murugapandian, S., Lotun, K., & Banerjee, S. (2019). Drug-coated balloon in peripheral artery disease.. Cardiovascular revascularization medicine : including molecular interventions, 20(4), 338-343. doi:10.1016/j.carrev.2018.04.017
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  Peripheral artery disease (PAD) is highly prevalent but is often underdiagnosed and undertreated. Lower extremity PAD can often be life style limiting. Revascularization in carefully selected lower extremity PAD patients improves symptoms and functional status. Surgical revascularization used to be the only available strategy, but in the recent years, endovascular strategies have gained popularity due to faster recovery times with low morbidity and mortality rates. Endovascular procedures have increased significantly in the United States in the past few years. That being said, higher restenosis rates and low long-term patency rates have been the limiting factors for this strategy. Drug eluting stents have been introduced to help with lowering restenosis, however lower extremity PAD involves long segment where the outcomes of stents are suboptimal. Also, the disease often crosses joint line that makes it less ideal for the stents. Drug-coated balloons (DCB) have been introduced to improve patency rates following endovascular intervention for lower extremity PAD. They have gained popularity among endovascular specialists due to its ease of use and the concept of "leave nothing behind". This is a review of scientific evidence supporting DCB use in PAD.
• Bhogal, S., Panchal, H. B., Bagai, J., Banerjee, S., Brilakis, E. S., Mukherjee, D., Kumar, G., Shanmugasundaram, M., & Paul, T. K. (2018). Drug eluting versus bare metal stents in saphenous vein graft intervention: An updated comprehensive meta-analysis of randomized trials. Cardiovascular revascularization medicine : including molecular interventions.
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  Drug eluting stents (DES) are preferred over bare metal stents (BMS) for native coronary artery revascularization unless contraindicated. However, the preferred stent choice for saphenous venous graft (SVG) percutaneous coronary interventions (PCI) is unclear due to conflicting results.
• Movahed, M. R., Shanmugasundaram, M., Movahed, M. R., & Hashemzadeh, M. (2018). MORTALITY FOLLOWING BLEEDING IN ATRIAL FIBRILLATION PATIENTS UNDERGOING PERCUTANEOUS CORONARY INTERVENTION. Journal of the American College of Cardiology, 71(11), A1023. doi:10.1016/s0735-1097(18)31564-x
• Movahed, M. R., Shanmugasundaram, M., Movahed, M. R., & Hashemzadeh, M. (2018). OUTCOMES OF PERCUTANEOUS CORONARY INTERVENTION IN PATIENTS WITH ATRIAL FIBRILLATION. Journal of the American College of Cardiology, 71(11), A1024. doi:10.1016/s0735-1097(18)31565-1
• Movahed, M., Shanmugasundaram, M., Movahed, M., & Hashemzadeh, M. (2018). CRT-100.22 Outcomes of Percutaneous Coronary Intervention in Patients with Atrial Fibrillation Presenting With Acute Myocardial Infarction. Jacc-cardiovascular Interventions, 11(4), S8. doi:10.1016/j.jcin.2018.01.221
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  Atrial fibrillation (AF) is common in patients presenting with myocardial infarction (MI). Percutaneous coronary intervention (PCI) has been shown to improve cardiovascular outcomes in MI. However, outcomes of PCI in AF patients presenting with MI remain largely unknown. We analyzed the Nationwide
• Shanmugasundaram, M., & Lotun, K. (2018). Refractory Out of Hospital Cardiac Arrest. Current cardiology reviews, 14(2), 109-114.
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  Refractory out of hospital cardiac arrest is a common problem that is associated with poor overall survival rates and neurological outcomes. There are various definitions that have been used but the most accepted one is cardiac arrest that requires more than 10 minutes of Cardiopulmonary Resuscitation (CPR) efforts or more than 3 defibrillation attempts. There have been different pharmacologic and non-pharmacologic therapies that were studied in these patients. None of the antiarrhythmic or vasopressor medications have been consistently shown to improve survival or neurological outcomes in this subset of patients. This has led to the introduction of various devices aimed at improving outcomes such as mechanical CPR devices, Extracorporeal Cardiopulmonary Resuscitation (ECPR), targeted temperature management and early invasive approach. There is accumulating evidence that there seems to be an improvement in outcomes when these devices are used in refractory cardiac arrest patients. But none of these devices have been shown to improve outcomes when used in isolation. This underscores the importance of systematic approach to these complex patients and using these therapies in combination. There has been a paradigm shift in the approach to these patients. Instead of repeated and prolonged CPR attempts in the field, it is suggested that these patients need to be moved to cardiac arrest centers with a mechanical CPR device in place, so a percutaneous Extracorporeal Membrane Oxygenator (ECMO) can be placed to "buy" time for other therapies such as therapeutic hypothermia and early coronary angiography followed by intervention as indicated. Careful selection of patients who might potentially benefit from this approach is critical to the success of these programs.
• Shanmugasundaram, M., Murugapandian, S., Truong, H. T., Lotun, K., & Banerjee, S. (2018). Drug coated balloon in peripheral artery disease. Cardiovascular revascularization medicine : including molecular interventions.
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  Peripheral artery disease (PAD) is highly prevalent but is often underdiagnosed and undertreated. Lower extremity PAD can often be life style limiting. Revascularization in carefully selected lower extremity PAD patients improves symptoms and functional status. Surgical revascularization used to be the only available strategy, but in the recent years, endovascular strategies have gained popularity due to faster recovery times with low morbidity and mortality rates. Endovascular procedures have increased significantly in the United States in the past few years. That being said, higher restenosis rates and low long-term patency rates have been the limiting factors for this strategy. Drug eluting stents have been introduced to help with lowering restenosis, however lower extremity PAD involves long segment where the outcomes of stents are suboptimal. Also, the disease often crosses joint line that makes it less ideal for the stents. Drug coated balloons (DCB) have been introduced to improve patency rates following endovascular intervention for lower extremity PAD. They have gained popularity among endovascular specialists due to its ease of use and the concept of "leave nothing behind". This is a review of scientific evidence supporting DCB use in PAD.
• Truong, H. T., & Shanmugasundaram, M. (2018). Saphenous vein graft interventions. Is it worth our time?. Cardiovascular revascularization medicine : including molecular interventions.
• Truong, H. T., Hunter, G., Lotun, K., Shetty, R., Shanmugasundaram, M., Kapoor, D., & Thai, H. M. (2018). Insertion of the Impella via the axillary artery for high-risk percutaneous coronary intervention. Cardiovascular revascularization medicine : including molecular interventions, 19(5 Pt A), 540-544.
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  Hemodynamic support with the Impella device is an important tool during high risk percutaneous coronary intervention. This device is usually inserted via the femoral artery. However, some patients have severe peripheral artery disease precluding the use of the femoral artery for this purpose. The axillary artery is a viable alternative in these cases. We reviewed the two access techniques for inserting the Impella via the axillary artery and also described 6 cases of successful implantation.
• Truong, H. T., Tran, A., Smith, N., Shanmugasundaram, M., Kern, K. B., Ho, D., & Cavalcante, A. (2018). Abstract 12422: Mild Therapeutic Hypothermia Can Extend the Stemi First Medical Contact to Reperfusion Time Without Increasing Myocardial Infarct Size. Circulation.
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  Background: Primary percutaneous coronary intervention (PPCI) is the preferred treatment for acute ST segment elevation myocardial infarction (STEMI). The goal is reperfusion within 90 minutes of f...
• Janardhanan, R., Janardhanan, R., Taylor, Z., Taylor, Z., Shanmugasundaram, M., Shanmugasundaram, M., Rozich, J. D., Rozich, J. D., Kapoor, D., Kapoor, D., Janardhanan, R., Janardhanan, R., Ebong, I., & Ebong, I. (2017). ACUTE LIMB ISCHEMIA IN A PREVIOUSLY UNDIAGNOSED CASE OF MID-VENTRICULAR NON-OBSTRUCTIVE HYPERTROPHIC CARDIOMYOPATHY. Journal of the American College of Cardiology, 69(11), 2350. doi:10.1016/s0735-1097(17)35739-x
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  Mid-ventricular hypertrophic cardiomyopathy (HCM) is rare and when associated with an apical aneurysm has a high risk of thrombus formation and embolization. We report a case of a 70-year-old man with peripheral vascular disease who presented with acute progressive right leg pain. Peripheral angiography showed complete thrombotic occlusion of his right superficial femoral artery. Thrombolysis was successfully performed using alteplase. His post-procedure angiography which was obtained the next day showed complete revascularization with no residual stenosis. His echocardiogram showed an ill-defined mass in the left ventricular apex. The absence of residual atheroma on peripheral angiography suggested a primary embolic event. We obtained cardiac MRI which showed mid-ventricular HCM complicated by an apical aneurysm and small thrombus. Left ventricular apical aneurysm occurs commonly in mid-ventricular HCM and is associated with a worse prognosis. Cardiac magnetic resonance imaging (MRI) is superior to echocardiography in identifying left ventricular apical aneurysms and apical thrombi. J Med Cases. 2017;8(10):322-325 doi: https://doi.org/10.14740/jmc2915w
• Janardhanan, R., Janardhanan, R., Taylor, Z., Taylor, Z., Shanmugasundaram, M., Shanmugasundaram, M., Rozich, J. D., Rozich, J. D., Kapoor, D., Kapoor, D., Janardhanan, R., Janardhanan, R., Ebong, I., & Ebong, I. (2017). Acute Limb Ischemia in a Previously Undiagnosed Case of Mid-Ventricular Non-Obstructive Hypertrophic Cardiomyopathy. Journal of Medical Cases, 8(10), 322-325. doi:10.14740/jmc.v8i10.2915
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  Mid-ventricular hypertrophic cardiomyopathy (HCM) is rare and when associated with an apical aneurysm has a high risk of thrombus formation and embolization. We report a case of a 70-year-old man with peripheral vascular disease who presented with acute progressive right leg pain. Peripheral angiography showed complete thrombotic occlusion of his right superficial femoral artery. Thrombolysis was successfully performed using alteplase. His post-procedure angiography which was obtained the next day showed complete revascularization with no residual stenosis. His echocardiogram showed an ill-defined mass in the left ventricular apex. The absence of residual atheroma on peripheral angiography suggested a primary embolic event. We obtained cardiac MRI which showed mid-ventricular HCM complicated by an apical aneurysm and small thrombus. Left ventricular apical aneurysm occurs commonly in mid-ventricular HCM and is associated with a worse prognosis. Cardiac magnetic resonance imaging (MRI) is superior to echocardiography in identifying left ventricular apical aneurysms and apical thrombi. J Med Cases. 2017;8(10):322-325 doi: https://doi.org/10.14740/jmc2915w
• Shanmugasundaram, M., Shanmugasundaram, ., Jeganathan, ., Krishnamoorthy, ., & Ravishankar, . (2017). Additional value of computed tomography angiography in multiple coronary artery aneurysms--a case report. Indian heart journal, 58(4), 359-61.
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  Though invasive coronary angiography is the gold standard for the diagnosis of coronary artery aneurysms, computed tomography angiography may be just as useful in providing details of their morphology, size, location and associated stenosis or ectasia. Besides, it has the advantage of being a non-invasive modality.We present a case in which an aneurysm, which was not identified by conventional angiography due to the presence of thrombus, was correctly identified by computed tomography angiography.
• Shanmugasundaram, M., Valles, A., Kellum, M. J., Ewy, G. A., & Indik, J. H. (2012). Analysis of amplitude spectral area and slope to predict defibrillation in out of hospital cardiac arrest due to ventricular fibrillation (VF) according to VF type: recurrent versus shock-resistant. Resuscitation, 83(10), 1242-7.
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  In out-of-hospital cardiac arrest (OHCA) due to ventricular fibrillation (VF), VF may recur during resuscitation (recurrent VF) or fail to defibrillate (shock-resistant VF). While retrospective studies have suggested that amplitude spectral area (AMSA) and slope predict defibrillation, it is unknown whether the predictive power is influenced by VF type. We hypothesized that in witnessed OHCA with initial rhythm of VF that the utility for AMSA and slope to predict defibrillation would differ between shock-resistant and recurrent VF.
• Shanmugasundaram, M. (2011). Percutaneous coronary intervention in elderly patients: is it beneficial?. Texas Heart Institute journal, 38(4), 398-403.
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  Persons aged 65 years or older, often referred to as the elderly, are a rapidly increasing population in the United States. Cardiovascular disease is the most common cause of morbidity and death in this age group, and acute coronary syndrome accounts for a significant proportion of the deaths. Percutaneous coronary intervention is a well-established treatment for acute coronary syndrome and symptomatic coronary artery disease. However, community studies have shown that elderly patients are less likely to undergo revascularization, perhaps due to a "treatment-risk" paradox: elderly patients-at higher risk of morbidity and death from acute coronary syndrome-are denied revascularization even though they are likely to benefit from it. Age alone is one of the many reasons why percutaneous coronary intervention is avoided in elderly patients. This review examines past clinical trials and the existing evidence that supports performing percutaneous coronary intervention in elderly patients.
• Shanmugasundaram, M., Ram, V. K., Luft, U. C., Szerlip, M., & Alpert, J. S. (2011). Peripheral arterial disease--what do we need to know?. Clinical cardiology, 34(8), 478-82.
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  Peripheral artery disease (PAD) results from progressive narrowing of arteries secondary to atherosclerosis and is defined as an Ankle Brachial Index of
• Shanmugasundaram, M., Ram, V., Jayasuria, S., Dewar, J., Boyella, R., Kalra, N., & Goldman, S. (2011). Zotarolimus Drug Eluting Stents in Percutaneous Coronary Revascularization Compared to 1st Generation DES in High Risk Patients with Left Main Coronary Artery Disease.. Journal of Investigative Medicine, 59(1), 88-217.
• Shanmugasundaram, M., Ram, V., Jayasuria, S., Dewar, J., Nguyen, J., Boyella, R., & Goldman, S. (2011). The Effect of IVUS Guidance on Clinical Outcomes in Percutaneous Revascularization compared to Coronary Artery Bypass Grafting among High Risk Patients with Left Main Coronary Artery Disease. Journal of Investigative Medicine, 59(1), 888-217.
• Zuercher, M., Kern, K. B., Indik, J. H., Loedl, M., Hilwig, R. W., Ummenhofer, W., Berg, R. A., & Ewy, G. A. (2011). Epinephrine improves 24-hour survival in a swine model of prolonged ventricular fibrillation demonstrating that early intraosseous is superior to delayed intravenous administration. Anesthesia and analgesia, 112(4), 884-90.
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  Vasopressors administered IV late during resuscitation efforts fail to improve survival. Intraosseous (IO) access can provide a route for earlier administration. We hypothesized that IO epinephrine after 1 minute of cardiopulmonary resuscitation (CPR) (an "optimal" IO scenario) after 10 minutes of untreated ventricular fibrillation (VF) cardiac arrest would improve outcome in comparison with either IV epinephrine after 8 minutes of CPR (a "realistic" IV scenario) or placebo controls with no epinephrine.
• Indik, J. H., Allen, D., Shanmugasundaram, M., Zuercher, M., Hilwig, R. W., Berg, R. A., & Kern, K. B. (2010). Predictors of resuscitation in a swine model of ischemic and nonischemic ventricular fibrillation cardiac arrest: superiority of amplitude spectral area and slope to predict a return of spontaneous circulation when resuscitation efforts are prolonged. Critical care medicine, 38(12), 2352-7.
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  We have demonstrated that a return of spontaneous circulation in the first 3 mins of resuscitation in swine is predicted by ventricular fibrillation waveform (amplitude spectral area or slope) when untreated ventricular fibrillation duration or presence of acute myocardial infarction is unknown. We hypothesized that in prolonged resuscitation efforts that return of spontaneous circulation immediately after a second or later shock with postshock chest compression is independently predicted by end-tidal CO2, coronary perfusion pressure, and ventricular fibrillation waveform measured before that shock in a swine model of ischemic and nonischemic ventricular fibrillation arrest.
• Indik, J. H., Kellum, M., Shanmugasundaram, M., & Ewy, G. A. (2010). Epinephrine Does Not Increase the Likelihood of Recurrent Ventricular Fibrillation in Witnessed Out Of Hospital Cardiac Arrest.. Circulation, 122(21), A228.
• Shanmugasundaram, M., Kellum, M., Ewy, G. A., & Indik, J. H. (2010). In Out of Hospital Cardiac Arrest Due to Ventricular Fibrillation Amplitude Spectral Area, Amsa, and Slope Predict Defibrillation in Shock Resistant Vf but Not Recurrent Vf.. Circulation, 122(21), A12812.
• Shanmugasundaram, M., Rough, S. J., & Alpert, J. S. (2010). Dyslipidemia in the elderly: should it be treated?. Clinical cardiology, 33(1), 4-9.
  More info

  Elderly or older adults constitute a rapidly growing segment of the United States population, thus resulting in an increase in morbidity and mortality related to cardiovascular disease-an increase that is reaching epidemic proportions. Dyslipidemia is a well established risk factor for cardiovascular disease and is estimated to account for more than half of the global cases of coronary artery disease. Despite the increased prevalence of dyslipidemia in the older adult population, controversy persists regarding the benefits of treatment in this group. Epidemiologic studies have shown that dyslipidemia is often underdiagnosed and under treated in this population probably as a result of a paucity of evidence regarding the impact of treatment in delaying the progression of atherosclerotic disease, concerns involving increased likelihood of adverse events or drug interactions, or doubts regarding the cost effectiveness of lipid-lowering therapy in older adults. In conclusion, despite the proven efficacy of lipid-lowering therapy in decreasing cardiovascular morbidity and mortality, these therapies have been underutilized in older patients.
• Thal, S., Moukaberry, T., Boyella, R., Shanmugasundaram, M., Pierce, M., Thai, H., & Goldman, S. (2010). The Relation between warfarin, aspirin and clopidogrel continuation in the peri-procedural period and the incidence of hematoma formation after device implantation. Pacing and Clinical Electrophysiology, 33(4), 385-388. doi:10.1111/j.1540-8159.2009.02674.x
• Indik, J. H., Shanmugasundaram, M., Allen, D., Valles, A., Kern, K. B., Hilwig, R. W., Zuercher, M., & Berg, R. A. (2009). Predictors of resuscitation outcome in a swine model of VF cardiac arrest: A comparison of VF duration, presence of acute myocardial infarction and VF waveform. Resuscitation, 80(12), 1420-3.
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  Factors that affect resuscitation to a perfusing rhythm (ROSC) following ventricular fibrillation (VF) include untreated VF duration, acute myocardial infarction (AMI), and possibly factors reflected in the VF waveform. We hypothesized that resuscitation of VF to ROSC within 3min is predicted by the VF waveform, independent of untreated VF duration or presence of acute MI.
• Shanmugasundaram, M., & Alpert, J. S. (2009). Acute coronary syndrome in the elderly. Clinical cardiology, 32(11), 608-13.
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  The spectrum of acute coronary syndrome (ACS) including unstable angina, non-ST-elevation myocardial infarction and ST-elevation myocardial infarction accounts for increasing numbers of deaths among persons age > or = 65 years in the US. This is important given demographic changes involving falling birth rates and increasing life expectancy. Elderly patients are likely to benefit the most from treatment of ACS, even though community practice still demonstrates less use of cardiac medications as an early-invasive approach among this population.
• Shanmugasundaram, M., Fain, M. J., Mohler, J., Wendel, C. S., & Alpert, J. S. (2009). Predictors of Recurrent Cardiovascular hospitalizations in Patients with Diastolic Heart Failure. Journal of Cardiac Failure, 15(6), S 121.
• Shanmugasundaram, M., Indik, J. H., Kern, K. B., Allen, D., Hilwig, R. W., & Berg, R. (2009). Predictors of resuscitation in a swine model of VF cardiac arrest: superiority of amplitude spectral area (AMSA) to predict a return of spontaneous circulation when resuscitation efforts are prolonged. Circulation, 120(supplemental), S 671.
• Shanmugasundaram, M., John, J., Huang, Y., Hagerty, T., Arsanjani, R., & Thai, H. (2009). Percutaneous Coronary Intervention of Left Main Coronary Artery Disease In Patients with High Surgical Risk. Journal of Investigative Medicine, 57(1), 97-242.
• Shanmugasundaram, M., Thal, S., Moukabary, T., & Boyella, R. (2009). The Relationship Between Warfarin Continuation in the Peri-procedural Period and the Incidence of Hematoma Formation after device implantation. Circulation, 120(supplemental), S 638.
• Shanmugasundaram, M., & Alpert, J. S. (2008). Diastolic Heart Failure: How should it be managed?. Arizona Geriatric Society Journal, 13(2), 7 - 10.
• Shanmugasundaram, M., & Shanmugasundaram, S. (2006). Cardiopulmonary Resuscitation - From concepts to standard of care. Annual Scientific Issue for Cardiological Society of India,, 1, 366-381.

Presentations

• Shanmugasundaram, M. (2024, July). Radiation Safety. Fellows Conference. Tuscon, AZ: U of A CME.
• Shanmugasundaram, M. (2024, May). Intro to Cath . Cardiology Fellowship Core Conference. University of Arizona College of Medicine, Tucson, AZ.
• Shanmugasundaram, M. (2022, July). Radiation Safety. Fellows Conference. Tuscon, AZ: U of A CME.
• Shanmugasundaram, M. (2021, July). Cath Radiation Safety. Boot Camp. Sarver Heart Center: University of Arizona.
• Shanmugasundaram, M. (2017, January). Carotid and Renal Artery Disease. U of A Cardiology Fellows Core Conference. Tucson, Az: U of A CME.
• Shanmugasundaram, M. (2017, March). Interventions for Renal Artery Stenois. Interventional Cardiology Fellowship Conference. Tucson, AZ: U of A CMe.

Reviews

• William, P., Shanmugasundaram, M., & Kazui, T. (2018. Aortic Stenosis in Older Adults.