Michael Picard | Massachusetts General Hospital (original) (raw)

Papers by Michael Picard

Research paper thumbnail of Myocardial Adaptations to Competitive Swim Training

Medicine and Science in Sports and Exercise, Jul 10, 2019

Purpose: Swim training is performed in the prone or supine position and obligates water immersion... more Purpose: Swim training is performed in the prone or supine position and obligates water immersion, factors that may augment cardiac volume loading more than other endurance sports. At present, prospective data defining the cardiac responses to swim training are lacking. We therefore studied myocardial adaptations among competitive swimmers to establish a causal relationship between swim training and left ventricular (LV) remodeling. Methods: Collegiate swimmers were studied before and after a 90-d period of training intensification. Transthoracic echocardiography was used to examine LV structural and functional adaptations under resting conditions and during an acute LV afterload challenge generated by isometric handgrip testing (IHGT). A sedentary control population was identically studied with IHGT. Results: In response to a discrete period of swim training intensification, athletes (n = 17, 47% female, 19 ± 0.4 yr old) experienced eccentric LV remodeling, characterized by proportionally more chamber dilation than wall thickening, with attendant enhancements of resting LV systolic (LV twist) and diastolic (early and late phase tissue velocities) function. Compared with baseline and controls, athletes posttraining demonstrated greater systolic twist impairment during IHGT. However, training-induced LV dilation coupled with gains in diastolic function offsets this acquired systolic susceptibility to acute afterload, resulting in the relative preservation of stroke volume during IHGT. Conclusion: Swim training, a sport characterized by unique cardiac loading conditions, stimulates eccentric LV remodeling with the concomitant augmentation of systolic twist and diastolic relaxation. This volume-mediated cardiac remodeling appears to result in greater systolic susceptibility to acute afterload challenge. Further work is required to establish how training-induced changes in function translate to human performance and whether these are accompanied by physiologic trade-offs with relevance to common forms of heart disease.

Research paper thumbnail of Myocardial Metabolism in Endurance Exercise-Induced Left Ventricular Hypertrophy

Jacc-cardiovascular Imaging, Jun 1, 2018

Research paper thumbnail of AB42-2

Heart Rhythm, May 1, 2006

Research paper thumbnail of P5-101

Heart Rhythm, May 1, 2006

Research paper thumbnail of A Leap Forward for Ischemia-Guided Revascularization

Circulation, Dec 10, 2019

For the patient with stable coronary artery disease, demonstrating provocative ischemia, either w... more For the patient with stable coronary artery disease, demonstrating provocative ischemia, either with stress testing or invasive measures of lesion-specific ischemia (eg, fractional flow reserve [FFR]), is central in the decision to perform coronary revascularization.1–4 Yet, current randomized trial evidence is unclear as to the role of stress-induced ischemia in discerning a clinical outcome benefit of interventional versus conservative strategies of care; with reports of similar rates of major adverse events, such as death or myocardial infarction.5,6 Moreover, the only sham-controlled randomized trial of percutaneous coronary intervention (PCI), the ORBITA trial (Objective Randomized Blinded Investigation With Optimal Medical Therapy of Angioplasty), reported no effect of PCI on exercise time or angina frequency among patients with single-vessel coronary artery disease.7 In this issue of Circulation, a secondary analysis from the ORBITA trial examined the relation between baseline dobutamine stress echocardiographic ischemia and randomized treatment on patient-reported symptoms.8 Several findings from this ORBITA trial analysis are worthy of discussion. At baseline, patients enrolled in the ORBITA trial had a stress wall motion score averaging ≈1.6 in both the PCI and placebo arms. As described by the authors, the stress echocardiographic wall motion score used in this study varies from the conventional wall motion score index because it is a sum of wall motion abnormalities within the 17 segments of the left ventricle, without indexing to the number of segments assessed. Despite this, there was a significant interaction between the prerandomization stress echocardiographic score and the effect of PCI on angina frequency (interaction P=0.031; Figure 2 in article).8 PCI-treated patients with an echocardiographic score ≥1.0 (consistent with a stress-induced wall motion abnormality in at least 1 segment) had a reduced frequency of angina at 6 weeks of follow-up (P=0.007). The ORBITA trial findings are consistent with prior stable ischemic heart disease trials whereby PCI was associated with a prompt improvement in angina symptoms moreso than with medical therapy alone.1,5,9 From the Veterans Affairs–sponsored COURAGE trial (Clinical Outcomes Using Revascularization and Aggressive Drug Evaluation), PCI with optimal medical therapy as compared to optimal medical therapy alone was more often associated with freedom from angina through 3 years of follow-up.5 As well, from the FAME 2 trial (FFR Versus Angiography for Multivessel Evaluation), there was a marked reduction (hazard ratio: 0.13, P<0.001) in unstable symptoms necessitating hospitalization and prompt revascularization.4 This improvement in patient-reported outcomes with PCI among those with evidence of ischemia is a theme within the published literature. Even more intriguing from this ORBITA trial secondary analysis was that the greater the ischemia on the stress echocardiogram, the greater the symptom im© 2019 American Heart Association, Inc.

Research paper thumbnail of Abstract 12499: Anomalous Coronary Arteries Are Associated With Ischemia in the Ischemia Trial

Circulation, Nov 8, 2022

Introduction: Coronary anomalies are detected in 0.3-2.3% of patients undergoing coronary compute... more Introduction: Coronary anomalies are detected in 0.3-2.3% of patients undergoing coronary computed tomography angiography (CCTA). Data are scarce on atherosclerosis severity in anomalous arteries and relationship to ischemia on stress testing. Hypothesis: High risk features of anomalous coronary arteries are associated with ischemia, even in the absence of coronary stenosis on CCTA. Methods: 5,903 participants enrolled in the ISCHEMIA trial program with site-determined moderate or severe ischemia underwent CCTA. A core laboratory assessed atherosclerosis severity and made note of anomalous coronary origin. A single reader at the CCTA core laboratory re-evaluated all identified anomalies to assess high risk features and origin, blinded to stress test results. Patients were excluded if stress test results were unavailable. We assessed the relationship between type of anomaly and vessel with ischemia in the subtended territory on stress imaging, and stenosis severity. Results: There was anomalous origin of a coronary artery in 56 of 5,903 CCTA cases (0.9%). Age, sex and CAD risk factors were similar between patients with vs. without anomalies. Anomalous origin affected the left circumflex (LCX) in 28, right coronary artery (RCA) in 21, left main (LM) in 4, and left anterior descending (LAD) in 3. Ischemia was severe on stress testing in 58.2%, moderate in 34.5%, mild in 3.6% and absent in 3.6%. High risk anomalies were present in 17/56 (30.3%, 16/21 RCA and 1/4 LM), including inter-arterial course in 28.6%, intra-mural course in 1.8%, and slit-like orifice in 12.5%. Most anomalous coronaries (82.9%) were associated with ischemia in the subtended territory. Among anomalies associated with ischemia, 37.9% had &lt;50% stenosis and 62.1% had &lt;70% stenosis (Figure). Of those with &lt;70% stenosis, 27.6% had high risk features. Conclusions: Anomalous coronary arteries in stable patients are associated with ischemia, even in the absence of severe atherosclerotic disease.

Research paper thumbnail of competitive athletes function: a prospective and longitudinal assessment of Training-specific changes in cardiac structure and

Research paper thumbnail of Inpatient vs. elective outpatient cardiac resynchronization therapy device implantation and long-term clinical outcome

Research paper thumbnail of 315 Assessment of diastolic function in endomyocardial fibrosis: value of flow propagation velocity

European journal of echocardiography, Dec 1, 2003

Background: Left ventricular ejection fraction (LVEF) is the parameter commonly used to evaluate ... more Background: Left ventricular ejection fraction (LVEF) is the parameter commonly used to evaluate systolic function and stratify prognosis in patients with idiopathic dilated cardiomyopathy (DCM). There are few data concerning the genetic determinants of systolic function in these patients. The aim of this study was to evaluate the association between b2-adrenergic receptor (b2-AR) polymorphisms and LVEF in DCM patients before and after optimal medical treatment. Patients and Methods: We enrolled 22 consecutive unrelated patients (age 45±14 years, 17 males, NYHA functional class 1.6 ± 0.6) with DCM (WHO Criteria) in wash out from beta-blockers (BB), ACE-inhibitors (ACE-i) and Angiotensin II receptor inhibitors (ARB). LVEF was evaluated by echocardiography at the time of the enrolment and after one year, when all patients were receiving optimal treatment with BB and ACE-i or ARB. The genotyping for the 5' leader cistron (5'LC) Arg19Cys, Arg16Gly, Gln27Glu and Thr164Ile polymorphism of the b2-AR was performed on the basis of PCR amplified DNA using RFLP. Results: LVEF significantly improved after optimization of therapy (from 37 ± 10 to 41 ± 10). We found a significant association between the Arg16Gly polymorphism and LVEF (Figure) before and after one year follow-up. In particular, homozygosity for the Gly16 allele identified a subgroup of patients showing lower LVEF values than the other patients. No association was found with the other studied polymorphisms. Conclusion: DCM patients homozygous for the b2-AR Gly16 allele show lower LVEF values before and after BB, ACE-i and ARB treatment. This leads to hypothesise an influence of this allelic variant on systolic function in DCM. 314 Correlation of decreased myocardial Doppler longitudinal velocities and intraventricular conduction abnormalities in patients with myotonic dystrophy.

Research paper thumbnail of Impact of Complete Revascularization in the ISCHEMIA Trial

Journal of the American College of Cardiology

Research paper thumbnail of Ischemia With Nonobstructive Coronary Arteries

JACC: Cardiovascular Imaging

Research paper thumbnail of JASE 3.0: Entering Our 4 th Decade

Journal of the American Society of Echocardiography, 2018

This issue marks the start of the 31 st year of the Journal of the American Society of Echocardio... more This issue marks the start of the 31 st year of the Journal of the American Society of Echocardiography (JASE) and my first issue at its helm. I am honored to have been selected to continue the great editorial works of Harvey Feigenbaum and Alan Pearlman.

Research paper thumbnail of Echocardiographic Features of COVID-19 Illness and Association with Cardiac Biomarkers

Journal of the American Society of Echocardiography, 2020

Research paper thumbnail of Prognostic importance of the transmitral pressure gradient in mitral annular calcification with associated mitral valve dysfunction

European Heart Journal, 2020

Aims The aim of this study was to define the natural history of patients with mitral annular cal... more Aims The aim of this study was to define the natural history of patients with mitral annular calcification (MAC)-related mitral valve dysfunction and to assess the prognostic importance of mean transmitral pressure gradient (MG) and impact of concomitant mitral regurgitation (MR). Methods and results The institutional echocardiography database was examined from 2001 to 2019 for all patients with MAC and MG ≥3 mmHg. A total of 5754 patients were stratified by MG in low (3–5 mmHg, n = 3927), mid (5–10 mmHg, n = 1476), and high (≥10 mmHg, n = 351) gradient. The mean age was 78 ± 11 years, and 67% were female. MR was none/trace in 32%, mild in 42%, moderate in 23%, and severe in 3%. Primary outcome was all-cause mortality, and outcome models were adjusted for age, sex, and MAC-related risk factors (hypertension, diabetes, coronary artery disease, chronic kidney disease). Survival at 1, 5, and 10 years was 77%, 42%, and 18% in the low-gradient group; 73%, 38%, and 17% in the mid-gradie...

Research paper thumbnail of Prediction of Left Main Disease Using Clinical and Stress Test Parameters

Journal of the American College of Cardiology, 2020

Background: Detection of flow-limiting left main (LM) coronary artery disease (CAD) has both prog... more Background: Detection of flow-limiting left main (LM) coronary artery disease (CAD) has both prognostic and therapeutic implications. Stress testing is the most common method to detect obstructive CAD, however stress markers of LM CAD remain unclear. We set out to identify markers of LM CAD using clinical and stress testing parameters. Methods: The population consisted of patients enrolled in the ISCHEMIA trial who underwent non-imaging exercise tolerance testing, stress nuclear imaging or stress echocardiography (SE) and who underwent coronary computed tomography angiography (CCTA). Patients were enrolled based on local determination of moderate or severe ischemia. Those with prior coronary artery bypass grafting were excluded. Multivariate modeling was used to identify predictors of ≥50% LM diameter stenosis ("LM disease"), first without and then with stress testing parameters included in the model. Results: Of the 5145 patients included (mean age: 63 years, male: 74%), 414 (8%) had LM disease. Predictors of LM disease are shown in the Table. The models were weakly predictive of LM disease (C index 0.643 for clinical model, 0.671 for clinical + stress model). Conclusion: In patients with moderate or severe ischemia on stress testing, clinical and stress testing parameters were weakly predictive of LM disease on CCTA. SE-detected TID and ST depression during ETT provided incremental information independent of clinical and other stress modality specific parameters for the prediction of LM disease.

Research paper thumbnail of Echocardiography in the Time of COVID-19

Journal of the American Society of Echocardiography, 2020

Research paper thumbnail of 2019 ACC/AHA/ASE Key Data Elements and Definitions for Transthoracic Echocardiography

Journal of the American Society of Echocardiography, 2019

Writing Committee Members 1165 † No financial benefit. ‡ This disclosure was entered under the Cl... more Writing Committee Members 1165 † No financial benefit. ‡ This disclosure was entered under the Clinical Trial Enroller category in the ACC's disclosure system. To appear in this category, the author acknowledges that there is no direct or institutional relationship with the trial sponsor as defined in the ACC/AHA Disclosure Policy for Writing Committees.

Research paper thumbnail of 2019 ACC/AHA/ASE Key Data Elements and Definitions for Transthoracic Echocardiography: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Data Standards (Writing Committee to Develop Clinical Data Standards for Transthoracic Echocardiography) and the ...

Circulation: Cardiovascular Imaging, 2019

Douglas et al; Transthoracic Echo Data Standards monization with other standards as health inform... more Douglas et al; Transthoracic Echo Data Standards monization with other standards as health information technology and clinical practice evolve. The Health Insurance Portability and Accountability Act privacy regulations, which went into effect in April 2003, have heightened all practitioners' awareness of our professional commitment to safeguard our patients' privacy. The Health Insurance Portability and Accountability Act privacy regulations 1 specify which information elements are considered "protected health information." These elements may not be disclosed to third parties (including registries and research studies) without the patient's written permission. Protected health information may be included in databases used for healthcare operations under a data use agreement. Research studies using protected health information must be reviewed by an institutional review board or a privacy board. We have included identifying information in all clinical data standards to facilitate uniform collection of these elements when appropriate. For example, a longitudinal clinic database may contain these elements because access is restricted to the patient's caregivers. Conversely, registries may not contain protected health information unless specific permission is granted by each patient. These fields are indicated as protected health information in the data standards. In clinical care, caregivers communicate with each other through a common vocabulary. In an analogous manner, the integrity of clinical research depends on firm adherence to prespecified procedures for patient enrollment and follow-up; these procedures are guaranteed through careful attention to definitions enumerated in the study protocol, case report forms, and clinical event committee charters. When data elements and definitions are standardized across studies, comparison, pooled analysis, and meta-analysis are enabled, thus deepening our understanding of individual studies. The recent development of quality-performance measurement initiatives, particularly those for which the comparison of providers is an implicit or explicit aim, has further raised awareness about the importance of data standards. Indeed, a wide audience, including nonmedical professionals such as payers, regulators, and consumers, may draw conclusions about care and outcomes. To understand and compare care patterns and outcomes, the data elements that characterize them must be clearly defined, consistently used, and properly interpreted.

Research paper thumbnail of Echocardiographic Surveillance of Valvular Heart Disease in Different Sociodemographic Groups

JACC: Cardiovascular Imaging, 2018

Research paper thumbnail of Baseline Characteristics and Risk Profiles of Participants in the ISCHEMIA Randomized Clinical Trial

JAMA Cardiology, 2019

It is unknown whether coronary revascularization, when added to optimal medical therapy, improves... more It is unknown whether coronary revascularization, when added to optimal medical therapy, improves prognosis in patients with stable ischemic heart disease (SIHD) at increased risk of cardiovascular events owing to moderate or severe ischemia. OBJECTIVE To describe baseline characteristics of participants enrolled and randomized in the International Study of Comparative Health Effectiveness With Medical and Invasive Approaches (ISCHEMIA) trial and to evaluate whether qualification by stress imaging or nonimaging exercise tolerance test (ETT) influenced risk profiles. DESIGN, SETTING, AND PARTICIPANTS The ISCHEMIA trial recruited patients with SIHD with moderate or severe ischemia on stress testing. Blinded coronary computed tomography angiography was performed in most participants and reviewed by a core laboratory to exclude left main stenosis of at least 50% or no obstructive coronary artery disease (CAD) (<50% for imaging stress test and <70% for ETT). The study included 341 enrolling sites (320 randomizing) in 38 countries and patients with SIHD and moderate or severe ischemia on stress testing. Data presented were extracted on December 17, 2018. MAIN OUTCOMES AND MEASURES Enrolled, excluded, and randomized participants' baseline characteristics. No clinical outcomes are reported. RESULTS A total of 8518 patients were enrolled, and 5179 were randomized. Common reasons for exclusion were core laboratory determination of insufficient ischemia, unprotected left main stenosis of at least 50%, or no stenosis that met study obstructive CAD criteria on study coronary computed tomography angiography. Randomized participants had a median age of 64 years, with 1168 women (22.6%), 1726 nonwhite participants (33.7%), 748 Hispanic participants (15.5%), 2122 with diabetes (41.0%), and 4643 with a history of angina (89.7%). Among the 3909 participants randomized after stress imaging, core laboratory assessment of ischemia severity (in 3901 participants) was severe in 1748 (44.8%), moderate in 1600 (41.0%), mild in 317 (8.1%) and none or uninterpretable in 236 (6.0%), Among the 1270 participants who were randomized after nonimaging ETT, core laboratory determination of ischemia severity (in 1266 participants) was severe (an eligibility criterion) in 1051 (83.0%), moderate in 101 (8.0%), mild in 34 (2.7%) and none or uninterpretable in 80 (6.3%). Among the 3912 of 5179 randomized participants who underwent coronary computed tomography angiography, 79.0% had multivessel CAD (n = 2679 of 3390) and 86.8% had left anterior descending (LAD) stenosis (n = 3190 of 3677) (proximal in 46.8% [n = 1749 of 3739]). Participants undergoing ETT had greater frequency of 3-vessel CAD, LAD, and proximal LAD stenosis than participants undergoing stress imaging. CONCLUSIONS AND RELEVANCE The ISCHEMIA trial randomized an SIHD population with moderate or severe ischemia on stress testing, of whom most had multivessel CAD.

Research paper thumbnail of Myocardial Adaptations to Competitive Swim Training

Medicine and Science in Sports and Exercise, Jul 10, 2019

Purpose: Swim training is performed in the prone or supine position and obligates water immersion... more Purpose: Swim training is performed in the prone or supine position and obligates water immersion, factors that may augment cardiac volume loading more than other endurance sports. At present, prospective data defining the cardiac responses to swim training are lacking. We therefore studied myocardial adaptations among competitive swimmers to establish a causal relationship between swim training and left ventricular (LV) remodeling. Methods: Collegiate swimmers were studied before and after a 90-d period of training intensification. Transthoracic echocardiography was used to examine LV structural and functional adaptations under resting conditions and during an acute LV afterload challenge generated by isometric handgrip testing (IHGT). A sedentary control population was identically studied with IHGT. Results: In response to a discrete period of swim training intensification, athletes (n = 17, 47% female, 19 ± 0.4 yr old) experienced eccentric LV remodeling, characterized by proportionally more chamber dilation than wall thickening, with attendant enhancements of resting LV systolic (LV twist) and diastolic (early and late phase tissue velocities) function. Compared with baseline and controls, athletes posttraining demonstrated greater systolic twist impairment during IHGT. However, training-induced LV dilation coupled with gains in diastolic function offsets this acquired systolic susceptibility to acute afterload, resulting in the relative preservation of stroke volume during IHGT. Conclusion: Swim training, a sport characterized by unique cardiac loading conditions, stimulates eccentric LV remodeling with the concomitant augmentation of systolic twist and diastolic relaxation. This volume-mediated cardiac remodeling appears to result in greater systolic susceptibility to acute afterload challenge. Further work is required to establish how training-induced changes in function translate to human performance and whether these are accompanied by physiologic trade-offs with relevance to common forms of heart disease.

Research paper thumbnail of Myocardial Metabolism in Endurance Exercise-Induced Left Ventricular Hypertrophy

Jacc-cardiovascular Imaging, Jun 1, 2018

Research paper thumbnail of AB42-2

Heart Rhythm, May 1, 2006

Research paper thumbnail of P5-101

Heart Rhythm, May 1, 2006

Research paper thumbnail of A Leap Forward for Ischemia-Guided Revascularization

Circulation, Dec 10, 2019

For the patient with stable coronary artery disease, demonstrating provocative ischemia, either w... more For the patient with stable coronary artery disease, demonstrating provocative ischemia, either with stress testing or invasive measures of lesion-specific ischemia (eg, fractional flow reserve [FFR]), is central in the decision to perform coronary revascularization.1–4 Yet, current randomized trial evidence is unclear as to the role of stress-induced ischemia in discerning a clinical outcome benefit of interventional versus conservative strategies of care; with reports of similar rates of major adverse events, such as death or myocardial infarction.5,6 Moreover, the only sham-controlled randomized trial of percutaneous coronary intervention (PCI), the ORBITA trial (Objective Randomized Blinded Investigation With Optimal Medical Therapy of Angioplasty), reported no effect of PCI on exercise time or angina frequency among patients with single-vessel coronary artery disease.7 In this issue of Circulation, a secondary analysis from the ORBITA trial examined the relation between baseline dobutamine stress echocardiographic ischemia and randomized treatment on patient-reported symptoms.8 Several findings from this ORBITA trial analysis are worthy of discussion. At baseline, patients enrolled in the ORBITA trial had a stress wall motion score averaging ≈1.6 in both the PCI and placebo arms. As described by the authors, the stress echocardiographic wall motion score used in this study varies from the conventional wall motion score index because it is a sum of wall motion abnormalities within the 17 segments of the left ventricle, without indexing to the number of segments assessed. Despite this, there was a significant interaction between the prerandomization stress echocardiographic score and the effect of PCI on angina frequency (interaction P=0.031; Figure 2 in article).8 PCI-treated patients with an echocardiographic score ≥1.0 (consistent with a stress-induced wall motion abnormality in at least 1 segment) had a reduced frequency of angina at 6 weeks of follow-up (P=0.007). The ORBITA trial findings are consistent with prior stable ischemic heart disease trials whereby PCI was associated with a prompt improvement in angina symptoms moreso than with medical therapy alone.1,5,9 From the Veterans Affairs–sponsored COURAGE trial (Clinical Outcomes Using Revascularization and Aggressive Drug Evaluation), PCI with optimal medical therapy as compared to optimal medical therapy alone was more often associated with freedom from angina through 3 years of follow-up.5 As well, from the FAME 2 trial (FFR Versus Angiography for Multivessel Evaluation), there was a marked reduction (hazard ratio: 0.13, P<0.001) in unstable symptoms necessitating hospitalization and prompt revascularization.4 This improvement in patient-reported outcomes with PCI among those with evidence of ischemia is a theme within the published literature. Even more intriguing from this ORBITA trial secondary analysis was that the greater the ischemia on the stress echocardiogram, the greater the symptom im© 2019 American Heart Association, Inc.

Research paper thumbnail of Abstract 12499: Anomalous Coronary Arteries Are Associated With Ischemia in the Ischemia Trial

Circulation, Nov 8, 2022

Introduction: Coronary anomalies are detected in 0.3-2.3% of patients undergoing coronary compute... more Introduction: Coronary anomalies are detected in 0.3-2.3% of patients undergoing coronary computed tomography angiography (CCTA). Data are scarce on atherosclerosis severity in anomalous arteries and relationship to ischemia on stress testing. Hypothesis: High risk features of anomalous coronary arteries are associated with ischemia, even in the absence of coronary stenosis on CCTA. Methods: 5,903 participants enrolled in the ISCHEMIA trial program with site-determined moderate or severe ischemia underwent CCTA. A core laboratory assessed atherosclerosis severity and made note of anomalous coronary origin. A single reader at the CCTA core laboratory re-evaluated all identified anomalies to assess high risk features and origin, blinded to stress test results. Patients were excluded if stress test results were unavailable. We assessed the relationship between type of anomaly and vessel with ischemia in the subtended territory on stress imaging, and stenosis severity. Results: There was anomalous origin of a coronary artery in 56 of 5,903 CCTA cases (0.9%). Age, sex and CAD risk factors were similar between patients with vs. without anomalies. Anomalous origin affected the left circumflex (LCX) in 28, right coronary artery (RCA) in 21, left main (LM) in 4, and left anterior descending (LAD) in 3. Ischemia was severe on stress testing in 58.2%, moderate in 34.5%, mild in 3.6% and absent in 3.6%. High risk anomalies were present in 17/56 (30.3%, 16/21 RCA and 1/4 LM), including inter-arterial course in 28.6%, intra-mural course in 1.8%, and slit-like orifice in 12.5%. Most anomalous coronaries (82.9%) were associated with ischemia in the subtended territory. Among anomalies associated with ischemia, 37.9% had &lt;50% stenosis and 62.1% had &lt;70% stenosis (Figure). Of those with &lt;70% stenosis, 27.6% had high risk features. Conclusions: Anomalous coronary arteries in stable patients are associated with ischemia, even in the absence of severe atherosclerotic disease.

Research paper thumbnail of competitive athletes function: a prospective and longitudinal assessment of Training-specific changes in cardiac structure and

Research paper thumbnail of Inpatient vs. elective outpatient cardiac resynchronization therapy device implantation and long-term clinical outcome

Research paper thumbnail of 315 Assessment of diastolic function in endomyocardial fibrosis: value of flow propagation velocity

European journal of echocardiography, Dec 1, 2003

Background: Left ventricular ejection fraction (LVEF) is the parameter commonly used to evaluate ... more Background: Left ventricular ejection fraction (LVEF) is the parameter commonly used to evaluate systolic function and stratify prognosis in patients with idiopathic dilated cardiomyopathy (DCM). There are few data concerning the genetic determinants of systolic function in these patients. The aim of this study was to evaluate the association between b2-adrenergic receptor (b2-AR) polymorphisms and LVEF in DCM patients before and after optimal medical treatment. Patients and Methods: We enrolled 22 consecutive unrelated patients (age 45±14 years, 17 males, NYHA functional class 1.6 ± 0.6) with DCM (WHO Criteria) in wash out from beta-blockers (BB), ACE-inhibitors (ACE-i) and Angiotensin II receptor inhibitors (ARB). LVEF was evaluated by echocardiography at the time of the enrolment and after one year, when all patients were receiving optimal treatment with BB and ACE-i or ARB. The genotyping for the 5' leader cistron (5'LC) Arg19Cys, Arg16Gly, Gln27Glu and Thr164Ile polymorphism of the b2-AR was performed on the basis of PCR amplified DNA using RFLP. Results: LVEF significantly improved after optimization of therapy (from 37 ± 10 to 41 ± 10). We found a significant association between the Arg16Gly polymorphism and LVEF (Figure) before and after one year follow-up. In particular, homozygosity for the Gly16 allele identified a subgroup of patients showing lower LVEF values than the other patients. No association was found with the other studied polymorphisms. Conclusion: DCM patients homozygous for the b2-AR Gly16 allele show lower LVEF values before and after BB, ACE-i and ARB treatment. This leads to hypothesise an influence of this allelic variant on systolic function in DCM. 314 Correlation of decreased myocardial Doppler longitudinal velocities and intraventricular conduction abnormalities in patients with myotonic dystrophy.

Research paper thumbnail of Impact of Complete Revascularization in the ISCHEMIA Trial

Journal of the American College of Cardiology

Research paper thumbnail of Ischemia With Nonobstructive Coronary Arteries

JACC: Cardiovascular Imaging

Research paper thumbnail of JASE 3.0: Entering Our 4 th Decade

Journal of the American Society of Echocardiography, 2018

This issue marks the start of the 31 st year of the Journal of the American Society of Echocardio... more This issue marks the start of the 31 st year of the Journal of the American Society of Echocardiography (JASE) and my first issue at its helm. I am honored to have been selected to continue the great editorial works of Harvey Feigenbaum and Alan Pearlman.

Research paper thumbnail of Echocardiographic Features of COVID-19 Illness and Association with Cardiac Biomarkers

Journal of the American Society of Echocardiography, 2020

Research paper thumbnail of Prognostic importance of the transmitral pressure gradient in mitral annular calcification with associated mitral valve dysfunction

European Heart Journal, 2020

Aims The aim of this study was to define the natural history of patients with mitral annular cal... more Aims The aim of this study was to define the natural history of patients with mitral annular calcification (MAC)-related mitral valve dysfunction and to assess the prognostic importance of mean transmitral pressure gradient (MG) and impact of concomitant mitral regurgitation (MR). Methods and results The institutional echocardiography database was examined from 2001 to 2019 for all patients with MAC and MG ≥3 mmHg. A total of 5754 patients were stratified by MG in low (3–5 mmHg, n = 3927), mid (5–10 mmHg, n = 1476), and high (≥10 mmHg, n = 351) gradient. The mean age was 78 ± 11 years, and 67% were female. MR was none/trace in 32%, mild in 42%, moderate in 23%, and severe in 3%. Primary outcome was all-cause mortality, and outcome models were adjusted for age, sex, and MAC-related risk factors (hypertension, diabetes, coronary artery disease, chronic kidney disease). Survival at 1, 5, and 10 years was 77%, 42%, and 18% in the low-gradient group; 73%, 38%, and 17% in the mid-gradie...

Research paper thumbnail of Prediction of Left Main Disease Using Clinical and Stress Test Parameters

Journal of the American College of Cardiology, 2020

Background: Detection of flow-limiting left main (LM) coronary artery disease (CAD) has both prog... more Background: Detection of flow-limiting left main (LM) coronary artery disease (CAD) has both prognostic and therapeutic implications. Stress testing is the most common method to detect obstructive CAD, however stress markers of LM CAD remain unclear. We set out to identify markers of LM CAD using clinical and stress testing parameters. Methods: The population consisted of patients enrolled in the ISCHEMIA trial who underwent non-imaging exercise tolerance testing, stress nuclear imaging or stress echocardiography (SE) and who underwent coronary computed tomography angiography (CCTA). Patients were enrolled based on local determination of moderate or severe ischemia. Those with prior coronary artery bypass grafting were excluded. Multivariate modeling was used to identify predictors of ≥50% LM diameter stenosis ("LM disease"), first without and then with stress testing parameters included in the model. Results: Of the 5145 patients included (mean age: 63 years, male: 74%), 414 (8%) had LM disease. Predictors of LM disease are shown in the Table. The models were weakly predictive of LM disease (C index 0.643 for clinical model, 0.671 for clinical + stress model). Conclusion: In patients with moderate or severe ischemia on stress testing, clinical and stress testing parameters were weakly predictive of LM disease on CCTA. SE-detected TID and ST depression during ETT provided incremental information independent of clinical and other stress modality specific parameters for the prediction of LM disease.

Research paper thumbnail of Echocardiography in the Time of COVID-19

Journal of the American Society of Echocardiography, 2020

Research paper thumbnail of 2019 ACC/AHA/ASE Key Data Elements and Definitions for Transthoracic Echocardiography

Journal of the American Society of Echocardiography, 2019

Writing Committee Members 1165 † No financial benefit. ‡ This disclosure was entered under the Cl... more Writing Committee Members 1165 † No financial benefit. ‡ This disclosure was entered under the Clinical Trial Enroller category in the ACC's disclosure system. To appear in this category, the author acknowledges that there is no direct or institutional relationship with the trial sponsor as defined in the ACC/AHA Disclosure Policy for Writing Committees.

Research paper thumbnail of 2019 ACC/AHA/ASE Key Data Elements and Definitions for Transthoracic Echocardiography: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Data Standards (Writing Committee to Develop Clinical Data Standards for Transthoracic Echocardiography) and the ...

Circulation: Cardiovascular Imaging, 2019

Douglas et al; Transthoracic Echo Data Standards monization with other standards as health inform... more Douglas et al; Transthoracic Echo Data Standards monization with other standards as health information technology and clinical practice evolve. The Health Insurance Portability and Accountability Act privacy regulations, which went into effect in April 2003, have heightened all practitioners' awareness of our professional commitment to safeguard our patients' privacy. The Health Insurance Portability and Accountability Act privacy regulations 1 specify which information elements are considered "protected health information." These elements may not be disclosed to third parties (including registries and research studies) without the patient's written permission. Protected health information may be included in databases used for healthcare operations under a data use agreement. Research studies using protected health information must be reviewed by an institutional review board or a privacy board. We have included identifying information in all clinical data standards to facilitate uniform collection of these elements when appropriate. For example, a longitudinal clinic database may contain these elements because access is restricted to the patient's caregivers. Conversely, registries may not contain protected health information unless specific permission is granted by each patient. These fields are indicated as protected health information in the data standards. In clinical care, caregivers communicate with each other through a common vocabulary. In an analogous manner, the integrity of clinical research depends on firm adherence to prespecified procedures for patient enrollment and follow-up; these procedures are guaranteed through careful attention to definitions enumerated in the study protocol, case report forms, and clinical event committee charters. When data elements and definitions are standardized across studies, comparison, pooled analysis, and meta-analysis are enabled, thus deepening our understanding of individual studies. The recent development of quality-performance measurement initiatives, particularly those for which the comparison of providers is an implicit or explicit aim, has further raised awareness about the importance of data standards. Indeed, a wide audience, including nonmedical professionals such as payers, regulators, and consumers, may draw conclusions about care and outcomes. To understand and compare care patterns and outcomes, the data elements that characterize them must be clearly defined, consistently used, and properly interpreted.

Research paper thumbnail of Echocardiographic Surveillance of Valvular Heart Disease in Different Sociodemographic Groups

JACC: Cardiovascular Imaging, 2018

Research paper thumbnail of Baseline Characteristics and Risk Profiles of Participants in the ISCHEMIA Randomized Clinical Trial

JAMA Cardiology, 2019

It is unknown whether coronary revascularization, when added to optimal medical therapy, improves... more It is unknown whether coronary revascularization, when added to optimal medical therapy, improves prognosis in patients with stable ischemic heart disease (SIHD) at increased risk of cardiovascular events owing to moderate or severe ischemia. OBJECTIVE To describe baseline characteristics of participants enrolled and randomized in the International Study of Comparative Health Effectiveness With Medical and Invasive Approaches (ISCHEMIA) trial and to evaluate whether qualification by stress imaging or nonimaging exercise tolerance test (ETT) influenced risk profiles. DESIGN, SETTING, AND PARTICIPANTS The ISCHEMIA trial recruited patients with SIHD with moderate or severe ischemia on stress testing. Blinded coronary computed tomography angiography was performed in most participants and reviewed by a core laboratory to exclude left main stenosis of at least 50% or no obstructive coronary artery disease (CAD) (<50% for imaging stress test and <70% for ETT). The study included 341 enrolling sites (320 randomizing) in 38 countries and patients with SIHD and moderate or severe ischemia on stress testing. Data presented were extracted on December 17, 2018. MAIN OUTCOMES AND MEASURES Enrolled, excluded, and randomized participants' baseline characteristics. No clinical outcomes are reported. RESULTS A total of 8518 patients were enrolled, and 5179 were randomized. Common reasons for exclusion were core laboratory determination of insufficient ischemia, unprotected left main stenosis of at least 50%, or no stenosis that met study obstructive CAD criteria on study coronary computed tomography angiography. Randomized participants had a median age of 64 years, with 1168 women (22.6%), 1726 nonwhite participants (33.7%), 748 Hispanic participants (15.5%), 2122 with diabetes (41.0%), and 4643 with a history of angina (89.7%). Among the 3909 participants randomized after stress imaging, core laboratory assessment of ischemia severity (in 3901 participants) was severe in 1748 (44.8%), moderate in 1600 (41.0%), mild in 317 (8.1%) and none or uninterpretable in 236 (6.0%), Among the 1270 participants who were randomized after nonimaging ETT, core laboratory determination of ischemia severity (in 1266 participants) was severe (an eligibility criterion) in 1051 (83.0%), moderate in 101 (8.0%), mild in 34 (2.7%) and none or uninterpretable in 80 (6.3%). Among the 3912 of 5179 randomized participants who underwent coronary computed tomography angiography, 79.0% had multivessel CAD (n = 2679 of 3390) and 86.8% had left anterior descending (LAD) stenosis (n = 3190 of 3677) (proximal in 46.8% [n = 1749 of 3739]). Participants undergoing ETT had greater frequency of 3-vessel CAD, LAD, and proximal LAD stenosis than participants undergoing stress imaging. CONCLUSIONS AND RELEVANCE The ISCHEMIA trial randomized an SIHD population with moderate or severe ischemia on stress testing, of whom most had multivessel CAD.