Indrajit Choudhuri | University of Wisconsin Milwaukee (original) (raw)

Papers by Indrajit Choudhuri

Pacing and Clinical Electrophysiology, Mar 20, 2014

Cardiac resynchronization therapy (CRT) has proven salutary effects in patients with congestive h... more Cardiac resynchronization therapy (CRT) has proven salutary effects in patients with congestive heart failure, systolic dysfunction, and electromechanical dyssynchrony in the setting of ischemic, nonischemic, and congenital cardiomyopathy. While CRT device implants have become routine in the adult ischemic or nonischemic cardiomyopathy populations, patients with congenital heart disease offer special challenges due to unusual anatomic variations. A comprehensive assessment of anatomic abnormalities is essential prior to implant. In addition, implant techniques and equipment must be tailored to the expected anatomy. A flexible approach is necessary-implant may require equipment and techniques adapted from vascular intervention. This article describes our approach to CRT implant in patients with congenital heart disease, and is illustrated by reports of several cases.

Cardio-Oncology

Background The many improvements in cancer therapies have led to an increased number of survivors... more Background The many improvements in cancer therapies have led to an increased number of survivors, which comes with a greater risk of consequent/subsequent cardiovascular disease. Identifying effective management strategies that can mitigate this risk of cardiovascular complications is vital. Therefore, developing computer-driven and personalized clinical decision aid interventions that can provide early detection of patients at risk, stratify that risk, and recommend specific cardio-oncology management guidelines and expert consensus recommendations is critically important. Objectives To assess the feasibility, acceptability, and utility of the use of an artificial intelligence (AI)-powered clinical decision aid tool in shared decision making between the cancer survivor patient and the cardiologist regarding prevention of cardiovascular disease. Design This is a single-center, double-arm, open-label, randomized interventional feasibility study. Our cardio-oncology cohort of > 40...

American Heart Journal Plus: Cardiology Research and Practice

$Research paper thumbnail of Withholding ICDs after EF improves to \u3e 35% can not be justified in all patients with CAD and left ventricular systolic dysfunction (LVSD)$

BACKGROUND: When EF≤35% is identified, ICDs are considered for SCD protection, but are withheld i... more BACKGROUND: When EF≤35% is identified, ICDs are considered for SCD protection, but are withheld if EF improves to \u3e35% within 90 days. This practice is not supported by direct evidence and may leave a significant segment of the population exposed to SCD risk. OBJECTIVE: Evaluate relationship of EF to timing of appropriate ICD therapy, as well as impact of withholding ICD after EF improves to \u3e35%, in CAD patients with at least moderate LVSD. METHOD: Aurora Healthcare patients with EF≤35% and subsequent improvement at any time to EF\u3e35% were included; excluding patients with: EF recovery in ≤7 days, CRT, LVAD, transplant, and inherited sudden death syndromes. After propensity matching, the study cohort (n=798) was segregated by presence/absence of ICD. SCD events and appropriate ICD therapies (ApprRx) were tabulated in ICD patients, as well as EF at the time of the event. RESULTS: Of 133 ICD recipients (48.1%\u3e65 years, 31.6% female) 6% suffered ApprRx over 23±13 months. I...

Circulation, 2015

Introduction: Despite chronic obstructive pulmonary disease (COPD) being recognized as a risk fac... more Introduction: Despite chronic obstructive pulmonary disease (COPD) being recognized as a risk factor for mortality in the general population, the impact of COPD diagnosis on early (&lt1 year) and long-term mortality (>=3 years) in patients at high risk of sudden cardiac death (SCD) with implantable cardioverter defibrillator (ICD) is inadequately studied. Methods: Consecutive patients from Jan 2010 to Dec 2013 who underwent an ICD placement were included and differences in overall mortality within 1 year and 3 years after ICD implant between COPD and non-COPD patients were determined using Kaplan-Meier analysis. Predictors of early and late mortality were determined using logistic regression. Results: Out of 3,464 patients (mean age 66.5 ± 13.3), 926 (26.7%) patients had a diagnosis of COPD. Overall mortality within 1 year after ICD implantation was 1.62 fold higher in patients with COPD (13% vs 8%: p&lt0.001) and 1.54 fold higher at 3 years (34% vs 22%: p&lt0.001) [Figure]. Ther...

Journal of the American College of Cardiology, 2017

Background: Prior studies have suggested a relationship between aortic dilatation and hypertrophi... more Background: Prior studies have suggested a relationship between aortic dilatation and hypertrophic cardiomyopathy (HCM). There are no data evaluating the relative strength of association between dilated aorta and HCM in terms of whether the dilatation was mediated by left ventricular outflow tract (LVOT) obstruction or due to hereditary factors. Methods: We retrospectively reviewed the medical and echocardiography records of the 175 patients with HCM seen and characterized by AJT in a tertiary-care HCM center. Of these, 124 received genetic testing. The patients (n=175) were categorized to have significant LVOT obstruction if the baseline dynamic LVOT gradient was >20 mmHg. All the patients underwent measurement of the sinus of Valsalva (SV) and mid ascending aorta (mAA) with leading edge-to-leading edge technique in diastole. The aorta was defined as dilated if it was >4 cm in the SV or mAA. Results: Out of the 124 patients tested, 56 (45%) were found to be gene-positive. The most common gene abnormalities detected were mutations in MYBPC3 (22%), MYH7 (13%) and TNNT2 (0.2%). Out of all 175 patients, the mean LVOT gradient was 24±34 and a range of 0-160 mmHg, with 49 patients having a gradient >20 mmHg. The gene-negative patients had a higher mean dilated SV (3.39 cm vs 3.12 cm; P=0.0038) and dilated mAA (3.3 cm vs 3 cm; P=0.005) than gene-positive patients (n=56). Gene-positive patients had a slightly lower prevalence of dilated SV (11% vs. 15%) and mAA (7% vs. 10%), which was not statistically significant. Patients with a baseline LVOT gradient ≥20 mmHg had a 4 times higher prevalence (16% vs 4%) of dilated mAA (>4 cm) than those with LVOT gradient of <20 mmHg (OR: 4.1, 95% CI 1.17-14.4, P=0.019), whereas no significant relationship was seen with dilated SV (OR: 1.7, 95% CI 0.61-4.8, P=0.3). This association with dilated mAA persisted after adjusting for hypertension, aortic stenosis, aortic regurgitation and aortic prosthesis in stratified and multivariate analyses. Conclusions: The dilatation of mAA in patients with HCM appears to be more strongly associated with baseline dynamic LVOT obstruction than with genetic abnormalities.

Journal of the American College of Cardiology, 2016

Background: Implantable cardioverter defibrillator (ICD) therapy is expensive, but cost effective... more Background: Implantable cardioverter defibrillator (ICD) therapy is expensive, but cost effectiveness has been demonstrated over longterm follow-up. Short-term mortality negatively impacts cost-effectiveness and ICD therapy is contraindicated in patients with expected longevityrecipients. Methods: Patients who underwent initial ICD implant from 2008-14 within the Aurora Health Care network (Wisconsin and northern Illinois) with at least 3 years of follow-up and/or suffered the primary endpoint of death were evaluated. Cox regression was used to determine hazard ratios (HR) for significant predictors identified through forward stepwise analysis. Results: In our ICD population (n=1560), total mortality was 194 (12.9%) and 42 patients died within 1 year of ICD implant (2.8%, 21.6% of total mortality). Clinical characteristics at the time of initial ICD implant that emerged as predictors of mortality included bradycardic arrest (HR 9.06, p70 (HR=2.39, p100 not meeting left bundle branch block [BBB] or right BBB criteria; HR 1.90, p Conclusions: A small but substantial percentage of central Midwestern ICD patients are at risk for 1-year mortality, and 1/5 of our total ICD mortality occurred within 1 year of implant. Several clinical characteristics at initial ICD implant predict mortality, including 1-year mortality, in our large cohort. Applying a priori knowledge of predictors of mortality, particularly 1-year mortality, may improve patient selection and cost-effectiveness of ICD therapy

Journal of Patient-Centered Research and Reviews, 2015

Europace, 2013

Multicenter Automatic Defibrillator Implantation Trial-Reduce Inappropriate Therapy (MADIT-RIT) c... more Multicenter Automatic Defibrillator Implantation Trial-Reduce Inappropriate Therapy (MADIT-RIT) confirmed the benefit of optimizing the programming of implantable cardioverter defibrillator (ICD) therapy for the reduction of inappropriate therapy and allcause mortality, with no impact on the incidence of syncope. 1 The true effectiveness of this intervention can be better illustrated by estimating the number needed to treat (NNT) 2 (Table 1): to avoid one death, 29 patients had to be programmed using high-rate therapy and 43 with delayed therapy, as compared with conventional programming. This means that physicians may start saving lives (see numbers above for NNT) in primary prevention patients more effectively than avoiding inappropriate shocks (NNT of 59-82 patients, according to the treatment arm) by just programming ICDs less aggressively.

Circulation, Oct 16, 2007

<jats:p> <jats:bold>Background:</jats:bold> A "cooling off" period (C... more <jats:p> <jats:bold>Background:</jats:bold> A "cooling off" period (COP) of 40 days after MI and 90 days after coronary revascularization or non-ischemic CM (NICM) diagnosis is customary to allow clinical improvement prior to assessing the need for ICD implantation. The COP creates a clinical dilemma that requires balancing ongoing sudden death (SD) risk and the cost of potentially unnecessary ICD implants. We reviewed our wearable defibrillator (WD) experience to assess its clinical utility during this period of uncertainty. </jats:p> <jats:p> <jats:bold>Methods:</jats:bold> Medical records from 27 patients with EF≤35% requiring a COP who were offered WD (LifeVest, ZOLL Lifecor) were reviewed for clinical indication, EF before and after WD use, sudden cardiac arrest (SCA) or treated VT/VF, and subsequent outcome. </jats:p> <jats:p> <jats:bold>Results:</jats:bold> Wearable defibrillator indications were: recent MI (n=7), ischemic CM (ICM) with recent revascularization (n=10), untreated NICM (n=9), and tachycardia-CM (n=1). Twenty-five of 27 patients agreed to WD and 23 complied. Two patients had 3 clinical events: 1 (not wearing WD) was resuscitated from SCA; 1 (treated by WD) survived sustained syncopal VT/VF but later died suddenly not wearing the WD. One patient was shocked for AF. After the COP (n=24), 6/24 (25%) patients had EF>35% (3 ICM and 3 NICM) and no ICD was implanted. Eighteen of 24 (75%) had an EF ≤ 35% and received an ICD. Three of 24 (12.5%) patients that received an ICD ultimately had an EF ≥35% over continued follow-up. </jats:p> <jats:p> <jats:bold>Conclusions:</jats:bold> During the COP, patients with EF ≤ 35% had a 12% clinical event rate (3 events in 25 patients). WD protected patients during this high-risk period but non-adherence was associated with death/cardiac arrest. While ICD implantation was safely avoided in 25%, unnecessary ICD implantation still occurred. Prolonged WD therapy beyond the COP may be more prudent in some to observe for delayed recovery (12%). In patients with newly diagnosed LV systolic dysfunction or after revascularization, risk and recovery are in flux. We suggest that this continuum is not confined to the COP. In patients with low EF, prolonged application of WD may provide additional SD prevention beyond the initial high-risk period and may prevent unnecessary ICD implantation. </jats:p>

Circulation, 2018

Introduction: ICD implantation is recommended in patients with LVEF<35%, while those with LVEF... more Introduction: ICD implantation is recommended in patients with LVEF<35%, while those with LVEF between 35 to 40% are not considered at high risk for primary prevention ICD implantation. A subset of these patients develops life threatening ventricular arrhythmias (VA) and improvement in risk stratification may help identify and implement life-saving intervention. Hypothesis: Prolonged repolarization is a marker of electrical instability and JTc interval on ECG could provide prognostic information in patients with LVEF 35-40% incremental to that from LVEF. Methods: Patients ≥18 yr with no history of VA and an ECG and echocardiogram obtained at initial encounter between 11/2011 to 12/2016 with long-term follow-up were identified. The incremental predictive ability of JTc interval on improvement in risk stratification for VA was determined by receiver operating characteristics (ROC) curve, integrated discrimination improvement (IDA) and net reclassification improvement (NRI) analysis...

European Heart Journal, 2017

Background: The effect of obesity on cerebrovascular disease may be underestimated by reverse cau... more Background: The effect of obesity on cerebrovascular disease may be underestimated by reverse causal causality of diseases leading to weight loss, which may impact general and central obesity differently. Purpose: To assess the relationships of measures of adiposity and change in adiposity to carotid artery plaque, a measure of pre-clinical atherosclerosis. Methods: The prospective China Kadoorie Biobank study in 0.5M participants aged 40-80 years included measurements of general obesity (BMI) and central obesity (waist-hip ratio), lean body mass (derived from impedance and body weight), other measures of adiposity and cardiovascular risk factors at recruitment. At a resurvey after 8 years, presence of carotid plaque was assessed by ultrasound in a random sample of 25K participants. The relationships of adiposity measurements to presence of carotid plaque (of any size) and hypertension were assessed in participants without history of stroke or heart disease, using logistic regression with adjustment for age, sex and region. Results: Among 22,489 participants (mean age 58 years at resurvey) the prevalence of carotid plaque was 37% and of hypertension was 46%. Although BMI in comparison with waist-hip ratio was much more strongly associated with hypertension, it was more weakly associated with carotid plaque (odds ratio across fifths 1.12 [95% CI 1.01-1.25] for BMI versus 1.29 [1.17-1.43] for waist-hip ratio). These differences persisted after ever smokers and those with diabetes were excluded to reduce potential reverse causality. Over a range of measures of adiposity, and change in adiposity between recruitment and resurvey, the strongest risk factors for carotid plaque were change in weight and change in BMI (inversely) and waist-hip ratio recruitment (positively). After restriction to never smokers without diabetes (n=12,885) and adjustment for blood pressure, change in lean body mass was the strongest risk factor for carotid plaque, with an odds ratio of 1.35 (95% CI 1.14-1.60) in the bottom versus top fifth (Figure). In contrast to this inverse association, change in lean body mass was positively associated with risk of hypertension at resurvey.