William T Abraham

The Ohio State University, Columbus, Ohio, United States

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Publications (489)2917.14 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Chronic obstructive pulmonary disease (COPD) is a frequent co-morbidity in patients with heart failure (HF). Elevated pulmonary artery (PA) pressure can be seen in both conditions and has been shown to predict morbidity and mortality. 550 subjects with New York Heart Association functional class III HF were randomly assigned to the Treatment (n=270) and Control groups (n=280) in the CHAMPION Trial. Physicians had access to the PA pressure measurements in the Treatment group only, which HF therapy was used to lower the elevated pressures. HF and respiratory hospitalizations were compared in both groups. 187 subjects met criteria for classification into the COPD subgroup. In the entire cohort, the Treatment group had a 37% reduction in HF hospitalization rates (p<0.0001) and a 49% reduction in respiratory hospitalization rates (p=0.0061). In the COPD subgroup, the Treatment group had a 41% reduction in HF hospitalization rates (p=0.0009) and a 62% reduction in respiratory hospitalization rates (p=0.0023). The rate of respiratory hospitalizations in subjects without COPD was not statistically different (p=0.76). HF management incorporating hemodynamic information from an implantable PA pressure monitor significantly reduces HF and respiratory hospitalizations in heart failure subjects with comorbid COPD over standard of care. Copyright © 2014 Elsevier Inc. All rights reserved.
    Journal of cardiac failure. 12/2014;
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    ABSTRACT: Cardiac resynchronization therapy (CRT) decreases mortality, improves functional status and induces reverse left ventricular (LV) remodeling in selected populations with heart failure (HF). The magnitude of reverse remodeling predicts survival with many HF medical therapies. However, there are little data assessing the impact of remodeling on long term survival with CRT. To assess the impact of CRT induced reverse remodeling on long term survival in mild HF. REVERSE was a multi-center, double-blind, randomized trial of CRT among patients with mild HF. Long-term follow-up for 5 years was pre-planned. The present analysis was confined to the 353 patients who were randomized to CRT ON with paired echocardiographic studies at baseline and 6 months post-implant. Left ventricular end systolic volume index (LVESVi) was measured by a core laboratory and was an independently powered endpoint of REVERSE. A 68% reduction in mortality was observed among patients with ≥15% decrease in LVESVi compared to the rest of the patients (p=0.0004). Multivariable analysis showed that the change in LVESVi was a strong independent predictor (p=0.0002) with a 14% reduction of mortality for every 10% decrease of LVESVi. Other remodeling parameters, including left ventricular end diastolic volume index and ejection fraction showed a similar relationship with mortality. Change in left ventricular end systolic volume over 6 months of CRT is a strong independent predictor of long term survival in mild HF. http://clinicaltrials.gov/ct2/show/NCT00271154. Unique identifier: NCT00271154. Copyright © 2014. Published by Elsevier Inc.
    Heart rhythm: the official journal of the Heart Rhythm Society 11/2014; · 4.56 Impact Factor
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    ABSTRACT: -No treatment strategies have been demonstrated to be beneficial for the population for patients with heart failure and preserved ejection fraction.
    Circulation Heart Failure 10/2014; · 6.68 Impact Factor
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    ABSTRACT: Cardiac contractility modulation (CCM) signals are nonexcitatory electrical signals delivered during the cardiac absolute refractory period that enhance the strength of cardiac muscular contraction. The FIX-HF-5 study was a prospective, randomized study comparing CCM plus optimal medical therapy (OMT) to OMT alone that included 428 NYHA Class III or IV heart failure patients with ejection fractions (EF) ≤45% by core laboratory assessment. The study met its primary safety endpoint, but did not reach its primary efficacy endpoint: a responders analysis of changes in ventilatory anaerobic threshold (VAT). However, in a pre-specified subgroup analysis, significant improvements in primary and secondary endpoints, including the responder VAT endpoint, were observed in patients with EF ranging from 25% to 45% (inclusive), who comprised about half of the study subjects. We therefore designed a new study to prospectively confirm the efficacy of CCM in this population. A hierarchical Bayesian statistical analysis plan was developed to take advantage of the data already available from the first study. In addition, based on technical difficulties encountered in reliably quantifying VAT and the relatively large amount of non-quantifiable studies, the primary efficacy endpoint was changed to peak VO2, with significant measures incorporated to minimize the influence of placebo effect. In this paper, we provide the details and rationale of the FIX-HF-5C study design to study CCM plus OMT compared to OMT alone in subjects with normal QRS duration, NYHA III or IV and EF 25% to 45%. This study is registered on HYPERLINKError! Hyperlink reference not valid. NCT01381172.
    Journal of cardiac failure. 10/2014;
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    ABSTRACT: The study sought to assess feasibility, safety, and potential efficacy of a novel implantable extra-aortic counterpulsation system (C-Pulse) in functional class III and ambulatory functional class IV heart failure (HF) patients.
    JACC. Heart failure. 10/2014; 2(5):526-33.
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    ABSTRACT: Implantable monitoring devices have been developed to detect early evidence of heart failure (HF) decompensation, with the hypothesis that early detection might enable clinicians to commence therapy sooner than would otherwise be possible, and potentially to reduce the rate of hospitalization. In addition to the usual challenges inherent to device trials (such as the difficulty of double-blinding and potential for bias), studies of implantable monitoring devices present unique difficulties because they involve assessment of therapeutic end points for diagnostic devices. Problems include the lack of uniform approaches to treatment in study protocols for device alerts or out-of-range values, and the requirement of levels of evidence traditionally associated with therapeutic devices to establish effectiveness and safety. In this Review, the approaches used to deal with these issues are discussed, including the use of objective primary end points with blinded adjudication, identical duration of follow-up and number of encounters for patients in active monitoring and control groups, and treatment recommendations between groups that are consistent with international guidelines. Remote monitoring devices hold promise for reducing the rate of hospitalization among patients with HF. However, optimization of regulatory approaches and clinical trial design is needed to facilitate further evaluation of the effectiveness of combining health information technology and medical devices.
    Nature Reviews Cardiology 08/2014; · 10.40 Impact Factor
  • Journal of cardiac failure. 08/2014; 20(8S):S111-S112.
  • Journal of Cardiac Failure 08/2014; 20(8S):S117-S118. · 3.32 Impact Factor
  • Journal of cardiac failure. 08/2014; 20(8S):S93.
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    ABSTRACT: -Left ventricle (LV) remodeling after anterior wall myocardial infarction leads to increased LV volumes, myocardial stress, and ultimately heart failure (HF). Treatment options are limited for these high-risk HF patients. A study was conducted to assess safety and feasibility of a percutaneous ventricular restoration (PVR) therapy using the Parachute(®) device in subjects with HF due to a cardiac ischemic event.
    Circulation Heart Failure 07/2014; · 6.68 Impact Factor
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    ABSTRACT: Several features of cardiovascular devices raise considerations for clinical trial conduct. Prospective, randomized, controlled trials remain the highest quality evidence for safety and effectiveness assessments, but, for instance, blinding may be challenging. In order to avoid bias and not confound data interpretation, the use of objective endpoints and blinding patients, study staff, core labs, and clinical endpoint committees to treatment assignment are helpful approaches. Anticipation of potential bias should be considered and planned for prospectively in a cardiovascular device trial. Prospective, single-arm studies (often referred to as registry studies) can provide additional data in some cases. They are subject to selection bias even when carefully designed; thus, they are generally not acceptable as the sole basis for pre-market approval of high risk cardiovascular devices. However, they complement the evidence base and fill the gaps unanswered by randomized trials. Registry studies present device safety and effectiveness in day-to-day clinical practice settings and detect rare adverse events in the post-market period. No single research design will be appropriate for every cardiovascular device or target patient population. The type of trial, appropriate control group, and optimal length of follow-up will depend on the specific device, its potential clinical benefits, the target patient population and the existence (or lack) of effective therapies, and its anticipated risks. Continued efforts on the part of investigators, the device industry, and government regulators are needed to reach the optimal approach for evaluating the safety and performance of innovative devices for the treatment of cardiovascular disease.
    International Journal of Cardiology. 07/2014; 175(1):30–37.
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    ABSTRACT: Aims: Elevated filling pressures of the left atrium (LA) are associated with poorer outcomes in patients with chronic heart failure. The V-Wave is a new percutaneously implanted device intended to decrease the LA pressure by the shunting of blood from the LA to the right atrium. This report describes the first-in-man experience with the V-Wave device. Methods and results: A 70-year-old man with a history of heart failure of ischaemic origin, left ventricular dysfunction (LVEF: 35%, pulmonary wedge: 19 mmHg), no right heart dysfunction, NYHA Class III and orthopnoea despite optimal treatment, was accepted for V-Wave device implantation. The device consists of an ePTFE encapsulated nitinol frame that is implanted at the level of the interatrial septum and contains a trileaflet pericardium tissue valve sutured inside which allows a unidirectional LA to right atrium shunt. The procedure was performed through a transfemoral venous approach under fluoroscopic and TEE guidance. The device was successfully implanted and the patient was discharged 24 hours after the procedure with no complications. At three-month follow-up a left-to-right shunt through the device was confirmed by TEE. The patient was in NYHA Class II, without orthopnoea, the Kansas City Cardiomyopathy index was 77.6 (from 39.1 at baseline) and NT-proBNP was 322 ng/mL (from 502 ng/mL at baseline). The QP/QS was 1.17 and the pulmonary wedge was 8 mmHg, with no changes in pulmonary pressure or right ventricular function. Conclusions: Left atrial decompression through a unidirectional left-to-right interatrial shunt represents a new concept for the treatment of patients with left ventricular failure. The present report shows the feasibility of applying this new therapy with the successful and uneventful implantation of the V-Wave device, which was associated with significant improvement in functional, quality of life and haemodynamic parameters at 90 days.
    EuroIntervention: journal of EuroPCR in collaboration with the Working Group on Interventional Cardiology of the European Society of Cardiology 05/2014; · 3.17 Impact Factor
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    ABSTRACT: Several features of cardiovascular devices raise considerations for clinical trial conduct. Prospective, randomized, controlled trials remain the highest quality evidence for safety and effectiveness assessments, but, for instance, blinding may be challenging. In order to avoid bias and not confound data interpretation, the use of objective endpoints and blinding patients, study staff, core labs, and clinical endpoint committees to treatment assignment are helpful approaches. Anticipation of potential bias should be considered and planned for prospectively in a cardiovascular device trial. Prospective, single-arm studies (often referred to as registry studies) can provide additional data in some cases. They are subject to selection bias even when carefully designed; thus, they are generally not acceptable as the sole basis for pre-market approval of high risk cardiovascular devices. However, they complement the evidence base and fill the gaps unanswered by randomized trials. Registry studies present device safety and effectiveness in day-to-day clinical practice settings and detect rare adverse events in the post-market period. No single research design will be appropriate for every cardiovascular device or target patient population. The type of trial, appropriate control group, and optimal length of follow-up will depend on the specific device, its potential clinical benefits, the target patient population and the existence (or lack) of effective therapies, and its anticipated risks. Continued efforts on the part of investigators, the device industry, and government regulators are needed to reach the optimal approach for evaluating the safety and performance of innovative devices for the treatment of cardiovascular disease.
    International journal of cardiology. 05/2014;
  • Mahmoud Houmsse, William T Abraham
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    ABSTRACT: Cardiac resynchronization therapy (CRT) is a well-established therapy to reduce morbidity and mortality in patients with moderate and severe symptomatic congestive heart failure. Left ventricular (LV) pacing that fuses with intrinsic right ventricular (RV) conduction results in similar or even better cardiac performance compared to biventricular (Biv) pacing. Optimal programming of the atrio-ventricular (AV) and inter-ventricular (VV) delays is crucial to improve LV performance since suboptimal programming of AV and VV delays affect LV filling as well as cardiac output. CRT optimization using echocardiogram is resource-dependent and time consuming. Adaptive CRT (aCRT) algorithm provides a dynamic, automatic, ambulatory adjustment of CRT pacing configuration (Biv or LV pacing) and optimization of AV and VV delays. aCRT algorithm is safe and efficacious for CRT-indicated patients without permanent atrial fibrillation. It has been shown to improve CRT response and reduce morbidity and mortality for patients with normal AV conduction.
    Expert Review of Cardiovascular Therapy 03/2014;
  • William T Abraham, Gaetano M De Ferrari
    Journal of Cardiovascular Translational Research 03/2014; · 3.06 Impact Factor
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    ABSTRACT: Implanted devices (eg, pacemakers and defibrillators) provide valuable information and may be interrogated to obtain diagnostic information and to direct management. During admission to an emergency department (ED), significant time and cost are spent waiting for device manufacturer representatives or cardiologists to access the data. If ED personnel could safely interrogate implanted devices, more rapid disposition could occur, thus leading to potentially better outcomes at a reduced cost. This was a pilot study examining the feasibility of ED device interrogation. This was a prospective convenience sample study of patients presenting to the ED with any chief complaint and who had an implantable device capable of being interrogated by a Medtronic reader. After obtaining informed consent, study patients underwent device interrogation by ED research personnel. After reviewing the device data, the physician documented their opinions of the value of data in aiding care. Patients were followed up at intervals ranging from 30 days out to 1 year to determine adverse events relating to interrogation. Forty-four patients underwent device interrogation. Their mean age was 56 ± 14.7 years (range, 28-83), 75% (33/44) were male and 75% (33/44) were hospitalized from the ED. The interrogations took less than 10 minutes 89% of the time. In 60% of the cases, ED physicians reported the data-assisted patient care. No adverse events were reported relating to the ED interrogations. In this pilot study, we found that ED personnel can safely and quickly interrogate implantable devices to obtain potentially useful clinical data.
    Critical pathways in cardiology 03/2014; 13(1):6-8.
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    ABSTRACT: Background PH associated with left heart disease (WHO Group II) has previously been associated with significant morbidity and mortality. However, there are currently no approved therapies or hemodynamic monitoring systems to improve outcomes in WHO Group II PH. Methods We conducted a retrospective analysis of the CHAMPION trial of an implantable hemodynamic monitor (IHM) in 550 NYHA functional class III HF patients regardless of LVEF or HF etiology. We evaluated clinical variables, changes in medical therapy, HF hospitalization rates and survival in patients with and without WHO Group II PH. Results 314 patients (59%) had WHO Group II PH. Patients without PH were at significantly lower risk for mortality than PH patients (HR 0.31, 95% CI 0.19-0.52, p<0.0001). PH patients had higher HF hospitalization rates than non-PH patients (0.77/year vs. 0.37/year, HR 0.49, 95%CI 0.39-0.61, P<0.001). In patients with and without PH, ongoing knowledge of hemodynamic data resulted in a reduction in HF hospitalization (HR 0.64, 95% CI 0.51-0.81, P=0.002) for PH patients and (HR 0.60, 95% CI 0.41-0.89, P=0.01) for non-PH patients. Amongst PH patients, there was a reduction in the composite endpoint of death and HF hospitalization with ongoing knowledge of hemodynamics (HR 0.74, 95% CI 0.55-0.99, p=0.04) but no difference in survival (HR 0.78, 95% CI 0.50-1.22, p=0.28). Conclusions WHO Group II PH is prevalent and identifies HF patients at risk for adverse outcomes. Ongoing knowledge of hemodynamic variables may allow for more effective treatment strategies to reduce the morbidity of this disease.
    The Journal of Heart and Lung Transplantation. 01/2014;
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    ABSTRACT: AimsWe hypothesized that diagnostic data in implantable devices evaluated on the day of discharge from a heart failure hospitalization (HFH) can identify patients at risk for HF readmission (HFR) within 30 days. Methods and resultsIn this retrospective analysis of four studies enrolling patients with CRT devices, we identified patients with a HFH, device data on the day of discharge, and 30-day post-discharge clinical follow-up. Four diagnostic criteria were evaluated on the discharge day: (i) intrathoracic impedance >8 Ω below reference impedance; (ii) AF burden >6 h; (iii) CRT pacing <90%; and (iv) night heart rate >80 b.p.m. Patients were considered to have higher risk for HFR if ≥2 criteria were met, average risk if 1 criterion was met, and lower risk if no criteria were met. A Cox proportional hazards model was used to compare the groups. The data cohort consisted of a total of 265 HFHs in 175 patients, of which 36 (14%) were followed by HFR. On the discharge day, ≥2 criteria were met in 43 (16% of 265 HFHs), only 1 criterion was met in 92 (35%), and none of the four criteria were met in 130 HFHs (49%); HFR rates were 28, 16, and 7%, respectively. HFH with ≥2 criteria met was five times more likely to have HFR compared with HFH with no criteria met (adjusted hazard ratio 5.0; 95% confidence interval 1.9–13.5, P = 0.001). Conclusion Device-derived diagnostic criteria evaluated on the day of discharge identified patients at significantly higher risk of HFR.
    European Journal of Heart Failure 12/2013; · 5.25 Impact Factor
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    ABSTRACT: -Cardiac resynchronization therapy (CRT) decreases mortality, improves functional status and induces reverse left ventricular (LV) remodeling in selected populations with heart failure (HF). These benefits have been noted with both CRT pacemakers (CRT-P) as well as those devices with defibrillator back-up (CRT-D). However, there are little data comparing mortality between these two device types. -REVERSE was a multi-center, randomized trial of CRT among patients with mild HF. Long-term annual follow-up for 5 years was preplanned. The present analysis was confined to the 419 patients who were randomized to CRT ON. CRT-P or CRT-D devices were implanted based on national guidelines at the time of enrollment, with 74 patients receiving CRT-P devices and the remaining 345 receiving CRT-D devices. After 12 months of CRT, changes in the Clinical Composite Score, left ventricular end systolic volume index (LVESVi), 6-minute walk time and quality of life indices were similar between CRT-P and CRT-D patients. However, long term follow-up showed lower morality in the CRT-D group. Specifically, multi-variable analysis showed that CRT-D (Hazard ratio 0.35, p= 0.003) was a strong independent predictor of survival. Female sex, longer unpaced QRS duration, and smaller baseline LVESVi also were also associated with better survival. -REVERSE demonstrated that the addition of ICD therapy to CRT is associated with improved long term survival compared with CRT pacing alone in mild HF. Clinical Trial Registration-URL: http://clinicaltrials.gov; Unique Identifier: NCT00271154.
    Circulation Arrhythmia and Electrophysiology 10/2013; · 5.95 Impact Factor
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    ABSTRACT: Adaptive cardiac resynchronization therapy (aCRT) is a novel algorithm for CRT pacing that provides automatic ambulatory selection between synchronized left ventricular (LV) or bi-ventricular (BiV) pacing and optimization of atrioventricular (AV) and inter-ventricular (VV) delays based on periodic measurement of intrinsic conduction. We aimed to compare the clinical response between aCRT and standard CRT in historical trials.METHODS AND RESULTS: The treatment arm of the aCRT trial was compared with a pooled historical control (HC) derived from the CRT arms of four clinical trials (MIRACLE, MIRACLE ICD, PROSPECT, and InSync III Marquis) with respect to the proportion of patients who had an improved clinical composite score (CCS) at the 6-month follow-up. Patients in the HC underwent echocardiography-guided AV optimization after the implant. A propensity score model was used to adjust for 22 potential baseline confounders of the effect of CRT. Patients were stratified into quintiles according to the propensity score and the adjusted absolute treatment effect was obtained by averaging estimates across these quintiles. The propensity score model included 751 patients (aCRT: 266, historical trials: 485). The adjusted absolute difference in percent improved in CCS between the aCRT and HC arms was 11.9% [95% confidence interval (CI): 2.7-19.2%] favouring aCRT. The patients in the aCRT group were significantly more likely to have an improved CCS than the patients in the HC (odds ratio = 1.65, 95% CI: 1.1-2.5).CONCLUSION: The aCRT algorithm may be associated with additional improvement in clinical response compared with historical CRT with echocardiographic AV optimization.
    Europace 09/2013; · 2.77 Impact Factor

Publication Stats

24k Citations
2,917.14 Total Impact Points

Institutions

  • 1999–2014
    • The Ohio State University
      • Division of Cardiovascular Medicine
      Columbus, Ohio, United States
  • 2013
    • Case Western Reserve University
      Cleveland, Ohio, United States
    • Technion - Israel Institute of Technology
      H̱efa, Haifa District, Israel
    • University of South Carolina
      Columbia, South Carolina, United States
  • 2006–2013
    • Karolinska University Hospital
      • Department of Cardiology
      Tukholma, Stockholm, Sweden
    • CSU Mentor
      Long Beach, California, United States
    • European Hospital
      Roma, Latium, Italy
  • 1990–2013
    • University of Colorado
      • • Division of Cardiology
      • • Department of Medicine
      Denver, Colorado, United States
  • 2012
    • University of Washington Seattle
      Seattle, Washington, United States
    • Detroit Medical Center
      Detroit, Michigan, United States
    • Thomas Jefferson University
      • Division of Hospital Medicine
      Philadelphia, PA, United States
  • 2008–2012
    • Duke University Medical Center
      • Division of Cardiology
      Durham, North Carolina, United States
    • Medical University of South Carolina
      • • Division of Cardiology
      • • Department of Medicine
      Charleston, SC, United States
    • Massachusetts General Hospital
      Boston, Massachusetts, United States
    • New York Presbyterian Hospital
      • Department of Cardiology
      New York City, New York, United States
    • Baylor Health Care System
      • Baylor Heart and Vascular Institute (BHVI)
      Dallas, Texas, United States
  • 2011
    • 4 Szpital Wojskowy z Polikliniką we Wrocławiu
      Vrotslav, Lower Silesian Voivodeship, Poland
  • 2010–2011
    • University of Zurich
      • Institute of Physiology
      Zürich, ZH, Switzerland
    • University of Otago
      Taieri, Otago Region, New Zealand
    • Henry Ford Hospital
      Detroit, Michigan, United States
    • Brigham and Women's Hospital
      • Center for Brain Mind Medicine
      Boston, MA, United States
  • 2006–2011
    • Northwestern University
      • Division of Cardiology (Dept. of Medicine)
      Evanston, Illinois, United States
  • 2006–2010
    • Canterbury District Health Board
      • Department of Cardiology
      Christchurch, Canterbury, New Zealand
  • 2009
    • Columbia University
      • Division of Cardiology
      New York City, NY, United States
    • Akershus universitetssykehus
      Kristiania (historical), Oslo County, Norway
    • Harvard Medical School
      • Department of Medicine
      Boston, Massachusetts, United States
    • Monash University (Australia)
      • School of Public Health and Preventive Medicine
      Melbourne, Victoria, Australia
    • Università degli Studi di Brescia
      Brescia, Lombardy, Italy
    • Centre Hospitalier Universitaire de Rennes
      Roazhon, Brittany, France
    • Hospital of the University of Pennsylvania
      Philadelphia, Pennsylvania, United States
  • 2008–2009
    • Mayo Foundation for Medical Education and Research
      • Cardiorenal Research Laboratory
      Scottsdale, AZ, United States
  • 2007–2009
    • Harbor-UCLA Medical Center
      Torrance, California, United States
    • University of California, San Francisco
      • Veterans Affairs Medical Center
      San Francisco, CA, United States
    • Stanford University
      • Division of Cardiovascular Medicine
      Stanford, CA, United States
    • National University (California)
      San Diego, California, United States
  • 2004–2009
    • University of California, Los Angeles
      • Department of Medicine
      Los Angeles, CA, United States
    • Hartford Hospital
      • Department of Pathology and Laboratory Medicine
      Hartford, CT, United States
    • Vanderbilt University
      Nashville, Michigan, United States
    • Boston Medical Center
      Boston, Massachusetts, United States
    • University Hospital Magdeburg
      Magdeburg, Saxony-Anhalt, Germany
  • 1999–2009
    • University of Cincinnati
      • Department of Emergency Medicine
      Cincinnati, OH, United States
  • 2006–2008
    • University of Alabama at Birmingham
      • Division of Cardiovascular Disease
      Birmingham, AL, United States
  • 2002–2008
    • University of California, San Diego
      • Division of Cardiology
      San Diego, California, United States
    • University of Maryland Medical Center
      Baltimore, Maryland, United States
    • Cincinnati Children's Hospital Medical Center
      • Division of Cardiology
      Cincinnati, Ohio, United States
  • 2002–2006
    • University of Maryland, Baltimore
      • • Department of Medicine
      • • Division of Cardiology
      Baltimore, MD, United States
  • 2005
    • Blue Water Task Force
      Big Sky, Montana, United States
    • San Francisco VA Medical Center
      San Francisco, California, United States
    • Lexington College
      Lexington, Kentucky, United States
    • Hôpital Bichat - Claude-Bernard (Hôpitaux Universitaires Paris Nord Val de Seine)
      Lutetia Parisorum, Île-de-France, France
  • 2004–2005
    • Oslo University Hospital
      • Department of Cardiology
      Kristiania (historical), Oslo County, Norway
    • Henry Ford Health System
      Detroit, Michigan, United States
  • 2001–2005
    • University of Kentucky
      • Department of Medicine
      Lexington, Kentucky, United States
  • 2003
    • William Beaumont Army Medical Center
      El Paso, Texas, United States
    • University of Oklahoma Health Sciences Center
      • Department of Internal Medicine
      Oklahoma City, OK, United States
    • Sharp Memorial Hospital
      San Diego, California, United States
    • University of Missouri - Kansas City
      • Department of Basic Med Sciences
      Kansas City, MO, United States
    • University of Texas Southwestern Medical Center
      • Department of Internal Medicine
      Dallas, TX, United States
  • 2000
    • Beverly Hospital, Boston MA
      Beverly, Massachusetts, United States
  • 1997
    • University of Utah
      Salt Lake City, Utah, United States
  • 1995
    • Montreal Heart Institute
      Montréal, Quebec, Canada
    • University of Colorado Hospital
      • Department of Medicine
      Denver, Colorado, United States