Jay Giri

University of Pennsylvania, Philadelphia, Pennsylvania, United States

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Publications (24)116.32 Total impact

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    ABSTRACT: A meta-analysis was performed to evaluate the risk of major bleeding with the use of New Oral Anticoagulants (NOACs).Methods Randomized controlled trials (RCTs) comparing NOACs (rivaroxaban, dabigatran, apixaban, edoxaban and darexaban) with comparators were selected.ResultsFifty trials included 155,537 patients. Pooled analysis of all NOACs for all indications together demonstrated no significant difference between NOACs and comparators for risk of major bleeding (odds ratio [OR] 0.93, 95% CI 0.79–1.09). Pooled analysis also showed that NOACs caused significantly less major bleeding compared to vitamin K antagonists (VKA) (0.77, 0.64–0.91). The analysis for individual NOACs showed risk of major bleeding were not different with rivaroxaban, apixaban or dabigatran compared to pharmacologically active comparators or VKA. Indication specific analysis showed that NOACs were associated with significantly higher major bleeding after hip surgery (1.43, 1.02–1.99), in patients with acute coronary syndrome (ACS), (compared against placebo) (2.89, 2.01–4.14), and for medically ill patients (2.79, 1.69–4.60). For the treatment of acute venous thromboembolism (VTE) or pulmonary embolism (PE), NOACs were associated with significantly less bleeding (0.63, 0.44–0.90). No significant difference was found between NOACs and comparators in treatment of atrial fibrillation and for extended treatment of VTE.Conclusions Risk of major bleeding with new oral anticoagulants varies with their indication for use. New agents may be associated with comparatively less major bleeding compared to VKA. NOAC may increase the risk of major bleeding after hip surgery, ACS and acute medically ill patients; but may be associated with less bleeding in treatment of acute VTE/PE.
    International Journal of Cardiology. 11/2014;
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    ABSTRACT: Background: Coronary artery aneurysms (CAA) are seen in 1-5% of angiograms. Aneurysmal coronary disease has been thought to be a variant of atherosclerotic coronary artery disease (CAD) in most patients, but this has not been systematically studied. Methods: To better understand the pathophysiology of CAA, we reviewed the cardiac catheterization films of 403 patients with ascending thoracic aortic aneurysms and 74 patients with abdominal aortic aneurysms (AAA) who underwent surgery for their aortic aneurysms at our institution. Coronary aneurysms had diameters 1.5-fold that of a reference segment. Results: The incidences of CAA in patients with ascending aneurysms and AAA were 17% and 16% respectively (p=0.92). CAAs in the ascending group were larger (mean diameter 5.9 vs 5.0 mm, p=0.12) with larger reference vessel size (3.1 vs 2.6 mm, p=0.03). CAAs in the patients with ascending aneurysms were less likely to be CAD-associated within the same vessel (12% vs 75%, p<0.001). This difference remained significant after controlling for the presence of generalized CAD. No other differences in CAAs between the two groups were found. Within the ascending aneurysm group, the only clinical variable independently associated with CAA was bicuspid aortic valve (OR 0.47, 95% confidence interval 0.25-0.89, p=0.02). The majority of patients with CAA in the ascending aortic aneurysm population did not have CAD or any other previously identified cause of CAA. Conclusions: There is a high incidence of CAA in patients with aortic aneurysms. In patients with ascending aortic aneurysms there is likely a mechanism distinct from CAD that causes CAAs. © 2014 Wiley Periodicals, Inc.
    11/2014;
  • International journal of cardiology. 11/2014; 179C:225-227.
  • Saurav Chatterjee, Jay Giri
    JAMA. 10/2014; 312(15):1589-1590.
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    ABSTRACT: Recent studies have suggested that transcatheter aortic valve replacement (TAVR) may have superior outcomes compared with aortic valve replacement (AVR) for high-risk patients with significant mitral regurgitation (MR). Considering significant MR is frequently addressed with a mitral valve repair or replacement (MVR) at the time of open aortic valve replacement, this study compares TAVR and AVR/MVR in propensity-matched pairs of patients with significant MR.
    The Annals of thoracic surgery. 08/2014;
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    ABSTRACT: Vascular complications after transfemoral transcatheter aortic valve replacement are common and associated with significant morbidity and mortality. Little is known about the effect of access approach on vascular complications.
    Circulation Cardiovascular Interventions 07/2014; · 6.54 Impact Factor
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    ABSTRACT: To systematically examine discontinuation rates with new US Food and Drug Administration-approved oral anticoagulants (NOACs) in patients with various indications for long-term anticoagulation.
    Mayo Clinic Proceedings 07/2014; 89(7):896-907. · 5.79 Impact Factor
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    ABSTRACT: Thrombolytic therapy may be beneficial in the treatment of some patients with pulmonary embolism. To date, no analysis has had adequate statistical power to determine whether thrombolytic therapy is associated with improved survival, compared with conventional anticoagulation.
    JAMA The Journal of the American Medical Association 06/2014; 311(23):2414-21. · 29.98 Impact Factor
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    ABSTRACT: Objectives. To describe the first single center experience with a novel aspiration thrombectomy device.Background. The appearance of inferior vena cava or right-sided intracardiac thrombus may prompt consideration of percutaneous thrombectomy as a method to prevent new or worsening pulmonary embolism (PE). The AngioVac is a novel thrombectomy device composed of a cannula and extracorporeal circuit with filter for pump-assisted removal of intravascular debris which is coupled with a reinfusion catheter for return of blood to the patient. The device has been approved by the United States Food and Drug Administration since 2009. This report represents the first significant case series describing its use, feasibility and outcomes in evacuating large caval thrombi or intracardiac masses in PE.Methods. This is a retrospective analysis of patient and case characteristics and in-hospital clinical outcomes of AngioVac thrombectomy in 14 consecutive patients treated between April 2010 and July 2013 at our institution.Results. Fourteen consecutive patients (mean age 50, 64% female) underwent 15 AngioVac procedures over 40 months. Indications included intracardiac mass (73%), acute pulmonary embolism (33%) and caval thrombus (73%). Four patients (27%) were in shock at the start of the procedure. Peri-procedure mortality was 0% and in-hospital mortality was 13% at a mean follow-up of 23 days. There were no pulmonary hemorrhages, strokes or myocardial infarctions. Though 73% had a post procedural drop in hematocrit, only two bleeding events were related to access site and required a transfusion.Conclusions. AngioVac thrombectomy is feasible in critically ill patients with acute DVT or PE and large caval thrombi or intracardiac masses. © 2014 Wiley Periodicals, Inc.
    Catheterization and Cardiovascular Interventions 06/2014; · 2.51 Impact Factor
  • Circulation Cardiovascular Interventions 04/2014; 7(2):266-7. · 6.54 Impact Factor
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    ABSTRACT: Direct transaortic (TAo) approach for transcatheter aortic valve replacement (TAVR) in patients with symptomatic, severe aortic stenosis (AS) with prohibitive transfemoral access is being increasingly performed. Furthermore, concomitant catheter-based procedures such as percutaneous coronary intervention (PCI) are also being increasingly performed during TAVR. We report a single-stage, catheter-based treatment of both critical AS and descending thoracic aortic aneurysm (DTA) by performing TAVR with concomitant thoracic aortic endovascular repair (TEVAR) through direct TAo access via a minimally invasive partial sternotomy approach. To our knowledge, this is the first report of a "hybrid" TAVR + TEVAR.
    The Annals of thoracic surgery 02/2014; 97(2):696-698. · 3.45 Impact Factor
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    ABSTRACT: This study sought to characterize usage and outcomes of carotid stenting platforms. A variety of stents and embolic protection devices (EPDs) are used for carotid artery stenting. Little is known about current usage patterns and differences in outcomes with these devices. We analyzed 12,135 consecutive carotid stent procedures in the NCDR (National Cardiovascular Data Registry) CARE (Carotid Artery Revascularization and Endarterectomy) registry performed between January 1, 2007 and March 31, 2012. We compared baseline characteristics and crude and multivariable-adjusted rates of in-hospital combined death/stroke among patients treated with Acculink/Accunet (Abbott Laboratories, Abbott Park, Illinois), Xact/Emboshield (Abbott), and Precise/Angioguard (Cordis Corporation, Bridgewater, New Jersey) stent/EPD combinations. In 78.2% of cases, stents were used in conjunction with their specific, corresponding U.S. Food and Drug Administration-approved EPD. The Acculink/Accunet (n =2,617, 21.6%), Xact/Emboshield (n = 3,507, 28.9%), and Precise/Angioguard (n = 2,696, 22.2%) stent/EPD combinations were used in 72.7% of all cases. The Protégé/SpiderFx (ev3 Endovascular Inc., Plymouth, Minnesota) (n = 453, 3.7%) and Wallstent/Filterwire (Boston Scientific, Natick, Massachusetts) (n = 213, 1.8%) devices were used in a minority of cases. In unadjusted analyses, the Precise/Angioguard system was associated with higher rates of the primary outcome than were the Acculink/Accunet (2.5% vs. 1.8%; p = 0.058) and Xact/Emboshield (2.5% vs. 1.9%; p = 0.14) systems that were not statistically different. In adjusted analyses, differences between Precise/Angioguard and Accunet/Acculink (odds ratio [OR]: 1.48, 95% confidence interval [CI]: 0.89 to 2.47; p = 0.065), Precise/Angioguard and Xact/Emboshield (OR: 1.16, 95% CI: 0.77 to 1.76; p = 0.38), and Xact/Emboshield and Accunet/Acculink (OR: 1.28, 95% CI: 0.82 to 1.97; p = 0.18) remained nonsignificant. In modern U.S. practice, the Acculink/Accunet, Xact/Emboshield, and Precise/Angioguard carotid stenting systems are used in most cases and are associated with similarly low rates of adverse events.
    JACC. Cardiovascular Interventions 01/2014; · 1.07 Impact Factor
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    ABSTRACT: Renal artery stent revascularization is commonly used for renovascular hypertension. Clinical predictors associated with blood pressure (BP) improvement after renal artery stent revascularization are not well understood. Patient-level data from 901 patients in five prospective multicenter Food and Drug Administration-approved investigational device exemption studies of renal artery stent revascularization was pooled. BP response was defined as reduction of systolic BP (SBP) by >10 mm Hg. Stent patency was defined within each study. Associations of BP reduction were determined by logistic regression. Of 901 patients, complete outcome information was available in 527. Of these, 212/527 (40%) were male, mean age was 63 ± 13 years, 196/544 (36%) were diabetic and 504/527 (96%) had a SBP ≥ 140 mm Hg or DBP ≥ 90 mm Hg at baseline. Compared to baseline, 9-month systolic (164 ± 21 mm Hg vs. 146 ± 22 mm Hg, P < 0.0001) and diastolic (79 ± 13 mm Hg vs. 76 ± 12 mm Hg, P < 0.0001) BP declined significantly. Nine-month stent patency was 90% (305/339). In a univariate analysis, baseline SBP >150 mm Hg (OR = 4.09, CI = 2.74-6.12, P < 0.0001) was positively associated with BP response following renal artery stent revascularization. In a multivariable analysis, baseline SBP remained associated with a positive BP response (OR = 1.76, CI = 1.53-2.03, P < 0.0001). In the largest pooled dataset of patients treated with renal artery stent revascularization, SBP and DBP were significantly lower at 9-months. Elevated baseline SBP (>150 mm Hg) was strongly associated with BP reduction after the procedure. © 2013 Wiley Periodicals, Inc.
    Catheterization and Cardiovascular Interventions 10/2013; · 2.51 Impact Factor
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    ABSTRACT: Percutaneous endovascular revascularization is emerging as the first line treatment for peripheral artery disease for both intermittent claudication and chronic critical limb ischemia. Radiation doses for these interventions have not been well documented. A single center retrospective study of therapeutic endovascular lower extremity interventions performed between September 2006 and December 2011 was undertaken. Collected data included patient demographics, procedure indication, procedural access, anatomic location of occlusive disease (pelvis, thigh, below-knee, or multilevel), and radiation exposure parameters including dose area product (DAP) and fluoroscopy time. Data was available for 382 procedures performed in 313 patients. Eighteen procedures bilateral procedures were excluded. Access site and complete anatomic data were available for 346 procedures. DAP was significantly higher for procedures performed in the pelvis compared with thigh procedures (179.6 vs 63.2 Gy*cm(2); P < .0001) and below-knee procedures (179.6 vs 28.9 Gy*cm(2); P < .0001), despite shorter fluoroscopy times (11.8 vs 16.4 minutes; P < .0001 and 11.1 vs 31.06 minutes; P < .0001, respectively). Procedure access-site affected radiation dose as well; contralateral up-and-over access resulted in a higher DAP than antegrade access (112.2 vs 42.6 Gy*cm(2); P < .0001). In a multivariable analysis, anatomic location of the procedure showed the strongest association with radiation dose (P < .0001). Percutaneous endovascular revascularization for lower extremity peripheral artery disease involves a substantial radiation dose, comparable, on average, to a computed tomography scan of the abdomen and pelvis. Procedures performed in the pelvis for intermittent claudication involve more radiation than thigh or below-knee procedures for chronic critical limb ischemia. Radiation dose should be considered when planning these procedures.
    Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 07/2013; · 3.52 Impact Factor
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    ABSTRACT: Background & Purpose: Embolic protection devices (EPD) may provide a mechanism to reduce peri-procedural strokes. They are advocated by consensus guidelines and mandated for Medicare reimbursement. However, outcomes data remain mixed. We aimed to characterize the population of patients undergoing unprotected carotid artery stenting (CAS) and assess the utility of distal filter EPD in elective CAS. Methods: We analyzed patients enrolled in the CARE Registry® undergoing CAS between May, 2005 and January, 2012. We assessed the relationship between distal filter EPD (F-EPD) use versus no use (No-EPD) and the composite of in-hospital death or stroke (MAE) in unadjusted and 1:3 propensity-matched analyses. Results: Embolic protection was not attempted in a total of 579 out of 13,263 cases performed (4.4%). Patients in the No-EPD group had worse pre-procedure neurologic risk factors including higher rates of acute evolving stroke, prior TIA/stroke, symptomatic lesion status, spontaneous carotid artery dissection, and use of general anesthesia intra-procedurally (all Standardized Differences{sd} >10). After exclusion of non-elective cases there was no significant difference in MAE between the No-EPD and F-EPD groups (1.6% vs. 2.3%, sd=4.72). Additionally, after propensity matching, rates of MAE did not differ between the No-EPD (n = 355) and F-EPD (n = 1065) groups (1.7% vs. 2.5%, sd=5.87). Conclusions: Patients selected to undergo unprotected CAS in contemporary practice have high rates of adverse pre-procedure neurologic risk factors. Our propensity-matched analysis did not demonstrate evidence of significant benefit or harm associated with use of distal filter EPD in elective CAS patients. © 2013 Wiley Periodicals, Inc.
    Catheterization and Cardiovascular Interventions 06/2013; · 2.51 Impact Factor
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    ABSTRACT: Objectives We developed and internally validated a risk score to predict in-hospital stroke or death after carotid artery stenting (CAS). Background A tool that accurately assesses CAS risk could aid clinical decision making and improve patient selection. Methods Patients undergoing CAS without acute evolving stroke from April 2005 through June 2011 as part of the NCDR Carotid Artery Revascularization and Endarterectomy (CARE) Registry were included. In-hospital stroke or death was modeled using logistic regression with 35 candidate variables. Internal validation was achieved with bootstrapping, and model discrimination and calibration were assessed. Results A total of 271 (2.4%) primary endpoint events occurred during 11,122 procedures. Independent predictors of stroke or death included impending major surgery, previous stroke, age, symptomatic lesion, atrial fibrillation, and absence of previous ipsilateral carotid endarterectomy. The model was well calibrated with moderate discriminatory ability (C-statistic: 0.71) overall, and within symptomatic (C-statistic: 0.68) and asymptomatic (C-statistic: 0.72) subgroups. The inclusion of available angiographic variables did not improve model performance (C-statistic: 0.72, integrated discrimination improvement 0.001; p = 0.21). The NCDR CAS score was developed to support prospective risk quantification. Conclusions The NCDR CAS score, comprising 6 clinical variables, predicts in-hospital S/D after CAS. This tool may be useful to assist clinicians in evaluating optimal management, share more accurate pre-procedural risks with patients, and improve patient selection for CAS.
    Journal of the American College of Cardiology 10/2012; 60(17):1617–1622. · 14.09 Impact Factor
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    ABSTRACT: BACKGROUND: Supra-normal ankle brachial index (ABI) (>1.40), poses diagnostic challenges to determine the presence, location, and severity of peripheral artery disease (PAD). The anatomic distribution of PAD in patients with elevated ABI has not been previously described. METHODS: A retrospective review of all patients referred to the Massachusetts General Hospital vascular diagnostic laboratory from 5/1/2006-12/1/2011 who had both a supra-normal ABI and contrast arteriography (CA) within 3 months of each other is reported. Angiographic patterns were described using the Trans Atlantic Inter Society Consensus II (TASC II) classification. RESULTS: One hundred sixteen limbs were analyzed in 92 patients. Mean age was 71.6 years (±11.2); 81.5% (75/92) were male; 85.9% Caucasian (79/92); 67.4% diabetics (62/92); 78.3% hypertensive (72/92); 67.4% hypercholesterolemic (62/92); and 64.1% were current or former tobacco users (59/92). Chronic hemodialysis was present in 18.5% (17/92) and 15.2% (14/92) received chronic corticosteroids. Intermittent claudication was present in 46.7% (43/92) and critical limb ischemia in 52.2% (48/92). Aortoiliac, femoral and infra-popliteal involvement per angiography occurred in 14.9% (15/101), 56.1% (60/107) and 84.0% (84/100), respectively. Multilevel disease was present in 48.8% (42/86) of patients. PAD was absent in 4.7% (4/86) of patients. Toe brachial index (TBI) <0.7 was found in 92% (92/100) of patients with angiographically confirmed PAD. CONCLUSION: In symptomatic patients referred to a vascular laboratory who were found to have supra-normal ABI, nearly one half exhibited multilevel PAD, and over 80% had infrapopliteal involvement. A supra-normal ABI in such patients mandates evaluation for the presence and extent of PAD. © 2012 Wiley Periodicals, Inc.
    Catheterization and Cardiovascular Interventions 08/2012; · 2.51 Impact Factor
  • Journal of the American College of Cardiology 08/2012; 60(6):e9. · 14.09 Impact Factor
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    ABSTRACT: To describe the clinical and procedural outcomes of patients treated with the valve-in-valve technique for severe aortic insufficiency (AI) after balloon-expandable transcatheter aortic valve replacement (TAVR). Severe AI immediately after valve implantation is a notable complication of TAVR. It can be treated with a valve-in-valve technique which involves deploying a second valve within the first one to crush the leaflets of the first implant leaving a new functional valve. We analyzed data on 142 consecutive patients at our institution undergoing TAVR with the Sapien valve between November of 2007 and April of 2011. Etiologies of acute AI, procedural and intermediate term clinical outcomes were reported for those in whom a valve-in-valve procedure was necessary. Post-hoc analysis of these cases with C-THV imaging (Paieon Medical Ltd.) was performed to elucidate the mechanism for successful AI treatment. A total of 5 of 142 (3.5%) patients were treated with the valve-in-valve technique. Etiologies of the aortic valve insufficiency included bioprosthesis malposition (n = 3), valve dysfunction (n = 1), and valve undersizing (n = 1). With placement of the second valve, the first valve dimensions increased to approach the nominal valve size while the second valve size remained less than nominal. The valve-in-valve technique is an appropriate bailout measure for patients with acute valvular AI after balloon-expandable TAVR.
    Catheterization and Cardiovascular Interventions 03/2012; 80(1):139-47. · 2.51 Impact Factor
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    ABSTRACT: Quantitative measures are needed to identify diabetic patients at higher risk for CV events. Cell-derived microparticles (MPs) are submicron membrane vesicles released from activated cells that are indicative of cell damage. Progenitor cells (PCs) including proangiogenic cells (PACs), often termed endothelial progenitor cells (EPCs), are mediators of reparative capacity. We examined whether the relationship of MPs to PCs/PACs could be used as an improved and clinically feasible index of vascular pathology. Plasma samples were collected from patients with early-stage (ES, Diagnosis < 1 year) and long-term (LT, Diagnosis > 5 years,) Type 2 diabetes and compared with age related healthy subjects (H). PC and MP subtypes were measured by a combination of flow cytometry and ELISA-based methods. The ratio of procoagulant MPs/CD34(+) PCs proved a valuable index to distinguish between subject groups (P = 0.01). This index of compromised vascular function was highest in the LT group despite intensive statin therapy and was more informative than a range of soluble protein biomarkers. This is the first report of a relationship between MPs and PCs in Type 2 diabetes. This ratio may provide a quantitative and clinically feasible measurement of vascular dysfunction and cardiovascular risk in patients with diabetes. © 2010 International Clinical Cytometry Society.
    Cytometry Part B Clinical Cytometry 09/2010; 78(5):329-37. · 2.23 Impact Factor

Publication Stats

74 Citations
116.32 Total Impact Points

Institutions

  • 2010–2014
    • University of Pennsylvania
      • • Department of Medicine
      • • Division of Cardiovascular Medicine
      Philadelphia, Pennsylvania, United States
  • 2008–2014
    • Hospital of the University of Pennsylvania
      • Division of Cardiovascular Medicine
      Philadelphia, Pennsylvania, United States
  • 2006
    • Massachusetts General Hospital
      Boston, Massachusetts, United States