Brian P Griffin

Metropolitan Heart and Vascular Institute, Minneapolis, Minnesota, United States

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Publications (150)1073.87 Total impact

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    ABSTRACT: We sought to a) assess predictors of mortality in consecutive patients with severe aortic stenosis (AS) undergoing aortic valve replacement (AVR) and b) determine if there are differences in mortality, separated on the basis of different AS subtypes and left ventricular stroke volume index (LV-SVI).
    Journal of Thoracic and Cardiovascular Surgery 03/2015; DOI:10.1016/j.jtcvs.2015.03.008 · 3.99 Impact Factor
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    ABSTRACT: Stress echocardiography is increasingly used in the management of patients with valvular heart disease and can aid in evaluation, risk stratification and clinical decision making in these patients. Evaluation of symptoms, exercise capacity and changes in blood pressure can be done during the exercise portion of the test, whereas echocardiographic portion can reveal changes in severity of disease, pulmonary artery pressure and left ventricular function in response to exercise. These parameters, which are not available at rest, can have diagnostic and prognostic importance. In this article, we will review the indications and diagnostic implications, prognostic implications, and clinical impact of stress echocardiography in decision making and management of patients with valvular heart disease.
    Expert Review of Cardiovascular Therapy 02/2015; 13(3):1-14. DOI:10.1586/14779072.2015.1013940
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    ABSTRACT: Malignancy-associated thoracic radiation leads to radiation-associated cardiac disease (RACD) that often necessitates cardiac surgery. Myocardial dysfunction is common in patients with RACD. We sought to determine the predictive value of global left ventricular ejection fraction and long-axis function left ventricular global longitudinal strain (LV-GLS) in such patients. We studied 163 patients (age, 63 ± 14 years; 74% women) who had RACD and underwent cardiac surgery (20% had reoperations) between 2000 and 2003. In addition to standard echocardiography, LV-GLS (%) was derived from the average of 18 segments in 3 apical views of the left ventricle, using velocity vector imaging. Standard clinical and demographic parameters were recorded. All-cause mortality was recorded. The mean duration between cardiac surgery and the last chest radiation was 18 ± 12 years. The median European System for Cardiac Operative Risk Evaluation (EuroSCORE) was 8, and 88 patients died over 6.6 ± 4 years. A total of 52% of patients had ≥II+ mitral regurgitation; 23% of patients had severe aortic stenosis; and 39% of patients had ≥II+ tricuspid regurgitation. The mean left ventricular ejection fraction was 54% ± 13%, and the mean LV-GLS was -12.9% ± 4%. In a Cox proportional survival analysis, lower LV-GLS was predictive of mortality in univariable analysis (hazard ratio, 1.07 (95% confidence interval, 1.01-1.14); P = .006); however, after adjustment for other variables, the association became nonsignificant. In patients with a EuroSCORE <median, abnormal LV-GLS (<-14.5%) was associated with significantly higher mortality (48%), compared with those with normal LV-GLS (32%). In patients who have RACD and undergo cardiac surgery, LV-GLS does not sufficiently discriminate and is not independently predictive of long-term outcomes. However, in patients with a low EuroSCORE, abnormal LV-GLS was associated with higher mortality, compared with those with normal LV-GLS. Copyright © 2015 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.
    Journal of Thoracic and Cardiovascular Surgery 02/2015; DOI:10.1016/j.jtcvs.2015.01.045 · 3.99 Impact Factor
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    ABSTRACT: Significant mitral regurgitation (MR) typically occurs as holosystolic (HS) or mid-late systolic (MLS), with differences in volumetric impact on the left ventricle (LV). We sought to assess outcomes of degenerative MR patients undergoing exercise echocardiography, separated based on MR duration (MLS versus HS). We included 609 consecutive patients with ≥III+myxomatous MR undergoing exercise echocardiography: HS (n=487) and MLS (n=122). MLS MR was defined as delayed appearance of MR signal during mid-late systole on continuous-wave Doppler while HS MR occurred throughout systole. Composite events of death and congestive heart failure were recorded. Compared to MLS MR, HS MR patients were older (60±14 versus 53±14 years), more were males (72% versus 53%), and had greater prevalence of atrial fibrillation (16% versus 7%; all P<0.01). HS MR patients had higher right ventricular systolic pressure (RVSP) at rest (33±11 versus 27±9 mm Hg), more flail leaflets (36% versus 6%), and a lower number of metabolic equivalents (METs) achieved (9.5±3 versus 10.5±3), compared to the MLS MR group (all P<0.05). There were 54 events during 7.1±3 years of follow-up. On step-wise multivariable analysis, HS versus MLS MR (HR 4.99 [1.21 to 20.14]), higher LV ejection fraction (hazard ratio [HR], 0.94 [0.89 to 0.98]), atrial fibrillation (HR, 2.59 [1.33 to 5.11]), higher RVSP (HR, 1.05 [1.03 to 1.09]), and higher percentage of age- and gender-predicted METs (HR, 0.98 [0.97 to 0.99]) were independently associated with adverse outcomes (all P<0.05). In patients with ≥III+myxomatous MR undergoing exercise echocardiography, holosystolic MR is associated with adverse outcomes, independent of other predictors. © 2015 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.
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    ABSTRACT: Recurrent pericarditis (RP) affects 10% to 50% of patients with acute pericarditis. The use of steroids has been associated with increased recurrence rate of pericarditis, along with known major side effects. Cardiac magnetic resonance imaging (CMR) is more frequently used to assess pericardial inflammation and less commonly to guide therapy. The aim of this study was to assess the utility of CMR in the management of RP compared with standard therapy. A total of 507 consecutive patients with RP after the first attack, all of whom were treated with colchicine and nonsteroidal anti-inflammatory drugs as first-line therapy, were retrospectively evaluated. There were 257 patients who were treated with medications and received CMR-guided therapy (group 1) and 250 patients who were treated with medications without CMR (group 2). The 2 groups had similar baseline characteristics and follow-up periods (17 ± 7.9 vs 16.3 ± 16.2 months, respectively, p = 0.97). CMR was used to assess the presence of pericardial inflammation, and on the basis of the results, the clinician made changes to the steroid dose dictated by the severity of inflammation. There was no significant difference in the incidence of constrictive pericarditis, pericardial window, or pericardiectomy between groups during the follow-up. However, group 2 patients had a larger number of steroid pulse therapies (defined as prednisone 50 mg/day orally for 10 days and tapering to none over 4 weeks), and higher overall total milligrams of steroid administered compared with the CMR group (p = 0.003 and p = 0.001, respectively). Recurrence and pericardiocentesis rates were lower in group 1 (p <0.0001). In conclusion, CMR-guided therapy modulates the management of RP. This approach decreased pericarditis recurrence and exposure to steroids. Copyright © 2014 Elsevier Inc. All rights reserved.
    The American Journal of Cardiology 12/2014; DOI:10.1016/j.amjcard.2014.11.041 · 3.43 Impact Factor
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    ABSTRACT: Data are lacking on the effect of renin-angiotensin system (RAS) blockade therapy with angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers after surgical aortic valve replacement (SAVR) for severe aortic stenosis (AS).
    Annals of internal medicine 11/2014; 161(10):699-710. DOI:10.7326/M13-1505 · 16.10 Impact Factor
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    ABSTRACT: Cardiac allograft vasculopathy (CAV), an important cause of graft failure and mortality after the third year of orthotopic heart transplant (OHT), is commonly evaluated using dobutamine stress echocardiography (DSE). We sought to study a) the incidence of positive results and diagnostic accuracy of DSE and b) the predictors of adverse outcomes in OHT patients.Methods We studied 497 consecutive patients (63±10 years, 78% men) with OHT who had undergone DSE as part of routine surveillance at our center between 1998 and 2013. Every DSE and coronary angiogram performed during follow-up was reviewed. CAV was re-graded according to 2010 recommendations of the International Society for Heart and Lung Transplantation. Composite events (death, coronary revascularization, myocardial infarction and re-transplantation) were recorded.ResultsThere were 1,243 DSE studies performed during a median of 8.7 (6.2-11.9) years following transplantation. Only 22 studies (1.8%) were positive, 978 (78.7%) were negative and 243 (19.5%) were non-diagnostic (submaximal heart rate response) for ischemia. Among 497 patients, only 20 (4%) had atleast one positive DSE study. There were 310 diagnostic DSE’s with coronary angiograms performed within 1 year of each other. In this subgroup, the sensitivity, specificity, positive and negative predictive value of DSE were as follows: to detect any CAV (7%, 98%, 82% and 41%, respectively) and to detect CAV grade 2-3 (28%, 98%, 71% and 89%, respectively). There were no deaths during DSE. In 5.6±3.6 years after DSE, there were 201 (40%) events. Degree of CAV (and not DSE-based ischemia, p=0.3) independently predicted outcomes (p<0.001).Conclusions In OHT patients undergoing surveillance DSE, the incidence of a positive result is very low. DSE is insufficiently sensitive for detection of early CAV. Degree of CAV and not DSE-based ischemia independently predicted outcomes.
    The Journal of Heart and Lung Transplantation 11/2014; DOI:10.1016/j.healun.2014.11.019 · 5.61 Impact Factor
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    ABSTRACT: We investigated the effects of lung transplantation on right ventricular (RV) function as well as the prognostic value of pre- and post-transplantation RV function.Background Although lung transplantation success has improved over recent decades, outcomes remain a challenge. Identifying predictors of mortality in lung transplant recipients may lead to improved long-term outcomes after lung transplantation.Methods Eighty-nine (age 60 ± 6 years, 58 men) consecutive patients who underwent single or double lung transplantation and had pre- and post-transplantation echocardiograms between July 2001 and August 2012 were evaluated. Echocardiographic measurements were performed before and after lung transplantation. Left ventricular (LV) and RV longitudinal strains were analyzed using velocity vector imaging. Cox proportional prognostic hazard models predicting all-cause death were built.ResultsThere were 46 all-cause (52%) and 17 cardiac (19%) deaths during 43 ± 33 months of follow-up. After lung transplantation, echocardiography showed improved systolic pulmonary artery pressure (SPAP) (50 ± 19 mm Hg to 40 ± 13 mm Hg) and RV strain (−17 ± 5% to −18 ± 4%). No pre-transplantation RV parameter predicted all-cause mortality. After adjustment for age, sex, surgery type, and etiology of lung disease in a Cox proportional hazards model, both post-transplantation RV strain (hazard ratio: 1.13, 95% confidence interval: 1.04 to 1.23, p = 0.005), and post-transplantation SPAP (hazard ratio: 1.03, 95% confidence interval: 1.01 to 1.05, p = 0.011) were independent predictors of all-cause mortality. When post-transplantation RV strain and post-transplantation SPAP were added the clinical predictive model based on age, sex, surgery type, and etiology, the C-statistic improves from 0.60 to 0.80 (p = 0.002).Conclusions Alterations of RV function and pulmonary artery pressure normalize, and post-transplantation RV function may provide prognostic data in patients after lung transplantation. Our study is based on a highly and retrospectively selected group. We believe that larger prospective studies are warranted to confirm this result.
    JACC Cardiovascular Imaging 11/2014; DOI:10.1016/j.jcmg.2014.07.012 · 6.99 Impact Factor
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    ABSTRACT: This study hypothesized that regurgitation severity, as determined by using the regurgitant volume index, would better delineate differential cardiac dysfunction in asymptomatic patients with moderate to severe aortic regurgitation (AR) and mitral regurgitation (MR). Frequent surveillance echocardiography is considered appropriate in asymptomatic patients with moderate to severe AR and MR. However, the evidence to support this practice and to define the appropriate frequency is limited. This was an observational cohort study of consecutive patients with moderate to severe asymptomatic AR or MR who underwent exercise echocardiography. Our cohort included 130 patients with moderate to severe asymptomatic MR and 130 patients with moderate to severe asymptomatic AR who were matched according to age and regurgitant volume index. All patients underwent yearly echocardiographic follow-up studies. Regurgitation severity was determined according to regurgitant volume index, with a level ≥30 ml/m(2) considered a marker of severe regurgitation. During follow-up, regardless of etiology, patients with severe regurgitation demonstrated increasing left ventricular volume indexes (4.2 ± 1.5 ml/m(2) per year; p = 0.01) and decreasing left ventricular ejection fractions (1.3 ± 0.4% per year; p = 0.002). In patients with moderate regurgitation, left ventricular volumes and ejection fractions did not significantly change. In addition, patients with severe regurgitation experienced a similar drop in contractility (end-systolic pressure/end-systolic volume ratio and single-beat preload recruitable stroke work) during follow-up independent of regurgitation etiology. Contractility parameters did not change in patients with moderate regurgitation. These asymptomatic patients with moderate AR or MR had stable cardiac function during 3 years of follow-up; thus, frequent echocardiography without a change in clinical status may not be necessary. In the setting of severe regurgitation, further cardiac deterioration occurred at a similar rate and manner irrespective of whether the dysfunction was related to AR or MR. Copyright © 2014 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.
    JACC Cardiovascular Imaging 11/2014; 8(1). DOI:10.1016/j.jcmg.2014.09.017 · 6.99 Impact Factor
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    ABSTRACT: -We sought to assess the utility of left ventricular global longitudinal strain (LV-GLS) in predicting mortality in moderate to severe and paradoxical severe aortic stenosis (AS) patients with preserved ejection fraction (EF).
    Circulation Cardiovascular Imaging 10/2014; DOI:10.1161/CIRCIMAGING.114.002041 · 5.80 Impact Factor
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    ABSTRACT: Longitudinal strain of right ventricle (RV) can be used to determine RV systolic function. This study compared RV longitudinal strain values of two different speckle tracking software technologies, velocity vector imaging (VVI) and two-dimensional speckle tracking echocardiography (2DSTE), and longitudinal strain by cardiac magnetic resonance (CMR).
    Echocardiography 09/2014; DOI:10.1111/echo.12740 · 1.26 Impact Factor
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    ABSTRACT: Background-In primary mitral regurgitation (MR), exercise echocardiography aids in symptom evaluation and timing of mitral valve (MV) surgery. In patients with grade >= 3 primary MR undergoing exercise echocardiography followed by MV surgery, we sought to assess predictors of outcomes and whether delaying MV surgery adversely affects outcomes. Methods and Results-We studied 576 consecutive such patients (aged 57 +/- 13 years, 70% men, excluding prior valve surgery and functional MR). Clinical, echocardiographic (MR, LVEF, indexed LV dimensions, RV systolic pressure) and exercise data (metabolic equivalents) were recorded. Composite events of death, MI, stroke, and congestive heart failure were recorded. Mean LVEF was 58 +/- 5%, indexed LV end-systolic dimension was 1.7 +/- 0.5 mm/m(2), rest RV systolic pressure was 32 +/- 13 mm Hg, peak-stress RV systolic pressure was 47 +/- 17 mm Hg, and percentage of age-and gender-predicted metabolic equivalents was 113 +/- 27. Median time between exercise and MV surgery was 3 months (MV surgery delayed >= 1 year in 28%). At 6.6 +/- 4 years, there were 53 events (no deaths at 30 days). On stepwise multivariable survival analysis, increasing age (hazard ratio of 1.07 [95% confidence interval, 1.03 to 1.12], P < 0.01), lower percentage of age-and gender-predicted metabolic equivalents (hazard ratio of 0.82 [95% confidence interval, 0.71 to 0.94], P = 0.007), and lower LVEF (0.94 [0.89 to 0.99], P = 0.04) independently predicted outcomes. In patients achieving > 100% predicted metabolic equivalents (n = 399), delaying surgery by >= 1 year (median of 28 months) did not adversely affect outcomes (P = 0.8). Conclusion-In patients with primary MR that underwent exercise echocardiography followed by MV surgery, lower achieved metabolic equivalents were associated with worse long-term outcomes. In those with preserved exercise capacity, delaying MV surgery by >= 1 year did not adversely affect outcomes.
    Journal of the American Heart Association 09/2014; 3(5). DOI:10.1161/JAHA.114.001010
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    Journal of the American Society of Echocardiography: official publication of the American Society of Echocardiography 09/2014; 27(9):911-39. DOI:10.1016/j.echo.2014.07.012 · 2.98 Impact Factor
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    ABSTRACT: Ischemic mitral regurgitation (IMR) is associated with poor outcomes in patients with coronary artery disease. The impact of percutaneous coronary intervention (PCI) on patients with IMR is not well elucidated. We sought to determine the outcomes of patients with severe IMR who underwent PCI. Patients with severe (≥3+) IMR who underwent PCI from 1998 to 2010 were identified. Improvement in IMR was defined as reduction in severity from ≥3+ to ≤2+ without any other invasive intervention beyond PCI. Outcomes were compared between patients with and without improvement in IMR after PCI. One hundred thirty-seven patients with severe IMR were included in our study. After PCI, 50 patients (36.5%) had improvement in IMR with PCI alone and 24 patients (18.5%) required another intervention. Left atrial size was a significant predictor of improvement in IMR (odds ratio 0.39, 95% confidence interval 0.2 to 0.8). Left ventricular size decreased (systolic diameter 3.9 ± 0.3 vs 4.6 ± 0.2 cm, p = 0.0008 and diastolic diameter 5.2 ± 0.2 vs 5.7 ± 0.2 cm, p = 0.002) and ejection fraction increased (39.1 ± 4.0% vs 33.1 ± 1.9%, p = 0.002) significantly after PCI in the patients with improvement in IMR compared with patients without improvement. Patients with improvement in IMR had numerically better survival; however, it was not statistically significant (p log-rank = 0.2). In conclusion, 1/3 of the patients with IMR had improvement in severity of IMR with PCI alone. Improvement in IMR was associated with left ventricular reverse remodeling. Left atrial size was an important predictor of improvement in IMR after PCI.
    The American Journal of Cardiology 07/2014; S0002-9149(14)01440-4(7). DOI:10.1016/j.amjcard.2014.07.012 · 3.43 Impact Factor
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    Journal of the American Heart Association 06/2014; 3(4). DOI:10.1161/JAHA.113.000748
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    ABSTRACT: The distinction of hypertrophic cardiomyopathy (HCM) or cardiac amyloidosis (CA) from hypertensive heart disease may be difficult. The aim of this study was to determine the impact of parametric (polar) maps of regional longitudinal strain on identification of the etiology of mild to moderate left ventricular hypertrophy (LVH).
    Journal of the American Society of Echocardiography: official publication of the American Society of Echocardiography 05/2014; DOI:10.1016/j.echo.2014.04.015 · 2.98 Impact Factor
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    ABSTRACT: Bicuspid aortic valve (BAV) is the most common congenital cardiac malformation, occurring in 1% to 2% of the population. Eventually, 20% develop clinically important valvar regurgitation requiring surgical intervention. Aortic valve repair avoids anticoagulation and prosthetic valve-related complications. This study evaluated long-term durability of BAV repair. From 1985 to 2011, 728 patients, mean age 42 ± 12 years, underwent BAV repair at Cleveland Clinic. Mean follow-up was 9.0 ± 6.2 years (median, 8.3). Factors associated with repair durability (expressed as aortic valve reoperations and echocardiographically estimated gradients and regurgitation) and survival were identified. Hospital mortality was 0.41% (n = 3), and stroke occurred in 0.27% (n = 2). Freedom from aortic valve reoperation at 10 years was 78%. Risk of reoperation was highest immediately after operation and fell rapidly to approximately 2.6%/year up to 15 years. Primary reasons for reoperation were cusp prolapse (38%), aortic stenosis or regurgitation (17%), and aortic regurgitation from root aneurysm (15%). Aortic valve gradients showed an early initial peak, rapidly declined, then rose steadily, accompanied by an increase in left ventricular mass. Survival was 94% at 10 years. A risk factor for early death was greater preoperative mitral valve regurgitation, and for late death, older age at operation, more severe symptoms, and poorer left ventricular function. BAV repair is safe and durable with low mortality, low prevalence of reoperation, and good long-term survival. Cusp prolapse from technical errors and natural progression of disease are the most common causes for reoperation, but progressive natural increase in valve gradient accounts for a substantial proportion as well.
    The Annals of thoracic surgery 03/2014; DOI:10.1016/j.athoracsur.2013.11.036 · 3.45 Impact Factor
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    ABSTRACT: Thoracic radiation leads to radiation-associated cardiac disease (RACD), associated with substantial cardiac morbidity and mortality, often requiring complex cardiothoracic surgery. In patients with RACD, along with valvular lesions, the aorto-mitral curtain (AMC, junction between base of anterior mitral leaflet and aortic root) thickness is increased on transthoracic echocardiography. We sought to identify clinical and transthoracic echocardiography predictors of long-term mortality in patients with RACD. We studied 173 patients with RACD (75% women, 63 ± 14 years, 53% with breast cancer, 27% with Hodgkin lymphoma; mean time from radiation, 18 ± 12 years), who underwent cardiothoracic surgery (26% redo) between 2000 and 2003. Clinical, transthoracic echocardiography (along with AMC), and surgical variables were recorded. Preoperative EuroSCORE and all-cause mortality were recorded. Mean left ventricular ejection fraction, right systolic ventricular pressure, and AMC thickness were 0.49 ± 0.13, 41 ± 15 mm Hg, and 0.54 ± 0.2 cm, respectively. Fifty-one percent of patients had II+ mitral regurgitation or greater, 29% patients had II+ aortic regurgitation or greater, 23% patients had severe aortic stenosis, and 34% patients had II+ tricuspid regurgitation or greater. In 7.6 ± 3 years of follow-up, there were 95 (55%) deaths, with a 30-day mortality rate of only 7 (4%). Absence of β-blockers (hazard ratio, 0.49; 95% confidence interval, 0.31 to 0.79), aspirin (hazard ratio, 0.53; 95% confidence interval, 0.33 to 0.84), higher EuroSCORE (hazard ratio, 1.11; 95% confidence interval, 1.02 to 1.21), and greater AMC thickness (hazard ratio, 5.75; 95% confidence interval, 1.57 to 21.03; all p < 0.01) independently predicted mortality. Aorto-mitral curtain thickness of at least 0.6 cm was associated with significantly increased mortality. Patients with RACD undergoing cardiothoracic surgery have high long-term mortality, which is independently predicted by AMC thickness, a higher preoperative risk score, and lack of cardioprotective medications.
    The Annals of thoracic surgery 02/2014; 97(4). DOI:10.1016/j.athoracsur.2013.12.029 · 3.45 Impact Factor
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    ABSTRACT: -The decision-making role of exercise echocardiography in the surgical timing for aortic regurgitation (AR) remains a matter of debate due to limited data on its link with outcome. The aim of this study was to assess the role of echocardiographic measurements at rest and during exercise as predictors of valve surgery in asymptomatic aortic regurgitation. -Comprehensive resting and exercise echocardiography was performed in 159 consecutive patients (50±15y; 80% male) with isolated moderately severe to severe AR and preserved left ventricular (LV) function (LV ejection fraction >50%, LV end-diastolic dimension ≤70mm, LV end-systolic dimension ≤50mm or ≤25mm/m(2)) in whom initial management was expectant. Echocardiographic measurements were performed at rest and during exercise. LV and right ventricular (RV) longitudinal strain was analyzed at rest using velocity vector imaging. Valve surgery was performed in 50 patients (31%) over 30±21 months. After adjustment for age and gender in a multivariable Cox proportional hazards model, exercise tricuspid annular plane systolic excursion (TAPSE) (HR=0.48 p=0.001) was associated with valve surgery-free, independent of resting LV strain (HR=1.63, p=0.005), exercise LV end-diastolic volume (HR=1.38, p=0.048) and resting RV strain (HR=1.69, p=0.002). In sequential Cox models, a model based on clinical data (chi-square, 20.4) was improved by resting LV strain (chi-square, 30.1, p=0.001), resting RV strain (chi-square, 49.7, p<0.001) and further increased by exercise TAPSE (chi-square, 64.4, p<0.001). -In asymptomatic AR, resting LV strain, resting RV strain and exercise TAPSE were independently associated with the need for earlier aortic surgery.
    Circulation Cardiovascular Imaging 02/2014; 7(2). DOI:10.1161/CIRCIMAGING.113.001177 · 5.80 Impact Factor
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    ABSTRACT: Significant myxomatous mitral regurgitation (MR) leads to progressive left ventricular (LV) decline, resulting in congestive heart failure (CHF) and death. Such patients benefit from mitral valve (MV) surgery. Exercise echocardiography (ExEc) aids in risk stratification and helps decide surgical timing. We sought to assess predictors of outcomes in such patients undergoing ExEc. This is an observational study of 884 consecutive patients (58±14 years, 67% men) with ≥III+ myxomatous MR who underwent ExEc between 1/2000 and 12/2011 (excluding functional MR, prior valvular surgery, hypertrophic cardiomyopathy, rheumatic valvular disease or >mild mitral stenosis). Clinical and echocardiographic data [MR, LV ejection fraction, LV dimensions, right ventricular systolic pressure (RVSP)] & exercise variables [metabolic equivalents (METS), heart rate recovery (HRR) at 1(st) minute post-exercise] were recorded. Composite events of death, myocardial infarction, stroke and progression to CHF were recorded. Mean LV ejection fraction, indexed LV end-systolic dimension, rest RVSP, peak-stress RVSP, METs achieved and HRR were 58±5%, 1.6±0.4 mm/m2, 31±12 mm Hg, 46±17 mm Hg, 9.6±3 and 33±14 beats, respectively. During 6.4±4 years of follow-up, there were 87 events. On stepwise multivariable Cox analysis, %age-gender predicted METs (Hazard ratio or HR 0.99 [0.98-0.99], p=0.005), HRR (HR 0.29 [0.17-0.50], p<0.001), resting RVSP (HR 1.03 [1.004-1.05], p=0.02), atrial fibrillation (HR 1.91 [1.07-3.41], p=0.03) and LV ejection fraction (HR 0.96 [0.92-0.99], p=0.04) predicted outcomes. In patients with ≥III+ myxomatous MR undergoing ExEc, lower %age-gender predicted METS, lower HRR, atrial fibrillation, lower LV ejection fraction and high resting RVSP predicted worse outcomes.
    Circulation 01/2014; 129(12). DOI:10.1161/CIRCULATIONAHA.113.005287 · 14.95 Impact Factor

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3k Citations
1,073.87 Total Impact Points


  • 2009–2014
    • Metropolitan Heart and Vascular Institute
      Minneapolis, Minnesota, United States
  • 1994–2014
    • Cleveland Clinic
      • • Department of Cardiovascular Medicine
      • • Department of Cardiology
      Cleveland, Ohio, United States
  • 2013
    • Case Western Reserve University
      Cleveland, Ohio, United States
  • 2004
    • William Penn University
      Filadelfia, Pennsylvania, United States
  • 2000
    • Baylor College of Medicine
      • Winters Center for Heart Failure Research
      Houston, Texas, United States
  • 1997
    • Dartmouth–Hitchcock Medical Center
      • Department of Surgery
      Lebanon, New Hampshire, United States
  • 1996
    • White River Junction VA Medical Center
      White River Junction, Vermont, United States
  • 1991
    • Massachusetts General Hospital
      • Department of Medicine
      Boston, MA, United States