Goldberg Trust supports residents' professional development
Four excellent Northwestern residents received a Goldberg Trust award to support their professional development. The award will go towards their presentation during these conferences:
Kartik Agusala, MD (PGY2): 2010 American Society of Echocardiography
Venkatesh Anjan, MD (PGY2): 2010 American Society of Echocardiography
Sara Westergaard, MD (PGY2): 2010 American Transplant Conference
Karolina Zareba, MD (PGY3): 2010 American College of Cardiology
Kartik Agusala, MD:
2D-Echocardiography Reference Values for Right Ventricular Size and Function: Differentiation between Normal and Pulmonary Hypertension Kartik Agusala, Keith Collins, Mardi Gomberg-Maitland, Roberto M. Lang, Alan Kadish, and Sanjiv J. Shah
Background: Current ASE guidelines for normal right ventricular (RV) size and function are based on data from small numbers of subjects and may be inaccurate. We hypothesized that studying a large number of normal subjects would lead to more accurate estimates of normal RV size and function, and that these parameters would be able to differentiate normals from pulmonary hypertension (PH).
Methods: We prospectively measured RV dimensions, area, fractional area change (FAC), wall thickness, RV/left ventricle (LV) ratio, and tricuspid annular plane systolic excursion (TAPSE) in 202 normal subjects free of cardiovascular or pulmonary disease and in 151 subjects with PH (mean pulmonary artery pressure > 25 mmHg by cardiac catheterization). We used interclass correlation to estimate inter-observer variability, and we compared healthy subjects with PH subjects using t-tests. Receiver-operating characteristic analysis was used to determine the utility of various RV size and function parameters for the differentiation between normal and PH.
Results: In the normal cohort, mean age was 34±10 years, mean BMI 25±8 kg/m2, and 50% were female. For all RV measurements, interclass correlations were high (>0.8). In normals, RV dimensions were found to be larger than those published in current guidelines. RV length was 7.9±0.9 cm (reference value 7.6±0.3 cm) and mid-RV diameter was 3.7±0.6 cm (reference value 3.0±0.2 cm). RV area, FAC, wall thickness, and TAPSE were similar to published reference values. Based on current ASE guidelines for RV dimensions, 100 (49.5%) of the 202 normal subjects would have falsely been diagnosed with RV enlargement. Compared with normals, subjects with PH had larger RV dimensions and area, increased RV wall thickness, reduced FAC and TAPSE, and increased RV/LV ratio (p<0.0001 for all parameters). FAC, RV/LV ratio, and TAPSE were all excellent parameters for the differentiation between normal and PH. For example, TAPSE < 1.8 cm had a sensitivity of 99% and a specificity of 90% for the diagnosis of PH.
Conclusions: Use of current ASE guidelines for RV dimensions leads to false diagnosis of RV enlargement in 50% of normal subjects. Use of FAC, RV/LV ratio, and TAPSE can help differentiate normal from PH.
Venkatesh Anjan, MD:
Right Ventricular Assessment Independently Predicts Late Mortality in Valve Surgery" Venkatesh Y. Anjan, Robert O. Bonow, Jyothy Puthumana, Asim Ansari, Karolina M. Zareba, Brittany R. Lapin, Nausheen Akhter, Patrick M. McCarthy, Vera H. Rigolin.
Northwestern University Feinberg School of Medicine, Chicago, IL
Background: Current models predicting heart valve surgery mortality are based on clinical preoperative factors and left ventricular function. However, the effect of right ventricular (RV) parameters on mortality is less well studied. This echocardiographic study investigated the prognostic impact of pre-op right heart parameters in addition to the Ambler clinical score (AS) and left ventricular end systolic volume index (LVESVI) to predict late mortality in patients undergoing mitral valve (MV) surgery.
Methods: We analyzed 758 pts undergoing MV surgery. All cause long term mortality was 11% (87 pts) in 3 yrs of follow up. All 87 pts that died were matched to 171 pts who survived (living controls). We analyzed pre-op echos in these 258 pts (mean age 67+/-13). The data was modeled using stratified survival analyses.
Results: The RV basal diastolic dimension (RVD) and LVESVI were higher in the group that died as seen in Table 1. When controlling for the 8 other variables listed in Table 2, AS and RVD were the only two variables predictive of mortality. By likelihood ratio test, AS was a predictor of long-term mortality (p = 0.026). Controlling for AS, RVD, but not LVESVI was an independent predictor of late mortality (p=0.011). RVD remained an independent predictor when controlling for both LVESVI and AS (p=0.010). AS was not an independent predictor when controlling for RVD or LVESVI.
Conclusions: RVD is an echo parameter that can independently assess mortality in patients undergoing MV surgery. Although AS, LVESVI, and RVD are univariate predictors of long-term mortality, only RVD is an independent predictor of long-term mortality.
Sara Westergaard, MD:
Clinical Implications of Neutropenia In Patients Treated With Alemtuzumab Induction And Steroid-Free Maintenance Therapy.S Westergaard1, A Daud, N Patel, M Ison, L Gallon, J Leventhal, D Kaufman, M Abecassis and John Friedewald. 1Comprehensive Transplant Center, Northwestern Univ.
Background: Alemtuzumab has been used as the primary induction agent for kidney transplant recipients at our center since 2001. Leukopenia is a recognized side-effect of the alemtuzumab/prednisone-free regimen but to date we had not analyzed the clinical implications of leukopenia in this pt population.
Methods: A retrospective cohort study of pts undergoing both deceased (CRT) and living donor (LRT) kidney transplants between 3/22/07 and 5/31/09. All patients received alemtuzumab induction, 3 doses of IV steroids and TAC/MMF maintenance. By protocol, patients are monitored regularly for early evidence of leukopenia with interventions that include medication change, dosage reduction (primarily MMF) and frequent clinical and lab monitoring focused on preventing neutropenia. By protocol, patients with an ANC less than 1000 cells/<image001.jpg>L receive G-CSF. We compared rates of neutropenia, modification of immunosuppressive drugs, and G-CSF dosing in this cohort.
Results: 400 patients were transplanted during the study period. A total of 147 patients (36.6%) developed neutropenia requiring at least one dose of G-CSF with a mean time to first dose of G-CSF of 122 days. 40 of 147 patients receiving G-CSF had biopsy proven acute rejection (BPAR) compared to 31 of 253 patients not requiring G-CSF (BPAR rate 27.2% vs 12.3%, p<0.001). Mean time to BPAR for non-neutropenic patients was 184 days vs 222 days in the group requiring G-CSF. Patients receiving G-CSF who went on to BPAR required more doses of G-CSF (12.9 vs 6.3, p <0.05) had a longer period of treated neutropenia (109.4 days vs 58.1, p <0.05) and had a trend toward larger dose reductions in MMF, although not statistically significant. Patients requiring G-CSF who went on to BPAR had a significant increase in one year serum creatinine (SCr) compared to nonrejectors receiving G-CSF (1.67 vs. 1.2 mg/dL, p <0.05).
Conclusions: Our data confirm that leukopenia is an important side-effect of this regimen and underscores the incidence of neutropenia in patients treated with alemtuzumab/prednisone-free regimen. Neutropenic patients with BPAR tended to have higher 1yr SCr, larger dose reductions in MMF, and required more G-CSF doses over a longer period of time than the group that required G-CSF but did not reject. Further study is warranted to determine if increased rates of BPAR are associated with receipt of G-CSF or other interventions, such as reduction of MMF.
Karolina Zareba, MD:
Gender Based Differences In Left And Right Ventricular Size And Function In Patients Undergoing Mitral Valve Surgery. Author Block: Karolina M. Zareba, Robert O. Bonow, Asim Ansari, Jyothy Puthumana, Venkatesh Y. Anjan, Brittany R. Lapin, Nausheen Akhter, Patrick M. McCarthy, Vera H. Rigolin, Northwestern University Feinberg School of Medicine, Chicago, IL
Abstract: Background: Guidelines for mitral valve (MV) surgery are similar for men and women and include symptoms and LV parameters. Prior studies have shown increased mortality in women. To address differences in outcome, we evaluated gender-specific indices of LV and RV function in pts undergoing MV surgery.
Methods: We analyzed 758 pts undergoing MV surgery. All cause long term mortality was 11% (87 pts) in 3 yrs of follow up. All 87 pts that died were matched to 171 pts who survived (living controls). We analyzed pre-op echos in these 258 pts (mean age 67+/-13).
Results: A mixed effects model was used to obtain adjusted means by gender using the matched set as random effects. Differences in LV and RV parameters between genders are shown in the table. ROC analysis revealed optimal thresholds for predicting overall mortality: basal RV diameter (RVD1) ≥ 3.5 cm (HR 6.5, p<0.0001), LV end-systolic volume index ≥ 27.6 ml/m2 (HR 2.0, p=0.004), LV end-diastolic volume index ≥ 55.4 ml/m2 (HR 2.1, p=0.004), and tricuspid regurgitation severity ≥2 (HR 1.9, p=0.007). RVD1 was an independent predictor of mortality (HR 1.9, p=0.003).
Conclusion: There are important gender differences in LV and RV volumes in pts undergoing MV surgery. Larger LV and RV volumes predict late mortality in both genders. Despite smaller volumes in women, mortality was similar in men and women. Although specific cut-off values for LV and RV volumes are not defined, echo parameters leading to surgical referral may need to be revised to reflect gender differences.