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Research Interests: Cardiology, Natural History, Medicine, Echocardiography, Prospective studies, and 15 moreHumans, Internal Medicine, Left Ventricular Assist Device, Hospitalization, Female, Male, Acute Myocardial Infarction, Middle Aged, Myocardial Infarction, Ejection Fraction, Embolism, Heart Diseases, Infarction, Left Ventricular, and Cardiovascular medicine and haematology
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Targeting ganglionated plexi (GP) during catheter ablation of atrial fibrillation (AF) is associated with improved outcome. We present a patient with speech and breathing induced atrial tachycardia (AT) originating in the superior vena... more
Targeting ganglionated plexi (GP) during catheter ablation of atrial fibrillation (AF) is associated with improved outcome. We present a patient with speech and breathing induced atrial tachycardia (AT) originating in the superior vena cava (SVC) and the right superior pulmonary vein (RSPV), near the anatomical location of the anterior right GP (ARGP). The trigger for the arrhythmia appeared to be vagal discharge from the GP, possibly induced by local stretch. Ablation with a 28 mm cryo-balloon advanced to the RSPV orifice through a patent foramen ovale (PFO) abolished the arrhythmia, probably involving the underlying parasympathetic influx to the SVC and RSPV myocardial sleeves.
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Neostigmine is a cholinesterase inhibitor which does not cross the blood brain barrier and a commonly used for reversal of nondepolarizing muscle relaxants. In the following case report, we present a patient who developed coronary artery... more
Neostigmine is a cholinesterase inhibitor which does not cross the blood brain barrier and a commonly used for reversal of nondepolarizing muscle relaxants. In the following case report, we present a patient who developed coronary artery spasm, after the administration of repeated doses of neostigmine. Ours is the first case to demonstrate such a longstanding coronary artery vasospasm that lasted several hours in response to neostigmine, resulting in myocardial damage and left ventricular dysfunction. We would like to draw the attention of the anesthesiologists to this rare effect that may lead to perioperative cardiac complications.
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We tested the clinically relevant diagnostic accuracy of a new electrocardiographic (ECG) recording system incorporating all 10 ECG electrodes in a single-size glove worn on the... more
We tested the clinically relevant diagnostic accuracy of a new electrocardiographic (ECG) recording system incorporating all 10 ECG electrodes in a single-size glove worn on the patient's left arm and placed on the chest. The PhysioGlove (PG) was designed to allow fast, reproducible, electrode placement with only minimal training. The American College of Cardiology/American Heart Association ECG recording guidelines and others have repeatedly highlighted the unacceptable progressive deterioration in ECG accuracy mainly resulting from a performer's lack of proficiency and diligence, leading to frequent electrode misplacement. We studied 428 consenting adult patients with a broad spectrum of anthropomorphic characteristics and ECG and cardiovascular pathologic entities. The chest girth was measured to ascertain the single-size PG clinical diagnostic accuracy in ≥90% of this patient population. For each patient, a PG and standard-cable electrocardiogram were consecutively recorded and interpreted by experienced electrocardiographers. The study included 3 phases: phase 1, run-in (n = 120); phase 2, comparative diagnostic accuracy (n = 208); and phase 3, randomized, blinded, diagnostic accuracy (n = 100). Of the entire study population (n = 428), 92% fit the chest girth range of 85 to 118 cm (34 to 47 in.), representing the reference standard clinical diagnostic PG chest girth range. The phase 2 PG diagnostic accuracy was 91.3% for entire chest girth range and 95.7% for the 89.4% of patients with a chest girth within the reference range. The mean PG diagnostic accuracy in phase 3 was 93% (95% confidence interval 89% to 95%). In conclusion, compared with standard-cable electrocardiograms, the PG demonstrated excellent diagnostic accuracy (93% to 95.7%) in ≥90% of a typical western adult patient population. The PG's ease of use and minimal training requirements offer a promising tool to markedly improve ECG clinical diagnostic accuracy in most adult western patients.
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Pharmacologic testing with dobutamine or dipyridamole in conjunction with echocardiography has become an accepted method for diagnosis of coronary artery disease (CAD). The sensitivity of dobutamine echo ranges from 68 to 86%, and of... more
Pharmacologic testing with dobutamine or dipyridamole in conjunction with echocardiography has become an accepted method for diagnosis of coronary artery disease (CAD). The sensitivity of dobutamine echo ranges from 68 to 86%, and of dipyridamole from 53 to 69% for diagnosis of CAD. Our purpose was to investigate whether the addition of dipyridamole to dobutamine, which may improve the test sensitivity, is safe. Ten patients with low probability of CAD underwent dobutamine echo; 5 were control patients and 5 patients had low dose dipyridamole added at the maximal dose of dobutamine. Four of the latter patients had severe hypotension, while no hypotension was observed in control patients. Our findings suggest that this combination of dobutamine and dipyridamole can be hazardous and should not be used in patients with suspected CAD.
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STEMI is thought to occur as a result of a vulnerable coronary plaque rupture. Statins possess hypolipidemic and pleotropic effects that stabilize coronary plaque. We sought to determine the association between LDL-C levels, statin use... more
STEMI is thought to occur as a result of a vulnerable coronary plaque rupture. Statins possess hypolipidemic and pleotropic effects that stabilize coronary plaque. We sought to determine the association between LDL-C levels, statin use prior to the index event on the type of acute coronary syndrome (ACS) presentation: STEMI vs. non-STEMI/unstable angina. Data was drawn from the ACS Israeli Survey (ACSIS), a biennial prospective survey of ACS patients hospitalized in all CCU/Cardiology departments during 2002-2010. Among 6790 patients, 2760 (41%) reported statin use prior to the index ACS event. The proportion of STEMI was significantly lower among statin treated vs. statin naive patients (36% vs. 57%, p<0.0001). At each LDL-C level, the proportion of STEMI was significantly lower only among statin treated patients (p<0.0001). LDL-C<70mg/dL was associated with a lower proportion of STEMI only among statin treated but not among statin naive patients (33% vs. 57%, p<0.0001). Multivariate analysis revealed that statin use was independently associated with a lower probability of presenting with STEMI (ORadj=0.73, p=0.007), but not LDL-C<70mg/dL (ORadj=1.13, p=0.32). Patients on high-intensity statin therapy (HIST) were less likely to present with STEMI as compared with low-intensity statin therapy (LIST) or statin naive patients (27%, 38%, 56%, respectively, p for trend <0.0001; HIST ORadj=0.28, p=0.01; LIST ORadj=0.48, p=0.026). Among patients admitted with ACS, statin use but not LDL-C level, was associated with a lower probability of presenting with STEMI. Patients on HIST had the lowest likelihood of presenting with STEMI.
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We sought to define reperfusion-induced ventricular arrhythmias (VAs) more precisely through simultaneous angiography, continuous ST-segment recovery, and beat-to-beat Holter analyses in subjects with anterior ST-elevation myocardial... more
We sought to define reperfusion-induced ventricular arrhythmias (VAs) more precisely through simultaneous angiography, continuous ST-segment recovery, and beat-to-beat Holter analyses in subjects with anterior ST-elevation myocardial infarction (STEMI) undergoing primary angioplasty [percutaneous coronary intervention (PCI)]. All 157 subjects with final TIMI 3 flow had continuous 12-lead electrocardiography with simultaneous Holter recording initiated prior to PCI for continuous ST-segment recovery and quantitative VA analyses. Ventricular arrhythmia bursts were detected against subject-specific background VA rates using a statistical outlier method. For temporal correlations, timing and quality of reperfusion were defined as first angiographic TIMI 3 flow with >or=50% stable ST-segment recovery. Almost all subjects had VAs [156/157 (99%)], whereas VA bursts during or subsequent to reperfusion occurred in 97/157 (62%). The majority of VA bursts (72%) arose within 20 min of reperfusion (95% CI: 26.7, 72), with onset at a median of 4 min post-reperfusion (IQR: 0-43) Bursts comprised a median of 1290 ventricular premature complexes (VPCs) (IQR: 415-4632) and persisted for a median of 105 min (IQR: 35-250). Most background VAs occurred as single VPCs; bursts typically comprised runs of three or more VPCs. Subjects with bursts had higher absolute peak ST segments and more frequent worsening of ST elevation immediately after reperfusion. Ventricular arrhythmia bursts temporally associated with TIMI 3 flow restoration and stable ST-segment recovery (reperfusion VA bursts) can be precisely defined in subjects with anterior STEMI and may constitute a unique electric biosignal of myocellular response to reperfusion.
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The absence of antegrade flow in a coronary artery during an intervention is an ominous finding requiring diagnosis of the underlying cause and rapid treatment to limit myocardial necrosis. The Twin-Pass dual access catheter allows for... more
The absence of antegrade flow in a coronary artery during an intervention is an ominous finding requiring diagnosis of the underlying cause and rapid treatment to limit myocardial necrosis. The Twin-Pass dual access catheter allows for distal coronary contrast injection without loss of wire position. The aim of this analysis was to determine the opacification and flow features of patients with abrupt arrest of antegrade flow to determine the underlying pathology. Coronary angiograms of patients with abrupt arrest of antegrade flow during an intervention that underwent distal vessel contrast injection with the Twin-Pass catheter were retrospectively analyzed for five features: antegrade flow, retrograde flow, myocardial blush, presence of contrast stasis in the vessel wall and evidence of an intraluminal filling defect. The features were then correlated with the underlying pathological process and treatment. Seven patients underwent distal contrast injections. Four specific pathologi...
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The Arterial Revascularization Therapies Study was a multicenter, randomized trial designed to compare percutaneous coronary intervention with stenting versus coronary artery bypass graft surgery in 1,205 patients with multivessel... more
The Arterial Revascularization Therapies Study was a multicenter, randomized trial designed to compare percutaneous coronary intervention with stenting versus coronary artery bypass graft surgery in 1,205 patients with multivessel coronary artery disease. The most appropriate type of treatment for these patients is still a matter of considerable debate. To evaluate the clinical characteristics of patients enrolled in the ARTS trial in Israel in comparison to those worldwide, and to assess the 1 year outcome in these patients. Between April 1997 and June 1998, a total of 1,205 patients with multivessel coronary artery disease, who were considered to be equally treatable with both modalities, were randomized to either stenting (n = 600) or CABG (n = 605) at 67 centers around the world. In Israel, 53 patients at four participating medical centers were randomized to either PCI with stents (n = 27) or CABG (n = 26). Clinical and angiographic characteristics were similar in the two groups...
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Prior studies have suggested that women are at higher risk for morbidity and mortality during coronary angioplasty, although long-term prognosis is similar after successful procedures. To examine the role of gender in coronary stenting,... more
Prior studies have suggested that women are at higher risk for morbidity and mortality during coronary angioplasty, although long-term prognosis is similar after successful procedures. To examine the role of gender in coronary stenting, including immediate procedural success as well as early and late outcomes. The study group comprised 560 consecutive patients (119 women and 441 men) who had undergone stenting over a 3 year period. The indications for coronary stenting were similar among women and men, and stents were successfully deployed at similar rates without complications (92 vs. 90% respectively). Cardiac death or myocardial infarction within 30 days of the procedure was observed in 5% of women and men, whereas none of the women, compared to 1.4% of men, had early revascularization. Bleeding complications occurred in 4% of women and 2% of men. During 10 +/- 2.8 months of follow-up, 58% of women and men underwent repeat cardiac catheterization, revealing similar rates of reste...
Research Interests: Israel, Humans, Female, Male, Risk factors, and 15 moreRecurrence, Aged, Middle Aged, Coronary Angiography, Myocardial Infarction, Morbidity, Analysis of Variance, Prognosis, Postoperative Hemorrhage, Risk Factors, Proportional Hazards Models, Logistic Models, Predictive value of tests, Patient selection, and Medical and Health Sciences
Myocardial ischemia during daily life can be induced by increased demand and by increased coronary tone. The purpose of this study was to assess the mechanism of action of mibefradil, a new T-channel calcium blocker that is a vasodilator... more
Myocardial ischemia during daily life can be induced by increased demand and by increased coronary tone. The purpose of this study was to assess the mechanism of action of mibefradil, a new T-channel calcium blocker that is a vasodilator with negative chronotropic properties. Included in this study were 114 patients with chronic stable angina pectoris and ischemic episodes during baseline 48-hour ambulatory ECG monitoring (AEM). After a placebo run-in period patients received 50 mg, 100 mg, or 150 mg of mibefradil per day and repeat 48 hours AEM was performed. Ischemic episodes were divided into 2 categories: Type I is those in which an increase in heart rate > 10% preceded the development of 1 mm ST depression; Type II is those with < or = 10% increase in heart rate. Of the 625 ischemic episodes recorded at baseline, 83% were Type I and 17% were Type II. At 50 mg mibefradil dose, there was a significant decrease in the number of Type I ischemic episodes but not of Type II. At...
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Myocardial blood flow in patients with coronary artery disease depends on the severity of the coronary narrowings and the functional status of the coronary vessels. Coronary atherosclerotic plaques, which contain high concentrations of... more
Myocardial blood flow in patients with coronary artery disease depends on the severity of the coronary narrowings and the functional status of the coronary vessels. Coronary atherosclerotic plaques, which contain high concentrations of lipids, are more sensitive to change in coronary tone. The increased tendency of these active plaques for vasoconstriction is caused by abnormal endothelial function. Because regression of significant coronary plaques is highly unlikely, effort is made to improve endothelial function, thereby improving myocardial blood flow. Reduction of the cholesterol level by lipid-lowering drugs is associated with restoration of the vasodilatory response of the coronary arteries, thereby reducing the likelihood of plaque rupture and its consequences: myocardial infarction and death. Myocardial ischemia during daily life is induced by increased demand and increased coronary tone; therefore, it was not surprising that recent studies have indicated that cholesterol l...
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The long-QT (LQT) syndrome is a genetically complex disorder that is characterized by syncope and fatal ventricular arrhythmias. LQT syndrome, as defined by a prolonged electrocardiographic QT interval, has a higher incidence in females... more
The long-QT (LQT) syndrome is a genetically complex disorder that is characterized by syncope and fatal ventricular arrhythmias. LQT syndrome, as defined by a prolonged electrocardiographic QT interval, has a higher incidence in females than in males and does not exhibit Mendelian transmission patterns in all families. Among those families that are nearly consistent with Mendelian transmission, linkage between a locus for LQT syndrome and the H-ras-1 locus on the short arm of chromosome 11 has been reported in some families but not in others. Earlier analyses suggesting that LQT syndrome might be caused by a gene in the HLA region of chromosome 6 were not confirmed by standard linkage analyses. Here, we present an analysis of HLA haplotype sharing among affected pedigree members, showing an excess of haplotype sharing in a previously published Japanese pedigree and possibly also in 15 families of European descent. The haplotypes shared by affected individuals derive from both affect...
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... Exercise and During Daily Activity Dan Tzivoni, MD, Shmuel Banai, MD, Shulamit Botvin, MD, Avraham Zilberman, MD, Teddy A. Weiss ... 18. Levy RD, Shapiro LM, Wright C, Mockus L, Fox K. The haemodynamic significance of asymptomatic ST... more
... Exercise and During Daily Activity Dan Tzivoni, MD, Shmuel Banai, MD, Shulamit Botvin, MD, Avraham Zilberman, MD, Teddy A. Weiss ... 18. Levy RD, Shapiro LM, Wright C, Mockus L, Fox K. The haemodynamic significance of asymptomatic ST segment depression assessed by ...
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Background One of the most daunting complications of cardiac catheterization is a cerebrovascular event ( CVE ). We aimed to assess the real‐life incidence, etiology, and risk factors of cardiac catheterization‐related acute CVE s in a... more
Background One of the most daunting complications of cardiac catheterization is a cerebrovascular event ( CVE ). We aimed to assess the real‐life incidence, etiology, and risk factors of cardiac catheterization‐related acute CVE s in a large cohort of patients treated in a single center. Methods and Results We undertook a retrospective analysis of 43 350 coronary procedures performed on 30 907 procedure days over the period 1992‐2011 and compared patient and procedural characteristics of procedures complicated by CVE s with the remaining cohort. CVE s occurred in 47 cases: 43 were ischemic, 3 intracerebral hemorrhages, and 1 undetermined. The overall CVE rate was 0.15%, with percutaneous coronary intervention ( PCI ) and diagnostic coronary angiography rates 0.23% and 0.09%, respectively. Using a forward stepwise multivariate logistic regression model including patient demographic and procedural characteristics, a total of 5 significant predictors were defined: prior stroke ( OR =15...
Research Interests: Israel, Multivariate Analysis, Humans, Female, Male, and 14 moreIncidence, Risk factors, Aged, Cardiac Catheterization, Middle Aged, Percutaneous Coronary Intervention, Coronary Angiography, Time Factors, Odds ratio, Retrospective Studies, Chi Square Distribution, Risk Factors, Cerebrovascular Disorders, and Logistic Models
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Predicting Major Adverse Cardiac Events and Infarct Size Using ST-Segment Resolution as a Continuous Rather Than a Dichotomous Variable in Patients Achieving Thrombolysis in Myocardial Infarction Flow Grade III After Primary Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial I...more