Khurram Owais MD, Mario Montealegre-Gallegos MD, Jelliffe Jeganathan MBBS, Robina Matyal MD, Kamal Khabbaz MD, Feroze Mahmood MD. Dynamic changes in the ischemic mitral annulus: Implications for ring sizing. Annals of Cardiac Anesthesia. 2016;19 (1) :15-9.Abstract


Contrary to the rest of the mitral annulus, inter-trigonal distance is known to be relatively less dynamic during the cardiac cycle. Therefore, intertrigonal distance is considered a suitable benchmark for annuloplasty ring sizing during mitral valve (MV) surgery. The entire mitral annulus dilates and flattens in patients with ischemic mitral regurgitation (IMR). It is assumed that the fibrous trigone of the heart and the intertrigonal distance does not dilate. In this study, we sought to demonstrate the changes in mitral annular geometry in patients with IMR and specifically analyze the changes in intertrigonal distance during the cardiac cycle.


Intraoperative three-dimensional transesophageal echocardiographic data obtained from 26 patients with normal MVs undergoing nonvalvular cardiac surgery and 36 patients with IMR undergoing valve repair were dynamically analyzed using Philips Qlab ® software.


Overall, regurgitant valves were larger in area and less dynamic than normal valves. Both normal and regurgitant groups displayed a significant change in annular area (AA) during the cardiac cycle (P < 0.01 and P < 0.05, respectively). Anteroposterior and anterolateral-posteromedial diameters and inter-trigonal distance increased through systole (P < 0.05 for all) in accordance with the AAs in both groups. However, inter-trigonal distance showed the least percentage change across the cardiac cycle and its reduced dynamism was validated in both cohorts (P > 0.05).


Annular dimensions in regurgitant valves are dynamic and can be measured feasibly and accurately using echocardiography. The echocardiographically identified inter-trigonal distance does not change significantly during the cardiac cycle.

Azad Mashari MD, Ziyad Knio BS, Jelliffe Jeganathan MBBS, Mario Montealegre-Gallegos MD, Lu Yeh MD, Yannis Amador MD, Robina Matyal MD, Rabya Saraf BA, Kamal Khabbaz MD, Feroze Mahmood MD. Hemodynamic Testing of Patient-Specific Mitral Valves Using a Pulse Duplicator: A Clinical Application of Three-Dimensional Printing. Journal of Cardiothoracic & Vascular Anesthesia. 2016;30 (5) :1278-85.Abstract

To evaluate the feasibility of obtaining hemodynamic metrics of echocardiographically derived 3-dimensional (3D) printed mitral valve models deployed in a pulse duplicator chamber.

Rabya Saraf BA, Feroze Mahmood MD, Rabia Amir MD, Robina Matyal MD. Neuropeptide Y is an Angiogenic Factor in Cardiovascular Regeneration. European Journal of Pharmacology. 2016.Abstract

In diabetic cardiomyopathy, there is altered angiogenic signaling and increased oxidative stress. As a result, anti-angiogenic and pro-inflammatory pathways are activated. These disrupt cellular metabolism and cause fibrosis and apoptosis, leading to pathological remodeling. The autonomic nervous system and neurotransmitters play an important role in angiogenesis. Therapies that promote angiogenesis may be able to relieve the pathology in these disease states. Neuropeptide Y (NPY) is the most abundantly produced and expressed neuropeptide in the central and peripheral nervous systems in mammals and plays an important role in promoting angiogenesis and cardiomyocyte remodeling. It produces effects through G-protein-coupled Y receptors that are widely distributed and also present on the myocardium. Some of these receptors are also involved in diseased states of the heart. NPY has been implicated as a potent growth factor, causing cell proliferation in multiple systems while the NPY3-36 fragment is selective in stimulating angiogenesis and cardiomyocyte remodeling. Current research is focusing on developing a drug delivery mechanism for NPY to prolong therapy without having significant systemic consequences. This could be a promising innovation in the treatment of diabetic cardiomyopathy and ischemic heart disease.

R D, Montealegre-Gallegos M, Matyal R, Belani K, Chawla N. Training the Anesthesiologist in Point-of-Care Ultrasound. International Anesthesiology Clinics. 2016;54 (1) :71-93.
Saraf R, Huang T, Mahmood F, Owais K, Bardia A, Khabbaz K, Liu D, Senthilanathan V, Lassaletta AD, Sellke F, et al. Early Cellular Changes in the Ascending Aorta and Myocardium in a Swine Model of Metabolic Syndrome. PLOS One. 2016;11 (1).Abstract

Background: Metabolic syndrome is associated with pathological remodeling of the heart and adjacent vessels. The early biochemical and cellular changes underlying the vascular damage are not fully understood. In this study, we sought to establish the nature, extent, and initial timeline of cytochemical derangements underlying reduced ventriculo-arterial compliance in a swine model of metabolic syndrome.

Methods: Yorkshire swine (n=16) were fed a normal diet (ND) or a high-cholesterol (HCD) for 12 weeks. Myocardial function and blood flow was assessed before harvesting the heart. Immuno-blotting and immuno-histochemical staining were used to assess the cellular changes in the myocardium, ascending aorta and left anterior descending artery (LAD).

Results: There was significant increase in body mass index, blood glucose and mean arterial pressures (p=0.002, p=0.001 and p=0.024 respectively) in HCD group. At the cellular level there was significant increase in anti-apoptotic factors p-Akt (p=0.007 and p=0.002) and Bcl-xL (p=0.05 and p=0.01) in the HCD aorta and myocardium, respectively. Pro-fibrotic markers TGF-β (p=0.01), pSmad1/5 (p=0.03) and MMP-9 (p=0.005) were significantly increased in the HCD aorta. The levels of pro-apoptotic p38MAPK, Apaf-1 and cleaved Caspase3 were significantly increased in aorta of HCD (p= 0.03, p=0.04 and p=0.007 respectively). Similar changes in coronary arteries were not observed in either group. Functionally, the high cholesterol diet resulted in significant increase in ventricular end systolic pressure and -dp/dt (p=0.05 and p=0.007 respectively) in the HCD group.

Conclusion: Preclinical metabolic syndrome initiates pro-apoptosis and pro-fibrosis pathways in the heart and ascending aorta, while sparing coronary arteries at this early stage of dietary modification.

Rabya Saraf BA, Feroze Mahmood MD. Cardiac Imaging - 3-Dimensional Echocardiography. International Anesthesia Clinics. 2016;54 (1) :39-53.Abstract

Perioperative transesophageal echocardiography (TEE) has gradually become an essential intraoperative imaging modality, evolving from being used as a hemodynamic monitor to becoming an important procedural adjunct. Minimally invasive approaches for structural heart diseases have gained wider popularity due to advances in cardiac surgery, thereby making TEE imaging an integral component of intraoperative decision-making. Although traditional two-dimensional (2D) TEE provides a dynamic display of cardiac anatomy, it is spatially limited. Recent technological advances have allowed for the development of three-dimensional (3D) TEE. Currently, 3D imaging is mainly used for qualitative imaging of intra-cardiac structures and the data has been used for 3D printing of intra-cardiac structures. It has also demonstrated value in quantitative analyses of structural heart diseases and hemodynamic calculations. 3D imaging is gaining widespread popularity due to its useful applicability, allowing anesthesiologists to expand their role as perioperative physicians.

Matyal R, Montealegre-Gallegos M, Mitchell JD, H K, R B, KM H, D O'H, Wong V, Hess PE, Mahmood F. Manual Skill Acquisition During Transesophageal Echocardiography Simulator Training of Cardiology Fellows: A Kinematic Assessment. Journal of Cardiothoracic & Vascular Anesthesia. 2015;29 (6) :1504-10.Abstract


To investigate whether a transesophageal echocardiography (TEE) simulator with motion analysis can be used to impart proficiency in TEE in an integrated curriculum-based model.


A prospective cohort study.


A tertiary-care university hospital.


TEE-naïve cardiology fellows.


Participants underwent an 8-session multimodal TEE training program. Manual skills were assessed at the end of sessions 2 and 8 using motion analysis of the TEE simulator's probe. At the end of the course, participants performed an intraoperative TEE; their examinations were video captured, and a blinded investigator evaluated the total time and image transitions needed for each view. Results are reported as mean±standard deviation, or median (interquartile range) where appropriate.


Eleven fellows completed the knowledge and kinematic portions of the study. Five participants were excluded from the evaluation in the clinical setting because of interim exposure to TEE or having participated in a TEE rotation after the training course. An increase of 12.95% in post-test knowledge scores was observed. From the start to the end of the course, there was a significant reduction (p<0.001 for all) in the number of probe. During clinical performance evaluation, trainees were able to obtain all the required echocardiographic views unassisted but required a longer time and had more probe transitions when compared with an expert.


A curriculum-based approach to TEE training for cardiology fellows can be complemented with kinematic analyses to objectify acquisition of manual skills during simulator-based training.

Feng R, Rabya Saraf BA, Alex Shapeton MD, Robina Matyal MD, Roger Laham MD, Feroze Mahmood MD. A Complex Atrial Septal Defect and Three-Dimensional Echocardiography: A Question and an Answer. Journal of Cardiothoracic and Vascular Anesthesia. 2015.
Jelliffe Jeganathan MBBS, Ziyad Knio BS, Feroze Mahmood MD. Drawing Our Inferences with Transesophageal Echocardiography. Journal of Cardiothoracic and Vascular Anesthesia. 2015.
Feroze Mahmood MD, Jelliffe Jeganathan MBBS, Rabya Saraf BA, Sajid Shahul MD, Madhav Swaminathan MD, Bukhard Mackensen MD, Ziyad Knio BS, Robina Matyal MD. A Practical Approach to an Intraoperative Three-Dimensional Transesophageal Echocardiography Examination. Journal of Cardiothoracic & Vascular Anesthesia. 2015.
Rabya Saraf BA, Mario Montealegre-Gallegos MD, Feroze Mahmood MD. Transesophageal Echocardiography and Mitral Valve Repair: Chasing a 'Not so Moving' Target. Journal of Cardiothoracic and Vascular Anesthesia. 2015.
Jiang L, Shakil O, Montealegre-Gallegos M, Jainandunsing JS, Matyal R, Wang A, Bardia A, Mahmood F. Systolic anterior motion of the mitral valve and three-dimensional echocardiography. J Cardiothorac Vasc Anesth. 2015;29 (1) :149-50.
Bardia A, Owais K, Khabbaz KR, O'Gara B, Mahmood F. Coronary Sinus and Another Sinus: Which One to Cannulate?. J Cardiothorac Vasc Anesth. 2015.
Zhong Q, Zhao S, Yu B, Wang X, Matyal R, Li Y, Jiang Z. High-density lipoprotein increases the uptake of oxidized low density lipoprotein via PPARγ/CD36 pathway in inflammatory adipocytes. Int J Biol Sci. 2015;11 (3) :256-65.Abstract
AIM: Previous studies have demonstrated that the dysregulated-secretion of adipokines by adipocytes may contribute to obesity-associated atherosclerosis (As) and high density lipoprotein (HDL) may protect against atherogenesis through multiple pathways. This study was to explore the effect of HDL on the oxLDL uptake in inflammatory adipocytes stimulated by endotoxin lipopolysaccharide (LPS) and the possible mechanism. METHODS AND RESULTS: 3T3-L1 adipocytes were cultured and induced to differentiation and maturation. Acute inflammation in adipocytes was induced by LPS (100 ng/ml) for 6 hours. The adipocytes were pretreated with HDL in various concentrations (10, 50, 100 μg/ml) for 16 hours or with specific PPARγ antagonist (GW9662, 10 μM) or agonist (Rosiglitazone, 10 μM) for 30 min before administration of LPS. The results showed that LPS significantly increased the release of inflammation-related adipokines, such as monocyte chemoattractant protein-1 (MCP-1), plasminogen activator inhibitor 1 (PAI-1), tumor necrosis factor-alpha (TNF-α), interleukin (IL)-8 and IL-6, while decreasing the release of leptin and adiponectin. Meanwhile, LPS reduced the uptake and degradation of 125I-oxLDL, and down-regulated the expression of PPARγ and CD36. Pretreatment with HDL dose-dependently affected the release of IL-8 and IL-6 and the reduced uptake and degradation of oxLDL of adipocytes stimulated by LPS, accompanied with marked upregulation of PPARγ and CD36 expression. Pretreatment with GW9662 markedly inhibited the upregulation of CD36 expression mediated by HDL (100 μg/ml), while the effects of Rosiglitazone were opposite to GW9662. CONCLUSIONS: HDL may increase oxLDL uptake of inflammatory adipocytes stimulated by LPS via upregulation of PPARγ/CD36 pathway, which may be a new mechanism of anti-atherosclerosis mediated by HDL.
Matyal R, Shakil O, Hess PE, Lo R, Jainandunsing JS, Mahmood B, Hartman GS, Schermerhorn ML, Mahmood F. Impact of gender and body surface area on outcome after abdominal aortic aneurysm repair. Am J Surg. 2015;209 (2) :315-23.Abstract
BACKGROUND: A gender-neutral threshold aneurysm diameter (AD) of more than 5.5 cm for surgical intervention in abdominal aortic aneurysms (AAA) ignores the fact that women have a smaller baseline AD. We hypothesized that women have a greater AD relative to body surface area (BSA) at the time of surgery and that this worsens outcome. METHODS: The Vascular Study Group of New England database was queried for elective AAA repairs performed from 2003 to 2011 to compare BSA-indexed AD, ie, aortic size index (ASI), between men and women at the time of surgery and the impact of ASI on outcome. RESULTS: Women were older and had higher ASI among both open-repair (n = 1,566) and endovascular repair (n = 2,172) patients (P < .001). Among open-repair patients, mean ASI for men undergoing repair at AD of 5.5 cm (2.75 cm/m²) was used to subdivide women into 2 categories: women with ASI of 2.75 or more were older (P < .001), had a larger aneurysm size (P < .001), and had a higher 1-year mortality (P = .042) than women with ASI less than 2.75. CONCLUSIONS: When indexed to BSA, women have a larger aneurysm size than men at the time of AAA repair.
Owais K, Montealegre-Gallegos M, Matyal R, Pal A, Mahmood F. Left atrial appendage.. and another appendage?. J Cardiothorac Vasc Anesth. 2015;29 (1) :248-9.
Mitchell JD, Mahmood F, Wong V, Bose R, Nicolai DA, Wang A, Hess PE, Matyal R. Teaching concepts of transesophageal echocardiography via Web-based modules. J Cardiothorac Vasc Anesth. 2015;29 (2) :402-9.Abstract
OBJECTIVES: Teaching transesophageal echocardiography (TEE) remains challenging. The authors hypothesized that using online modules with live teaching in an echo training course would be feasible and result in superior knowledge acquisition to live teaching only. DESIGN: In this prospective cohort study, the authors implemented a TEE course with online modules and live teaching and compared it to a live-teaching-only version. SETTING: The online-and-live-teaching version of the course consisted of online modules and live sessions at Beth Israel Deaconess Medical Center (BIDMC), an academic medical center. The live-teaching-only version consisted of live sessions at BIDMC. PARTICIPANTS: Course participants included anesthesia trainees at BIDMC. INTERVENTIONS: Trainees taking the online-and-live-teaching version viewed online modules before live review lectures and simulation. Trainees taking the live-teaching-only version viewed live lectures before simulation. MEASUREMENTS AND MAIN RESULTS: Twenty-seven trainees completed the online-and-live-teaching version; six completed the live-teaching-only version. Trainees took a course exam after the first and last live sessions. For the online-and-live-teaching version, average pretest and posttest scores were 62.0%±13.7% and 77.5%±8.1%, respectively; pretest and posttest passing (≥70%) rates were 29.6% and 85.2%, respectively. Compared to the live-teaching-only version, the average pretest score was not significantly different (p=0.17), but the average posttest score was significantly higher (p=0.01). Trainee comfort with, and knowledge of, TEE increased after both versions. Trainees rated the utility of the live lectures and online modules similarly. CONCLUSIONS: A multimodal TEE curriculum increased trainees' knowledge of TEE concepts and had a positive reception from trainees.
Mahmood F, Owais K, Taylor C, Montealegre-Gallegos M, Manning W, Matyal R, Khabbaz KR. Three-dimensional printing of mitral valve using echocardiographic data. JACC Cardiovasc Imaging. 2015;8 (2) :227-9.
Matyal R, Montealegre-Gallegos M, Shnider M, Owais K, Sakamuri S, Shakil O, Shah V, Pawlowski J, Gangadharan S, Hess P. Preemptive ultrasound-guided paravertebral block and immediate postoperative lung function. Gen Thorac Cardiovasc Surg. 2015;63 (1) :43-8.Abstract

BACKGROUND AND OBJECTIVES: The aim of this study was to investigate the effects of preemptive ultrasound-guided thoracic paravertebral block versus intercostal block on postoperative respiratory function and pain control in patients undergoing video-assisted thoracoscopic surgery. SUBJECTS: 50 consecutive patients undergoing video-assisted thoracoscopic surgery. METHOD: A prospective cohort of patients who received either ultrasound-guided thoracic paravertebral block immediately before the procedure or intercostal block placed by the surgeon at the end of the procedure were studied. Pulmonary function was assessed before surgery and 4 h postoperatively. Pain was assessed with the visual analog scale at 2 and 4 h after surgery both at rest and on coughing. RESULTS: 30 patients on the paravertebral block group and 20 on the intercostal block group were studied. Forced vital capacity (p < 0.001), forced expiratory volume at 1 s (p < 0.001) and forced expiratory flow 25-75% (p = 0.001) were significantly higher at 4 h with paravertebral block compared to the intercostal block group. The visual analog score for pain was significantly improved with paravertebral block at rest (p < 0.05) and with cough (p = 0.00). Perioperative narcotic use was significantly reduced with paravertebral block in comparison to intercostal block (p = 0.04). CONCLUSIONS: When compared to intercostal blocks, ultrasound-guided thoracic paravertebral block appears to preserve lung function and provide better pain control in the immediate postoperative period after video-assisted thoracoscopic surgery.