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Prognostic impact of QRS axis deviation in patients treated with cardiac resynchronization therapy: Prognosis of QRS axis deviation in CRT-D. - Journal of cardiovascular electrophysiology
QRS duration and morphology are currently recognized as recommended criteria for the selection of CRT candidates. It has recently been shown that patients with left bundle branch block (LBBB) derive substantial clinical benefit from CRT. The aim of this study is to investigate the prognostic impact of QRS axis deviation (AD) in HF patients with LBBB undergoing CRT.We retrospectively evaluated 707 HF patients with LBBB who underwent CRT at 5 centers. Baseline QRS axis was defined as normal (NA: -30Â° to 90Â°), right axis deviation (RAD: 90Â° to 180Â°) and left axis deviation (LAD: â†30Â°). The primary endpoint was a composite of all cause death/HF hospitalization. The risk of endpoint by AD was evaluated with both Kaplan-Meier and Cox proportional-hazard analysis. Among 707 patients (73% M, median age: 71[62,77]years), 323 (46%) had NA, 359 (51%) LAD and 25 (3.5%) RAD. Baseline clinical characteristics were similar between the 3 groups. Over a mean follow-up of 32Â±25 months, 141 deaths occurred (21%) and 36% (n = 255) met with the composite endpoint. A significantly higher proportion of RAD patients (52%) reached the endpoint (LAD 40%, NA 30%). KM analysis showed that RAD and LAD patients had worse event free survival and in multivariate analysis both LAD (HR: 1.40; 95%CI: 1.05-1.86; p = 0.021) and RAD (HR: 2.49; 95%CI: 1.31-4.74; p = 0.005) were independently associated with worse clinical outcome.Right or left axis deviation in the presence of LBBB in HF patients undergoing CRT are independent predictors of poor prognosis. This article is protected by copyright. All rights reserved.This article is protected by copyright. All rights reserved.
Impact of Tricuspid Regurgitation on the Success of Atrioventricular Node Ablation for Rate Control in Patients With Atrial Fibrillation: The Node Blast Study. - The American journal of cardiology
Atrioventricular node (AVN) ablation is an effective treatment for symptomatic patients with atrial arrhythmias who are refractory to rhythm and rate control strategies where optimal ventricular rate control is desired. There are limited data on the predictors of failure of AVN ablation. Our objective was to identify the predictors of failure of AVN ablation. This is an observational single-center study of consecutive patients who underwent AVN ablation in a large academic center. Baseline characteristics, procedural variables, and outcomes of AVN ablation were collected. AVN "ablation failure" was defined as resumption of AVN conduction resulting in recurrence of either rapid ventricular response or suboptimal biventricular pacing. A total of 247 patients drug refractory AF who underwent AVN ablation at our center with a mean age of 71 Â± 12 years with 46% being males were included. Ablation failure was seen in 11 (4.5%) patients. There were no statistical differences between patients with "ablation failure" versus "ablation success" in any of the baseline clinical variables. Patients with moderate-to-severe tricuspid regurgitation (TR) were much more likely to have ablation failure than those with ablation success (8 [73%] vs 65 [27%]; p = 0.003). All 11 patients with ablation failure had a successful redo procedure, 9 with right and 2 with the left sided approach. On multivariate analysis, presence of moderate-to-severe TR was found to be the only predictor of failure of AVN ablation (odds ratio 9.1, confidence interval 1.99 to 42.22, p = 0.004). In conclusion, moderate-to-severe TR is a strong and independent predictor of failure of AVN ablation.Copyright Â© 2015 Elsevier Inc. All rights reserved.
Differences in complication rates between large bore needle and a long micropuncture needle during epicardial access: time to change clinical practice? - Circulation. Arrhythmia and electrophysiology
A dry epicardial access (EA) is increasingly used for advanced cardiovascular procedures. Conventionally used large bore needles (Tuohy or Pajunk needle; LBN) have been associated with low but definite incidence of major complications with EA. Use of micropuncture needle (MPN) may decrease the risk of complications. We intended to compare the outcomes of LBN with MPN for EA.We report a multicenter observational study of consecutive patients who underwent EA for ventricular tachycardia ablation or Lariat procedure using the LBN or MPN. Oral anticoagulation was stopped before the procedure. Baseline characteristics and procedure-related complications were collected and compared. Of the 404 patients, LBN and MPN were used in 46% and 54% of patients, respectively. There was no significant difference in the incidence of inadvertent puncture of myocardium between LBN and MPN (7.6% versus 6.8%, P=0.76). However, there was a significantly higher rate of large pericardial effusions with LBN compared with MPN (8.1% versus 0.9%; P<0.001). The incidence of pleural effusions were not significantly different between both (1.6% versus 2.3%; P=0.64). LBN group had an increase in other complications compared with MPN (open heart surgery to repair cardiac laceration [6 versus 0], injury to liver [1 versus 0], coronaries [1 versus 0], and superior epigastric artery requiring surgical exploration [0 versus 1]).The use of MPN is associated with decreased incidence of major complications, and the need for surgical repair and routine use should be considered for EA.Â© 2015 American Heart Association, Inc.
Initial real world experience with a novel insertable (Reveal LinQ(@Medtronic)) compared to the conventional (Reveal XT(@Medtronic)) implantable loop recorder at a tertiary care center - Points to ponder! - International journal of cardiology
Limited data is available regarding the novel Reveal LinQ (LinQ) which is a new generation implantable loop recorders (ILRs).We performed a prospective, observational study of all consecutive patients undergoing conventional (Reveal XT; XT) and LinQ devices at our institution between January 2012 and December 2014.A total of 217 patients underwent ILR implantation. XT was implanted in 105 and LinQ in 112 patients. There were no significant differences in baseline characteristics between the two groups. LinQ implantation using the manufacturer's technique termed, "manufacturer's method" group had significantly higher incidence of pocket infection compared to XT (6/50, 12% vs 3/105, 3%, p=0.032). With modifications to the LinQ implantation technique (using a conventional scalpel and placing a suture when needed to the incision) termed "modified method" group, the rate of infection has decreased significantly compared to "manufacturer's method group" (0/62, 0% vs 6/50, 12%, p=0.004) (Table 3). In multivariate regression analysis, the only independent predictors of infection were younger age (OR 0.95; p=0.04), insertion of LinQ device (OR 30.02; p=0.006) and procedure time (OR 1.07; p=0.03).In our single-center, prospective, observational study we found that with the current implantable techniques, the novel insertable LinQ device is associated with increased risk of complications.Copyright Â© 2015 Elsevier Ireland Ltd. All rights reserved.
Electrolyte and hemodynamic changes following percutaneous left atrial appendage ligation with the LARIAT device. - Journal of interventional cardiac electrophysiology : an international journal of arrhythmias and pacing
The left atrial appendage (LAA) is a well-known source of atrial natriuretic peptide (ANP) and therefore plays an important role in homeostasis. The neurohormonal impact of epicardial exclusion of the LAA with the LARIAT procedure is unknown. In this proof-of-concept study, we postulated that LAA exclusion would impact homeostasis as evidenced by changes in electrolytes and blood pressure (BP).A total of 76 patients who underwent successful LAA exclusion were enrolled in this retrospective observational study utilizing a prospective registry. Electrolytes, BP, and heart rate (HR) were monitored before LARIAT and post-LARIAT (24 and 72 h and 6 months).There was a significant reduction of systolic BP (mmHg) at 24 h (113.3â€‰Â±â€‰16.0; pâ€‰<â€‰0.0001) and 72 h (119.0â€‰Â±â€‰18.4 mmHg; pâ€‰<â€‰0.0001) post-LARIAT when compared with pre-LARIAT BP (138.2â€‰Â±â€‰21.3). The reduction in systolic BP persisted at 6-month follow-up (128.8â€‰Â±â€‰17.3; pâ€‰=â€‰0.0005). There was significant reduction in serum sodium (mmol/L) at 24 h (135.4â€‰Â±â€‰3.6; pâ€‰<â€‰0.0001) and 72 h (136.3â€‰Â±â€‰3.7; pâ€‰<â€‰0.001) post-LARIAT when compared to pre-LARIAT (138.7â€‰Â±â€‰3.2). The reduction in sodium was not persistent at 6-month follow-up (138.4â€‰Â±â€‰3.3; pâ€‰=â€‰0.453).LAA exclusion results in an early and persistent decrease in systolic BP. Additionally, there is an early decline in serum sodium, which normalizes at long-term follow-up. The underlying mechanism leading to these changes is not entirely clear; however, it is likely related to neurohormonal changes post LAA exclusion.
Over, Under, or Just Right? How do we interpret ICD utilization in the modern era? - Indian pacing and electrophysiology journal
Despite ACC/AHA guidelines indicating implantable cardioverter defibrillator (ICD) as class I therapy for primary prevention of sudden cardiac death in patients with EFâ‰¤35%, ICD utilization rates in real world practice have been low.To determine the rate of ICD implantation at a tertiary care academic center and to assess the reasons for under-utilization of the same.Review of a prospectively collected database which included all patients diagnosed with an EFâ‰¤35% was performed to assess the rate of ICD implantation and mortality. Reasons for non-implantation of ICD were then assessed from detailed chart review.A total of 707 patients (age 69.4 Â± 14.1 years) with mean EF of 26Â±7% were analyzed. Only 28% (200/707) of patients had ICDs implanted. Mortality was lower in the group with ICD (25% vs 37%, p=0.004). When patients who either died or were lost to follow-up prior to 2005 were excluded, ICD utilization rate was still low at 37.6%. The most common reason for non-implantation of ICD was physicians not discussing this option with their patients. Patient refusal was the second most common reason.ICD Implantation rates for primary prevention of SCD in patients with EFâ‰¤35% is low. Physician and patient education should be addressed to improve the utilization rates.
Endocardial (Watchman) vs epicardial (Lariat) left atrial appendage exclusion devices: Understanding the differences in the location and type of leaks and their clinical implications. - Heart rhythm : the official journal of the Heart Rhythm Society
Watchman and Lariat left atrial appendage (LAA) occlusion devices are associated with LAA leaks postdeployment.The purpose of this study was to compare the incidence, characteristics, and clinical significance of these leaks.We performed a multicenter prospective observational study of all patients who underwent LAA closure. Baseline, procedural, and imaging variables along with LAA occlusion rates at 30-90 days and 1-year postprocedure were compared.A total of 478 patients (219 with the Watchman device and 259 with the Lariat device) with successful implants were included. Patients in the Lariat group had a higher CHADS2 (congestive heart failure, hypertension, age >74 years, diabetes, stroke) score and a larger left atrium and LAA. A total of 79 patients (17%) had a detectable leak at 1 year. More patients in the Watchman group had a leak compared with those in the Lariat group (46 [21%] vs 33 [14%]; P = .019). All the leaks were eccentric (edge effect) in the Watchman group and concentric (gunny sack effect) in the Lariat group. The size of the leak was larger in the Watchman group than in the Lariat group (3.10 Â± 1.5 mm vs 2.15 Â± 1.3 mm; P = .001). The Watchman group had 1 device embolization requiring surgery and 2 pericardial effusions requiring pericardiocentesis. In the Lariat group, 4 patients had cardiac tamponade requiring urgent surgical repair. Three patients in each group had a cerebrovascular accident and were not associated with device leaks.The Lariat device is associated with a lower rate of leaks at 1 year as compared with the Watchman device, with no difference in rates of cerebrovascular accident. There was no correlation between the presence of residual leak and the occurrence of cerebrovascular accident.Copyright Â© 2015 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.
Feasibility of Transseptal Puncture Using a Nonfluoroscopic Catheter Tracking System. - Pacing and clinical electrophysiology : PACE
Radiation exposure in the electrophysiology lab is a major occupational hazard to the electrophysiologists. A catheter localization system (MediGuide Technology, St. Jude Medical Inc., St. Paul, MN, USA) allows the integration of electroanatomical mapping and x-ray imaging, and has been shown to be effective in reducing radiation exposure during several electrophysiological procedures. We intended to evaluate the feasibility of this catheter tracking system to guide transseptal (TS) access.The feasibility of performing TS puncture with MediGuide (MDG) was assessed in a prospective observational study in 16 patients undergoing radiofrequency ablation for atrial fibrillation. These patients were compared to 16 matched patients undergoing similar procedures during the same time frame using conventional approach. There were no differences in mean age, gender distribution, and body mass index between the two groups. Total duration of fluoroscopic exposure during TS puncture was compared between the two groups.All patients underwent successful TS puncture. Fluoroscopy time for double TS puncture using the MDG system was significantly lower than the control group (0.48 Â± 0.17 minutes vs. 5.9 Â± 0.65 minutes; P < 0.0001). No major complications occurred during the procedures in either group.TS puncture can be successfully performed using MDG, and results in significant reduction in radiation exposure.Â©2015 Wiley Periodicals, Inc.
Characterization of pleural effusion after left atrial appendage exclusion using the lariat procedure. - Journal of cardiovascular electrophysiology
The Lariat procedure is increasingly used for the exclusion of the left atrial appendage (LAA) in atrial fibrillation (AF) patients. There are anecdotal reports of pleural effusions after the Lariat procedure. However, the incidence, demographics, and pathophysiology of these effusions are largely unknown.Characterization of pleural effusions in patients who underwent LAA exclusion using the Lariat procedure.We report the incidence, demographics, and clinical and laboratory characteristics of patients from a multicenter prospective registry who underwent the Lariat procedure and subsequently developed pleural effusions.A total of 10 out of 310 (3.2%) patients developed significant pleural effusions after the Lariat procedure. The mean age of these patients was 67 Â± 9, ranging from 52 to 78 years and included 5 (50%) males. Nine patients had persistent AF with median CHADS2 score of 2.7 Â± 1.2. The LAA was successfully ligated in all these patients. Post-Lariat procedure, 6 patients developed bilateral and 4 patients developed left-sided pleural effusions. Pleural tap revealed transudative in 2 and exudative in 6 patients. The remaining 2 patients responded to active diuresis and behaved clinically like transudative effusions. There is a statistically significant difference between the onset of pleural effusion after the Lariat procedure between tPLE versus ePLE groups (14 Â± 1.2 vs. 6 Â± 6, P = 0.05).Incidence of clinically significant pleural effusion is uncommon after the Lariat procedure and can be either exudative or transudative in nature depending on the underlying mechanisms. More prospective studies are needed to study the pathophysiologic basis of development of pleural effusions after the Lariat procedure.Â© 2015 Wiley Periodicals, Inc.
IMpact of pocKet rEvision on the rate of InfecTion and other CompLications in patients rEquiring pocket mAnipulation for generator replacement and/or lead replacement or revisioN (MAKE IT CLEAN): A prospective randomized study. - Heart rhythm : the official journal of the Heart Rhythm Society
The fibrous capsule around cardiac implantable device generators is known to promote bacterial colonization and latent infection. Removal of the capsule during device replacement procedures may reduce infection rates but may increase hemorrhagic complications.The purpose of this study was to evaluate the effect of pocket capsule decortication procedure on infection and bleeding rates in patients undergoing device replacement procedures.In a prospective randomized single-blind control study, patients undergoing device replacement, upgrade, or lead extraction were randomized to Group A "with pocket revision" (n = 131) and group B "without pocket revision" (n = 127). Deep and superficial infection rates, bleeding, and prolonged serous drainage were assessed during 12 months of follow-up. Data were analyzed according to intention-to-treat principle.A total of 258 patients were enrolled in the study. Rates of generator change, upgrade, and lead extraction/replacement were similar between both groups. There was no incidence of deep infection in either group at 12-month follow-up. There was no significant difference in the incidence of superficial infection between groups (1.5% vs 4.7%, P = .13) during 12-month follow-up. There was a significant increase in acute hematoma formation in group A compared to group B (6.1% vs 0.8%, P = .03). Two patients in group A had to undergo hematoma evacuation.There was increased incidence of hematoma formation in group A with no effect on infection rates. Our study suggests that there is no benefit to performing empiric pocket revision.Copyright Â© 2015 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.
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