Cardiology 2019 Projects

Project Title: A comparison of esophageal cancer calculators

Faculty Mentor’s Name: Dr. David Winchester
Email: David.Winchester@medicine.ufl.edu

Student: Denslow Trumbull
Email: dtrumbull@ufl.edu

Project Description:

Cancer treatment options are always evolving along with complementary outcome statistics and ways to measure them. In addition, the progression of personalized medicine is continually improving patient care and outcome. This personalized medicine is specifically important for cancer which is the second leading cause of death worldwide and treatment options are diversifying. With the continued production of cancer survival calculators (nomograms), patients and physicians are able to make informed decisions on cancer treatment that corresponds to the best predicted outcome for that specific patient. These calculators take into account a variety of factors including demographics and cancer types and progression. The nomograms enhance informed decision making in the clinic and improved individualized medicine.


Treatment for esophageal cancer has been especially challenging because of variation in treatment responses to neoadjuvant chemoradiation. Ideally, an outcomes calculator for esophageal cancer treatments would identify the important patient predictors to help personalize treatment. This study will compare two esophageal cancer calculators in order to identify which one has the greater accuracy for survival outcomes. In addition, this study will help determine whether a variety and plethora of variables is necessary for determining outcome or if a few select variables are sufficient.

Project Title: Cardiac magnetic resonance imaging detects indications of cardiotoxicity in a pediatric population exposed to chemotherapy

Faculty Mentor’s Name: Dr. Jennifer Co-Vu
Email: jcovu@peds.ufl.edu

Student: Amanda Vozzola
Email: avozzola@ufl.edu

Project Description:

Anthracyclines have been used to treat over 50% of childhood cancer survivors in the United States, leading to a large at-risk population for anthracycline-induced cardiotoxicity (3). Many cancer survivors who were treated with anthracyclines experience significant cardiovascular morbidity and mortality in the future. Transthoracic 2-dimensional echocardiograms (2D-TTE) are the standard of care in assessing left ventricular function in cancer survivors, which is recommended by the Children’s Oncology Group (4). However, there have been recent indications that patients can have echocardiogram imaging indicating normal myocardial function, but have abnormalities seen on cardiac magnetic resonance imaging (CMR) prior to a critical level of cardiac damage (3).

CMR is considered the gold standard for ventricular volume and systolic function quantification (5). T1 Mapping by CMR is a marker of interstitial myocardial fibrosis (6). Myocardial strain by tagged cine MRI can also be used to detect subclinical myocardial dysfunction (7). Extracellular volume (ECV) measurement by CMR has also been validated as a measurement of the expansion of extracellular matrix in several disease processes (8).

Cardiotoxicity secondary to anthracyclines has been demonstrated to be due to a variety of factors, including generation of free oxygen radicals which could induce apoptosis as well as DNA and myocyte membrane damage, and also due to an effect of the loss of extracellular matrix and increase in fibrosis (9-10). Cardiotoxicity secondary to anthracyclines can be separated into three chronological categories: (1) acute, (2) early-onset, and (3) late-onset (11).

Previous studies have shown early indicators of cardiac damage on CMR such as myocardial T1 and extracellular volume, decreased left ventricular myocardial peak circumferential strain, and longitudinal strain magnitude in children with normal ejection fractions who have undergone anthracycline therapy (3,4). These abnormal values are associated with pediatric childhood cancer survivors with normal left ventricular systolic function, which is characteristically measured as the standard of care in this population. This standard does not indicate the presence of myocardial damage until a significant level is reached, thus it may not be an adequate way to screen this population.

Previous studies have shown that CMR is more sensitive in detecting the initial stages of myocardial function decline. The earlier detection of cardiotoxicity and cardiac functioning decline can allow for earlier treatment and change in clinical management to prevent further deterioration. Cardiovascular related disorders secondary to the toxicity of anthracyclines are the second most common cause of morbidity and mortality in childhood cancer survivors (1). This demonstrates the importance of early detection and treatment in this population during long-term follow up, which can be enhanced with better imaging techniques.

Project Title: Comparing Open Repair and Endovascular Repair of Aortic Aneurysms in Patients with Connective Tissue Disorders

Faculty Mentor’s Name: Dr. Javairiah Fatima
Email: javairiah.fatima@surgery.ufl.edu

Student: Zoya Shakeel
Email: zshakeel@ufl.edu

Project Description:

Due to the complicated and multifaceted nature of connective tissue disorders, there is currently a lack of high-quality evidence to support any one approach to aortic repair in patients with connective tissue disorders. In patients with connective tissue disorders, aneurysmal degeneration of the aorta in its entirety is common. Feasible treatment techniques include open repair and endovascular repair. There is a limited amount of reports comparing perioperative and post-operative outcomes in these approaches1. Our wish is to potentially elucidate if there is a more prevalent role of endovascular repair in this patient population.

Open repair of aortic aneurysms remains the standard approach in aortic disease of patients with connective tissue disorders, specifically the preferred technique is open branched graft repair1. However, endovascular interventions have shown increasing promise2 in specific patient populations and have generally show less immediate demand of the cardiovascular system1. Our objective herein is to review the available evidence from University of Florida, Vascular Surgery Department with hopes of illuminating the chance of a more prevalent role of endovascular repair in this patient population.

Project Title: Implications of updated blood cholesterol management guidelines for women with history of adverse pregnancy conditions

Faculty Mentor’s Name: Dr. Ki Park
Email: ki.park@medicine.ufl.edu

Student: Sarah Sherman
Email: sarahsherman95@ufl.edu

Project Description:

Cardiovascular disease (CVD) remains the largest cause of morbidity and mortality in women in the US. Despite the significant health burden CVD poses to women, risk assessment can be problematic as traditional risk factors may not be present in women, leading to misleading assessments of low risk. Adverse pregnancy outcomes as risk factors for future CVD in women remain under-recognized and are not included in traditional risk stratification calculators (Park et al. 2015). Adverse pregnancy conditions include pre-eclampsia, gestational hypertension, gestational diabetes, small for gestational age birth weight and preterm birth. It has been well established that risk for CVD is increased in women who experienced adverse pregnancy conditions compared to those with uncomplicated pregnancies (Grandi et al. 2019). While the causative and associative mechanisms behind the observed increased CVD risk with pregnancy complications are not clear, history of such conditions serve as useful markers for greater likelihood of future cardiovascular events.

The American College of Cardiology recently published updated guidelines on cholesterol management and for the first time include pregnancy-associated conditions as risk-enhancing factors for atherosclerotic cardiovascular disease (ASCVD). In addition, the updated guidelines now include considering history of pregnancy-associated conditions in recommendations for discussing lifestyle interventions and potential statin therapy. (Grundy et al. 2018). Therefore, consistent screening for adverse pregnancy outcomes would allow for potentially earlier detection of future CVD risk in women who may not have traditional risk factors and allow for earlier intervention (Mehta et al. 2015). Documented history of adverse pregnancy conditions would be an indication for annual screening for other CVD risk factors, which would include lipids, blood pressure, and fasting glucose (Mosca et al. 2011). Although the recognition of adverse pregnancy conditions in assessing cardiovascular risk is becoming more recognized, how the most recently published lipid guidelines impact consideration of statin therapy based on pregnancy history is unknown. The University of Florida Women’s Heart Health Clinic routinely screens new female patients for pregnancy history and provides an opportunity to assess the impact of the newest lipid guidelines on potential statin therapy.

Project Title: Stewardship for Inhaled Nitric Oxide Use in the Pediatric Cardiac Intensive Care Unit

Faculty Mentor’s Name: Dr. Joseph Philip
Email: subijo9@ufl.edu

Student: Heather DeReus
Email: hdereus@ufl.edu

Project Description:

The use of inhaled Nitric Oxide (iNO) in the pediatric cardiac intensive care unit has become the standard of care and is supported in the literature across a variety of clinical presentations (Yoshimura et al., 2005) (Beghetti et al., 1995). iNO serves to reduce pulmonary arterial pressure, decreasing pulmonary vascular resistance (Miller OI et al., 2000) which is highly effective in patients with pulmonary hypertension including as a result of cardiac surgery (Beghetti et al., 1995). Pulmonary hypertension in the pediatric population is commonly defined as having a systolic pulmonary arterial pressure that is greater than half of the value of the systemic pressure (Hawkins).

iNO has a clinical role in the clinical course for patients with specific cardio-respiratory pathologies and is used extensively in the pediatric cardiac intensive care unit. From clinical observations, it is noted that iNO is started on an empiric basis on multiple patient but there is limited available data to indicate utility. Our goal is to identify clinical practice and the profiles of patients who benefit from NO.

Project Title: The implication of differing TAVR variables on moderate-to-severe and severe mitral regurgitation

Faculty Mentor’s Name: Dr. David Anderson
Email: david.anderson@medicine.ufl.edu

Student: Adriana Della Porta
Email: a.dellaporta@ufl.edu

Project Description:

Transcatheter Aortic Valve Replacement (TAVR) is a first-line treatment for patients with symptomatic, severe aortic stenosis who are intermediate-, extreme-, and high-risk candidates for standard Surgical Aortic Valve Replacement (SAVR) (1, 3). Multi-valvular disease in this patient population is common, and it is reported that, at a minimum, one-third of patients who undergo TAVR have moderate or severe mitral regurgitation (2). Mitral regurgitation is a valvular disease in which the mitral valve of the heart, instead of closing normally, leaks blood back into the left atrium, which decreases the blood volume entering the systemic circulation from the left ventricle of the heart.

Due to the prevalence of combined mitral regurgitation and aortic stenosis in patients referred for TAVR, many studies have aimed to enumerate the risks and assess clinical outcomes for patients with moderate or severe mitral regurgitation compared to those without, who undergo the TAVR procedure. Physiological changes to the heart that occur post-TAVR include a reduction in left ventricular systolic pressure, improved valve hemodynamics, and reduction in left ventricular end-diastolic volume and mitral tethering forces. In looking only at patients with mitral regurgitation who undergo TAVR, regurgitation severity was found to be decreased in 51% of patients, with 47% experiencing no change and 2% experiencing worsening mitral regurgitation (2). Despite improved regurgitation severity, registry and meta-analysis data sets have shown an increase in long and short-term mortality for patients undergoing TAVR with moderate or severe mitral regurgitation compared to those without (2, 4, 5).

Improvement of mitral valve regurgitation severity post-TAVR, specifically the relation to valve type, valve size, and whether or not balloon aortic valvuloplasty and post-deployment balloon aortic dilation were performed, has yet to be fully explored. These factors likely hold clinical significance when predicting outcomes and effect of treatment for mitral regurgitation patients undergoing TAVR.

Project Description: The Utility of Mobile ECGs in Detection of Subclinical AF in High Risk Outpatient Populations

Faculty Mentor’s Name: Dr. Ramil Goel
Email: ramil.goel@medicine.ufl.edu

Student: Riken Nathu
Email: rnathu@ufl.edu

Project Description:

Cardiovascular disease is the leading cause of death in the United States. (1) It is estimated that by 2030, 43.9% of US adults will have at least one type of cardiovascular disease. (2) Atrial fibrillation (AF) is the most common sustained arrhythmia diagnosed in clinical practice. (3,4) It reduces a patient’s quality of life and has increased morbidity and mortality rates that may lead to increased risk of heart failure. (5)

In order to diagnose AF, an ECG reading must show irregular RR intervals without distinct P waves. (5) Standard 12-lead ECGs are costly and time-consuming devices that are used to detect AF. (5) The development of new devices like the one-lead portable, phone-based KardiaMobile device may be an efficient and cost-effective alternative that can potentially offer feasible mass screenings for AF. The standardization of mass screenings for AF in primary and outpatient clinics can thus help improve the implementation of prevention strategies for cardiovascular diseases. Risks for AF has been associated with reduced kidney function, diabetes mellitus type 2, and reduced lung function. (6,7,8) Hence, we would like to investigate whether increase screenings in different outpatient clinics will be beneficial in diagnosing previously undetected cardiovascular diseases–especially since AF is often asymptomatic. Costs, availability, and time required to use ECG machines are prohibiting factors for conducting regular ECG’s. Therefore, we hope that the use of the KardiaMobile one-lead ECG device will help increase screenings as the device does not require time to set up and takes 30 seconds to one minute to capture an ECG.

Project Description: Too Well for a VAD?

Faculty Mentor’s Name: Dr. Mustafa Ahmed
Email: mustafa.Ahmed@medicine.ufl.edu

Student: James Cooper
Email: james.cooper@ufl.edu

Project Description:

Heart failure affects millions of people in the U.S. each year and is one of the leading causes of hospitalizations in the elderly. As this number widens, more and more patients are looking for an alternative to a rising shortage in donor organs. Left ventricular assist devices (LVADs) have become a more viable option to provide patients with improved functional capacity and quality of life.

We aim to define the outcomes and progression of disease of those patients who were referred to the UF Advanced Heart Failure Clinic for consideration for LVAD implantation and underwent formal multidisciplinary evaluation. The research team hypothesizes that those who were deemed “too healthy” may experience a disproportionate amount of bad outcomes, or their condition may deteriorate before they are given a second evaluation. By studying the outcomes of this population, clinicians may be able to form a model for how often these patients should be re-evaluated.

The specific aims of this proposed project are:

1) To understand and model the clinical outcomes of advanced heart failure patients deemed too well for LVAD implementation.

2) Create an estimate for how often these patients should be reevaluated for LVAD implementation.

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