Cheng-Hsu Yang

Early extracorporeal membrane oxygenator-assisted primary percutaneous coronary intervention improved 30-day clinical outcomes in patients with ST-segment elevation myocardial infarction complicated with profound cardiogenic shock

Objectives:This study tested the hypothesis that early extracorporeal membrane oxygenator offered additional benefits in improving 30-day outcomes in patients with acute ST-segment elevation myocardial infarction complicated with profound cardiogenic shock undergoing primary percutaneous coronary intervention. Methods:Between May 1993 and July 2002, 920 patients with acute ST-segment elevation myocardial infarction underwent primary percutaneous coronary intervention. Of these patients, 12.5% (115) with cardiogenic shock were enrolled in this study (group 1). Between August 2002 and December 2009, 1650 patients with acute ST-segment elevation myocardial infarction underwent primary percutaneous coronary intervention. Of these patients, 13.3% (219) complicated with cardiogenic shock were enrolled (group 2). Results:The incidence of profound shock (defined as systolic blood pressure remaining ≤75 mm Hg after intra-aortic balloon pump and inotropic agent supports) was similar in both groups (21.7% vs. 21.0%, p > .5). Extracorporeal membrane oxygenator support, which was available only for patients in group 2, was performed in the catheterization room. The results demonstrated that final thrombolysis in myocardial infarction grade 3 flow in infarct-related artery was similar between the two groups (p = .678). However, total 30-day mortality and the mortality of patients with profound shock were lower in group 2 than in group 1 (all p < .04). Additionally, the hospital survival time was remarkably longer in patients in group 2 than in patients in group 1 (p = .0005). Furthermore, multivariate analysis demonstrated that unsuccessful reperfusion, presence of advanced congestive heart failure, profound shock, and age were independent predictors of 30-day mortality (all p < .02). Conclusion:Early extracorporeal membrane oxygenator-assisted primary percutaneous coronary intervention improved 30-day outcomes in patients with ST-segment elevation myocardial infarction with complicated with profound cardiogenic shock.

The effect of acupuncture on the incidence of postextubation laryngospasm in children

Laryngospasm occurring after tracheal extubation in children is potentially dangerous. This study uses acupuncture with bloodletting at the Shao Shang (L 11) or Shang Yang (Li 1) acupoints to investigate whether this technique can prevent or treat laryngospasm. Seventy‐six patients were randomly divided into two groups. Patients in the acupuncture group (n = 38) were treated with bilateral Shao Shang acupunctures at the end of the operation. Patients in the control group (n = 38) were not. The incidence of laryngospasm in the acupuncture group (5.3%) was less than that in the control group (23.7%) (p < 0.05). If laryngospasm developed, patients were immediately treated with acupuncture at either the Shao Shang or Shang Yang acupoints. As judged by an increase in peripheral oxygen saturation, the laryngospasm was relieved within 1 min of acupuncture in all patients. It is concluded that acupuncture with bloodletting at the Shao Shang acupoint may prevent and treat laryngospasm occurring after tracheal extubation in children.

Feasibility and safety of transbrachial approach for patients with severe carotid artery stenosis undergoing stenting.

Although sporadic successful cases using the transradial approach (TRA) for carotid stenting have been reported, the safety and feasibility of carotid stenting using either TRA or a transbrachial approach (TBA) have not been fully investigated. Recently, we have developed a safe and feasible method of TRA for cerebrovascular angiographic studies. This study investigated whether a TBA approach using a 7‐French (F) Kimny guiding catheter for carotid stenting is safe and feasible for patients with severe carotid stenosis. Thirteen patients were enrolled into this study (age range, 63–78 years). Seven of these 13 patients had severe peripheral vascular disease. A retrograde‐engagement technique, involving looping 6‐F Kimny guiding catheter, was utilized for carotid angiographic study. For carotid stenting, the 6‐F Kimny guiding catheter was replaced with a 7‐F Kimny guiding catheter, and the procedure was performed as the follows. First, an extra‐support wire was inserted into the middle portion of external carotid artery (ECA). Second, a 0.035‐inch Teflon wire was advanced into the common carotid artery. Then, the 6‐F guiding catheter was exchanged for a 7‐F Kimny guiding catheter. Third, if the first and second steps did not provide adequate support for exchanging the guiding catheter, a PercuSurge GuardWire™ was inserted into the ECA, followed by distal balloon inflation for an anchoring support. FilterWire EX™ was used in 9 patients and PercuSurge GuardWire in 4 patients to protect from distal embolization during the procedure. The procedure was successful in all patients. No neurological or vascular bleeding complications were observed and all patients were discharged uneventfully. The TBA for carotid stenting was safe and effective, providing a last resort for patients unsuited to femoral arterial access and surgical intervention.

Feasibility and safety of transradial artery approach for selective cerebral angiography.

The transradial artery (TRA) approach is a conventional means of diagnostic cardiac catheterization and catheter‐based coronary intervention. However, to our knowledge, the safety and feasibility of cerebrovascular angiographic studies using the TRA approach for patients with brain ischemia has not been reported. This study investigated whether the TRA approach using 6 Fr Kimny guiding catheter for both extracranial and intracranial angiographies is safe and effective for patients with a history of stroke, transient ischemic attack, or significant carotid stenosis. From February 2003 to June 2004, a total of 46 consecutive patients with an age range from 50 to 83 years were enrolled into the study. The retrograde engagement technique that involved lopping the guiding catheter was utilized. Outpatient carotid angiography was performed in 40% of the study patients. The overall procedural success (defined as completely evaluating both carotid and vertebral arteries and intracranial vessels) was 93.5% (n = 43) using the Kimny guiding catheter. Significant cerebrovascular stenosis (> 50%), including carotid artery in 52.2% (n = 24), vertebral artery in 15.2% (n = 7), and intracranial major artery in 15.2% (n = 7), was found in 82.6% of the patients. Notably, 17 (37.0%) of these patients with severe carotid stenosis (≥ 70%) required staged carotid stenting. Concomitant vertebral artery stenting was performed in four (8.7%) patients because of severe stenosis (≥ 70%) of these vessels. Two patients experienced transient dizziness (duration < 30 min) following the procedure. TRA approach for selective cerebral angiography is safe and feasible in patients with a history of brain ischemia.

Atrial myocardial nox2 containing NADPH oxidase activity contribution to oxidative stress in mitral regurgitation: potential mechanism for atrial remodeling

BACKGROUND Oxidative stress is linked with several cardiovascular diseases. However, the NADPH oxidase activity in severe mitral regurgitation patients with and without atrial fibrillation has not yet been explored. METHODS This study involved 16 adult patients (eight patients with persistent atrial fibrillation and eight with sinus rhythm) with severe mitral and moderate-to-severe tricuspid regurgitation and five control patients without mitral and tricuspid disease. Atrial tissues of the right and left atrial appendages were obtained during surgery. Superoxide anion production was measured by lucigenin-enhanced chemiluminescence, and the expression of nox2 containing NADPH oxidase mRNA was measured by quantitative real-time RT-PCR. Additionally, immunohistochemical study was performed. RESULTS NADPH-stimulated superoxide release was significantly higher than basal superoxide production from right [5671.9±3498.7 vs. 232.7±70.0 relative light units per second per milligram of protein (RLU s(-1) mg protein(-1)), P=.008) and left atrial homogenates (6475.1±1890.8 vs. 229.0±79.6 RLU s(-1) mg protein(-1), P=.008) in atrial fibrillation patients. The NADPH-stimulated superoxide release from right atrial homogenates was also significantly higher than basal superoxide production in sinus patients (6809.1±1327.1 vs. 244.2±65.5 RLU s(-1) mg protein(-1), P=.008). Additionally, there was a borderline significant correlation between NADPH-stimulated superoxide production from left atrial homogenates and left atrial sizes (r=0.683, P=.062) in atrial fibrillation patients. Membrane-bound nox2 containing NADPH oxidase mRNA expression was increased and was similar in both the atrial fibrillation patients and sinus patients. The NADPH-stimulated superoxide production in right atrial homogenates in control atrial samples was 1863.7±137.2 RLU s(-1) mg protein(-1). Immunohistochemical study demonstrated increased expression of nox2 in myocytes with moderate-to-severe myolysis and hypertrophy. CONCLUSIONS Results of this study demonstrate that membrane-bound nox2 containing NADPH oxidase activity and expression in the atrial myocardium is increased in patients with severe mitral regurgitation, possibly contributing to atrial remodeling in this clinical setting.

Transradial and Transbrachial Arterial Approach for Simultaneous Carotid Angiographic Examination and Stenting Using Catheter Looping and Retrograde Engagement Technique

BACKGROUND The purpose of this study was to introduce a novel and safe technique with high procedural success for carotid artery stenting (CAS). METHODS From April 2004 to May 2009, 161 patients underwent CAS using either a high transradial arterial approach (TRA, defined as 10 cm above styloid process) or a transbrachial arterial approach (TBA) with a 7F arterial sheath. Selective carotid angiography was performed using a 6F Kimny guiding catheter and Teflon wire (260 cm in length) by Catheter Looping And Retrograde Engagement Technique (CLARET) with the guiding catheter seated on the right coronary cusp and its tip engaged into the common carotid artery (CCA). Teflon wire was introduced into the CCA again after the diagnostic procedure, followed by replacement of the 6F Kimny guiding catheter by a 7F Kimny catheter for CAS using one of the following techniques: (1) direct-engagement method, i.e., from right innominate artery into the right CCA; (2) looping method plus double-wire technique (utilized two Teflon wires to provide an adequate support) for both the right and left CCA; and (3) looping method plus a PercuSurge balloon anchoring at the external carotid artery. RESULTS This distinctive technique offered 100% diagnostic success and 99.4% CAS success. Two patients (1.2%) experienced major ischemic stroke after CAS and two (1.2%) died during hospitalization. CONCLUSION The results of the present study showed that high TRA/TBA using CLARET for CAS in patients with severe carotid artery stenosis is safe and technically feasible with an extremely high success rate.

Application of penetration device (Tornus) for percutaneous coronary intervention in balloon uncrossable chronic total occlusion—procedure outcomes, complications, and predictors of device success†

Objective: To evaluate procedure outcomes, complications, and the predictors of device success while using the Tornus in CTO revascularization. Background: The success of percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) may be limited by the presence of severe calcified CTO lesions, especially in the smallest balloon uncrossable arteries. A penetrating device (Tornus) could improve the success rate. Methods: Device and angiographic success rates as well as procedural complications were assessed in 56 patients, who were consecutively and retrospectively enrolled into this study. Device success was defined as successful passage of the Tornus catheter through a CTO lesion. Procedure success was defined by a final TIMI 3 flow and <30% residual stenosis. Results: The device success rate was 71.4% in 40 patients and failure rate was 28.6% in 16 patients. The final procedure success was significantly higher in the Tornus success group compared with the Tornus failure group (87.5% vs. 37.5%, P < 0.001). One patient in the Tornus success group (1.8%) had wire perforation resulting in cardiac tamponade and cardiac death. Another patient (1.8%) in the Tornus success group had acute in‐stent thrombosis and non‐Q MI in 24 hr and was resuscitated by emergent PCI. The only independent predictor of device success was a calcium score < 2 (odds ratio (OR): 3.86 (95% CI: 1.14–13.1, P = 0.03). Conclusion: The Tornus catheter can be used in severe calcified CTO PCI when the calcium score <2 and not be used in patients with a calcium score ≥2.

Interleukin-18: a strong predictor of the extent of coronary artery disease in patients with unstable angina

The aim of this study was to confirm that plasma interleukin (IL)-18 level is associated with the extent of coronary artery disease in unstable angina patients. Previous studies have shown that patients with unstable angina have significantly higher plasma IL-18 levels than healthy volunteers. However, the association between IL-18 and the extent of coronary artery atherosclerosis in patients with unstable angina remains unclear. Plasma concentrations of IL-18 and high-sensitivity C-reactive protein (hs-CRP) were measured in 166 consecutive patients admitted for coronary arteriography. One hundred and eighteen patients with unstable angina had coronary artery disease (coronary artery disease group; severity score: 2.32 ± 1.47; Gensini score: 31.3 ± 25.9), and 48 patients with coronary risk factors and without coronary artery lesions served as the risk control group. Plasma levels of IL-18 were higher in the coronary artery disease group than in the risk control group (P = 0.062). Additionally, plasma levels of IL-18 were significantly higher in 77 coronary artery disease patients with severity score ≥2 than in the risk control group (242.3 ± 110.6 vs 209.8 ± 120.3 pg/ml, P = 0.016). By univariate analysis, log-transformed plasma IL-18 concentration was positively correlated with coronary artery disease severity score (r = 0.244, P = 0.009). By multiple regression analyses, the association between coronary artery disease severity score and IL-18 remained significant (β = 0.733, P = 0.017) when controlling for age, diabetes mellitus and left ventricular ejection fraction. Additionally, coronary artery disease severity score was greater in the highest tertile (>246 pg/ml) of plasma IL-18 levels than in the middle (176–246 pg/ml) and the lowest (<176 pg/ml) tertiles (2.79 ± 1.52 vs 2.05 ± 1.08 vs 2.13 ± 1.66, P = 0.028). Of note, plasma hs-CRP level had no significant correlation with coronary artery severity. Plasma IL-18 level is associated with the extent of coronary artery disease in unstable angina patients, suggesting the link between IL-18 and coronary artery atherosclerosis in these patients.

Intracoronary Transfusion of Circulation-Derived CD34+ Cells Improves Left Ventricular Function in Patients With End-Stage Diffuse Coronary Artery Disease Unsuitable for Coronary Intervention.

Objective:This study tested the hypothesis that intra-coronary transfusion of circulation-derived autologous CD34+ cells can improve ischemia-related left ventricular dysfunction in patients with severe diffuse coronary artery disease refractory to medication and unsuitable for coronary intervention. Design:A prospective, randomized, double-blinded phase I clinical trial. Setting:Tertiary care center. Patients:Thirty-eight patients with severe diffuse coronary artery disease were randomized into group 1 and group 2 receiving CD34+ cell infusion with dosages of 1.0 x 107 and 3.0 x 107 cells/vessel, respectively, after subcutaneous G-CSF injection (5 &mgr;g/kg twice a day for 4 d). Interventions:Cardiac catheterization and intra-coronary administration of CD34+ cells. Measurements and Main Results:This clinical trial was to test effectiveness and safety of these two different dosages of CD34+ cells in the setting of severe diffuse coronary artery disease. Blood samples were collected for endothelial progenitor cell culture before and after granulocyte colony-stimulating factor injection for matrigel-assay and comparison of levels of soluble angiogenesis factors (vascular endothelial growth factor, epithelial growth factor, hepatocyte growth factor, angiopoietin-1, and transforming growth factor-&bgr;). Procedural safety was 100% with all patients uneventfully discharged. The numbers of endothelial progenitor cells in blood samples from coronary sinus after transfusion were higher than those in circulation, and the circulatory level was higher after granulocyte colony-stimulating factor treatment (all p < 0.001). Cardiac MRI and three-dimensional echocardiography at 6 month and angiographic follow-up at 9 month showed improvement in left ventricular ejection fraction (p < 0.001) and consistent increase in neovascularization (p < 0.001), respectively, in both groups. Despite good correlation in angiogenesis between 9-month angiography and matrigel-assay (p < 0.001), no significant correlation was noted in of soluble angiogenesis factor levels. Angina and heart failure were improved in both groups at 12-month follow-up (all p < 0.001). The survival rate at 18.5-month follow-up was 94.7 % (n = 36). Conclusions:CD34+ cell therapy was safe and efficacious in improving heart function for patients with severe diffuse coronary artery disease unsuitable for coronary intervention and with poor response to pharmacotherapy.

Level and value of circulating endothelial progenitor cells in patients with acute myocardial infarction undergoing primary coronary angioplasty: in vivo and in vitro studies

Levels of circulating endothelial progenitor cells (EPCs) in acute ST-elevation myocardial infarction (STEMI) patients undergoing primary coronary intervention (PCI) were investigated in this study. Flow cytometric analysis of the circulating EPC level (CD31/CD34 [E(1)], CD62E/CD34 [E(2)], and KDR/CD34 [E(3)]) was determined from blood samples of 161 consecutive patients with STEMI undergoing primary PCI. Angiogenesis was evaluated using mononuclear cell-derived EPCs on Matrigel. The EPC number (E(1-3)) was lower in STEMI patients than in normal subjects (n = 25) (P < 0.005). Patients with high EPCs (E(1-3)) (≥1.2%) had a lower left ventricular ejection fraction, elevated white blood cell count and creatinine level, advanced Killip score (≥class 3), more advanced congestive heart failure (CHF) (≥class 3), and increased 30-day mortality than those with a low EPC (E(1-3)) level (<1.2%) (P < 0.0001). Angiogenesis was lower in patients with a high EPC level than those with a low EPC level and normal controls (P < 0.001). Both the advanced Killip score and the CHF were independent predictors of increased EPC levels (P < 0.05). Multivariate analysis identified a high EPC (E(3)) level to be the most important predictor of increased 30-day major adverse clinical outcome (MACO) (P < 0.0001). In conclusion, the circulating EPC level is a major independent predictor of 30-day MACO in patients with STEMI undergoing primary PCI.