Chi-Cheng Lai

STROBE--Radiation Ulcer: An Overlooked Complication of Fluoroscopic Intervention: A Cross-Sectional Study.

AbstractWith increasing numbers of percutaneous coronary intervention (PCI) and complex cardiac procedures, higher accumulated radiation dose in patient has been observed. We speculate cardiac catheter intervention induced radiation skin damage is no longer rare.To study the incidence of cardiac fluoroscopic intervention induced radiation ulcer.We retrospectively reviewed medical records of those who received cardiac fluoroscopic intervention in our hospital during 2012 to 2013 for any events of radiation ulcer. Only patients, whose clinical photos were available for reviewing, would be included for further evaluation. The diagnosis of radiation ulcers were made when there is a history of PCI with pictures proven skin ulcers, which presented typical characteristics of radiation injury.Nine patients with radiation ulcer were identified and the incidence was 0.34% (9/2570) per practice and 0.42% (9/2124) per patient. Prolonged procedure time, cumulative multiple procedures, right coronary artery occlusion with chronic total occlusion, obesity, and diabetes are frequent characteristics. The onset interval between the first skin manifestation and the latest radiation exposure varied from 3 weeks to 3 months. The histopathology studies failed to make diagnosis correctly in 5 out of 6 patients. To make thing worse, skin biopsy exacerbated the preexisting radiation dermatitis. Notably, all radiation ulcers were refractory to conventional wound care. Surgical intervention was necessary to heal the wound.Diagnosis of cardiac fluoroscopy intervention induced radiation skin damage is challenging and needs high index of clinical suspicion. Minimizing the radiation exposure by using new approaches is the most important way to prevent this complication. Patient education and a routine postprocedure dermatology follow up are mandatory in high-risk groups for both radiation skin damage and malignancies.This is a retrospective study, thus the true incidence of radiation ulcer caused by cardiac fluoroscopic intervention could be higher.

Percutaneous management of acutely thrombosed hemodialysis grafts: the double balloon occlusion technique.

Objectives: The aim of this article is to introduce a new technique, named the “double balloon occlusion technique” (DBOT), for the salvage of acutely thrombosed grafts and to demonstrate its safety and efficacy. Background: Acute thrombosis is recognized as the most common factor of acute graft failures. A suitably percutaneous technique should be devised to remove thrombi safely and effectively. Care should also be taken to prevent possible thromboembolic complications during procedures. Mainly composed of two balloons, the percutaneous DBOT has been developed to meet the clinical needs. Methods: Thirty‐two patients with graft failures undergoing the DBOT were recruited between May 2007 and May 2008. The DBOT is itemized in the text and a practical case undergoing successful DBOT is also demonstrated. Results: Of the 32 DBOT treatments, the procedural success rate was 100% (32/32). The clinical success rate was 94% (30/32). One complicated case with severe hematoma resulting from a balloon‐induced graft rupture received surgery, although the graft outflow restored. The mean procedure time was 92 minutes. Three patients died and two patients were lost within the 3‐month follow‐up. The 3‐month graft patency rate was 70% (19/27). Conclusion: The DBOT has the potential to be operated safely and effectively. Preliminary results had high success rates and patency rates. With basic devices, it may serve as an option to rescue thrombosed grafts. More data are needed to identify its clinical role.

Role of Shortened QTc Dispersion in In-hospital Cardiac Events in Patients Undergoing Percutaneous Coronary Intervention for Acute Coronary Syndrome

Background: QT dispersion (QTD) refers to the difference between maximal and minimal QT values on the electrocardiogram (ECG). QTD values are calculated and corrected with Bazetts formula (corrected QTD = QTcD = QTD/vRR). QTcD increases in patients with acute coronary syndrome (ACS). Recovery of increased QTcD (shortened QTcD) develops after successful revascularization, but prolonged QTcD occurs in certain patients. The aim of this study is to ascertain the clinical significance between shortened and prolonged QTcD groups after percutaneous coronary intervention (PCI). Methods: We retrospectively enrolled 128 patients with ACS who had received PCI. The values of QTcD were measured manually on 12‐lead standard ECGs obtained within 3 days before and after PCI (pre‐PCI QTcD and post‐PCI QTcD). All the patients were divided into 2 groups. The shortened QTcD group was defined as those patients with a decrease in QTcD after PCI and the prolonged QTcD group as those with an increase in QTcD after PCI. The underlying diseases, various clinical classifications and some prognostic factors were taken into comparison and statistical analysis between these 2 groups. Results: The shortened QTcD group showed a significantly higher rate of in‐hospital cardiac death (13% vs. 0%, p = 0.006) and a greater pre‐PCI QTcD (100.8 ± 39.5 vs. 61.3 ± 24.1 ms, p < 0.001) than the prolonged QTcD group. There was a significantly greater pre‐PCI QTcD in patients with cardiac death than those without cardiac death (111.6 ± 38.3 vs. 83.3 ± 38.3 ms, p = 0.027). Furthermore, the patients with in‐hospital cardiac death presented with a significantly more frequent occurrence of in‐hospital ventricular arrhythmia, compared with those without cardiac death (30.0% vs. 4.0%, p = 0.014). Conclusion: Among the patients with ACS undergoing PCI, directly divided into shortened and prolonged QTcD groups regardless of initial pre‐PCI QTcD, the shortened QTcD group showed a higher occurrence of in‐hospital cardiac death and a greater pre‐PCI QTcD. Shortened QTcD might be 1 risk factor for in‐hospital cardiac death.

Intragraft pressures predict outcomes in hemodialysis patients with graft outflow lesions undergoing percutaneous transluminal angioplasty

Objectives: This study is to introduce intragraft pressure (IGP) as intraprocedural parameter for outcome survey in hemodialysis patients with graft outflow lesions undergoing percutaneous transluminal angioplasty (PTA). Background: The role of IGP on procedural endpoint and patency is unknown. Methods: Seventy‐five participants with graft outflow lesions receiving PTA were enrolled. Procedural data regarding IGP and angiographic findings were collected and the 1‐year graft patency through collaboration with hemodialysis units. Analyses and comparisons among IGP, angiographic findings, and patency were conducted. Using the receiver operating characteristic (ROC) curve and Kaplan–Meier survival analysis, we intended to detect significance and the cut‐off points of IGP for patency prediction, and difference in patency between the two groups divided by using the cut‐off points. Results: Pre‐PTA and post‐PTA IGP were significantly associated with 1‐year patency (both significance <0.01) with 0.756 and 0.791 areas under the ROC curves, respectively. The cut‐off points of pre‐PTA and post‐PTA IGP were closer to 106 and 47 mm Hg for prediction of 1‐year patency (sensitivity = 0.76, specificity = 0.69; sensitivity = 0.79, specificity = 0.69, respectively; 95% CI). Significant reductions in 1‐year patency were shown in the subjects with greater than the cut‐off values, either pre‐PTA or post‐PTA IGP, compared with those with smaller than these values (both log rank test < 0.001). Conclusion: IGP might be useful to evaluate procedural endpoints and predict patency outcomes in hemodialysis patients with graft outflow lesions undergoing PTA. Patients with the greater pre‐PTA or post‐PTA IGP, to some level, seem to have the shorter patency.

Drug-Eluting Stents versus Bare-Metal Stents in Taiwanese Patients with Acute Coronary Syndrome: An Outcome Report of a Multicenter Registry

BACKGROUND The study aims to compare cardiovascular outcomes of using bare-metal stents (BMS) and drug-eluting stents (DES) in patients with acute coronary syndrome (ACS) through analysis of the database from the Taiwan ACS registry. Large domestic studies comparing outcomes of interventional strategies using DES and BMS in a Taiwanese population with ACS are limited. METHODS AND RESULTS Collected data regarding characteristics and cardiovascular outcomes from the registry database were compared between the BMS and DES groups. A Cox regression model was used in an unadjusted or adjusted manner for analysis. Baseline characteristics apparently varied between DES group (n = 650) and BMS group (n = 1672) such as ACS types, Killips classifications, or coronary blood flows. Compared with the BMS group, the DES group was associated with significantly lower cumulative incidence of all-cause mortality (3.4% vs. 5.8%, p = 0.008), target vessel revascularization (TVR) (5.2% vs. 7.4%, p = 0.035), or major adverse cardiac events (MACE) (10.2% vs. 15.6%, p < 0.001) at 1 year in a real-world setting. Cox regression analysis showed the BMS group referenced as the DES group had significantly higher risk-adjusted total mortality [hazard ratio (HR) = 1.85, p = 0.026], target vessel revascularization (TVR) (HR = 1.59, p = 0.035), and MACE (HR = 1.68, p = 0.001). CONCLUSIONS The data show use of DES over BMS provided advantages to patients with ACS in terms of lower 1-year mortality, TVR, and MACE. The study suggests implantation of DES compared with BMS in Taiwanese patients with ACS is safe and beneficial in the real-world setting. KEY WORDS Acute coronary syndrome; Bare-metal stent; Cardiovascular outcome; Drug-eluting stent; Percutaneous coronary intervention.

One-year cardiovascular outcomes of drug-eluting stent versus bare-metal stent implanted in diabetic patients with acute coronary syndrome

Background The outcomes of drug‐eluting stent (DES) versus bare‐metal stent (BMS) use in patients with diabetic mellitus (DM) and acute coronary syndrome (ACS) are rarely reported in Taiwan. This study aimed to investigate the 1‐year cardiovascular outcomes of DESs versus BMSs implanted in Taiwanese patients with DM and ACS. Methods For this study, we collected and analyzed patient information from the database of the Taiwan ACS Full Spectrum registry regarding characteristics and cardiovascular events in participants with DM and ACS who received implantation of either BMS (BMS group) or DES (DES group) from October 2008 to January 2010. Results We found that several characteristics significantly varied between the groups. Compared with the BMS group (n = 575), the DES group (n = 199) had significantly lower rates of in‐hospital cardiogenic shock (1.5% vs. 4.9%, p = 0.037) and acute renal failure (0.5% vs. 4.5%, p = 0.008), all‐cause mortality (5.0% vs. 8.9%, p = 0.048), and major adverse cardiac events (MACEs) at 1 year (11.1% vs. 18.6%, p = 0.006) with an identical target vessel revascularization (TVR) rate (6.0% vs. 7.3%, p = 0.395). The BMS group had significantly higher risk‐adjusted all‐cause mortality [hazard ratio (HR) = 2.4, 95% confidence interval (CI) 1.0–5.7; p = 0.048] and MACE (HR = 2.2, 95% CI 1.2–3.9; p = 0.011) at 1 year with identical risks of TVR (HR = 1.3, 95% CI 0.6–2.9; p = 0.505) and nonfatal myocardial infarction (HR = 1.5, 95% CI 0.5–4.4; p = 0.478). Conclusion The results of this study support the use of DES over BMS in Taiwanese patients with DM and ACS, providing the clinical benefits of lower rates of total mortality and MACE, and without increased TVR at 1 year in a real‐world setting.

Effects of Door-to-Balloon Times on Outcomes in Taiwanese Patients Receiving Primary Percutaneous Coronary Intervention: A Report of Taiwan Acute Coronary Syndrome Full Spectrum Registry

PURPOSE The impact of door-to-balloon (DTB) time on patient outcomes is unclear in a Taiwanese population receiving primary percutaneous coronary intervention (PCI). The study aimed to investigate the relationship between stratified DTB times and outcomes through analysis of the database from the Taiwan acute coronary syndrome full spectrum registry. METHODS Relevant data were collected from case report forms of patients receiving primary PCI who were categorized as group 1, 2, 3, and 4 according to the DTB time < 45, 45-90, 91-135, and > 135 minutes, respectively. The differences were analyzed by using ANOVA and Kaplan-Meier analyses. RESULTS There were significant variations in DTB times at baseline, which included patients salvaged at centers, patients with prior cardiovascular disease, and those patients with different coronary artery flows (p < 0.01) separated into 4 groups (n = 189, 443, 299, and 401, respectively). The in-hospital adverse event rates were identical among the 4 groups except for a higher rate of acute renal failure and a longer hospital stay observed in group 4 (p < 0.01). The results showed no decrease in the incidences of repeated revascularization, major adverse cardiac event, or cardiovascular composite at 1 year in group 1. CONCLUSIONS This study suggested that the DTB time is not a good determinant for outcomes in Taiwanese patients receiving primary PCI. KEY WORDS Acute myocardial infarction; Cardiovascular outcome; Door-to-balloon time; Myocardial ischemia; Percutaneous coronary intervention.

Distal Radial Artery Pressures Predict Angiographic Result and Short-Term Patency Outcome in Hemodialysis Patients With Juxta-Anastomotic Inflow Stenosis of Radiocephalic Fistula Undergoing Transradial Angioplasty

Distal radial artery pressure (RAP) was observed to be reduced after transradial percutaneous transluminal angioplasty (PTA) on the juxta‐anastomotic venous stenosis of radiocephalic arteriovenous fistula (RCAVF). Distal RAPs are easily obtained from a pressure transducer connected with an introducer retrograde inserted into distal radial artery. The clinical role of distal RAP in the setting of transradial PTA remains unknown. This prospective and observational study aimed to explore the relationship between distal RAPs and clinical outcomes. This study recruited hemodialysis patients with RCAVF juxta‐anastomotic venous stenosis undergoing transradial PTA. RAP‐related variables and procedural data before PTA (pre‐PTA) and after PTA (post‐PTA) were analyzed. The study endpoint was dysfunction‐driven re‐PTA during the 1‐year follow‐up. Overall, 73 PTAs significantly reduced the mean of systolic RAPs from 159.6 ± 41.4 to 108.4 ± 41.5 mm Hg; P < 0.0001. Post‐PTA systolic RAP was associated with angiographic outcome (P = 0.004) and unassisted patency at 3 months (P = 0.036), but not at 6, 9, or 12 months (P > 0.05). The group with angiographically successful PTAs had a significantly lower mean of post‐PTA systolic RAPs compared with that with unsuccessful PTAs (98.4 ± 35.4 vs. 128.7 ± 46.1 mm Hg; P = 0.003). The post‐PTA systolic RAP may be seen as a predictor for 3‐month unassisted patency (AUC = 0.669; P = 0.048). In conclusion, this study provides the RAP profile to help guide transradial PTA on RCAVF juxta‐anastomotic venous stenosis and predict 3‐month unassisted patency in a hemodynamic manner.

Risk Factors For Radiation-Induced Skin Ulceration in Percutaneous Coronary Interventions of Chronic Total Occluded Lesions: A 2-Year Observational Study

Relationship between radiation-induced skin ulceration (RSU) and variables in percutaneous coronary interventions (PCI) was rarely reported. RSU is a severe complication in PCIs, especially for chronic total occlusion (CTO) lesions. We investigated the RSUs and their risk factors in patients receiving CTO PCIs over a 2-year period. Data were analyzed using chi-square tests, t-tests and receiver operating characteristic (ROC) curve. Of 238 patients, 11 patients (4.6%) had RSUs all at right upper back. RSUs were significantly associated with use of left anterior oblique (LAO) views (100% vs. 47.1%, p < 0.001), retrograde techniques (36.3% vs. 7.9%, p = 0.012), or a procedure time (PT) defined as a time duration between the first and last angiograms of > 120, 180, or 240 minutes (p < 0.05). ROC analysis showed a long PT was an accurate predictor of RSUs (AUC = 0.88; p < 0.001) at a cut-off of 130 minutes (sensitivity = 0.91, specificity = 0.81). The results showed risk factors for RSUs containing use of large LAO views, retrograde techniques, and prolonged PTs. This study suggests that, to minimize RSU, interventionalists should limit PT to roughly 2 hours in fixed LAO views.

Author Reply to Letter to the Editor: Drug-Eluting Stents versus Bare-Metal Stents in Taiwanese Patients with Acute Coronary Syndrome: An Outcome Report of a Multicenter Registry.

The article entitled “Drug-Eluting Stents versus Bare-Metal Stents in Taiwanese Patients with Acute Coronary Syndrome: An Outcome Report of a Multicenter Registry” was published in the Journal of Acta Cardiologica Sinica in November 2014.1 Several experts offered constructive comments about this article in the ACS letter to the Editor section, and their comments focused on two primary points. First, that the 1-year survival benefit of drug-eluting stents (DES) group should be adjusted by the patients’ baseline renal function and in-hospital acute kidney injury (AKI). Second, the results regarding mortality differences shown in the article1 and another systemic review2 were inconsistent between patients treated with implanted DES and bare-metal stents (BMS). Although we could hardly list all variables potentially affecting the outcome in the article, I concur with the experts’ comment indicating that baseline renal function and in-hospital AKI should be adjusted when investigating clinical outcomes between acute coronary syndrome (ACS) patients treated with implantation of DES and BMS. I am unaware of the changes in cardiovascular risks at 1 year after adjustment by baseline renal function and in-hospital AKI because the analytic center organized for the registry has been terminated. I suppose that the 1-year cardiovascular outcomes determined using Kaplan-Meier analysis should remain unchanged between the DES and BMS groups, even taking into account the estimated glomerular filtration rate (eGFR) at baseline. I would also speculate that the adjusted risks by several variables including baseline eGFR for a variety of cardiovascular composites (p < 0.01 for all) would remain statistically powerful between the groups. However, the marginal differences for all-cause mortality (p = 0.026) and target vessel revascularization (p = 0.035) are likely to be challenged (Table 3). On the other hand, it is well-documented that chronic kidney disease (CKD) is a powerful independent predictor for clinical outcomes in patients receiving stentings.3-7 Nonetheless, the values of baseline eGFR may be influenced by and/or accompanied by several clinical circumstances during the event of ACS.3-7 According to the 2012 Kidney Disease Improving Global Outcomes (KDIGO) clinical practice guideline, CKD is defined as kidney damage or eGFR < 60 ml/min/1.73 m2 for a period exceeding three months.8 Therefore, the researchers did not accurately determine “true” CKD or the stages of CKD merely based upon one value of serum creatinine recorded in each case report form without assessing renal function for 3 months or more. Thus, the incidence of CKD (33.6%) could possibly have been overestimated.5,6 A proportional number of cases with CKD previously identified by one value of eGFR < 60 ml/min/1.73 m2 may be those cases with “secondary and/or transient” renal dysfunction. In addition, renal function of eGFR 60 ml/min/1.73 m2 at baseline was reported to be associated with higher rates of negative factors such as elderly, hypertension, diabetes mellitus, dyslipidemia, history of cardiovascular diseases, shock on presentation, multi-vessel coronary disease, and so on.3-7 These negative factors, including renal dysfunction, may account for the worse clinical outcome.3-7 Moreover, the impact of implanted DES versus BMS on mortality in ACS patients remains controversial.9-12 Additionally, physicians should not only be concerned with patient mortality, but other clinical endpoints as well. As described in the “Discussion” section of the article (page 560-561), the differences in mortality as analyzed from the registry studies and randomized controlled trials (RCTs) are inconsistent.9-12 It is reasonable that the systemic review the experts referenced that enrolled more than 14,500 patients with coronary artery disease (not all ACS patients) in 47 RCTs showed no statistically significant difference in mortality between DES and BMS groups.2 In contrast, the present result regarding survival outcome is compatible with other results from several registry studies.9-12 Taken together, the experts provided their constructive comments and highlighted the points which may remind researchers to consider the effect of baseline renal function, CKD and/or in-hospital AKI on cardiovascular outcome in subsequent study designs. In conclusion, we suggest that there is merit to the idea that the effect of renal function on cardiovascular outcome should be considered, and to assess renal function exceeding 3 months in designing further similar studies.