Chiao-Po Hsu

Ten-year experience with surgical repair of mycotic aortic aneurysms

Background: Mycotic aneurysm remains a lethal pathologic entity, especially when rupture occurs. It may result from primary aortitis, be induced by septic emboli, or be secondary to an adjacent infection, such as pancreatitis or a psoas muscle abscess. Surgical intervention is the only way to treat such disease. Even when successful repair is achieved by insertion of an interposition in situ graft or by performance of an extra‐anatomic bypass, the prognosis is poor. The aim of this study was to present our experience of managing mycotic aortic aneurysms during the past 10 years. Methods: From January 1994 to June 2004, a total of 734 patients with aortic aneurysms underwent surgical repair at our institution. Among these cases, 17 (2.3%) were shown to be mycotic aneurysms of the ascending aorta (n = 1), aortic arch (2), thoracic and thoracoabdominal aorta (3), or abdominal aorta (11); 14 patients (mean age, 58.8 years) were male. Preoperative imaging studies were performed in all patients. Mycotic aortic aneurysms were suspected in 12 of the 17 patients (70.6%) preoperatively, and 4 of these 12 patients were found to have ruptures on imaging. At the time of surgery, 9 of the 17 aneurysms (52.9%) were ruptured. Fifteen patients had an interposition graft inserted after meticulous debridement, 1 underwent an aorto‐aortic bypass, and 1 underwent an extra‐anatomic (axillo‐femoral) bypass. An omentum patch was applied to wrap the graft in 8 of 11 mycotic aortic aneurysms of the abdominal aorta. The most common pathogens were Salmonella spp. (n = 7) and Staphylococcus spp. (4). All patients received antibiotic therapy, according to the culture report, for about 4–6 weeks postoperatively. Results: In‐hospital mortality was 11.8% (n = 2). Another patient died from massive upper gastrointestinal bleeding 6 months after operation because of complications involving an aorto‐duodenal fistula, and another died from stomach cancer 6 years after surgery. Long‐term follow‐up (mean, 37 months; range, 3–111 months) revealed that, at the time of writing, the remaining 13 patients were alive and well, without any recurrence of aneurysm. Conclusion: Mycotic aneurysm of the aorta is a life‐threatening disease, especially when rupture occurs. The high mortality rate is due not only to the high rupture rate, but also to sepsis. When mycotic aortic aneurysm is diagnosed, early surgical intervention is mandatory.

Downregulation of Sirt1 as aging change in advanced heart failure

BackgroundIn congestive heart failure the balance between cell death and cell survival in cardiomyocytes is compromised. Sirtuin 1 (Sirt1) activates cell survival machinery and has been shown to be protective against ischemia/reperfusion injury in murine heart. The role of Sirt1 in heart failure, especially in human hearts is not clear.ResultsThe expression of Sirt1 and other (associated) downstream molecules in human cardiomyocytes from patients with advanced heart failure was examined. Sirt1 was down-regulated (54.92%u2009±u20097.80% in advanced heart failure samples compared with healthy control cardiomyocytes). The modulation of molecules involved in cardiomyocyte survival and death in advanced heart failure were also examined. The expression of Mn-superoxide dismutase and thioredoxin1, as well as an antiapoptotic molecule, Bcl-xL, were all significantly reduced in advanced heart failure cardiomyoctes (0.71u2009±u20090.02-fold, 0.61u2009±u20090.05-fold, and 0.53u2009±u20090.08-fold vs. control, respectively); whereas the expression of proapoptotic molecule Bax was significantly increased (1.62u2009±u20090.18-fold vs. control). Increased TUNEL-positive number of cardiomyocytes and oxidative stress, confirmed by 8-hydorxydeoxyguanosine staining, were associated with advanced heart failure. The AMPK-Nampt-Sirt1 axis also showed inhibition in advanced heart failure in addition to severely impaired AMPK activation. Increased p53 (acetyl form) and decreased FoxO1 translocation in the nucleus may be the mechanism of down-regulation of antioxidants and up-regulation of proapoptotic molecules due to low expression of Sirt1.ConclusionIn advanced heart failure, low Sirt1 expression, like aging change may be a significant contributing factor in the downregulation of antioxidants and upregulation of proapoptotic molecules through the p53, FoxO1, and oxidative stress pathways.

Reintervention for distal stent graft-induced new entry after endovascular repair with a stainless steel-based device in aortic dissection.

OBJECTIVEnStent graft-induced new entry (SINE) has been increasingly observed after thoracic endovascular aortic repair (TEVAR) for aortic dissection. We investigated the mechanism of late distal SINE, prevention strategies, proper size selection of the stent graft, and implantation sequence.nnnMETHODSnFrom November 2006 to May 2011, 99 patients with aortic dissection underwent TEVAR with Zenith TX2 stent grafts (Cook, Bloomington, Ind) at our center. Among them, 27 distal SINEs were recognized. Eight of these patients with complicated distal SINE required intervention with new distal endografts, and all were enrolled for further analysis.nnnRESULTSnEight of the 27 patients with distal SINE underwent a secondary endograft procedure from February 2011 to July 2011. All were successfully treated without any complications or deaths. A high taper ratio (35%±11%) and excessive oversizing of the true lumen area at the distal stent level (293%±76%) were noted among these patients.nnnCONCLUSIONSnThe incidence of distal SINE seemed to be high; however, there were also low rates of death and complications after TEVAR for aortic dissection using stainless steel-based stent grafts. Complicated distal SINE can successfully be resolved by distal endograft implantation. Excessive oversizing of the distal stent graft, as measured by the true lumen area, may be a significant factor causing delayed distal SINE. Precise size selection is crucial for the distal end of the stent, especially for high taper ratio dissection pathology in which the implantation sequence of a distal small-sized stent graft first might be considered to prevent future distal SINE.

The impact of bird-beak configuration on aortic remodeling of distal arch pathology after thoracic endovascular aortic repair with the Zenith Pro-Form TX2 thoracic endograft

OBJECTIVEnStructural changes and incomplete endograft apposition to the aortic arch (bird-beak configuration) after thoracic endovascular aortic repair are poorly understood. The aim of this study was to analyze the morphologic changes, conformability, and angulation factors in patients who underwent stainless steel-based stent graft repair of thoracic aortic pathology.nnnMETHODSnFrom March 2011 to March 2012, the study enrolled 19 patients with aortic pathology requiring proximal fixation in zones 2 and 3 who underwent stent graft repair using Zenith Pro-Form TX2 stent grafts (Cook Medical, Bloomington, Ind). For comparison, another 19 patients who received Zenith Z-Trak stent grafts were selected from December 2009 to February 2011. Chest computed tomography scans were analyzed at baseline, and then at 1, 6, and 12 months postoperatively. Arch angulation and bird-beak configuration were evaluated according to sealing zones of attachment by Aquarius iNtuition software (TeraRecon, San Mateo, Calif).nnnRESULTSnThe treated diseases included chronic type B aortic dissection in 17 patients and degenerative aneurysms in 21. Significant arch angle transformation was noted at the zone 2 level between the Pro-Form and Z-Trak treated groups (150° ± 11° vs 158° ± 6°; P = .033) and left subclavian artery level (152° ± 12° vs 160° ± 8°; P = .031) during 1 year of follow-up. The bird-beak configuration was detected in six patients (32%) in the Pro-Form group and in 11 (58%) in the Z-Trak group (P = .096) at 1 month, and in six (32%) in the Pro-Form group and in 14 (74%) in the Z-Trak group (P = .022) at 12 months. The mean bird-beak angle was significantly less in Pro-Form-treated patients at 1 month (5° ± 9° vs 15° ± 13°; P = .019) and at 1 year (6° ± 10° vs 18° ± 15°; P = .033). In the Pro-Form platform, a preoperative zone 2 angle <151.1° was a better estimation of the presence of a postoperative bird-beak configuration, with a sensitivity of 86% and specificity of 83%.nnnCONCLUSIONSnAortic remodeling after stainless steel stent graft repair of thoracic aortic pathology is a continuous process. Significant arch angle transformation was discovered over the zone 2 and left subclavian artery levels. TX2 Pro-Form stent grafts improved arch conformation after 1 year of follow-up. Furthermore, in the patients with dissection, a preoperative distal arch angle of zone 2 was predictive of postoperative bird-beak configuration, regardless of whether they were treated with a Pro-Form stent graft.

Factors predictive of distal stent graft-induced new entry after hybrid arch elephant trunk repair with stainless steel–based device in aortic dissection

OBJECTIVESnStent graft-induced new entry (SINE) has been increasingly observed after thoracic endovascular aortic repair of aortic dissection. We illustrate the possible mechanism by exploring predictive factors of late distal SINE after hybrid arch elephant trunk repair for aortic dissection.nnnMETHODSnFrom November 2006, to May 2011, 20 of 99 patients underwent hybrid arch repair using the elephant trunk graft as the proximal landing zone. After a mean follow-up period of 27.9 ± 12.0 months, 12 patients had late distal SINE events and the others were free of events. False lumen remodeling level was observed and maximal longitudinal diameter, average of longitudinal and transverse maximal diameter, circumference, and area of true lumen were analyzed for precise size selection of stent graft before and after the procedure. Taper ratio, true lumen:aorta ratio, prestent grafting oversizing ratio, poststent grafting oversizing ratio, and expansion mismatch ratio of distal true lumen were proposed and calculated for further evaluation of the mechanism of late distal SINE.nnnRESULTSnOnly the area oversizing ratio between true lumen and the distal selected stent graft at the presumed distal end of stent grafting was found as a significant predictive factor of SINE before procedure (4.00 ± 2.96 vs 1.98 ± 0.66 for SINE vs non-SINE, respectively; P = .031). The significant difference of the expansion mismatch ratio of true lumen between the 2 groups was found not only in the size measurement of mean diameter (1.48 ± 0.29 vs 1.22 ± 0.15; P = .039), but also in the area (2.39 ± 0.85 vs 1.58 ± 0.42; P = .031) and circumference (1.43 ± 0.27 vs 1.18 ± 0.14; P = .016) after stent grafting.nnnCONCLUSIONSnWe found that taper ratio is not an optimal criteria for stent graft size selection and distal oversizing calculated by true-lumen area is a significant factor causing delayed distal SINE. Use of the prestenting area oversizing ratio should be limited.

Extracorporeal membrane oxygenation use, expenditure, and outcomes in taiwan from 2000 to 2010.

Background No study to date has systematically examined use, expenditure, and outcomes associated with extracorporeal membrane oxygenation (ECMO) use in Taiwan. The aim of this study was to examine ECMO use, expenditure, and outcomes during an 11-year period in Taiwan. Methods Claims data were collected from the Taiwan National Health Insurance Research Database for patients who received ≥1 ECMO treatment between January 2000 and December 2010. Measurements included demographics, indications for ECMO use, length of hospital stay, outcome, and expenditure. Results A total of 3969 patients received ECMO during the study period (median age: 54.6 years). The number of patients receiving ECMO increased from 52 in 2000 to 1045 in 2010. The major indication for ECMO was cardiovascular disease (68.7%), followed by respiratory disease (17.9%). Median length of hospital stay was 13 days in 2000 and 17 days in 2010. Median expenditure (New Taiwan dollars) was

Percutaneous pharmacomechanical thrombectomy offers lower risk of post-thrombotic syndrome than catheter-directed thrombolysis in patients with acute deep vein thrombosis of the lower limb.

604 317 in 2000 and

Endomyocardial Biopsy-related Tricuspid Regurgitation After Orthotopic Heart Transplantation: Single-center Experience

673 888 in 2010. Some variables significantly differed by age, sex, hospital setting, calendar year, and indication for ECMO, and were associated with in-hospital and after-discharge mortality. Conclusions ECMO use has increased dramatically in Taiwan over the last decade. The high mortality rate of ECMO users suggested that ECMO may be being used in Taiwan for situations in which it provides no added benefit. This situation may be a reflection of the current reimbursement criteria for National Health Insurance in Taiwan. Refinement of the indications for use of ECMO is suggested.

Early endovascular experience for treatments of Takayasu's arteritis.

BACKGROUNDnDespite optimal anticoagulant therapy, patients with proximal deep vein thrombosis (DVT) will often develop post-thrombotic syndrome (PTS). Early thromboreduction can potentially decrease the risk of PTS by restoring venous patency and preserving valvular function. This study was undertaken to compare the efficacy and treatment outcomes of patients with acute proximal DVT of the lower limb who underwent either catheter-directed thrombolysis (CDT) or percutaneous pharmacomechanical thrombectomy (PMT).nnnMETHODSnThirty-nine patients with acute proximal DVT of the lower limb who were diagnosed by Wells Score, PMT or CDT was chosen depending on the patient. They underwent early thromboreduction, and 3 died postoperatively in less than 12 months, while 2 were removed for not following-up. Thirty-four patients, 16 in PMT and 18 in CDT, were followed up for more than 1 year. Venous Registry Index (VRI) was used to evaluate the postprocedural patency, while PTS was assessed using the Villalta scale.nnnRESULTSnThe technical success was 100% in both the groups, without any 30-day mortality. VRI changed from 13.1 ± 4.3 preoperatively to 2.4 ± 1.5 postoperatively in the PMT group, and from 11.8 ± 2.4 to 3.6 ± 2.2 in the CDT group. Thrombolysis rate was 81.5 ± 8.5% and 67.7 ± 21.0% in the PMT and CDT groups, respectively (P = 0.059). There were no differences in complications, thrombus score, and VRI between the 2 groups. Primary patency rate at 1 year was 93.8% in the PMT group and 88.9% in the CDT group (P = 0.648). The Villalta scale was 2.1 ± 3.0 in the PMT group and 5.1 ± 4.1 in the CDT group (P = 0.030).nnnCONCLUSIONSnBoth PMT and CDT are effective treatment modalities in patients with acute proximal DVT. Compared with CDT, PMT provides similar treatment success, but with lower risk of PTS at 1-year follow-up.

Cardiac Myocyte Progenitors from Adult Hearts for Myocardial Regenerative Therapy

Background: Damage of tricuspid valve (TV) with resultant tricuspid regurgitation (TR) induced by endomyocardial biopsy (EMB) following heart transplantation has been reported in several studies. This study tried to determine the prevalence of EMB‐related iatrogenic damage over tricuspid apparatus following orthotopic heart transplantation and to evaluate its impact on the patients. Methods: Fifty patients received orthotopic heart transplantation between July 1987 and March 2005. Eleven patients were excluded from the study due to early postoperative mortality or inadequate follow‐up. The medical records of the remaining 39 patients were reviewed retrospectively for basic characteristics as well as each attempted EMB. The iatro‐genic damage of tricuspid apparatus and serial change of TR were accessed with 2‐D and Doppler echocardiography. The obtained data were analyzed for their statistical significance with SPSS (version 12.0). Results: A total of 373 biopsies were performed on the 39 patients between 1987 and 2005. The follow‐up duration was 42.9 ± 26.7 months. The prevalence of TR immediately following heart transplantation was 84.6%, with only 25.6% of patients having moderate or severe TR. At the end of the follow‐up, the prevalence of TR increased to 92.3% and 61.5% of patients having moderate or severe TR, respectively. Eight patients (20.5%) had small chordae rupture (SCR) noted after 6.6 ± 3.2 biopsies, and 10 patients (25.6%) had flail tricuspid valve (FTV) after 5.7 ± 5.1 biopsies. Of patients with SCR, 62.5% had progression of TR, and 70% of patients with FTV showed significant TR change. Conclusion: The prevalence of iatrogenic tricuspid apparatus damage was high in this study. It contributed to the progression of TR significantly regardless of the damage severity. Measurements should be taken for prevention of iatro‐genic tricuspid apparatus damage induced by EMB.