Chih-Fan Yeh

Use of Extracorporeal Membrane Oxygenation to Rescue Patients With Refractory Ventricular Arrhythmia in Acute Myocardial Infarction

Abstract Refractory ventricular arrhythmia is a serious problem in acute myocardial infarction (AMI), with an extremely high mortality rate and limited effective treatment. Extracorporeal membrane oxygenation (ECMO) is useful to rescue patients with cardiopulmonary collapse. However, little is known about whether ECMO is a potential rescue technique for patients with refractory ventricular arrhythmia in AMI. We retrospectively analyzed prospectively collected data on patients with AMI and refractory ventricular arrhythmia who underwent ECMO as rescue therapy and the bridge to revascularization from February 2001 to January 2013. Primary endpoint was mortality on index admission, and secondary endpoint was mortality on index admission or advanced brain damage at discharge. A total of 69 (62 men) patients were enrolled in this study. During the index admission, 39 patients (56.5%) met primary endpoint, and 45 patients (65.2%) met secondary endpoint, respectively. In multivariate Cox regression analysis, both the presence of profound anoxic encephalopathy and acute renal failure requiring dialysis were significant predictive factors for both primary and secondary endpoints. ECMO is a feasible rescue therapy and bridge to revascularization in patients with refractory ventricular arrhythmia in acute myocardial infarction. The presence of profound anoxic encephalopathy and acute renal failure requiring dialysis were significant prognostic factors.

Prevalence and outcome of patients with non-ST segment elevation myocardial infarction with occluded “culprit” artery – a systemic review and meta-analysis

BackgroundThe aim was to determine the prevalence and impact of an occluded “culprit” artery (OCA) in patients with non-ST segment elevation myocardial infarction (NSTEMI).MethodsWe searched PubMed, EMBASE, and Web of Science, with no language restrictions, up to 1 Jul. 2016. Observational cohorts or clinical trials of adult NSTEMI were eligible for inclusion to determine the prevalence if the proportion of OCA on coronary angiography was reported. Studies were further eligible for inclusion to determine the outcome if the association between OCA and clinical endpoints was reported.ResultsAmong the 60,898 patients with NSTEMI enrolled in 25 studies, 17,212 were found to have OCA. The average proportion of OCA in NSTEMI was 34% (95% CI 30–37%). Patients with OCA were more likely to have left circumflex artery as their culprit artery (odds ratio (OR) 1.65, 95% CI 1.15–2.37, p = 0.007), and this was associated with lower left ventricular ejection fraction (standard mean difference -0.29, 95% CI -0.34 to -0.34, p < 0.001), higher peak enzyme level (standard mean difference 0.43, 95% CI 0.27–0.58, p < 0.001), and higher risk for cardiogenic shock (OR 1.66, 95% CI 1.35–2.04, p < 0.001), compared with patients with a non-occlusive culprit artery. Death rate (OR 1.72, 95% CI 1.49–1.98, p < 0.001) and recurrent myocardial infarction (OR 1.7, 95% CI 1.06–2.75, p = 0.029) were also higher in patients with OCA, compared with patients with a non-occlusive culprit artery.ConclusionsPatients with OCA comprised a substantial portion of the NSTEMI population. These patients present with more severe symptoms and worse clinical outcome. Whether these patients should be treated with more aggressive strategy warrants further study.

Collateral Channel Size and Tortuosity Predict Retrograde Percutaneous Coronary Intervention Success for Chronic Total Occlusion

Background— There is little evidence on how to select an interventional collateral channel (CC) in retrograde chronic total occlusion (CTO) percutaneous coronary intervention. We aimed to identify independent angiographic predictors of CC tracking and technical success in retrograde CTO percutaneous coronary intervention. Methods and Results— From January 2012 to December 2015, a total of 216 consecutive retrograde CTO percutaneous coronary intervention attempts by a high-volume operator in a tertiary university-affiliated hospital were enrolled. The clinical, angiographic, and procedural details were collected. The characteristics analyzed included channel type, size, tortuosity, angle of attack, length to emerging point, and the Multicenter CTO Registry of Japan score. The Multicenter CTO Registry of Japan score was 4.2±0.8. A total of 242 CCs were attempted for intervention. CC tracking success rate was 83.5%, and the technical success rate (per CC) was 81.4%. The per-patient technical success rate was 91.2%, and the major procedural complication rate was 4.6%. The atrioventricular groove, epicardial, and septal CCs were used in 36 (14.9%), 84 (34.7%), and 122 (50.4%) tracking attempts, respectively. In multivariable analysis, only large channel size and lack of tortuosity were significant independent predictors of CC tracking and technical success. A new scoring system was developed, while large size was given 1 point and lack of tortuosity was given 2 points. The receiver-operating characteristic area by the new model to predict CC tracking and technical success were 0.800 and 0.752, respectively. Conclusions— In retrograde CTO percutaneous coronary intervention, only size and tortuosity of a CC are independent angiographic predictors of CC tracking and technical success.

Carotid‐cavernous fistula after endovascular intervention for chronic carotid artery total occlusion

In addition to head trauma and cranial surgery, endovascular intervention for chronic carotid artery occlusion (CAO) may also result in carotid‐cavernous fistula (CCF). The management and prognosis of iatrogenic CCF during CAO recanalization have never been well described and discussed in the literature.

Long-term Outcomes After Endovascular Recanalization in Patients with Chronic Carotid Artery Occlusion

Successful carotid artery stenting may correct ipsilateral hemisphere hypoperfusion and improve neurocognitive function in patients with chronic internal carotid artery occlusion (ICAO). Its effect on long-term outcomes, however, has never been studied. From May 2004 to April 2015, endovascular recanalization for chronic ICAO was attempted in 118 consecutive patients (119 lesions; 98 men; 67 ± 10 years old) with either recurrent neurologic events or objectively impaired ipsilateral hemisphere perfusion. Technical success in recanalization was achieved in 70 lesions (59%, 70/119). 3-months cumulative any stroke or death rate was 5% (6/119; 4 in recanalized group, 2 in failure group), including 2 periprocedural ischemic stroke, 2 intracranial hemorrhage, and 2 subarachnoid hemorrhage. In recanalized patients without periprocedural complication, 1-year reocclusion rate was 15% (10/65). Up to 7 years after procedure, cumulative events of transient ischemic attack (TIA), or any stroke, or death were 17 in recanalized group, compared with 23 in failure group (hazard ratio 0.51, 95% confidence interval 0.27 to 0.97; p = 0.04). The difference became more significant after excluding patients with periprocedure events (hazard ratio 0.41, 95% confidence interval 0.20 to 0.84, p = 0.015). In conclusions, the technical success and periprocedural complication rates of endovascular recanalization for chronic ICAO were acceptable. The cumulative event rates of any stroke or death up to 7 years were more favorable in patients after successful recanalization, compared to those in patients after failed procedure.

Frequency and Significance of Intravascular Hemolysis Before and After Transcatheter Aortic Valve Implantation in Patients With Severe Aortic Stenosis

Intravascular hemolysis (IVH) has been identified in patients with surgical prosthetic valves, but few have been reported after transcatheter aortic valve implantation (TAVI). We conducted a prospective analysis of 64 TAVI patients. The hemolysis profiles were collected at baseline and 6 months after TAVI. The echocardiography was performed at baseline and 6 months after TAVI. There are 14 patients (21.9%) with IVH before and 24(37.5%) after TAVI. The serum haptoglobin values before and 6 months after TAVI are 126.7 ± 75.1 vs 86.3 ± 57.1 mg/dl (p < 0.001). More ≥moderate paravalvular leakage (PVL) (50% vs 7.5%, p < 0.001), bicuspid aortic valve (BAV) (33.3% vs 5.0%, p = 0.004), use of 23 mm prosthesis (29.2% vs 7.5%, p = 0.03), higher residual valvular pressure gradient (17.9 ± 6.8 mm Hg vs 14.7 ± 5.7 mm Hg, p = 0.05), and lower effective orifice area index (1.05 ± 0.21 vs 1.21 ± 0.29, p = 0.03) were observed in patients with post-TAVI IVH. On multivariate regression analysis, BAV and ≥moderate PVL are independently related to post-TAVI IVH. With log-rank test, 1-year rates of readmission due to cardiovascular cause were significantly higher in patients with post-TAVI IVH (odds ratio 4.5; 95% confidence interval 1.3 to 15.6; p = 0.02), after adjusting age and gender. In conclusion, ≥moderate PVL and BAV are predictors of post-TAVI IVH, which is associated with increased cardiovascular readmission in 1-year follow-up.

Impact of hospital volume on long‐term neurological outcome in patients undergoing carotid artery stenting

The impact of hospital volume on long‐term outcome after carotid artery stenting (CAS) remains unknown.

Impact of Hospital Volume on Long‐Term Neurological Outcome in Patients Undergoing Carotid Artery Stenting: A Nationwide Propensity Score‐Matched Study. DOI: 10.1002/ccd.26989

DOI: 10.1002/ccd. 27389 TABLE 2 Periprocedural neurologic complications Unmatched cohort Propensity score-matched cohort High-volume hospital Low-volume hospital p-value High-volume hospital Low-volume hospital p-value Ischemic stroke 127 (5.7%) 72 (7.1%) 0.14 55 (5.5%) 70 (7.0%) 0.17 Intracranial hemorrhage 2 (0.1%) 1 (0.1%) 0.94 1 (0.1%) 1 (0.1%) 1.00 High-volume hospital, defined as annual carotid stenting procedures >520.