Guang-Yuan Mar

Predictors of 1-year outcomes in the Taiwan Acute Coronary Syndrome Full Spectrum Registry.

BACKGROUND/PURPOSE Evidence-based guidelines have been formulated for optimal management of acute coronary syndrome (ACS). The Taiwan ACS Full Spectrum Registry aimed to evaluate the ACS management and identify the predictors of clinical outcomes of death/myocardial infarction/stroke 1 year post hospital discharge. METHODS Three thousand and eighty confirmed ACS patients enrolled in this registry were followed up for 1 year at 3-month intervals. Patient data on medical interventions as well as clinical events were recorded and analyzed by descriptive statistics. RESULTS One-year mortality among patients with ST-segment elevation myocardial infarction (STEMI), non-STEMI (NSTEMI) and unstable angina was 6.1%, 10.1%, and 6.2%, respectively. Use of secondary preventive therapies was suboptimal throughout the follow-up phase, especially dual antiplatelet therapy, which fell from 74.8% patients at discharge to 24.9% patients at 1-year follow-up. The odds of an adverse incidence of death/myocardial infarction/stroke 1 year after discharge was significantly reduced in patients receiving aspirin and clopidogrel for ≥9 months and was consequently higher in patients in whom dual antiplatelet therapy was discontinued or prescribed for <9 months. Chronic renal failure, in-hospital bleeding, a diagnosis of NSTEMI, and antiplatelet therapy discontinuation had a negative association with 1-year outcomes, whereas the use of drug-eluting stents and antiplatelet agents, clopidogrel and aspirin, were predictors of positive outcomes. CONCLUSION There is a significant deviation from evidence-based guidelines in ACS management in Taiwan as reported in other countries. Policy adherence, especially with regard to dual antiplatelet therapy may hold the key to long-term favorable outcomes and improved survival rates in ACS patients in Taiwan.

TSOC-HFrEF Registry: A Registry of Hospitalized Patients with Decompensated Systolic Heart Failure: Description of Population and Management

INTRODUCTION Heart failure (HF) is a medical condition with a rapidly increasing incidence both in Taiwan and worldwide. The objective of the TSOC-HFrEF registry was to assess epidemiology, etiology, clinical management, and outcomes in a large sample of hospitalized patients presenting with acute decompensated systolic HF. METHODS The TSOC-HFrEF registry was a prospective, multicenter, observational survey of patients presenting to 21 medical centers or teaching hospitals in Taiwan. Hospitalized patients with either acute new-onset HF or acute decompensation of chronic HFrEF were enrolled. Data including demographic characteristics, medical history, primary etiology of HF, precipitating factors for HF hospitalization, presenting symptoms and signs, diagnostic and treatment procedures, in-hospital mortality, length of stay, and discharge medications, were collected and analyzed. RESULTS A total of 1509 patients were enrolled into the registry by the end of October 2014, with a mean age of 64 years (72% were male). Ischemic cardiomyopathy and dilated cardiomyopathy were diagnosed in 44% and 33% of patients, respectively. Coronary artery disease, hypertension, diabetes, and chronic renal insufficiency were the common comorbid conditions. Acute coronary syndrome, non-compliant to treatment, and concurrent infection were the major precipitating factors for acute decompensation. The median length of hospital stay was 8 days, and the in-hospital mortality rate was 2.4%. At discharge, 62% of patients were prescribed either angiotensin-converting enzyme-inhibitors or angiotensin receptor blockers, 60% were prescribed beta-blockers, and 49% were prescribed mineralocorticoid receptor antagonists. CONCLUSIONS The TSOC-HFrEF registry provided important insights into the current clinical characteristics and management of hospitalized decompensated systolic HF patients in Taiwan. One important observation was that adherence to guideline-directed medical therapy was suboptimal.

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.

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.

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.

Translesional pressure ratio predicts technical outcome and patency in angioplasty on outflow stenosis of hemodialysis graft.

Purpose Translesional pressure ratio (TLPR) indicating fractional flow reserve has been applied to physiological assessment of moderate coronary stenosis. The role of TLPR in hemodialysis (HD) patients with arteriovenous graft (AVG) outflow stenosis undergoing percutaneous transluminal angioplasty (PTA) is unclear. The purpose of the study was to assess the validation of TLPR in such patients undergoing PTA. Methods Patients with pure AVG outflow stenosis confirmed by angiography were prospectively enrolled. A TLPR defined as a ratio of the mean pressure downstream to the lesion(s) to the vein-sided intragraft pressure was measured using a catheter pullback method. Relationship among TLPR, angiographic result and clinical outcome within 6 months was detected. Results Of 65 PTAs, the post-PTA TLPR significantly increased (from 0.28±0.10 to 0.50±0.11; p<0.0001). A significantly greater pre-PTA TLPR was observed in the simple lesions at baseline compared with the complex lesions (0.32±0.09 vs. 0.20±0.06; p<0.0001). Post-PTA TLPR ≥0.5 was powerfully related to angiographic success (p<0.0001). The group with angiographic success plus post-PTA TLPR ≥0.5 had a longer PTA-free patency (208.7±188.7 vs. 109.8±67.7 days; p=0.013) compared with that with angiographic nonsuccess plus post-PTA TLPR <0.5. Conclusions Our data show that TLPR correlates well with lesion properties and angiographic results, and helps predict following unassisted patency. The study suggests TLPR as a hemodynamic indicator during PTA.