Huang-Chung Chen

Outcomes of patients with Killip class III acute myocardial infarction after primary percutaneous coronary intervention.

Objectives:Little is known about the outcomes of patients with Killip class III acute ST-segment elevation myocardial infarction in the reperfusion era. This study investigated the short- and long-term outcomes of these patients who underwent primary percutaneous coronary intervention. Methods:Between January 2002 and November 2009, a total of 1,278 consecutive patients with acute ST-segment elevation myocardial infarction underwent primary percutaneous coronary intervention. Of these patients, 230 (17.0%) with Killip III, 216 (16.9%) with Killip II, and 832 (65.1%) with Killip I upon presentation were prospectively recruited. Results:Angiographic study showed significantly lower final thrombolysis in myocardial infarction 3 flow in patients with Killip III compared with those with Killip II and I (83.5% vs. 94.9% vs. 95.7%, p < .0001). The incidence of multiple vessel disease was also notably higher in Killip III than in Killip II and I (65.7% vs. 13.9% vs. 53.8%, p < .001). Besides, the incidence of advanced congestive heart failure (defined as greater than or equal to New York Heart Association functional class 3) during hospitalization was remarkably higher in Killip III compared to Killip II and I (71.3% vs. 13.9% vs. 6.6%, p < .001). Furthermore, the 30-day mortality and 1-yr cumulative mortality were notably higher in Killip III than in Killip II and I (20.0% vs. 4.2% vs. 1.7%, p < .001 and 31.7% vs. 7.9% vs. 4%, p < .001, respectively). Multivariate analysis showed that Killip III was independently predictive of 30-day and 1-yr mortality (all p < .04). Conclusion:Killip III remains strongly and independently predictive of 30-day and 1-yr mortality in ST-segment elevation myocardial infarction patients even undergoing primary percutaneous coronary intervention.

Major Adverse Upper Gastrointestinal Events in Patients with ST-Segment Elevation Myocardial Infarction Undergoing Primary Coronary Intervention and Dual Antiplatelet Therapy

The aim of this study was to investigate the incidence of composite short-term and long-term major adverse upper gastrointestinal (UGI) events (MAUGIEs; defined as gastric ulcer, duodenal ulcer, gastroduodenal ulcer, or UGI bleeding) in patients with acute ST-segment elevation myocardial infarction who underwent primary percutaneous coronary intervention and routinely received dual-antiplatelet therapy. From May 2002 to September 2010, a total of 1,368 consecutive patients who experienced ST-segment elevation myocardial infarction and underwent primary percutaneous coronary intervention were prospectively enrolled in the study. The incidence of in-hospital UGI bleeding complications and composite MAUGIEs was 8.9% and 9.9%, respectively. The in-hospital mortality rate was significantly higher in patients with in-hospital MAUGIEs than in those without (p <0.001). Multivariate analysis showed that age, advanced Killip score (≥3), and respiratory failure were the strongest independent predictors of in-hospital composite MAUGIEs (all p <0.003). The cumulative composite of MAUGIEs after uneventful discharge in patients without adverse UGI events who continuously received dual-antiplatelet therapy for 3 to 12 months, followed by aspirin therapy, was 10.4% during long-term (mean 4.0 years) follow-up. In conclusion, the results of this study show a remarkably high incidence of composite short-term and long-term MAUGIEs in patients with ST-segment elevation myocardial infarction who underwent primary percutaneous coronary intervention and received routine dual-antiplatelet therapy. Age, advanced Killip score, and respiratory failure were significantly and independently predictive of in-hospital composite MAUGIEs.

Thrombocytopenia, Dual Antiplatelet Therapy, and Heparin Bridging Strategy Increase Pocket Hematoma Complications in Patients Undergoing Cardiac Rhythm Device Implantation

BACKGROUND Pocket hematoma is a troublesome complication associated with the implantation of cardiac implantable electronic devices (CIEDs). This study aims to determinate the risk factors of pocket hematoma complications in relation to different antithrombotic strategies and severity of thrombocytopenia in Chinese patients. METHODS We conducted a retrospective study of 1093 consecutive patients undergoing implantation of CIEDs and divided them into 3 groups: no antithrombotic group (n = 512), continuing antiplatelet group (n = 477), and temporarily discontinuing warfarin with or without heparin bridging strategy (n = 104). RESULTS A pocket hematoma developed in 40 patients (3.7%). The temporarily discontinuing warfarin group (7.7%) had a higher incidence of pocket hematoma than no oral antithrombotic group (2.1%) and continuing antiplatelet group (4.4%) (P = 0.012). The dual antiplatelet group (16.2%) and the heparin bridging strategy group (14.0%) had significantly higher incidence of pocket hematoma compared with the no antithrombotic group (2.1%; P < 0.001, both). Patients having aspirin or clopidogrel alone had low incidence of pocket hematoma (3.9% and 1.2%, respectively), similar to the no antithrombotic group (P = not significant). Multivariate analysis revealed that dual antiplatelet agents (P = 0.004), heparin bridging strategy (P < 0.001), and moderate to severe thrombocytopenia (P = 0.007) were independent predictors for pocket hematoma complications. CONCLUSIONS The use of dual antiplatelet agents, heparin bridging strategy, and the presence of moderate to severe thrombocytopenia significantly increased the risk of pocket hematoma complications in the periprocedural period of CIED implant. Aspirin or clopidogrel alone did not increase the risk of pocket hematoma complications.

Transradial percutaneous coronary intervention for chronic total occlusion of coronary artery disease using sheathless standard guiding catheters

Objectives Our aim was to evaluate the feasibility and safety of routine transradial approach (TRA) percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) lesions using the sheathless technique with standard guiding catheters. Background Transradial approach PCI was applied for CTO lesions. A major limitation of TRA CTO PCI is the inability to use large guiding catheters because of the relatively small size of the radial artery. Therefore, the sheathless technique for TRA PCI has been recently developed. However, reports on TRA CTO PCI using the sheathless technique are still lacking. Methods Sixty-eight patients with CTO lesions were enrolled for TRA PCI using the sheathless technique with standard guiding catheters. The baseline characteristics, coronary angiographic characteristics and major procedure or access site related complications were compared between procedure success and procedure failure group to determine the predictors of success in sheathless CTO PCI. In-hospital and 30-day clinical outcomes were also evaluated in this study. Routine assessments of radial artery occlusion via Doppler ultrasound and pulse oximeter were recorded during one-year clinical follow-up. Results The mean duration of CTO by history was 31.8 ± 42.3 months. The 7 Fr standard guiding catheter was used with the sheathless technique in 91.2%, and bilateral sheathless approach in 42.6% of the study patients. The procedure-related complications included coronary perforation needing covered stent deployment (2.9%), cardiac tamponade (2.9%), collateral perforation needing coil deployment (4.4%), and contrast induced nephropathy (2.9%). Only 2 patients (2.9%) experienced forearm ecchymosis at the radial artery access sites. In-hospital mortality and 30-day all-cause mortality were 2.9%, and 30-day MACEs were 1.5%. The rate of radial artery occlusion during one-year clinical follow-up was only 3.0%. Conclusions It is feasible and safe to routinely use the sheathless technique with standard guiding catheters for TRA CTO PCI, with a low incidence of procedure-related complications and long-term radial artery occlusion.

Anemia: A significant cardiovascular mortality risk after ST-segment elevation myocardial infarction complicated by the comorbidities of hypertension and kidney disease

Background The effect of anemia on patients with ST-segment elevation myocardial infarction (STEMI) remains a controversial issue. The aim of this study was to explore the effect of anemia on STEMI patients. Methods and results From January 2005 to December 2014, 1751 patients experienced STEMI checked serum hemoglobin initially before any administration of fluids or IV medications. 1751 patients then received primary percutaneous intervention immediately. A total of 1388 patients were enrolled in the non-anemia group because their serum hemoglobin level was more than 13 g/L in males, and 12 g/L in females. A total of 363 patients were enrolled in the anemia group because their serum hemoglobin level was less than 13 g/L in males, and 12 g/L in females. Higher incidences of major adverse cerebral cardiac events (22.9% vs. 33.8%; p<0.001) were also noted in the anemia group, and these were related to higher incidence of cardiovascular mortality (6.5% vs. 20.4%; p<0.001). A higher incidence of all-cause mortality (8.6% vs. 27.7%; p<0.001) was also noted in the anemia group. A Kaplan-Meier curve of one-year cardiovascular mortality showed significant differences between the non-anemia and anemia group in all patients (P<0.001), and the patients with hypertension (P<0.001), and chronic kidney disease (CKD) (P = 0.011). Conclusion Anemia is a marker of an increased risk in one-year cardiovascular mortality in patients with STEMI. If the patients have comorbidities such as hypertension, or CKD, the effect of anemia is very significant.

Aspiration Thrombectomy and Drug-Eluting Stent Implantation Decrease the Occurrence of Angina Pectoris One Year After Acute Myocardial Infarction.

AbstractAngina pectoris is a treatable symptom that is associated with mortality and decreased quality of life. Angina eradication is a primary care goal of care after an acute myocardial infarction (AMI). Our aim was to evaluate factors influencing angina pectoris 1 year after an AMI.From January 2005 to December 2013, 1547 patient received primary percutaneous intervention in our hospital for an acute ST-segment elevation myocardial infarction (MI). Of these patients, 1336 patients did not experience post-MI angina during a 1-year follow-up, and 211 patients did. Univariate and multivariate logistic regression analyses were performed to identify the factors influencing angina pectoris 1 year after an AMI. Propensity score matched analyses were performed for subgroups analyses.The average age of the patients was 61.08 ± 12.77 years, with a range of 25 to 97 years, and 82.9% of the patients were male. During 1-year follow-up, 13.6% of the patients experienced post-MI angina. There was a longer chest pain-to-reperfusion time in the post-MI angina group (P = 0.01), as well as a higher fasting sugar level, glycohemoglobin (HbA1C), serum creatinine, troponin-I and creatine kinase MB (CK-MB). The post-MI angina group also had a higher prevalence of multiple-vessel disease. Manual thrombectomy, and distal protective device and intracoronary glycoprotein IIb/IIIa inhibitor injection were used frequently in the no post-MI angina group. Antiplatelet agents and post-MI medication usage were similar between the 2 groups. Multivariate logistic regression analyses demonstrated that prior MI was a positive independent predictor of occurrence of post-MI angina. Manual thrombectomy use and drug-eluting stent implantation were negative independent predictors of post-MI angina. Higher troponin-I and longer chest pain-to-reperfusion time exhibited a trend toward predicting post-MI angina.Prior MIs were strong, independent predictors of post-MI angina. Manual thrombectomy and drug-eluting stent implantation could decrease the occurrence of angina pectoris 1 year after an AMI, decrease long-term healthy costs, and increase post-MI quality of life.

Comparison of a Sheathless Transradial Access With Looping Technique and Transbrachial Access for Carotid Artery Stenting

Purpose: To evaluate the feasibility and safety of sheathless transradial access (TRA) with the looping technique for carotid artery stenting (CAS) compared with the transbrachial approach (TBA). Methods: Among 99 symptomatic patients with a history of transient ischemic attack (TIA) or stroke, 38 patients (mean age 69±10 years; 28 men) with documented internal carotid artery stenosis were selected for CAS via a sheathless TRA and compared with 61 patients who received CAS via the brachial artery. Routine assessments of radial artery patency using duplex ultrasound and clinical follow-up were performed at 1, 6, and 12 months. Results: The sheathless TRA technique offered 100% procedure success; only 1 patient in the sheathless TRA group and 2 patients in the TBA group experienced TIAs during the procedure. There were no major complications (major stroke or 30 day in-hospital death) in either group or radial access site complications. The incidence of radial artery occlusion in the sheathless TRA CAS group was 9% (3/33) at 1 year (5 patients died unrelated to the procedure). Conclusion: The sheathless TRA with looping technique may be an alternative to transbrachial access for CAS in patients who have small radial arteries and are unsuitable for the transfemoral approach.

Mitochondrial apoptotic pathway activation in the atria of heart failure patients due to mitral and tricuspid regurgitation

Apoptosis occurs in atrial cardiomyocytes in mitral and tricuspid valve disease. The purpose of this study was to examine the respective roles of the mitochondrial and tumor necrosis factor-α receptor associated death domain (TRADD)-mediated death receptor pathways for apoptosis in the atrial cardiomyocytes of heart failure patients due to severe mitral and moderate-to-severe tricuspid regurgitation. This study comprised eighteen patients (7 patients with persistent atrial fibrillation and 11 in sinus rhythm). Atrial appendage tissues were obtained during surgery. Three purchased normal human left atrial tissues served as normal controls. Moderately-to-severely myolytic cardiomyocytes comprised 59.7±22.1% of the cardiomyocytes in the right atria and 52.4±12.9% of the cardiomyocytes in the left atria of mitral and tricuspid regurgitation patients with atrial fibrillation group and comprised 58.4±24.8% of the cardiomyocytes in the right atria of mitral and tricuspid regurgitation patients with sinus rhythm. In contrast, no myolysis was observed in the normal human adult left atrial tissue samples. Immunohistochemical analysis showed expression of cleaved caspase-9, an effector of the mitochondrial pathways, in the majority of right atrial cardiomyocytes (87.3±10.0%) of mitral and tricuspid regurgitation patients with sinus rhythm, and right atrial cardiomyocytes (90.6±31.4%) and left atrial cardiomyocytes (70.7±22.0%) of mitral and tricuspid regurgitation patients with atrial fibrillation. In contrast, only 5.7% of cardiomyocytes of the normal left atrial tissues showed strongly positive expression of cleaved caspase-9. Of note, none of the atrial cardiomyocytes in right atrial tissue in sinus rhythm and in the fibrillating right and left atria of mitral and tricuspid regurgitation patients, and in the normal human adult left atrial tissue samples showed cleaved caspase-8 expression, which is a downstream effector of TRADD of the death receptor pathway. Immunoblotting of atrial extracts showed that there was enhanced expression of cytosolic cytochrome c, an effector of the mitochondrial pathways, but no expression of membrane TRADD and cytosolic caspase-8 in the right atrial tissue of mitral and tricuspid regurgitation patients with sinus rhythm, and right atrial and left atrial tissues of mitral and tricuspid regurgitation patients with atrial fibrillation. Taken together, this study showed that mitochondrial pathway for apoptosis was activated in the right atria in sinus rhythm and in the left and right atria in atrial fibrillation of heart failure patients due to mitral and tricuspid regurgitation, and this mitochondrial pathway activation may contribute to atrial contractile dysfunction and enlargement in this clinical setting.

Effect of improved door-to-balloon time on clinical outcomes in patients with ST segment elevation myocardial infarction

OBJECTIVE Few studies have focused on the effects of an improved door-to-balloon time on clinical outcomes in patients with ST-segment elevation myocardial infarction (STEMI). The aim of this study was to explore the effect of improving door-to-balloon time on prognosis and to identify major predictors of mortality. METHODS From January 2005 to December 2014, 1751 patients experienced STEMI and received primary percutaneous intervention in our hospital. During a 10-year period, the patients were divided into two groups according to the time period. Since mid-2009, shortening door-to-balloon time has been an important concern of health care. As a result of targeted efforts, as of January 2010, door-to-balloon time shortened significantly. In our study, a total 853 patients were in group 1 during January 2005 to December 2009, and a total 898 patients were in group 2 during January 2010 to December 2014. RESULTS The incidence of major adverse cardiac cerebral events (26.7% vs. 23.2%; p=0.120), the incidence of cardiovascular mortality (9.3% vs. 8.8%; p=0.741), and the incidence of all-cause mortality (12.6% vs. 12.2%; p=0.798) were similar between the two groups. The incidence of target vessel revascularization significantly decreased in group 2 (17.8% vs. 12.6%; p=0.008). However, the incidence of stroke increased in group 2 (1.8% vs. 3.6%; p=0.034). CONCLUSION Improving door-to-balloon time could not improve 1-year cardiovascular mortality whether low-risk or high-risk patients. The improvement in the door-balloon time does not improve outcomes studied, probably because it is not accompanied by a reduction in total reperfusion time, which means from onset of symptoms to reperfusion.

Intra-Coronary Administration of Tacrolimus Prior to First-BalloonInflation Attenuates Infarct Size and Improves Left Ventricular Function in Patients with ST-segment Elevation Myocardial Infarction (COAT-STEMI) Undergoing Primary Coronary Intervention

Background: Slow-flow and no-reflow phenomenon which occurred frequently during primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) caused unfavorable prognostic outcomes. Currently, no effectively therapeutic strategy to prevent this phenomenon. Objectives/Design: To evaluate the efficacy and safety of intra-Coronary Administration of Tacrolimus prior to firstballoon inflation, a pilot study was performed. Methods/Results of Pilot Study: Twenty-nine STEMI patients (group 1) were first prospectively administered tacrolimus (2.5 mg intra-coronary slow injection using thrombuster) prior to first-balloon inflation. A historical-control group (group 2) was chosen from fifty-two consecutive patients undergoing primary PCI just prior to the pilot study. Age, gender, CAD-risk factors, peak CK-BM, and baseline left-ventricular performance were not different between groups 1 and 2 (all p>0.1). Chest pain onset-to-door and door-to-balloon times, mean Killip score upon presentation, number of multi-vessel disease, pre-PCI TIMI flow, and 30-day death were similar between these two groups (all p>0.1). The incidences of advanced CHF (≥ NYHA 3) and pulmonary edema were higher in group 2 than in group 1, whereas the incidence of anterior-wall infarction, final TIMI-3 flow and 90 minute ST-segment-resolution rate showed an opposite pattern of advanced CHF between these two groups. The incidence of myocardial blushing grade was significantly higher in group 2 than in group 1 (p=0.034). Conclusion: Tacrolimus therapy shows promise as a safe and effective therapeutic agent for STEMI. The positive preliminary outcomes from this pilot study suggests randomized-controlled trials are now required to evaluate the effectiveness and safety of Tacrolimus for STEMI patients. (clinical trials no: ISRCTN38455499).