Mason Shing Young

Assessment of Aortic Regurgitation by Live Three‐Dimensional Transthoracic Echocardiographic Measurements of Vena Contracta Area: Usefulness and Validation

In this report, we evaluate 56 consecutive adult patients who underwent standard two‐dimensional (2D) and live three‐dimensional transthoracic echocardiography (3D TTE), as well as left heart catheterization with aortography (45 patients) or cardiac surgery (11 patients), for evaluation of aortic insufficiency. Similar to the method we previously described for mitral insufficiency, aortic regurgitant vena contracta area (VCA) was obtained by 3D TTE by systematic and sequential cropping of the acquired 3D TTE data set. Assessments of aortic regurgitation (AR) by aortography and surgery are compared to measurements of VCA by 3D TTE and to 2D TTE measurements of vena contracta width (VCW). Aortographic or surgical grading correlated well with 2D TTE measurements of VCW (r = 0.92), but correlated better with 3D TTE measurements of VCA (r = 0.95), with improved dispersion between angiographic grades demonstrated by the 3D TTE technique. Live 3D TTE color Doppler measurements of VCA can be used for accurate assessment of AR and are comparable to assessment by aortography.

The prognostic value of circulating soluble cell adhesion molecules in patients with chronic congestive heart failure

Circulating soluble (s) cell adhesion molecules (CAMs) are elevated in patients with congestive heart failure (CHF) and may play an important role in the pathogenesis of CHF by mediating the cell–cell interactions of the immune response. However, clinical data about the prognostic value of sCAMs are sparse. The purpose of this study is to determine whether various sCAMs can provide prognostic information in patients with CHF.

Comparison of Real Time Two-Dimensional with Live/Real Time Three-Dimensional Transesophageal Echocardiography in the Evaluation of Mitral Valve Prolapse and Chordae Rupture

We compared live/real time three‐dimensional transesophageal echocardiography (3D TEE) with real time two‐dimensional transesophageal echocardiography (2D TEE) in the assessment of individual mitral valve (MV) segment/scallop prolapse and associated chordae rupture in 18 adult patients with a flail MV undergoing surgery for mitral regurgitation. 2D TEE was able to diagnose the prolapsing segment/scallop and associated chordae rupture correctly in only 9 of 18 patients when compared to surgery. In three of these, 2D TEE diagnosed an additional segment/scallop not confirmed at surgery. In the remaining nine patients, surgical findings were missed by 2D TEE. On the other hand with 3D TEE, the prolapsed segment/scallop and associated ruptured chords correlated exactly with the surgical findings in the operating room in 16 of 18 patients. The exceptions were two patients. In one, 3D TEE diagnosed prolapse and ruptured chordae of the A3 segment and P3 scallop, while the surgical finding was chordae rupture of the A3 segment but only prolapse without chordae rupture of the P3 scallop. In the other patient, 3D TEE diagnosed prolapse and chordae rupture of P1 scallop and prolapse without chordae rupture of the A1 and A2 segments, while at surgery chordae rupture involved A1, A2, and P1. This preliminary study demonstrates the superiority of 3D TEE over 2D TEE in the evaluation of individual MV segment/scallop prolapse and associated ruptured chordae.

Fenofibrate attenuates endothelial monocyte adhesion in chronic heart failure: an in vitro study

Background  Inflammation is implicated in chronic heart failure (CHF). In this study, the potential inhibitory effect of peroxisome proliferator‐activated receptor‐α (PPARα) activator fenofibrate on monocyte adhesion in CHF patients was investigated in vitro.

Effect of emergency department in-hospital tele-electrocardiographic triage and interventional cardiologist activation of the infarct team on door-to-balloon times in ST-segment-elevation acute myocardial infarction.

Current guidelines recommend that >75% of patients with ST-elevation myocardial infarction (STEMI) receive primary percutaneous coronary intervention (PPCI) within 90 minutes. The goal has been hardly achievable, so we conducted a 2-year before-and-after study to determine the impact of emergency department (ED) tele-electrocardiographic (tele-ECG) triage and interventional cardiologist activation of the infarct team at door-to-balloon time (D2BT) and the proportion of patients undergoing PPCI within 90 minutes since arrival. In total 105 consecutive patients with acute STEMI (mean age 62 ± 13 years, 82% men) were studied, 54 before and 51 after the change in protocol. The 51patients in the tele-ECG group underwent tele-electrocardiography at the ED and electrocardiograms were transmitted to a third-generation mobile telephone of an on-call interventional cardiologist within 10 minutes of ED arrival. The infarct team was activated and PPCI was performed by the interventional cardiologist. Fifty-four patients with acute STEMI who underwent PPCI in the year before implementation of tele-electrocardiography served as control subjects. Median D2BT of the tele-ECG group was 86 minutes, significantly shorter than the median time of 125 minutes of the control group (p <0.0001). The proportion of patients who achieved a D2BT <90 minutes increased from 44% in the control group to 76% in the tele-ECG group (p = 0.0001). In conclusion, implementation of ED tele-ECG triage and interventional cardiologist activation of the infarct team can significantly shorten D2BT and result in a larger proportion of patients achieving guideline recommendations.

Malignant presentation of cardiac hemangioma: a rare cause of complete atrioventricular block.

A 46-year-old woman suffered effort intolerance for months. She had been healthy in the past, without systemic diseases. She had experienced near-syncope before arrival at our center. On admission, her physical examination was unremarkable. ECG exhibited normal sinus rhythm, P pulmonale, and first-degree atrioventricular (AV) block. A transthoracic echocardiogram demonstrated a huge right atrial (RA) mass, 7.98×5.70 cm in size, with 23 mm Hg of transvalvular pressure gradient. The global ventricular contractility was normal (Data Supplement Movies I and II). These findings were confirmed by 3-dimensional echocardiography (Figure 1; Data Supplement Movies III and IV). Cardiac magnetic resonance imaging showed a large, well-defined intracavity mass on T1-weighted image. After contrast injection, delayed images revealed a strong signal indicating hypervascularity (Figure 2 and online-only Data Supplement), highly suggestive …

Transradial approach in myocardial infarction

Objective This study investigates the feasibility, effi cacy, and safety of routine primary percutaneous coronary intervention via transradial approach in patients with acute ST-elevation myocardial infarction. Methods and results From 2005 to 2007, 122 consecutive patients with acute ST-elevation myocardial infarction within 12 hours, including those experiencing cardiogenic shock, were eligible for primary transradial PCI if the radial artery pulse could be felt. Effi cacy, safety, and major adverse cardiac events regarding mortality, recurrent non-fatal myocardial infarction, and revascularization were recorded. Eighty-fi ve of 122 patients underwent transradial PCI, and 37 had transfemoral PCI. Older women, haemodynamic instability, and the presence of severe chronic kidney disease (stages 4 and 5) or end-stage renal disease were signifi cantly related to choice of transfemoral approach (P < 0.05). Glycoprotein IIb/IIIa inhibitors were used more often in patients who underwent transradial PCI than in those who underwent transfemoral PCI (37% vs 16%; P = 0.043). The incidence of major bleeding complications requiring blood transfusion was signifi cantly higher in the transfemoral group (P= 0.004). A similar procedural success rate was achieved in both groups (P = 0.737). During follow-up of 580 days, the total major adverse cardiac events were similar in both groups (P = 0.299). Conclusions Routine transradial primary PCI can be safely and successfully performed on up to 70% of acute ST-elevation myocardial infarction patients and, compared with transfemoral approach, is associated with a signifi cantly reduced rate of major bleeding complications.

Transradial versus transfemoral rotablation for heavily calcified coronary lesions in contemporary drug-eluting stent era

Background Although radial access for drug-eluting stent (DES) combined with rotational atherectomy (RA) in patients with calcified coronary lesions may be associated with a lower risk of major bleeding complications and obtain favorable clinical results compared with femoral access, the long-term outcome data of this approach were limited in contemporary DES era. Methods & Results This retrospective study sought to compare in-hospital and long-term outcomes for patients undergoing RA via the transradial (TR) and transfemoral (TF) route in 126 consecutive patients (59 radial, 67 femoral) from 2009 to 2014. TR RA procedures were performed in 44/62 (71%) by the three TR operators, compared with 15/64 (23%) by the four TF operators in the present study. Significantly smaller diameter guide catheters and burrs (1.39 ± 0.16 mm vs. 1.53 ± 0.24 mm, P = 0.001) were used in the TR group. Procedural success rates were similar in both TR and TF groups. There was a significantly less major access site bleeding complications in favor of radial artery access (2% vs. 16%, P = 0.012). The incidence of in-hospital death or myocardial infarction was low in both groups. Although a trend of lower adverse event rate was demonstrated in the TR group compared with the TF one, no statistical significance (21% vs. 27%, P = 0.135) was detected. Conclusions Radial access, a useful alternative to femoral access for RA and DES, can be safely and successfully performed on up to 71% of the patients with heavily calcified coronary lesions needing RA by experienced TR operators.

Circulating Soluble Tumor Necrosis Factor-α and Cell Adhesion Molecules in Patients with Acute Cardiogenic Pulmonary Edema

Background: Circulating soluble tumor necrosis factor-alpha (TNF-α) and cell adhesion molecules (CAMs) are elevated in patients with heart failure. Whether this elevation plays a role in heart failure or is merely a marker of inflammatory response remains to be determined. We hypothesized that TNF-α activated the vascular endothelium, resulting in endothelial dysfunction and permeability changes that may play a role in the development of acute cardiogenic pulmonary edema. Materials and Methods: We measured plasma levels of TNF-α and three CAMs [vascular cell adhesion molecule-1, (VCAM-1) intercellular adhesion molecule-1, (ICAM-1) and P-selectin] in 35 patients (mean age, 64±14 years) with acute myocardial infarction. Patients who had acute pulmonary edema (APE) were placed in the APE group, and those with no pulmonary edema were placed in the non-APE group. Univariate and multivariate comparisons of the clinical and hemodynamic characteristics and levels of TNF-α and CAMs between these two groups were performed. Results: The left ventricular ejection fraction was significantly lower (p=0.00l), the left ventricular end-diastolic pressure was significantly higher (p=0.005), and the levels of the TNF-ct and VCAM-1 were also significantly higher (p＜0.0001 and p=0.003, respectively) in the APE group than in the non-APE group. After adjustment for possible adverse baseline variables, circulating levels of TNF-α and VCAM-1 remain significant predictors of the development of APE [hazard ratio (HR) 32.7, p=0.015 and HR 27.6, p=0.048, respectively]. Conclusions: These findings indicated that inflammation and immune activation were associated with the development of acute cardiogenic pulmonary edema.

Long-term survival and prognostic implications after coronary artery bypass grafting in Chinese patients with coronary artery disease

Objectives — This hospital-based study was conducted to determine the survival rates of patients after coronary artery bypass grafting (CABG) surgery and the associated prognostic factors related to all-cause mortality during a 7-year follow-up in Taiwan. Methods and results — Between January 1997 and December 2003, the medical records of 1877patients who underwent primary, isolated CABG surgery were studied. The Kaplan-Meier method was used to estimate survival. Multiple Cox regression was used to investigate the independence of prognostic factors associated with all-cause mortality. Of the 1877patients who underwent CABG surgery, 192 expired during the 7-year study period. The overall patient survival rate was 85.96% (95% CI: 83.74-88.16). Using multiple Cox regression analysis, in addition to female gender, older age at surgery, pulmonary oedema, longer ischaemic time, longer cardiopulmonary bypass time, and poorer postoperative left ventricular ejection fraction were significant factors associated with all-cause mortality for both men and women. Associated prognostic factors varied by gender. For men, smoking (RR=2.82, 95% CI: 1.06-4.16), respiratory failure (RR=6.88, 95% CI: 3.29-14.40) and cardiogenic shock (RR=4.04, 95% CI: 2.13-7.67) were significantly related to all-cause mortality, but not for women. Sepsis (RR=8.97, 95% CI: 1.19-19.81) and ICU stay (RR=1.03, 95% CI: 1.01-1.05) were significantly related to all-cause mortality among female patients only. Conclusions — Several gender-related differences were noted pertaining to all-cause mortality and the relationships between smoking, sepsis, respiratory failure, cardiogenic shock, and ICU stay.