Pao-Hsien Chu

Mucin gene expression in cardiac myxoma.

Myxoma is the most common benign neoplasm of the heart. This work is the first to present an unusual left atrium and mitral valve cardiac myxoma which cannot be completely resected. This cardiac myxoma was also associated with abundant mucopolysaccharidic matrix, including mucin. Mucin gene expression is cell‐ and tissue‐specific, with variations during cell differentiation and inflammation, and is altered during carcinogenesis. The expression of mucin genes in cardiac myxoma has never been elucidated previously. Detailed immunohistochemical analysis of MUC1, MUC2 and MUC5AC has been performed in this left atrium and mitral valve myxoma. Notably, the expressions of mucins in cardiac myxoma must be further evaluated.

Apoptosis in primary cardiac tumours

Apoptosis, or programmed cell death, is now recognised as an important cellular event during both normal development and specific disease progression. Apoptosis has been suggested to play a critical role in several cardiovascular diseases, but has not yet been identified as a major influence in primary cardiac tumours. A retrospective review of the achieved material at Chang Gung Memorial Hospital revealed seven patients with cardiac myxoma and one with a tumour originating from the crista terminalis, from January 2002 to December 2002. The medical chart, surgical pathology reports and microscopic slides were available in all cases. All patients, including eight cardiac myxomas and one tumour from crista terminalis, were assessed for apoptosis by terminal deoxynucleotidyl transferase nick‐end labelling assay. In this study, apoptosis is well documented in all seven myxoma and has even been reported in tumour from the crista terminalis. Interestingly, apoptosis appears related to the nature of the cell properties rather than the incidence of embolism. In conclusion, apoptosis is important in the progression of the primary cardiac tumours, but the mechanism of cardiac tumour regression still remains uncertain.

Haemophilus influenzae pericarditis with tamponade as the initial presentation of systemic lupus erythematosus.

Although cardiac tamponade is an important and emergent complication of systemic lupus erythematosus (SLE), purulent pericarditis is rare despite the high frequency of pericardial effusion in SLE. We describe the first SLE case of Haemophilus influenzae type‐f pericarditis with cardiac tamponade with SLE as the initial presentation. The pathophysiology and therapy are discussed.

Nationwide cohort study of mitral valve repair versus replacement for infective endocarditis

Objectives The feasibility and long‐term outcomes of mitral valve (MV) repair in patients with infective endocarditis (IE) remain unclear. Methods Using Taiwans National Health Insurance Research Database, we identified 1999 patients who underwent MV surgery for IE during 2000 to 2013. The patients were more likely to have undergone valve replacement (1575 patients; 78.8%) than valve repair (424 patients; 21.2%). After 1:1 propensity score matching, 352 patients in each group were included for analysis. Perioperative outcomes and late composite end points, comprising all‐cause mortality, MV reoperation, any stroke, major bleeding, and readmission for heart failure, were compared. Results Patients who received MV repair had fewer perioperative complications, lower in‐hospital mortality rates (6.3% vs 10.8%; P = .031), and lower risks of late mortality (hazard ratio [HR], 0.59; 95% confidence interval [CI], 0.44‐0.80), and composite end point (HR, 0.67; 95% CI, 0.52‐0.87) during a mean follow‐up of 4.8 years. Subgroup analysis revealed a trend in which the beneficial effect of MV repair was not apparent when surgeries were performed in hospitals within the lowest volume quartile (P for interaction = .091). In patients who underwent surgery during active IE, MV repair was also related to a lower rate of late mortality (HR, 0.64; 95% CI, 0.48‐0.85). Conclusions Mitral repair for IE has better perioperative and late outcomes than mitral replacement. Mitral repair performed by an experienced team is recommended for IE patients instead of MV replacement whenever possible, even with an active infection status.

Effect of dialysis dependence and duration on post-coronary artery bypass grafting outcomes in patients with chronic kidney disease: A nationwide cohort study in Asia.

BACKGROUNDnChronic kidney disease (CKD) is associated with adverse outcomes in patients who undergo coronary artery bypass grafting (CABG). However, the impact of preoperative dialysis dependence and duration in CKD patients on outcomes after CABG has limited research.nnnOBJECTIVESnTo evaluate the effect of preoperative dialysis dependence and duration on CABG outcomes in patients with CKD.nnnMETHODSnA total of 33,920 patients without CKD and 2573 patients with CKD, all of whom underwent isolated CABG between 1998 and 2009, were identified using the Taiwan National Health Insurance Research Database. The patients with CKD were divided into non-dialysis (N=1167), dialysis<3years (N=749), and dialysis≥3years (N=657) groups. The primary outcomes were cumulative incidence of all-cause mortality, cardiovascular (CV) death, and myocardial infarction (MI) or repeat revascularization.nnnRESULTSnAfter adjustment of all covariates, a higher all-cause mortality was associated with dialysis≥3years than with dialysis<3years (hazard ratio [HR], 1.56; 95% confidence interval [CI], 1.35-1.80; P<0.001) and with non-dialysis (HR, 1.41; 95% CI, 1.20-1.66; P<0.001) after 2years of follow-up. Similar results were observed for CV death. In addition, both the dialysis groups had a higher risk of MI or revascularization than the non-dialysis group. Furthermore, subgroup analysis revealed that longer duration was associated with a higher risk of 30-day mortality (P for linear trend <0.001).nnnCONCLUSIONSnAmong the CABG recipients, dialysis dependence is associated with a higher incidence of MI or repeat revascularization, and longer dialysis duration is associated with a higher risk of mortality.

Comparison of cardiovascular outcomes and all-cause mortality in patients with chronic hepatitis B and C: A 13-year nationwide population-based study in Asia

BACKGROUND AND AIMSnViral hepatitis infection has been linked to increased atherosclerosis. We therefore investigated cardiovascular outcomes in patients with hepatitis B virus (HBV) and hepatitis C virus (HCV) infection.nnnMETHODSnElectronic medical records during 2000-2012 were retrieved from the Taiwan National Health Insurance Research Database. Exclusion criteria were age <18, history of coexisting HBV and HCV infection, acute coronary syndrome, coronary intervention, venous thromboembolism, peripheral artery disease, stroke, major or gastrointestinal bleeding, malignancy, and a follow-up period <180 days. Patients with HBV and HCV infection were propensity-matched then compared for outcomes. Primary outcomes were cardiovascular events at the 1-year follow-up, 3-year follow-up, 5-year follow-up, and at the end of follow-up.nnnRESULTSn41,554 patients with diagnosis of HBV or HCV were retrieved from 2000 to 2012. After exclusion criteria, 31,943 patients were eligible for analysis and propensity score matched. The study population consisted of 6030 patients with HBV infection and 6030 patients with HCV infection. Risk of composite arterial events (acute coronary syndrome, peripheral artery disease, and acute ischemic stroke) was significantly higher in patients with HCV infection compared with patients with HBV infection (pu202f=u202f0.012u202fat 5-year follow-up and pu202f=u202f0.003u202fat the end of follow-up). All-cause mortality was significantly higher in patients with HCV infection compared with patients with HBV infection (pu202f<u202f0.001u202fat 3-year follow-up, 5-year follow-up, and at the end of follow-up).nnnCONCLUSIONSnIn patients with chronic viral hepatitis, subjects with HCV infection had a significantly higher risk of composite arterial events and all-cause mortality compared with those with HBV infection.

Impact of prior coronary stenting on the outcome of subsequent coronary artery bypass grafting.

Background The percentage of patients referred for coronary artery bypass grafting (CABG) who have previously undergone percutaneous coronary interventions (PCIs) is increasing. The purpose of this study was to review the outcomes of patients who had received coronary stenting before CABG, and to examine the validity of a mortality risk stratification system in this patient group. Methods From 2010 to 2012, 439 patients who underwent isolated CABG at our medical center were reviewed. The patients were divided into two study groups: those who had previously received coronary artery stenting (97 patients, 24.7%), and those who had not (342 patients, 75.3%). The patients who received balloon angioplasty were excluded. Results There were no significant differences in baseline characteristics. The prior stenting group had a lower risk of mortality, although the difference was not significant. The prior stenting group had fewer graft anastomoses (p = 0.005), and hence a significantly shorter cardiopulmonary bypass time (p = 0.045) and shorter aortic cross-clamping time. Surgical mortality was similar between the two groups. The durations of intensive care unit stay and hospitalization were also similar. The discriminatory power of the logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) was lower in both group. Conclusions Prior coronary stenting does not affect short-term mortality in patients subsequently undergoing CABG surgery. The EuroSCORE does not predict perioperative mortality well for the patients who undergo coronary stenting before CABG.

Use of a B-type natriuretic peptide in evaluating the treatment response of a relapsed lymphoma with cardiac involvement

A 50-year-old woman received a diagnosis of diffuse large B-cell non-Hodgkin’s lymphoma in 2000 and achieved complete remission. In April 2004, echocardiography and computed tomography examinations identified a tumor attached to the tricuspid valve and protruding within the right atrium. Bone marrow and lymph node biopsies showed a relapse of large cell lymphoma. The patient had a markedly elevated level of B-type natriuretic peptide (BNP) but a normal level of cardiac tro-ponin I. The follow-up evaluation of the BNP level after chemotherapy showed that it had returned to within normal limits, and an echocardiogram showed regression of the tumor. Use of the BNP level as a monitor in the treatment of cardiac lymphoma has never been reported. This article is the first to report the use of BNP monitoring before and after chemotherapy to evaluate a patient with an unusual relapsed lymphoma with cardiac involvement.

Microenvironment of saphenous vein graft preservation prior to coronary artery bypass grafting

OBJECTIVESnThe best preservation solution for a free vascular graft prior to coronary artery bypass grafting (CABG) remains controversial. The aim of this investigation was to evaluate the microenvironment of the human saphenous vein graft when preserved in normal saline (NS) solution or autologous heparinized whole blood (AWB).nnnMETHODSnBetween January 2014 and December 2014, 21 patients who underwent CABG were enrolled and a total of 162 saphenous vein graft rings were collected. NS and AWB were used to investigate the influence of the microenvironment. The hypoxia, oxidative stress and vascular apoptosis were assayed by western blot, and endothelial integrity was assessed by immunohistochemical analysis.nnnRESULTSnThe level of PaO2 in AWB was lower than that in NS (median: 100.5u2009mmHg vs 185.8u2009mmHg, Pu2009=u20090.004). This hypoxic condition led to the production of more hypoxia-inducible factor-1 (median: 60.1% vs 15.1%, Pu2009=u20090.008) and endothelial nitric oxide synthase (median: 52.6% vs 25%, Pu2009=u20090.046) within 30u2009min of preservation time. The fact that higher levels of glutathione peroxidase resulted in the preservation of AWB suggests that it is beneficial to boost the vascular antioxidant defense with lower levels of NOX2. AWB led to increased Bcl-2, reduced cytochrome c and cleaved 85u2009kDa poly ADP-ribose polymerase apoptotic fragments.nnnCONCLUSIONSnWe concluded that AWB possesses a microenvironment that is superior to that of NS for saphenous vein graft preservation prior to CABG.

Propensity Score Matched Analysis of Mechanical vs. Bioprosthetic Valve Replacement in Patients With Previous Stroke

BACKGROUNDnThis study compared the long-term outcomes of prosthetic heart valve replacement with mechanical or bioprosthetic valves in patients with prior stroke.Methodsu2004andu2004Results:In total, 1,984 patients with previous stroke who had received valve replacement between 2000 and 2011 were identified using the Taiwan National Health Insurance Research Database. Propensity score matching analysis was used. Ultimately, 547 patients were extracted from each group and were eligible for analysis. On survival analysis, the risks of all-cause mortality and recurrence of stroke were similar. The incidence of major bleeding was greater in the mechanical valve group than in the bioprosthetic valve group (P=0.040), whereas no difference was observed in re-do valve surgery. On subgroup analysis, the bioprosthetic valve was favored for older age (≥60 years) and previous gastrointestinal (GI) bleeding patients. The mechanical valve, however, was favored for younger patients (<60 years).nnnCONCLUSIONSnIn patients with previous stroke, bioprosthetic valves had a lower incidence of complications connected to major bleeding than did the mechanical valves. Survival and stroke recurrence rates, however, did not differ between the 2 groups. We recommend bioprosthetic valves for patients >60 years or who have a history of GI bleeding.