Teng-Yao Yang

Changes of the Cardiac Architectures and Functions for Chronic Hemodialysis Patients with Dry Weight Determined by Echocardiography

Background/Aims: Left ventricular hypertrophy (LVH) has long been known as an independent risk factor for cardiovascular deaths, in both dialysis and general populations. Numerous factors influence the pathophysiology of LVH. However, extracellular fluid may have a particularly important influence on this impact. Inferior vena cava diameter (IVCD) estimation is a non-invasive and relatively convenient method for obtaining a good correlation with the intravascular fluid status, and may obtain an optimal dry weight (DW) for chronic hemodialysis patients. This study estimates the DW of end-stage renal disease (ESRD) patients by echocardiographic measurement of the IVCD to observe changes in cardiac morphology and function. Methods: A total of 88 patients, ranging from 26 to 90 (59.4 ± 13.3) years of age, were involved in this study. The patients were divided into study (n = 48) and control (n = 40) groups. All patients received IVCD assessment via echocardiography bi- monthly for 1 year. In the study group patients, DW was adjusted according to the IVCD by echocardiography. Meanwhile, in the control group patients, DW was adjusted based on traditional clinical parameters. All patients underwent cardiac examinations and measurements, including left ventricular mass (LVM), wall thickness, chamber size and left ventricular systolic function by echocardiography, at the beginning and end of the study. Results: Both groups displayed comparable clinical and biochemical parameters. The IVCD index correlated well with the cardiac parameters estimated by echocardiography. The LVM and left ventricular mass index (LVMI) was reduced significantly in the study group patients (from 200 ± 64.2 to 187 ± 63.2 g, p = 0.021; from 132 ± 37.6 to 123 ± 37.3 g/m2, p = 0.014, respectively). Furthermore, the study group patients with fluid overload, named study subgroup A, displayed significant differences not only in LVM and LVMI, but also in septal wall thickness, left ventricular end-diastolic dimension and left atrial dimension. In contrast, the control group displayed no changes in these cardiac architectures during the study period. Conclusion: Adjusting DW via the IVCD measured by echocardiography for hemodialysis patients may prevent the progression of chamber dilatation and LVH, especially for patients with fluid overload.

Arterial Stiffness Is the Independent Factor of Left Ventricular Hypertrophy Determined by Electrocardiogram

Introduction:Arterial stiffness may contribute to left ventricular hypertrophy (LVH). This study was conducted to evaluate the independent factor of LVH and the quantification of LVH by electrocardiogram (ECG) to predict the degree of aortic stiffness using brachial-ankle pulse wave velocity (baPWV) in subjects with hypertension. Materials and Methods:A total of 984 consecutive patients who were diagnosed as having essential hypertension were entered into the study. baPWV determination, ECG and blood sampling were performed after a 12-hour overnight fast. LVH was diagnosed using electrocardiography; Romhilt-Estes point score was subsequently calculated. Participants were separated into LVH and non-LVH groups. Additional factors associated with LVH were examined using multivariate analyses. Results:The non-LVH groups were younger (P = 0.001), had less men (P = 0.001), lower systolic and diastolic blood pressure and pulse pressure (P < 0.001 for each) and lower baPWV (P < 0.001). Stepwise multiple logistic regression analysis demonstrated that sex, age, systolic blood pressure and baPWV are independent factors. Using a baPWV value of 1825 cm/sec, the area under the receiver operating characteristic curve was 0.644 and the highest discriminating sensitivity and specificity were 60% and 65%, respectively. Conclusion:Aortic stiffness may be related to electrocardiographically determined LVH in patients with hypertension. Thus, stiffening of large arteries, together with increased systolic blood pressure, seems to significantly contribute to the pathogenesis of LVH. Quantification of LVH by ECG can also predict the degree of aortic stiffness.

Quantification of Aortic Stiffness to Predict the Degree of Left Ventricular Diastolic Function

Introduction:The association between the arterial stiffness and the severity of left ventricular (LV) diastolic function in hypertension has not been fully evaluated. This study was conducted to evaluate the relationship of aortic stiffness by brachial-ankle pulse wave velocity (baPWV) to parameters reflecting the atherosclerosis and the severity of LV diastolic function in patients with hypertension. Methods:LV ejection fraction, the ratio of peak velocity of early rapid filling and peak velocity of atrial filling (E/A ratio) and LV mass index were determined with echocardiography in 800 patients with hypertension. LV diastolic function was estimated by pulsed-tissue Doppler imaging (TDI) echocardiography, averaging diastolic mitral annular velocity measurements (Emav, Amav and Emav/Amav ratio) from 2 separate sites (basal septal and lateral). The baPWV was measured by the volume rendering method. Results:Stepwise multiple logistic regression analysis demonstrated that the independent factors of LV diastolic function were deceleration time, baPWV, age and Emav/Amav ratio. The receiver- operator characteristic curve demonstrated a baPWV of 1566 cm/sec was useful to discriminate mild LV diastolic dysfunction (sensitivity, 78%; specificity, 78%), and that a baPWV of 1730 cm/sec was useful to discriminate moderate LV diastolic dysfunction (sensitivity, 73%; specificity, 57%). Conclusions:Increased baPWV relates not only to the parameters reflecting atherosclerosis but also to those reflecting LV diastolic dysfunction. TDI-detected LV diastolic dysfunction is accompanied by increased aortic stiffness in essential hypertension. Therefore, quantification of aortic stiffness can predict the degree of LV diastolic function.

QT interval is prolonged but QT dispersion is maintained in patients with primary aldosteronism.

The relationship between QT duration and its dispersion in patients with primary hyperaldosteronism is not clearly known. We studied 26 patients (nine males and 17 females) with primary hyperaldosteronism. The serum potassium levels were low (2.32 ± 0.52 mmol/l), did not correlate with serum renin or aldosterone levels, or aldosterone/renin ratio (ARR). The maximum QT intervals (QTmax) were prolonged (502 ± 62 ms), correlated well with ARRs (p = 0.005) and aldosterone levels (p = 0.019), but not to renin (p = 0.517) or potassium levels (p = 0.196). The QT dispersions (QTd) were small (60 ± 28.8 ms) and did not correlate with potassium, renin or aldosterone levels.

In-Hospital and 4-Year Clinical Outcomes Following Transcatheter Versus Surgical Closure for Secundum Atrial Septal Defect in Adults: A National Cohort Propensity Score Analysis.

AbstractAtrial septal defect (ASD) closure is major therapy for patients with secundum ASD. Although surgical closure (SC) and transcatheter closure (TC) are usually performed in such patients, data on the long-term outcomes comparing TC and SC in adults are limited.Data on the participants of this cohort study were retrieved from Taiwans National Health Insurance Research Database from 2004 to 2011. Secundum ASD patients > 18 years of age who underwent TC or SC were initially enrolled, and those with associated comorbidities were excluded. After propensity score matching, the clinical outcomes between the TC and SC groups were analyzed.There were 595 patients recruited in the TC group and 308 patients in the SC group. The SC group had a higher incidence of systemic thromboembolism (P < 0.001), ischemic stroke (P = 0.002), and all-cause mortality (P = 0.013) when compared with those of the TC group at the index hospitalization, and similar phenomena could also be seen in a around 4-year follow-up period after the procedures (systemic thromboembolism (P < 0.001, HR = 11.48, 95% CI: 3.29–40.05), ischemic stroke (P = 0.005, HR = 9.28, 95% CI: 1.94–44.39), and all-cause mortality (P = 0.035, HR = 2.28, 95% CI: 1.06–4.89). In addition, atrial fibrillation (P = 0.005) and atrial flutter (P = 0.049) more frequently developed in the SC group than in the TC group at the index hospitalization.The adult secundum ASD patients had lower incidence rates of systemic thromboembolism, ischemic stroke, and all-cause mortality after TC than those after SC in the 4-year follow-up after procedures. Transcatheter ASD closure should therefore be given priority

Relation of arterial stiffness assessed by brachial-ankle pulse wave velocity to complexity of coronary artery disease.

Background:The progression of atherosclerosis leads to increased arterial stiffness. The present study used brachial-ankle pulse wave velocity (baPWV) to evaluate the connection between arterial stiffness in patients with chest pain and the presence and extent of coronary artery disease (CAD). Methods:On a retrospective basis, we analyzed the data of 703 consecutive patients who had undergone baPWV and an elective coronary angiogram for suspected CAD, between June 2010 and July 2012, at a single cardiovascular center. Results:The baPWV was one of the statistically meaningful predictors of significant CAD (diameter of stenosis >50%) in addition to diabetes and dyslipidemia in a multivariate analysis. When the extent of CAD was classified into nonsignificant or significant CAD (ie, 1-, 2- and 3-vessel disease), there was a significant difference in baPWV between the significant and nonsignificant CAD groups, but there was no difference in baPWV among the 3 significant CAD groups. Linear regression analyses showed that baPWV was significantly associated with the SYNTAX (SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery) score. The cutoff value of baPWV at 1735 cm/s had a sensitivity of 55.6%, specificity of 62.4%, and area under receiver operating characteristic curve of 0.612 in predicting CAD. Conclusions:Arterial stiffness as determined by baPWV is associated independently with significant CAD in patients with angina. Arterial stiffness is related to CAD severity as assessed by the SYNTAX score. As a result, increased arterial stiffness assessed by baPWV is associated with the severity and presence of CAD.

Feasibility of Trans‐Radial Approach in Percutaneous Intervention for Upper Arm Dialysis Access

Background:  This retrospective study evaluated the feasibility and efficacy of trans‐radial intervention for upper arm dialysis access.

Percutaneous Transluminal Angioplasty for Radial-Cephalic Fistulae With Stenosis at the Arteriovenous Junction

Introduction: The aim of this study was to analyze the predictive factors for initial success and long-term patency of percutaneous transluminal angioplasty for radial-cephalic (RC) fistulae with stenosis at the arteriovenous junction (AVJ). Stenosis at the AVJ of RC fistulae involves both the feeding artery and drainage vein and is similar to a bifurcation lesion, which carries a worse outcome. The optimal intervention method for this type of lesion is currently unknown. Methods: Ninety-one percutaneous transluminal angioplasty procedures for stenosis at the AVJ of RC fistulae were reviewed retrospectively. Parameters including age, sex, location of the RC fistula (right or left arm), approach site (radial artery or cephalic vein) and involvement of proximal radial artery (PRA) dilatation were analyzed for initial procedure success and long-term patency rates. Results: The total initial success rate was 94.5%. The existence of total occlusion was recognized as the only factor significantly associated with a high procedural failure rate (39% versus 0%, P < 0.001). For long-term patency rate, the only significant factor was the involvement of PRA dilatation (P = 0.026 by Cox-Mantel and 0.03 by generalized Wilcoxon methods). The 6-month, 1-year and 18-month patency rates were 64%, 45.3% and 20.9%, respectively, for all procedures, and 70.7% versus 57.8%, 56.1% versus 35.6% and 36.6% versus 6.7% for procedures with and without PRA dilatation, respectively. Conclusions: In treating stenosis at the AVJ of RC fistulae, while initial procedural failure occurred mainly in occluded lesions, involvement of PRA dilatation was the only significant predictive factor associated with long-term patency.

Different degrees of overweight: anthropometric indices in patients with coronary heart disease

Objectives — Obesity is a risk factor for all-cause mortality.The obesity incidence depends on different definitions. Among patients with high-risk coronary heart disease (HRCA), we have studied differences in obesity incidence, according to different anthropometric indices. Methods and results — Based on the definitions of the International Guidelines Committees for body mass index (BMI), waist circumference (WCF), and waist-hip ratio (WHR), we have classified 487 CAD patients into 3 groups: normal (group 1), overweight (group 2), and obese patients (group 3). Among men, obesity criteria BMI, WCF and WHR were positive in 17.5%, 14.2%, and 66.4% of the subjects. Among male subjects < 65 years, the incidence of HRCA (%), for the 3 groups (normal, overweight, obese) were for BMI (2.4, 21.5, 28.9, P = 0.005); WCF (17.9, 12.1, 37.9, P= 0.012); WHR (0, 15.4, 30.4, P= 0.024). In male subjects > 65 years, for the HRCA incidence (%), only WHR showed a significant difference between the 3 groups (0, 15.4, 30.4, P= 0.024). Among women, 30.6%, 63.6%, and 87.6% were obese by the BMI, WCF, and WHR criteria, respectively. We did not find any significant differences in the HRCA distribution between age groups and degrees of obesity. Conclusions — HRCA distribution varied among obese male patients. According to the different methods of measurement, obesity percentages varied from 4- to 5-fold among men and 3-fold among women. In our view, WHR measurement is the method of choice for the determination of obesity among patients with CAD.

Comparison of Clinical Outcomes Among Patients With Atrial Fibrillation or Atrial Flutter Stratified by CHA2DS2-VASc Score

This cohort study uses Taiwan National Health Insurance database data to evaluate the incidence of ischemic stroke, hospitalization for heart failure, and all-cause mortality among patients with atrial fibrillation and atrial flutter stratified by CHA2DS2-VASc score.