Victor Chien-Chia Wu

Comparison of Baseline versus Posttreatment Left Ventricular Ejection Fraction in Patients with Acute Decompensated Heart Failure for Predicting Cardiovascular Outcome: Implications from Single-Center Systolic Heart Failure Cohort.

Aims The prognostic values of left ventricular ejection fraction (LVEF) during heart failure (HF) with acute decompensation or after optimal treatment have not been extensively studied. We hypothesized that posttreatment LVEF has superior predictive value for long-term prognosis than LVEF at admission does. Methods and Results In Protocol 1, 428 acute decompensated HF (ADHF) patients with LVEF ≤35% in a tertiary medical center were enrolled and followed for a mean period of 34.7 ± 10.8 months. The primary and secondary end points were all-cause mortality and HF readmission, respectively. In total, 86 deaths and 240 HF readmissions were recorded. The predictive values of baseline LVEF at admission and LVEF 6 months posttreatment were analyzed and compared. The posttreatment LVEFs were predictive for future events (P = 0.01 for all-cause mortality, P < 0.001 for HF readmission), but the baseline LVEFs were not. In Protocol 2, the outcomes of patients with improved LVEF (change of LVEF: ≥+10%), unchanged LVEF (change of LVEF: –10% to +10%), and reduced LVEF (change of LVEF: ≤–10%) were analyzed and compared. Improved LVEF occurred in 171 patients and was associated with a superior long-term prognosis among all groups (P = 0.02 for all-cause mortality, P < 0.001 for HF readmission). In Protocol 3, independent predictors of improved LVEF were analyzed, and baseline LV end-diastolic dimension (LVEDD) was identified as a powerful predictor in ADHF patients (P < 0.001). Conclusions In patients with ADHF, posttreatment LVEF but not baseline LVEF had prognostic power. Improved LVEF was associated with superior long-term prognosis, and baseline LVEDD identified patients who were more likely to have improved LVEF. Therefore, baseline LVEF should not be considered a relevant prognosis factor in clinical practice for patients with ADHF.

Predicting Acute Kidney Injury Following Mitral Valve Repair

Background: Acute kidney injury (AKI) after cardiac surgery is associated with short-term and long-term adverse outcomes. Novel biomarkers have been identified for the early detection of AKI; however, examining these in every patient who undergoes cardiac surgery is prohibitively expensive. Society of Thoracic Surgeons (STS) and Age, Creatinine, and Ejection Fraction (ACEF) scores have been proven to predict mortality in bypass surgery. The aim of this study was to determine whether these scores can be used to predict AKI after mitral valve repair. Materials and Methods: Between January 2010 and December 2013, 196 patients who underwent mitral valve repair were enrolled. The clinical characteristics, outcomes, and scores of prognostic models were collected. The primary outcome was postoperative AKI, defined using the Kidney Disease Improving Global Outcome 2012 clinical practice guidelines for AKI. Results: A total of 76 patients (38.7%) developed postoperative AKI. The STS renal failure (AUROC: 0.797, P < .001) and ACEF scores (AUROC: 0.758, P < .001) are both satisfactory tools for predicting all AKI. The STS renal failure score exhibited superior accuracy compared with the ACEF score in predicting AKI stage 2 and 3. The overall accuracy of both scores was similar for all AKI and AKI stage 2 and 3 when the cut-off points of the STS renal failure and ACEF scores were 2.2 and 1.1, respectively. Conclusion: In conclusion, the STS renal failure score can be used to accurately predict stage 2 and 3 AKI after mitral valve repair. The ACEF score is a simple tool with satisfactory power in screening patients at risk of all AKI stages. Additional studies can aim to determine the clinical implications of combining preoperative risk stratification and novel biomarkers.

Comparison of contemporary preoperative risk models at predicting acute kidney injury after isolated coronary artery bypass grafting: a retrospective cohort study

Objectives Acute kidney injury (AKI) after coronary artery bypass grafting (CABG) is associated with short-term and long-term adverse outcomes. The European System for Cardiac Operative Risk Evaluation (EuroSCORE), EuroSCORE II, the Society of Thoracic Surgeons (STS) score and Age, Creatinine and Ejection Fraction (ACEF) score, have been widely used for predicting the operative risk of cardiac surgery. The aim of this study is to investigate the discriminant ability among current available models in predicting postoperative AKI. Methods From January 2010 to December 2012, 353 patients who underwent isolated CABG were enrolled. The clinical characteristics, outcomes and scores of prognostic models were collected. The primary outcome was postoperative AKI, defined based on the Kidney Disease Improving Global Outcome (KDIGO) Clinical Practice Guideline for AKI, in 2012. Results 102 patients (28.9%) developed postoperative AKI. For AKI prediction, EuroSCORE II, STS score and ACEF score were all good tools for stage-3 AKI. The ACEF score was shown to have satisfied discriminant ability to predict postoperative AKI with area under a receiver operating characteristic curve: 0.781±0.027, (95% CI 0.729 to 0.834, p value <0.001). Multivariate logistic analysis identified that lower ejection fraction and higher serum creatinine were independent risk factors for AKI. Conclusions The simple and extremely user-friendly ACEF score can accurately identify the risk of postoperative AKI and has shown satisfactory discriminant ability when compared with other systems. The ACEF score might be the easiest tool for predicting postoperative AKI.

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.

Relationship Between Right Ventricular Function and Atrial Fibrillation After Cardiac Surgery

OBJECTIVEnThe aim of this study was to explore the relationship between perioperative right ventricular (RV) function and postoperative atrial fibrillation (POAF) in the context of cardiac surgery.nnnDESIGNnProspective, observational study.nnnSETTINGnA single medical center setting.nnnPARTICIPANTSnThe study comprised 92 patients undergoing elective cardiac surgery.nnnINTERVENTIONSnNone.nnnMEASUREMENTS AND MAIN RESULTSnConsecutive patients without previous history of atrial fibrillation referred for cardiac surgery were enrolled prospectively. Comprehensive transesophageal echocardiography was recorded at the following 2 specific timeframes: before sternotomy (T1) and after sternal closure (T2). Four RV measurements, including RV global longitudinal strain (RVGLS), were performed offline. POAF was defined as any sustained episode of atrial fibrillation recorded within 14 days postoperatively. Ninety-two patients (mean age 61.2 ± 10.8 yr, 63 men) were included in this study; 25 patients (27%) experienced POAF, with a median occurrence of 3 days after cardiac surgery. Multivariable logistic regression models demonstrated that RVGLST1 (odds ratio 1.13, p = 0.047) and RVGLST2 (odds ratio 1.38, p = 0.001) were associated independently with POAF. However, changes in RV indices were not correlated to POAF. The optimal cutoff points obtained from the receiver operating characteristic curve analysis were as follows: -16.7% of RVGLST1 (positive likelihood ratio 2.21, negative likelihood ratio 0.59) and -16.1% of RVGLST2 (positive likelihood ratio 2.68, negative likelihood ratio 0.38).nnnCONCLUSIONSnRV dysfunction is associated significantly with the occurrence of POAF in the context of cardiac surgery, and perioperative RVGLS measured using transesophageal echocardiography is a useful index to predict POAF in patients referred for cardiac surgery.

Risk factor analysis of postoperative acute respiratory distress syndrome in valvular heart surgery

PURPOSEnThe aim of this study is to investigate the incidence, severity, and outcome of postoperative acute respiratory distress syndrome (ARDS), according to the Berlin definition, in isolated valvular heart surgery. The preoperative and perioperative predisposing factors of this complication were also identified.nnnMETHODSnA retrospective chart review was conducted on 457 patients who underwent isolated valvular heart surgery between January 2010 and December 2012. Clinical characteristics and outcomes were collected. The primary outcome was postoperative ARDS, according to the 2012 Berlin definition for ARDS.nnnRESULTSnA total of 37 patients (8.1%) developed postoperative ARDS, with a mortality rate of 29.7%. The multivariate analysis identified that age (odds ratios [ORs], 1.067, P ≤ .001), liver cirrhosis (OR, 7.159; P = .001), massive blood transfusion (OR, 2.980; P = .005), and tricuspid valve replacement (OR, 5.197; P = .012) were independent risk factors of postoperative ARDS. Furthermore, we have determined that the increased severity stages of ARDS were associated with decreased postoperative survival.nnnCONCLUSIONSnIn conclusion, postoperative ARDS, according to Berlin definition, in valvular surgery, was associated with high in-hospital mortality. The severity of ARDS was associated with patient midterm mortality. In multivariate analysis, age, liver cirrhosis, massive blood transfusion, and tricuspid valve replacement were identified as independent risk factors of ARDS.

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.

Comparison of right ventricular measurements by perioperative transesophageal echocardiography as a predictor of hemodynamic instability following cardiac surgery

Background The relationship between perioperative right ventricular (RV) performance and hemodynamic instability after cardiac surgery seemed less portrayed. Therefore, we sought to elucidate this relationship and compare the accuracy of different RV systolic indices in predicting outcome of cardiac surgery. Methods This study enrolled consecutive patients referred for cardiac surgeries. Exclusion criteria were non‐sinus rhythm or contraindications to transesophageal echocardiography (TEE). TEE exam and simultaneous pulmonary hemodynamics were recorded in two stages: after induction of anesthesia and before sternotomy (stage 1), and after sternal closure (stage 2). RV measurements performed offline included fractional area change (RVFAC), tricuspid annular plane systolic excursion (TAPSE), peak systolic tricuspid annular velocity (RVS′), myocardial performance index (RVMPI), and global longitudinal strain (RVGLS). The end point was defined as prolonged use (>24 h) of postoperative inotropic agent in the intensive care unit (ICU). Results The study population included 68 patients (mean age 61 ± 11 y; 49 men). Twenty‐two of these patients (32%) were administered inotropic agents for a prolonged period with a mean duration of 63.9 ± 5.3 h, accompanied with significantly longer ventilator use (p = 0.006) and longer ICU stay (p = 0.001) than patients without a prolonged inotropic agent use. Multivariable analysis demonstrated that only RVGLS in either stage 1 (odds ratio [OR] 1.11, p = 0.048) or stage 2 (OR 1.15, p = 0.018) was significantly associated with the outcome, especially a RVGLS > −13.5% in stage 2 demonstrating high risk of prolonged inotropic agent use after cardiac surgery (OR 7.37, p = 0.016). Conclusion RVGLSs performed using perioperative TEE are reliably associated with hemodynamic instability following cardiac surgery. This finding adds substantial information to postoperative critical care.

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.