Yuan-Kai Hsieh

Early extracorporeal membrane oxygenator-assisted primary percutaneous coronary intervention improved 30-day clinical outcomes in patients with ST-segment elevation myocardial infarction complicated with profound cardiogenic shock

Objectives:This study tested the hypothesis that early extracorporeal membrane oxygenator offered additional benefits in improving 30-day outcomes in patients with acute ST-segment elevation myocardial infarction complicated with profound cardiogenic shock undergoing primary percutaneous coronary intervention. Methods:Between May 1993 and July 2002, 920 patients with acute ST-segment elevation myocardial infarction underwent primary percutaneous coronary intervention. Of these patients, 12.5% (115) with cardiogenic shock were enrolled in this study (group 1). Between August 2002 and December 2009, 1650 patients with acute ST-segment elevation myocardial infarction underwent primary percutaneous coronary intervention. Of these patients, 13.3% (219) complicated with cardiogenic shock were enrolled (group 2). Results:The incidence of profound shock (defined as systolic blood pressure remaining ≤75 mm Hg after intra-aortic balloon pump and inotropic agent supports) was similar in both groups (21.7% vs. 21.0%, p > .5). Extracorporeal membrane oxygenator support, which was available only for patients in group 2, was performed in the catheterization room. The results demonstrated that final thrombolysis in myocardial infarction grade 3 flow in infarct-related artery was similar between the two groups (p = .678). However, total 30-day mortality and the mortality of patients with profound shock were lower in group 2 than in group 1 (all p < .04). Additionally, the hospital survival time was remarkably longer in patients in group 2 than in patients in group 1 (p = .0005). Furthermore, multivariate analysis demonstrated that unsuccessful reperfusion, presence of advanced congestive heart failure, profound shock, and age were independent predictors of 30-day mortality (all p < .02). Conclusion:Early extracorporeal membrane oxygenator-assisted primary percutaneous coronary intervention improved 30-day outcomes in patients with ST-segment elevation myocardial infarction with complicated with profound cardiogenic shock.

Comparison of impact of primary percutaneous transluminal coronary angioplasty and primary stenting on short-term mortality in patients with cardiogenic shock and evaluation of prognostic determinants

sestamibi in patients undergoing cardiac transplantation. A scintigraphic/pathological study. Circulation 1996;94:1010–1017. 9. Maes AF, Borgers M, Flameng W, Nuyts JL, van de Werf F, Ausma JJ, Sergeant P, Mortelmans LA. Assessment of myocardial viability in chronic coronary artery disease using technetium-99m sestamibi SPECT. Correlation with histologic and positron emission tomographic studies and functional followup. J Am Coll Cardiol 1997;29:62–68. 10. Dakik HA, Howell JF, Lawrie GM, Espada R, Weilbaecher DG, He ZX, Mahmarian JJ, Verani MS. Assessment of myocardial viability with 99m Tcsestamibi tomography before coronary bypass graft surgery: correlation with histopathology and postoperative improvement in cardiac function. Circulation 1997;96:2892–2898. 11. Miller TD, Christian TF, Hopfenspirger MR, Hodge DO, Gersh BJ, Gibbons RJ. Infarct size after acute myocardial infarction measured by quantitative tomographic 99m Tc sestamibi imaging predicts subsequent mortality. Circulation 1995;92:334–341. 12. Miller TD, Hodge DO, Sutton JM, Grines CL, O’Keefe JH, DeWood MA, Okada RD, Fletcher WO Jr, Gibbons RJ. Usefulness of technetium-99m sestamibi infarct size in predicting posthospital mortality following acute myocardial infarction. Am J Cardiol 1998;81:1491–1493. 13. Gibbons RJ, Holmes DR, Reeder GS, Bailey KR, Hopfenspirger MR, Gersh BJ. Inmediate angioplasty compared with the administration of a thrombolytic agent followed by a conservative treatment for myocardial infarction. N Engl J Med 1993;328:685–691. 14. O’Keefe JH, Grines CL, DeWood MA, Schaer GL, Browne K, Magorien RD, Kalbfleisch JM, Fletcher WO Jr, Bateman TM, Gibbons RJ. Poloxamer-188 as an adjunct to primary percutaneous transluminal coronary angioplasty for acute myocardial infarction. Am J Cardiol 1996;78:747–750. 15. Collaborative Organization for RheothRx Evaluation (CORE). Effects of RheothRX on mortality, morbidity, left ventricular function and infarct size in patients with acute myocardial infarction. Circulation 1997;96:192–201. 16. Anglo Scandinavian Study of Early Thrombolysis Study Group. Trial of tissue plasminogen activator for mortality reduction in acute myocardial infarction. Anglo-Scandinavian Study of Early Thrombolysis (ASSET). Lancet 1988; 2:525–530. 17. Christian TF, Gibbons RJ, Gersh BJ. Effect of infarction location on myocardial salvage assessed by technetium-99m isonitrile. J Am Coll Cardiol. 1991; 17:1303–1308. 18. The GUSTO Angiographic Investigators. The effects of tissue plasminogen activator, streptokinase, or both on coronary-artery patency, ventricular function, and survival after acute myocardial infarction. N Engl Med 1993;329:1615–1622. 19. Galli M, Marcassa C, Bolli R, Giannuzzi P, Temporelli PL, Imparato A, Silva Orrego PL, Giubbini R, Giordano A, Tavazzi L. Spontaneous delayed recovery of perfusion and contraction after the first 5 weeks after anterior infarction. Evidence for the presence of hibernating myocardium in the infarcted area. Circulation 1994;90:1386–1397.

Feasibility and safety of transbrachial approach for patients with severe carotid artery stenosis undergoing stenting.

Although sporadic successful cases using the transradial approach (TRA) for carotid stenting have been reported, the safety and feasibility of carotid stenting using either TRA or a transbrachial approach (TBA) have not been fully investigated. Recently, we have developed a safe and feasible method of TRA for cerebrovascular angiographic studies. This study investigated whether a TBA approach using a 7‐French (F) Kimny guiding catheter for carotid stenting is safe and feasible for patients with severe carotid stenosis. Thirteen patients were enrolled into this study (age range, 63–78 years). Seven of these 13 patients had severe peripheral vascular disease. A retrograde‐engagement technique, involving looping 6‐F Kimny guiding catheter, was utilized for carotid angiographic study. For carotid stenting, the 6‐F Kimny guiding catheter was replaced with a 7‐F Kimny guiding catheter, and the procedure was performed as the follows. First, an extra‐support wire was inserted into the middle portion of external carotid artery (ECA). Second, a 0.035‐inch Teflon wire was advanced into the common carotid artery. Then, the 6‐F guiding catheter was exchanged for a 7‐F Kimny guiding catheter. Third, if the first and second steps did not provide adequate support for exchanging the guiding catheter, a PercuSurge GuardWire™ was inserted into the ECA, followed by distal balloon inflation for an anchoring support. FilterWire EX™ was used in 9 patients and PercuSurge GuardWire in 4 patients to protect from distal embolization during the procedure. The procedure was successful in all patients. No neurological or vascular bleeding complications were observed and all patients were discharged uneventfully. The TBA for carotid stenting was safe and effective, providing a last resort for patients unsuited to femoral arterial access and surgical intervention.

Correlation among subcortical white matter lesions, intelligence and CTG repeat expansion in classic myotonic dystrophy type 1

Objectivesu2002–u2002 To analyze the correlation among intelligence, brain magnetic resonance images (MRI) and genotype in classic myotonic dystrophy type 1 (DM1) patients.

A single transradial guiding catheter for right and left coronary angiography and intervention.

AIMSnThere is no data about the utilisation of a single guiding catheter for current routine, transradial, right and left coronary diagnosis and intervention. We investigated the feasibility and safety of using 6Fr, Ikari left (IL) 3.5 guiding catheter for this purpose.nnnMETHODS AND RESULTSnThis prospective single-centre study enrolled 621 consecutive patients referred for transradial coronary angiography with ad hoc coronary intervention. The radial artery was successfully accessed in 96.8% of patients. Right and left coronaries were successfully engaged in 98.1% of cases. Engagement with good back-up at right and left coronaries (device success) was achieved in 96.6% of cases. Coronary intervention was performed in 61.2% of the cases, among them, 84.5% had coronary stenting. Procedure success was 98.2%. Procedure time was 21.4+/-15.1 and 65.4+/-36.1 minutes; mean fluoroscopy time was 6.8+/-7.2 and 24.1+/-18.9 minutes and mean contrast volume was 96.2+/-45.3 and 197.9+/-46.2 ml for diagnostic and interventional cases respectively. One patient (0.16%) had catheter related radial artery spasm and three patients (0.48%) encountered a catheter induced RCA dissection.nnnCONCLUSIONSnRight and left coronary angiography and intervention is feasible and highly successful using IL 3.5 as a single transradial guiding catheter.

Application of penetration device (Tornus) for percutaneous coronary intervention in balloon uncrossable chronic total occlusion—procedure outcomes, complications, and predictors of device success†

Objective: To evaluate procedure outcomes, complications, and the predictors of device success while using the Tornus in CTO revascularization. Background: The success of percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) may be limited by the presence of severe calcified CTO lesions, especially in the smallest balloon uncrossable arteries. A penetrating device (Tornus) could improve the success rate. Methods: Device and angiographic success rates as well as procedural complications were assessed in 56 patients, who were consecutively and retrospectively enrolled into this study. Device success was defined as successful passage of the Tornus catheter through a CTO lesion. Procedure success was defined by a final TIMI 3 flow and <30% residual stenosis. Results: The device success rate was 71.4% in 40 patients and failure rate was 28.6% in 16 patients. The final procedure success was significantly higher in the Tornus success group compared with the Tornus failure group (87.5% vs. 37.5%, P < 0.001). One patient in the Tornus success group (1.8%) had wire perforation resulting in cardiac tamponade and cardiac death. Another patient (1.8%) in the Tornus success group had acute in‐stent thrombosis and non‐Q MI in 24 hr and was resuscitated by emergent PCI. The only independent predictor of device success was a calcium score < 2 (odds ratio (OR): 3.86 (95% CI: 1.14–13.1, P = 0.03). Conclusion: The Tornus catheter can be used in severe calcified CTO PCI when the calcium score <2 and not be used in patients with a calcium score ≥2.

Interleukin-18: a strong predictor of the extent of coronary artery disease in patients with unstable angina

The aim of this study was to confirm that plasma interleukin (IL)-18 level is associated with the extent of coronary artery disease in unstable angina patients. Previous studies have shown that patients with unstable angina have significantly higher plasma IL-18 levels than healthy volunteers. However, the association between IL-18 and the extent of coronary artery atherosclerosis in patients with unstable angina remains unclear. Plasma concentrations of IL-18 and high-sensitivity C-reactive protein (hs-CRP) were measured in 166 consecutive patients admitted for coronary arteriography. One hundred and eighteen patients with unstable angina had coronary artery disease (coronary artery disease group; severity score: 2.32 ± 1.47; Gensini score: 31.3 ± 25.9), and 48 patients with coronary risk factors and without coronary artery lesions served as the risk control group. Plasma levels of IL-18 were higher in the coronary artery disease group than in the risk control group (P = 0.062). Additionally, plasma levels of IL-18 were significantly higher in 77 coronary artery disease patients with severity score ≥2 than in the risk control group (242.3 ± 110.6 vs 209.8 ± 120.3u2009pg/ml, P = 0.016). By univariate analysis, log-transformed plasma IL-18 concentration was positively correlated with coronary artery disease severity score (r = 0.244, P = 0.009). By multiple regression analyses, the association between coronary artery disease severity score and IL-18 remained significant (β = 0.733, P = 0.017) when controlling for age, diabetes mellitus and left ventricular ejection fraction. Additionally, coronary artery disease severity score was greater in the highest tertile (>246u2009pg/ml) of plasma IL-18 levels than in the middle (176–246u2009pg/ml) and the lowest (<176u2009pg/ml) tertiles (2.79 ± 1.52 vs 2.05 ± 1.08 vs 2.13 ± 1.66, P = 0.028). Of note, plasma hs-CRP level had no significant correlation with coronary artery severity. Plasma IL-18 level is associated with the extent of coronary artery disease in unstable angina patients, suggesting the link between IL-18 and coronary artery atherosclerosis in these patients.

Level and value of circulating endothelial progenitor cells in patients with acute myocardial infarction undergoing primary coronary angioplasty: in vivo and in vitro studies

Levels of circulating endothelial progenitor cells (EPCs) in acute ST-elevation myocardial infarction (STEMI) patients undergoing primary coronary intervention (PCI) were investigated in this study. Flow cytometric analysis of the circulating EPC level (CD31/CD34 [E(1)], CD62E/CD34 [E(2)], and KDR/CD34 [E(3)]) was determined from blood samples of 161 consecutive patients with STEMI undergoing primary PCI. Angiogenesis was evaluated using mononuclear cell-derived EPCs on Matrigel. The EPC number (E(1-3)) was lower in STEMI patients than in normal subjects (n = 25) (P < 0.005). Patients with high EPCs (E(1-3)) (≥1.2%) had a lower left ventricular ejection fraction, elevated white blood cell count and creatinine level, advanced Killip score (≥class 3), more advanced congestive heart failure (CHF) (≥class 3), and increased 30-day mortality than those with a low EPC (E(1-3)) level (<1.2%) (P < 0.0001). Angiogenesis was lower in patients with a high EPC level than those with a low EPC level and normal controls (P < 0.001). Both the advanced Killip score and the CHF were independent predictors of increased EPC levels (P < 0.05). Multivariate analysis identified a high EPC (E(3)) level to be the most important predictor of increased 30-day major adverse clinical outcome (MACO) (P < 0.0001). In conclusion, the circulating EPC level is a major independent predictor of 30-day MACO in patients with STEMI undergoing primary PCI.

Relationship of the percentage of circulating endothelial progenitor cell to the severity of coronary artery disease

Previous study demonstrated that the percentage of circulating endothelial progenitor cells was reduced in patients with coronary artery disease. However, the relationship of the percentage of circulating endothelial progenitor cells to the severity of coronary artery disease has not been investigated. The percentages of circulating endothelial progenitor cells were measured in 78 consecutive patients with unstable angina, as well as in 32 healthy volunteers. Dual-stained cells expressing CD34 and vascular endothelial growth factor receptor-2 were judged to be endothelial progenitor cells and were analyzed using flow cytometry. On stepwise multiple linear regression analysis, the percentages of circulating endothelial progenitor cells were independently decreased in patients with unstable coronary artery disease compared with those in the healthy volunteers (P < 0.05). Among patients with unstable coronary artery disease, the percentage of patients with at least one occluded vessel was significantly higher in patients with multi-vessel disease than in patients with single-vessel disease (P < 0.04). On stepwise multiple linear regression analysis, the percentages of circulating endothelial progenitor cells were independently decreased in patients with multi-vessel coronary artery disease compared with those in patients with single-vessel coronary artery disease (P < 0.03). Among patients with unstable coronary artery disease, the percentage of circulating endothelial progenitor cells was significantly related to the severity of coronary artery disease.

Increased serum oxidative stress in patients with severe mitral regurgitation: A new finding and potential mechanism for atrial enlargement

OBJECTIVEnThe aim of this study was to examine the serum oxidative stress in patients with severe mitral regurgitation.nnnDESIGN AND METHODSnThis study analyzed serum oxidative stress index in patients with severe mitral regurgitation [persistent atrial fibrillation (AF) or sinus rhythm], paroxysmal lone AF patients and healthy subjects.nnnRESULTSnThe serum oxidative stress index was significantly higher in the mitral regurgitation AF group and sinus group than in the lone AF group and healthy subjects (p<0.0001). Left atrial size was significantly larger in the mitral regurgitation AF group and sinus group than in the lone AF group and healthy subjects (p<0.0001). The oxidative stress index significantly and positively correlated with left atrial size in the overall study population (r=0.439, p=0.0008).nnnCONCLUSIONSnThis study provides new evidence of increased oxidative stress in human severe mitral regurgitation, probably contributing to atrial enlargement.