The clinical significance of osteopontin on the cardiovascular outcomes in patients with stable coronary artery disease.

BACKGROUND: Osteopontin (OPN) is a noncollagenous matricellular protein which is mainly present in bone matrix. A high OPN level has been associated with heart failure and acute coronary syndrome, however data on patients with chronic coronary syndrome (CCS) are lacking. The present study aimed to evaluate the association between OPN and the prognosis of Taiwanese patients with CCS. METHODS: We enrolled participants from the Biosignature Registry, a nationwide prospective cohort study conducted at nine different medical centers throughout Taiwan. The inclusion criteria were participants who had received successful percutaneous coronary intervention at least once previously, and stable under medical therapy for at least 1 month before enrollment. They were followed for at least 72 months. Logistic regression and Cox proportional hazard model were used to investigate the association between OPN and clinical outcomes. The outcomes of this study were the first occurrence of hard cardiovascular events and composite cardiovascular outcomes including cardiovascular mortality, revascularization, hospitalization for acute myocardial infarction (AMI) or heart failure. RESULTS: A total of 666 patients with both hs-CRP and osteopontin measurements were enrolled and followed for 72 months. OPN was correlated positively with AMI-related hospitalization, where the highest tertile (Tertile 3) of baseline OPN had the highest risk of AMI-related hospitalization, which remained significant after multivariate adjustments (HR 3.20, p = 0.017). In contrast, combining OPN and hs-CRP did not improve the prediction of CV outcomes. CONCLUSION: OPN may be a potentially valuable biomarker in predicting CV outcomes. During 6 years of follow-up period, an OPN level >4810 pg/ml was associated with a significantly higher incidence of AMI-related hospitalization in CCS patients who received successful PCI before the enrollment.

Intraoperative Measurement of Fractional Flow Reserve in Off-Pump Coronary Artery Bypass: A Pilot Study.

BACKGROUNDS: Fractional flow reserve of myocardium (FFRmyo) is a functional study of significant coronary artery stenosis, defined as the ratio of the pressure distal to the stenosis (poststenosis) divided by the pressure of aortic root (prestenosis). Instead of cath laboratory, we could measure it in operating room for off-pump coronary artery bypass (OPCAB) surgery and here shared our methods in the pilot study. METHODS AND RESULTS: We used needles, catheters, and pressure tracing but without guidewires or fluoroscopy to measure FFRmyo during OPCAB. In February 2010, we conducted the pilot study and collected 32 anastomosis data from 10 patients. Without revising the anastomosis plans based on coronary angiographies, 24 FFRmyo of the 32 anastomoses (75%) were less than 0.75, which represented significant functional stenosis. The FFRmyo measurements did not lead to any adverse events. CONCLUSION: The measurement of fractional flow reserve in OPCAB is safe and feasible. It can serve as a functional assessment of coronary artery stenosis in adjuvant to conventional coronary angiography.

Detection of asymptomatic paroxysmal atrial fibrillation with the trans-telephonic electrocardiograph system.

Paroxysmal atrial fibrillation (PAF) carries an equally high annual stroke rate as chronic atrial fibrillation (AF). Furthermore, the frequency and duration of PAF are thought to be associated with stroke risk. In this pilot study, a trans-telephonic electrocardiograph (TTE) monitoring system was used to detect asymptomatic PAF and to study the relationship between ischemic stroke and the frequency of PAF. Between December 2004 and April 2006, 70 patients enrolled in the TTE monitoring program. Patients either transmitted electrocardiograms (ECGs) daily or upon experiencing cardiac symptoms. Of the 70 patients included, 25 were diagnosed with PAF. In total, 11% (855/7,768) of the recordings were diagnosed as PAF, yet less than 2% of total calls collected and less than 17% of all the calls with PAF were associated with obvious symptoms. Four patients developed five ischemic strokes resulting in a calculated annual stroke rate of 0.56%. Patients with stroke had more episodes of AF (56.5±106.3 versus 6.7±85.9, p=0.685) and symptomatic AF episodes (9.8±17.5 versus 4.9±8.1, p=0.381) than the patients who did not have a stroke, but the differences were not statistically significant because of the low numbers of patients and episodes. Most PAF episodes were asymptomatic, and the TTE system could easily detect these episodes. Furthermore, these four patients tended to have more episodes of PAF and more symptomatic attacks of PAF than patients who did not have a stroke.

Recurrent cervical carcinoma presenting as a primary aortoduodenal fistula.

Aortoduodenal fistula is a rare cause of gastrointestinal (GI) bleeding, and carries high morbidity and mortality even in modern practice. Cervical carcinoma is a major health threat among adult women, and its recurrence is not uncommon. We herein present a case of primary aortoduodenal fistula because of recurrent cervical carcinoma. Our case demonstrated that diagnosis of primary aortoenteric fistula requires a high index of suspicion and a combination of diagnostic modalities to establish the diagnosis. Prompt diagnosis and rapid treatment are critical in reducing mortality and morbidity. Although rare, metastatic carcinoma can lead to aortoenteric fistula.

Dimethylthiourea normalizes velocity-dependent, but not force-dependent, index of ventricular performance in diabetic rats: role of myosin heavy chain isozyme.

Hydroxyl radicals and hydrogen peroxide are involved in the pathogenesis of systolic dysfunction in diabetic rats, but the precise mechanisms and the effect of antioxidant therapy in diabetic subjects have not been elucidated. We aimed to evaluate the effects of dimethylthiourea (DMTU), a potent hydroxyl radical scavenger, on both force-dependent and velocity-dependent indexes of cardiac contractility in streptozotocin (STZ)-induced early and chronic diabetic rats. Seventy-two hours and 8 wk after STZ (55 mg/kg) injection, diabetic rats were randomized to either DMTU (50 mg x kg(-1) x day(-1) ip) or vehicle treatment for 6 and 12 wk, respectively. All rats were then subjected to invasive hemodynamic studies. Maximal systolic elastance (E(max)) and maximum theoretical flow (Q(max)) were assessed by curve-fitting techniques in terms of the elastance-resistance model. Both normalized E(max) (E(maxn)) and afterload-adjusted Q(max) (Q(maxad)) were depressed in diabetic rats, concomitant with altered myosin heavy chain (MHC) isoform composition and its upstream regulators, such as myocyte enhancer factor-2 (MEF-2) and heart autonomic nervous system and neural crest derivatives (HAND). In chronic diabetic rats, DMTU markedly attenuated the impairment in Q(maxad) and normalized the expression of MEF-2 and eHAND and MHC isoform composition but exerted an insignificant benefit on E(maxn). Regarding preventive treatment, DMTU significantly ameliorated both E(maxn) and Q(maxad) in early diabetic rats. In conclusion, our study shows that DMTU has disparate effects on Q(maxad) and E(maxn) in chronic diabetic rats. The advantage of DMTU in chronic diabetic rats might involve normalization of MEF-2 and eHAND, as well as reversal of MHC isoform switch.

CT of two hearts beating in one chest.

OBJECTIVE: Because of the improvements in cardiac transplantation technology, pharmacology, and diagnostic imaging, the survival rate of patients who have undergone heterotopic heart transplantation has significantly increased, which makes postoperative evaluation of these patients increasingly important. Monitoring patients who have undergone heterotopic heart transplantation is technically more demanding than those who have undergone orthotopic heart transplantation because it is more difficult to monitor two hearts beating in one chest. In this article, we describe and evaluate cardiac and vascular anatomy and the status of the lungs in patients who have undergone heterotopic heart transplantation. CONCLUSION: ECG-gated cardiac CT has proven to be particularly important in evaluating the complex anatomy and anastomoses of the donor and recipient hearts as well as the postoperative follow-up status of the two hearts, the cardiac arteries and great vessels, and the lungs, ultimately contributing to the prolonged survival of heterotopic heart transplantation patients.

Heart transplantation in patients with liver cirrhosis.

OBJECTIVE: Liver cirrhosis is considered to be a contraindication to heart transplantation. However, the clinical outcome of heart transplantation in patients with liver cirrhosis has not been reported. Here, we sought to evaluate the clinical outcome of heart transplantation in cirrhotic patients. METHODS: Data were collected by retrospective chart review. Patients with liver cirrhosis at the time of transplantation were included. RESULTS: Between 1987 and 2007, 12 patients with liver cirrhosis underwent heart transplantation at the authors' hospital. Diagnosis of liver cirrhosis was based on preoperative abdominal sonography in five, autopsy in five, and laparotomy in two patients. Causes of heart failure were dilated cardiomyopathy in four, coronary artery disease in three, congenital heart disease in three and valvular heart disease in two patients. Causes of liver cirrhosis were alcoholism in two, cardiac in seven, and unknown in three patients. The Child classification was class A in three, class B in five and class C in four patients. Overall, the hospital mortality rate was 50% and major in-hospital complications occurred in nine patients (75%). Patients with non-cardiomyopathy diagnosis, previous sternotomy, and massive ascites had a high hospital mortality rate. The median follow-up duration was 33.5 months. There was no late death. Late post-transplant complications occurred in four patients and there was no event of liver dysfunction. All survivors were in Child class A at outpatient follow-up. CONCLUSIONS: Although there was high mortality and morbidity, patients with end-stage heart failure and liver cirrhosis can be considered for heart transplantation with careful case selection.

Total laparoscopic repair for abdominal aortic aneurysm.

Surgical resection and grafting have long been the standard treatment for abdominal aortic aneurysm and provide an excellent long-term outcome. However, there is tremendous impact on patients due to the surgical invasiveness. Endovascular aortic repair using stent graft was introduced in 1991. After refinement of the techniques and technology, endovascular aortic repair was approved by most health authorities and is associated with less periprocedural morbidities. In between these two extremes, some surgeons endeavored to create an alternative and perform less invasive surgeries. Hand-assisted laparoscopic aortic surgery and laparoscopic-assisted aortic surgery were introduced in 1996. In 2001, total laparoscopic abdominal aortic aneurysm resection with tube graft interposition was first performed in Canada. Till now, only a few vascular units in North America and Europe perform these delicate techniques. We report our first case of total laparoscopic abdominal aortic aneurysm repair. Laparoscopic aortic surgery provides better visualization of the aneurysm neck, less bowel manipulation and avoidance of hypothermia. The minimal invasiveness could translate to better perioperative outcome. To our knowledge, this is also the first case report in Asia. The detailed techniques are described.

Incidence, risk factors, and prognosis of postoperative hyperbilirubinemia after heart transplantation.

OBJECTIVE: The clinical significance of postoperative hyperbilirubinemia after heart transplantation has not been reported. Here, we sought to evaluate the incidence, risk factors, and prognosis of postoperative hyperbilirubinemia after heart transplantation. METHODS: Between 1987 and 2005, 256 consecutive patients undergoing heart transplantation were studied prospectively. Postoperative hyperbilirubinemia was defined as occurrence of a serum total bilirubin concentration of more than 3mg/dl in any measurement during the postoperative period. Logistic regression was done to identify possible risk factors for postoperative hyperbilirubinemia and hospital mortality. RESULTS: Overall incidence of postoperative hyperbilirubinemia was 57%. Among all patients, there were 35 hospital deaths (14%). In patients with postoperative hyperbilirubinemia, the mean onset time was 2.4+/-4.4 days after transplantation and the mean peak serum total bilirubin was 10.1+/-10.4 mg/dl. Development of postoperative hyperbilirubinemia was associated with a higher mortality (21% vs 5%, P<0.001 by Fisher's exact test). The onset time of postoperative hyperbilirubinemia, the peak serum total bilirubin level, and the time at which the peak bilirubin level was reached were associated with hospital mortality. Old donor age, valvular heart disease, high right atrial pressure, use of mechanical ventilation before transplant, and ascites at transplant were the significant risk factors for postoperative hyperbilirubinemia. CONCLUSIONS: Postoperative hyperbilirubinemia is common in patients undergoing heart transplantation and is associated with high hospital mortality. Patients with valvular heart disease, high preoperative right atrial pressure, and ascites at transplant, who then receive an old donor heart, are at greater risk for development of postoperative hyperbilirubinemia.

Clinical features and outcome of tuberculosis in solid organ transplant recipients.

BACKGROUND: : Taiwan is an area with moderate to high incidence of Mycobacterium tuberculosis infection. The risk of M tuberculosis infection in transplantation recipients is considered to be significant. Our aim in this study was to investigate the clinical spectrums of M tuberculosis-infected transplantation recipients in a southeast Asian country, Taiwan. METHODS: : We retrospectively analyzed the demographic data, clinical features, treatment, and outcome of M tuberculosis infection in kidney, heart, and liver transplant recipients from May 1996 to April 2005 at the National Taiwan University Hospital. RESULTS: : Fifteen patients who had received solid organ transplantation developed tuberculosis (kidney = 6, heart = 7, liver = 2). The median duration from transplantation to diagnosis of tuberculosis was 31 months. The cumulative incidence of post-transplantation tuberculosis was 2.0% (15/760), ie, approximately 3 times that of the general population. Ten patients (66.7%) had pulmonary tuberculosis, 1 (6.7%) had extrapulmonary tuberculosis, and 4 (26.7%) had disseminated tuberculosis. Nine patients completed the anti-tuberculosis treatment; the median treatment duration was 12 months (pulmonary: 9 months; extrapulmonary: 13.5 months). No treatment failure was noted in patients receiving the complete treatment course. The graft failure and mortality rates of post-transplantation tuberculosis were 13.3% each (2/15). The tuberculosis-associated mortality rate was 6.7% (1/15). CONCLUSIONS: : Cumulative incidence of tuberculosis was slightly higher in transplant recipients than in the general population in Taiwan. Conventional 4-combined anti-tuberculosis regimen for 12 months can treat the potentially fatal infection successfully in post-transplantation tuberculosis patients without recurrence.

Carvedilol can restore the multifractal properties of heart beat dynamics in patients with advanced congestive heart failure.

INTRODUCTION: Human heart beats in an extremely inhomogeneous and non-stationary manner. Recent study has demonstrated that it belongs to a class of signals called multifractal. Loss of multifractality was also uncovered in patients with congestive heart failure. We investigated whether carvedilol could restore the multifractal properties in a group of patients with advanced congestive heart failure. METHODS AND RESULTS: A Holter ECG recording was obtained before and 1 and 3 months after titrated addition of carvedilol therapy in 10 patients with advanced congestive heart failure. Multifractal spectrum, detrended fluctuation analysis (DFA) as well as the traditional time- and frequency-domain heart rate variability (HRV) parameters were compared before and after carvedilol therapy together with those in age and sex-matched normal control. The results showed that the multifractal spectrum tau(q) vs. q of N-N interval time series returned toward normal during carvedilol treatment. All the traditional HRV parameters and the short-term DFA improved significantly after 3 months of carvedilol therapy. CONCLUSION: We concluded that the deteriorated multifractal properties could be reversed by carvedilol treatment in patients with advanced congestive heart failure.

Spiral saphenous vein graft for portal vein reconstruction in pancreatic cancer surgery.

The curative strategy for most pancreatic cancer is surgical resection. Extensive resection with lymph node dissection is the key to providing long-term survival. However, early diagnosis of pancreatic cancer is not always possible (ie, resectability is limited). One reason for such a nonresectable condition is vascular invasion or encasement. Portal vein involvement has been a contraindication for pancreatic cancer surgery for most general surgeons. Combining oncologic and vascular surgeons in the procedure has been a good solution. A multidisciplinary approach that includes general and vascular surgeons is appropriate in selected patients requiring vascular reconstruction at the time of pancreatectomy. The objective of this paper is to report a case in which spiral saphenous vein was used for portal vein reconstruction during pancreatic cancer resection.

The thicker the skin fold, the less hematoma development: a novel parameter other than body mass index associated with transradial vascular complication.

It was reported recently that body mass index (BMI) is a prognostic factor of vascular complications after radial puncture, and that extremely thin patients are at higher risk than obese subjects. However, the underlining mechanism of this phenomenon has rarely been studied. Therefore, we conducted a survey measuring a novel parameter, the skin fold thickness, and other potential risk factors in our patients developing postprocedure hematoma. In 1176 consecutive patients undergoing percutaneous radial catheterization, 18 (1.53%) developed hematoma afterward. When a patient with hematoma had been identified, the next patient having no hematoma after radial puncture was enrolled into the control group, which thus turned out to have 18 patients. In addition, we also compared the BMI, skin fold thickness, and other potential risk factors, including heparin dosage and antiplatelet medication, between these 2 groups. We found hematoma patients to be older (69.5 +/- 10.3 years vs 61.50 +/- 11.7 years, P = .037), to have more cases of coronary intervention (10/18 vs 4/18, P = .04), to have lower BMI (23.63 +/- 4.03 vs 27.25 +/- 4.38, P = .014), and to have thinner skin folds of forearm (5.94 +/- 4.56 vs 9.27 +/- 3.06 mm, P = .015), deltoid area (14.61 +/- 9.00 vs 19.73 +/- 7.15 mm, P = .042), and waist (21.94 +/- 9.90 vs 29.00 +/- 8.46 mm, P = .028) than the nonhematoma group. On the contrary, no statistical difference in heparin dosage or other factors was noted between the 2 groups. We conclude that the vascular complication rate after radial catheterization is higher in elderly patients with lower BMI, body weight, or thinner skin folds.

Two donor hearts beat in one chest.

We present the case of a 52-year-old man who had end-stage dilated cardiomyopathy (left ventricular ejection fraction, 0.14) and type-A blood. He underwent orthotopic transplantation with a heart from a blood-type-A male donor on 18 January 2001. After transplantation, the patient could not be weaned from cardiopulmonary bypass. Due to calcification of the left main and right coronary arteries, we performed triple coronary artery bypass (left anterior descending, circumflex, and right coronary arteries) with the recipient's saphenous vein. Despite high doses of inotropic agents and intra-aortic balloon pumping, the patient could not be weaned from cardiopulmonary bypass; he was put on extracorporeal membrane oxygenation 2 hours later. Meanwhile, there was another donor (a woman with type-O blood), who weighed 48 kg. Upon harvesting that heart for a recipient who weighed 68 kg, we found a laceration of the right ventricle. Therefore, we decided to use this marginal donor heart to rescue the graft-failure transplant by means of heterotopic heart transplantation. We left the 1st donor heart in situ. The postoperative series of endomyocardial biopsies showed variations between the 2 donor hearts in degrees of mild-to-moderate rejection. During the 6-year, 2-month follow-up period, the patient has fared well with 2 donor hearts, which beat independently but in conjunction. We conclude that heterotopic transplantation of a marginal donor heart can save an otherwise-dying orthotopic transplant recipient.

Surgical resection of primary cardiac lymphoma.

Primary cardiac lymphoma is a rare cardiac malignancy. Surgical resection is rarely performed on this disease entity. We report a case of primary cardiac lymphoma with rapid progression. Debulking surgery was done extensively before final pathology was obtained. Complete remission was exhibited after several courses of chemotherapy.

Extracorporeal membrane oxygenation for perioperative cardiac allograft failure.

The utility of mechanical support in pretransplant stabilization and postcardiotomy shock is well established, but its use in perioperative cardiac allograft failure (PCAGF) rescue has not been well documented. Ventricular assist devices (VADs) have been applied to PCAGF rescue with acceptable results. However, studies have not described the results of using extracorporeal membrane oxygenation (ECMO) in PCAGF. We evaluated the outcome of PCAGF rescue with ECMO. A retrospective review of 204 consecutive heart transplants revealed 19 cases of PCAGF requiring ECMO rescue. Donor-, surgery- and ECMO-related variables were evaluated for association with operative mortality, success of weaning, and survival rate. Transplant recipients included 14 males and 5 females with median age of 44.2 years. Weaning rate was 84.2% and survival rate was 52.6%, with duration of ECMO support 157 +/- 129 hours. Long ischemic time is a PCAGF risk factor (206.8 +/- 96.1 minutes vs. 158.3 +/- 60.8 minutes in non-PCAGF, p < 0.05). PCAGF etiology included primary graft failure (n = 7); right heart failure secondary to pulmonary hypertension, coagulopathy/intraoperative hemorrhage (n = 7); and sepsis (n = 2). Compared with data from VAD-supported PCAGF, ECMO had a better weaning and graft survival rates (p < 0.05). ECMO is another choice for PCAGF rescue. It has an acceptable survival rate and may be considered instead of VADs as a first-line rescue for PCAGF.

Less invasive mitral valve surgery via right minithoracotomy.

BACKGROUND/PURPOSE: Current trends in cardiac surgical intervention are moving toward less invasiveness, with smaller wound or sternum-sparing, less pump time or off-pump, and beating rather than arrested heart. Data on the efficacy and safety of these newer less invasive techniques, as well as their cosmetic results, are limited. This study analyzed the results of a sternum-sparing mitral valve operation. METHODS: Thirty patients with mitral valve diseases, including 20 who underwent mitral valve repair and 10 mitral valve replacement, were enrolled. Cardiopulmonary bypass was established via femoral cannulation, and blood cardioplegic arrest was induced by using a percutaneous, transthoracic cross-clamp. The main surgical wound was made over the lateral border of the right breast. Two additional small wounds were required for the transthoracic aortic clamp and the mitral retractor. RESULTS: There was no operative mortality, and all patients had an uneventful recovery. Two patients underwent redo mitral surgery. Nine associated procedures were performed including tricuspid valve annuloplasty in six patients, tricuspid valve replacement in two patients and atrial septal defect repair in one patient. The length of the main wound was between 5.8 and 7.8 cm (mean, 7.1 cm). The mean cardiopulmonary bypass time and cross-clamp time were 91.1 and 43.7 minutes, respectively. Although the length of stay was not significantly reduced compared with traditional median sternotomy, all patients had satisfactory results with good cosmesis. CONCLUSION: Sternum-sparing mitral valve surgery appears to be a safe and effective alternative to conventional mitral valve surgery; it is less invasive and provides superior cosmetic results for patients.

Endoscopic radial artery harvest for coronary artery bypass surgery.

BACKGROUND/PURPOSE: Coronary artery bypass grafting (CABG) provides better long-term patency than percutaneous intervention in patients with significant coronary artery disease. The radial artery is the second most common arterial conduit used for CABG in Western countries. However, radial artery harvesting necessitates a large surgical wound and has gained few patients' acceptance in subtropical areas. This study investigated the use of the minimally invasive approach of endoscopic radial artery harvest for CABG, and the surgical results at the harvest site. METHODS: An endoscopic harvest program for radial arteries was implemented in this hospital in September 2003. During the first 12 months of the program until September 2004, 122 patients underwent the procedure. Preoperative evaluation included Allen's test and the modified palmar arch perfusion test. The age of patients ranged from 32 to 88 years old. Patients were excluded from participation if they had undergone recent transradial catheterization, had end-stage renal disease or documented peripheral artery occlusive disease. The VasoView system was utilized for the procedure. Details of the surgical techniques used were recorded and analyzed. RESULTS: Using the endoscopic technique, 122 radial arteries were harvested successfully. The mean resting length of the harvested radial artery was 15.7 cm. No obvious arterial injury was visually confirmed. All radial arteries were used for CABG, except for two which were noted to have atherosclerotic plaques causing stenoses. Forty-seven patients presented with mild numbness over the dorsum of the thumb base, which improved significantly during the 3-month follow-up. No arterial insufficiency in the forearms or hands was noted. CONCLUSION: Endoscopic harvest of the radial artery is technically demanding, but excellent results can be achieved. The endoscopic approach can provide suitable conduits in a less invasive way than the open harvest technique.

Influence of ciprofloxacin resistance on risk factors for endovascular infection in patients with infection due to group C nontyphoid salmonellae.

From January 2000 through September 2004, a total of 54 patients with infection due to group C nontyphoid salmonellae were evaluated; 8 patients had gastroenteritis alone, and 46 patients had bacteremia. Of the 46 patients who had bacteremia, 12 had endovascular infection and 34 did not. The number of infections due to ciprofloxacin-resistant Salmonella organisms is increasing. Ciprofloxacin-resistant Salmonella organisms predisposed patients to acquire bacteremia, but they did not seem to predispose patients to acquire endovascular infection.