Effects of mitral valve disease etiology on the outcomes of mechanical and biological valve replacement: retrospective cohort study.

INTRODUCTION: The choice of an artificial mitral valve (MV) is a crucial clinical decision that affects the long-term survival and quality of life of patients. However, current guidelines recommend selecting MV based on patient age and life expectancy at the time of mitral valve replacement (MVR), without considering the etiology of MV disease. This study aimed to investigate whether MV disease etiology should be considered when choosing a valve for MVR and to evaluate the impact of MV disease etiology on long-term patient survival. METHODS: Using data (2002-2018) from Taiwan's National Health Insurance Research Database, the authors conducted a nationwide retrospective cohort study to compare the biological and mechanical valves in terms of all-cause mortality as the primary outcome. The inverse probability of the treatment weighting method was used to reduce the effects of the confounding factors. The following etiologies were assessed: infective endocarditis, rheumatic heart disease, ischemic mitral regurgitation, and degenerative mitral regurgitation. RESULTS: In patients aged below 70 years, it was observed that mechanical valves demonstrated an association with benefits compared to biological valves in the context of survival. In patients with infective endocarditis aged below 72 years, mechanical valves were associated with survival benefits, but not in those with stroke during hospitalization. These valves were also found to be linked with survival advantages for patients with rheumatic heart disease aged below 60 years and for those with degenerative mitral regurgitation aged below 72 years. However, no age-dependent effects of valve type on all-cause mortality were observed in patients with ischemic mitral regurgitation. CONCLUSION: The etiology of MV disease appears to be important in the selection of a suitable MV and determination of a cutoff age for mechanical and biological MVR.

Early Surgery for Infective Endocarditis Complicated With Neurologic Injury.

OBJECTIVES: To estimate the association between early surgery and the risk of mortality in patients with left-sided infective endocarditis in the context of stroke. DESIGN: Retrospective cohort study. SETTING: This study was a multiinstitution study based on the Chang Gung Research Database, which contains electronic medical records from 7 hospitals in northern and southern Taiwan; these include 2 medical centers, 2 regional hospitals, and 3 district hospitals. PARTICIPANTS: Patients with active left-sided infective endocarditis who underwent valve surgery between September 2002 and December 2018. INTERVENTIONS: The authors divided patients into 2 groups, with versus without preoperative neurologic complications, had undergone early (within 7 d) or later surgery, and with brain ischemia or hemorrhage. MEASUREMENTS AND MAIN RESULTS: Three hundred ninety-two patients with a median time from diagnosis to surgery of 6 days were included. No significant differences in postoperative stroke, in-hospital mortality, or follow-up outcomes were observed between the patients with and without neurologic complications. Among the patients with preoperative neurologic complications, patients who underwent early surgery had a lower 30-day postoperative mortality rate (13.1% v 25.8%; hazard ratio, 0.21; 95% CI 0.07-0.67). In the subgroup analysis of the comparison between brain ischemia and hemorrhage groups, there was no significant between-group difference in the in-hospital outcomes or outcomes after discharge. CONCLUSIONS: Early cardiac surgery may be associated with more favorable clinical outcomes in patients with preoperative neurologic complications. Thus, preoperative neurologic complications should not delay surgical interventions.

Sex Differences in Epidemiological Distribution and Outcomes of Surgical Mitral Valve Disease.

BACKGROUND: Mitral valve (MV) disease is the most common form of valvular heart disease. Findings that indicate women have a higher risk for unfavorable outcomes than men remain controversial. This study aimed to determine the sex-based differences in epidemiological distributions and outcomes of surgery for MV disease. METHODS AND RESULTS: Overall, 18,572 patients (45.3% women) who underwent MV surgery between 2001 and 2018 were included. Outcomes included in-hospital death and all-cause mortality during follow up. Subgroup analysis was conducted across different etiologies, including infective endocarditis (IE), degenerative, ischemic, and rheumatic mitral pathology. The overall MV repair rate was lower in women than in men (20.5% vs. 30.6%). After matching, 6,362 pairs (woman : man=1 : 1) of patients were analyzed. Women had a slightly higher risk for in-hospital death than men (10.8% vs. 9.8%; odds ratio [OR]: 1.11, 95% confidence interval [CI]: 0.99-1.24; P=0.075). Women tended to have a higher incidence of de novo dialysis (9.8% vs. 8.6%; P=0.022) and longer intensive care unit stay (8 days vs. 7.1 days; P<0.001). Women with IE had poorer in-hospital outcomes than men; however, there were no sex differences in terms of all-cause mortality. CONCLUSIONS: Sex-based differences of MV intervention still persist. Although long-term outcomes were comparable between sexes, women, especially those with IE, had worse perioperative outcomes than men.

Mechanical Versus Bioprosthetic Aortic Valve Replacement in Patients Undergoing Bentall Procedure.

BACKGROUND: The widely used Bentall procedure is the criterion standard treatment for aortic root pathology. Studies comparing the long-term outcomes of bioprosthetic and mechanical valves in patients undergoing the Bentall procedure are limited. METHODS AND RESULTS: Patients who underwent the Bentall procedure with a bioprosthetic or mechanical valve between 2001 and 2018 were identified from Taiwan's National Health Insurance Research Database. The primary outcome of interest was all-cause mortality. Inverse probability of treatment weighting was performed to compare the 2 prosthetic types. In total, 1052 patients who underwent the Bentall procedure were identified. Among these patients, 351 (33.4%) and 701 (66.6%) chose bioprosthetic and mechanical valves, respectively. After inverse probability of treatment weighting, no significant differences in the in-hospital mortality (odds ratio, 0.96 [95% CI, 0.77-1.19]; P=0.716) and all-cause mortality (34.1% vs. 38.1%; hazard ratio, 0.90 [95% CI, 0.78-1.04]; P=0.154) were observed between the groups. The benefits of relative mortality associated with mechanical valves were apparent in younger patients and persisted until ≈50 years of age. CONCLUSIONS: No differences in survival benefits were observed between the valves in patients who underwent the Bentall procedure. Additionally, bioprosthetic valves may be a reasonable choice for patients aged >50 years when receiving the Bentall procedure in this valve-in-valve era.

Durability of Biological Valves Implanted in Aortic or Mitral Positions: A Nationwide Cohort Study.

BACKGROUND: Biologic prostheses are being increasingly used for aortic and mitral valve replacement (AVR and MVR). This study evaluated the long-term durability of bioprosthetic valves in the mitral and aortic positions, as no well-designed population-based studies have addressed this issue before. METHODS: Using Taiwan's National Health Insurance Research Database, we compared biologic valve durability in the mitral and aortic positions in patients hospitalized between 2001 and 2017, with reoperation as the primary outcome. Both between-subject and within-subject designs were used, and the propensity score matching cohort (1:1 ratio) was created for the former. RESULTS: We identified a total of 10,308 patients, 5462 of whom received AVR, 3901 received MVR, and 945 received double valve replacement. Both AVR and MVR cohorts had 2259 patients after matching. During a mean follow-up of 4.2 years (range, 1 day to 17.9 years), the reoperation rate in the MVR cohort (3.5%) was higher than that in the AVR cohort (2.6%) (hazard ratio 1.41; 95% CI, 1.01-1.98). A higher risk of all-cause death was observed in the MVR cohort (36.5%) than in the AVR cohort (32.6%) (hazard ratio 1.21; 95% CI, 1.10-1.34). Among patients receiving double valve replacement with the same prosthesis type, valves implanted in the aortic position were considerably less likely to require reimplantation. CONCLUSIONS: Bioprosthetic valve placement in the aortic position is associated with superior outcomes in terms of durability, long-term mortality, and perioperative morbidity. Developing novel interventions and enhancing valve durability would expand bioprosthesis use for valve replacement.

Artificial intelligence-driven radiomics study in cancer: the role of feature engineering and modeling.

Modern medicine is reliant on various medical imaging technologies for non-invasively observing patients' anatomy. However, the interpretation of medical images can be highly subjective and dependent on the expertise of clinicians. Moreover, some potentially useful quantitative information in medical images, especially that which is not visible to the naked eye, is often ignored during clinical practice. In contrast, radiomics performs high-throughput feature extraction from medical images, which enables quantitative analysis of medical images and prediction of various clinical endpoints. Studies have reported that radiomics exhibits promising performance in diagnosis and predicting treatment responses and prognosis, demonstrating its potential to be a non-invasive auxiliary tool for personalized medicine. However, radiomics remains in a developmental phase as numerous technical challenges have yet to be solved, especially in feature engineering and statistical modeling. In this review, we introduce the current utility of radiomics by summarizing research on its application in the diagnosis, prognosis, and prediction of treatment responses in patients with cancer. We focus on machine learning approaches, for feature extraction and selection during feature engineering and for imbalanced datasets and multi-modality fusion during statistical modeling. Furthermore, we introduce the stability, reproducibility, and interpretability of features, and the generalizability and interpretability of models. Finally, we offer possible solutions to current challenges in radiomics research.

Learning curve for open surgical repair of acute type A aortic dissection.

There is scarce evidence about the surgeon learning curve of acute type A aortic dissection surgery and whether the optimal procedure number exists when training a cardiovascular surgeon. A total of 704 patients with acute type A aortic dissection surgery performed by 17 junior surgeons who can identify their first career surgery from January 1, 2005, to December 31, 2018, are included. The surgeon experience volume is defined as the cumulative number of acute type A aortic dissection surgery of the surgeon since January 1, 2005. The primary outcome was in-hospital mortality. The possibility of non-linearity and cutoffs for surgeon experience volume level was explored using a restricted cubic spline model. The results revealed that more surgeon experience volume is significantly correlated to a lower in-hospital mortality rate (r = - 0.58, P = 0.010). The RCS model shows for an operator who reaches 25 cumulative volumes of acute type A aortic dissection surgery, the average in-hospital mortality rate of the patients can be below 10%. Furthermore, the longer duration from the 1st to 25th operations of the surgeon is significantly correlated to a higher average in-hospital mortality rate of the patients (r = 0.61, p = 0.045). Acute type A aortic dissection surgery has a prominent learning curve in terms of improving clinical outcomes. The findings suggest fostering high-volume surgeons at high-volume hospitals can achieve optimal clinical outcomes.

Surgical volume and outcomes of surgical ablation for atrial fibrillation: a nationwide population-based cohort study.

BACKGROUND: Atrial fibrillation is the most common cardiac arrythmia and causes many complications. Sinus rhythm restoration could reduce late mortality of atrial fibrillation patients. The Maze procedure is the gold standard for surgical ablation of atrial fibrillation. Higher surgical volume has been documented with favorable outcomes of various cardiac procedures such as mitral valve surgery and aortic valve replacement. We aimed to determine the volume-outcome relationship (i.e., association between surgical volume and outcomes) for the concomitant Maze procedure during major cardiac surgeries. METHODS: This nationwide population-based cohort study retrieved data from the Taiwan National Health Insurance Research Database. Adult patients undergoing concomitant Maze procedures during 2010-2017 were identified; consequently, 2666 patients were classified into four subgroups based on hospital cumulative surgery volumes. In-hospital outcomes and late outcomes during follow-up were analyzed. Logistic regression and Cox proportional hazards model were used to analyze the volume-outcome relationship. RESULTS: Patients undergoing Maze procedures at lower-volume hospitals tended to be frailer and had higher comorbidity scores. Patients in the highest-volume hospitals had a lower risk of in-hospital mortality than those in the lowest-volume hospitals [adjusted odds ratio, 0.30; 95% confidence interval (CI), 0.15-0.61; P < 0.001]. Patients in the highest-volume hospitals had lower rates of late mortality than those in the lowest-volume hospitals, including all-cause mortality [adjusted hazard ratio (aHR) 0.53; 95% CI 0.40-0.68; P < 0.001] and all-cause mortality after discharge (aHR 0.60; 95% CI 0.44-0.80; P < 0.001). CONCLUSIONS: A positive hospital volume-outcome relationship for concomitant Maze procedures was demonstrated for in-hospital and late follow-up mortality. The consequence may be attributed to physician skill/experience, experienced multidisciplinary teams, and comprehensive care processes. We suggest referring patients with frailty or those requiring complicated cardiac surgeries to high-volume hospitals to improve clinical outcomes. TRIAL REGISTRATION: the institutional review board of Chang Gung Memorial Hospital approved all data usage and the study protocol (registration number: 202100151B0C502).

MicroRNA-Mediated Mitochondrial Dysfunction Is Involved in the Anti-triple-Negative Breast Cancer Cell Activity of Phytosesquiterpene Lactones.

Aims: Emerging evidence suggests that modulating redox homeostasis through targeting mitochondrial functions may be a useful strategy for suppressing triple-negative breast cancer (TNBC) activities. However, whether there are specific microRNAs (miRNAs) involved in regulating oxidative stress-associated mitochondrial functions that can act as therapeutic targets to suppress TNBC activities remains unclear. Here, we aimed to identify the role of redox-associated miRNAs in TNBC and investigated their potential as therapeutic targets. Results: We identified oxidative stress-responsive differentially expressed miRNAs (DEMs) regulated by phytosesquiterpene lactone deoxyelephantopin (DET) and its novel derivative DETD-35, which are known to inhibit TNBC growth and metastasis in vitro and in vivo, using comparative miRNA microarray analysis and reactive oxygen species (ROS) scavenging approaches. Mitochondrial dysfunction was identified as a major biological function regulated by a few specific DEMs. In particular, miR-4284 was identified to play a role in DET- and DETD-35-mediated ROS production, mitochondrial basal proton leak, and antiproliferation activity in TNBC cells. Moreover, DET- and DETD-35-induced mitochondrial DNA damage was observed in TNBC cells and xenograft tumors. miR-4284 was also identified to play a role in oxidative DNA damage in TNBC tumors. Innovation: We identified a novel role for miR-4284 in regulating mitochondrial basal proton leak in TNBC cells, and highlighted its significance in TNBC tumor oxidative DNA damage, and its direct correlation with TNBC patient survival. Conclusion: We used DET and DETD-35 as proof of concept to demonstrate that activities of anticancer agents can involve regulation of multiple miRNAs playing different roles in cancer progression. Antioxid. Redox Signal. 38, 198-214.

Long-term Outcomes of Concomitant Surgical Ablation for Atrial Fibrillation.

BACKGROUND: The long-term outcomes of surgical ablation for atrial fibrillation (AF) during cardiac surgery remain unclear. METHODS: This nationwide population-based retrospective cohort study used data from Taiwan's National Health Insurance Research Database. Overall, 11,459 patients undergoing coronary artery bypass graft, valve, or aortic surgery and diagnosed as having AF between January 1, 2001, and December 31, 2016, were included. To reduce possible selection bias, we created a propensity score-matched cohort and compared outcomes between groups. The outcomes of interest were long-term survival and late ischemic stroke. RESULTS: The surgical ablation group had a significantly lower risk of all-cause mortality (5.74 and 7.69 events per 100 patient-years, respectively; hazard ratio, 0.75; 95% CI, 0.69-0.81) and ischemic stroke after discharge (1.88 and 2.52 events per 100 patient-years, respectively; subdistribution hazard ratio, 0.78; 95% CI, 0.67-0.91). AF ablation performed concomitantly with coronary artery bypass graft surgery, tissue aortic valve replacement, tissue mitral valve replacement, or mitral valve repair led to significantly better long-term survival (P = .0176, P = .0001, P < .0001, P < .0001, respectively). The surgical ablation group also had better long-term survival than the matched general AF population (log-rank test, P < .001). CONCLUSIONS: Concomitant AF ablation during cardiac surgery is safe, does not increase the rate of perioperative complications, and confers the benefit of long-term survival after cardiac surgery in adults. AF ablation also improved cardiac surgery patients' long-term survival compared with the matched general AF population.

Infective endocarditis after surgical aortic or mitral valve replacement: A nationwide population-based study.

OBJECTIVE: Evidence regarding the incidence of prosthetic valve endocarditis and its association with the use of mechanical or biologic prosthetic valves is limited. METHODS: Patients who underwent aortic or mitral valve replacement in the years 2000 to 2017 were identified from Taiwan's National Health Insurance Research Database and grouped according to the type of prosthesis used (mechanical or biologic). Propensity score matching was performed to reduce confounding. RESULTS: A total of 22,844 patients were included, with 11,950 (52.2%) and 10,934 (47.8%) in the mechanical prosthesis and biologic prosthesis groups, respectively. After matching, each group contained 5441 patients. During follow-up, patients with a biologic prosthesis had a significantly higher risk of infective endocarditis (IE) than those with a mechanical valve (3.4% vs 1.9%; subdistribution hazard ratio, 1.78; 95% CI, 1.40-2.26). Moreover, biologic prostheses were associated with greater risks of all-cause mortality and redo valve surgery, but lesser risks of ischemic stroke, hemorrhagic stroke, major bleeding, and gastrointestinal bleeding. In subgroup analysis, biologic prostheses were consistently associated with a greater risk of IE in all subgroups, specifically single-valve replacement-aortic, single-valve replacement-mitral, double-valve replacement, active IE (IE diagnosed during index hospitalization), any IE (active or old), and not having a history of IE. CONCLUSIONS: In this nationwide population-based retrospective cohort study, biologic prosthesis use was associated with a greater risk of IE during follow-up compared with mechanical valve use. However, mechanical valve use was associated with a greater risk of ischemic stroke and hemorrhagic complications.

Bioprosthetic versus mechanical mitral valve replacements in patients with rheumatic heart disease.

BACKGROUND: Rheumatic heart disease (RHD) remains a critical problem in developed countries. Few studies have compared the long-term outcomes of bioprosthetic valves and mechanical valves in patients with RHD who have received mitral valve (MV) replacement. METHODS: Patients with RHD who received MV replacement with bioprosthetic or mechanical valves were identified between 2000 and 2013 from Taiwan's National Health Insurance Research Database. The primary late outcomes of interest were all-cause mortality and redo MV surgery. Propensity score matching at a 1:1 ratio was performed. RESULTS: We identified 3638 patients with RHD who underwent MV replacement. Among those patients, 1075 (29.5%) and 2563 (70.5%) chose a bioprosthetic valve and mechanical valve, respectively. After matching, 788 patients were assigned to each group. No significant difference in the risk of in-hospital mortality was observed between groups (P = .920). Higher risks of all-cause mortality (10-year actuarial estimates: 50.6% vs 45.5%; hazard ratio, 1.19; 95% confidence interval, 1.01-1.41; P = .040) and MV reoperation (10-year actuarial estimates: 8.9% vs 0.93%; subdistribution hazard ratio, 4.56; 95% confidence interval, 1.71-12.17; P <.01) were observed in the bioprosthetic valve group. Furthermore, the relative mortality benefit associated with mechanical valves was more apparent in younger patients and the beneficial effect persisted until approximately 65 years of age. CONCLUSIONS: In the patients with RHD who underwent MV replacement, mechanical valves were associated with more favorable long-term outcomes in patients younger than the age of 65 years.

Tracheostomy and venovenous extracorporeal membrane oxygenation for difficult airway patient with carinal melanoma: A case report and literature review.

BACKGROUND: Anesthesia for tracheal tumor resection is challenging, particularly in patients with a difficult upper airway. We report a case of a difficult upper airway with a metastatic tracheal tumor causing near-total left bronchial obstruction and requiring emergency tracheostomy and venovenous extracorporeal membrane oxygenation (VV-ECMO) support for rigid bronchoscopy-assisted tumor resection. CASE SUMMARY: A 41-year-old man with a history of right retromolar melanoma treated by tumor excision and myocutaneous flap reconstruction developed progressive dyspnea on exertion and syncope episodes. Chest computed tomography revealed a 3.0-cm tracheal mass at the carinal level, causing 90% tracheal lumen obstruction. Flexible bronchoscopy revealed a pigmented tracheal mass at the carinal level causing critical carinal obstruction. Because of aggravated symptoms, emergency rigid bronchoscopy for tumor resection and tracheal stenting were planned with standby VV-ECMO. Due to limited mouth opening, tracheostomy was necessary for rigid bronchoscopy access. While transferring the patient to the operating table, sudden desaturation occurred and awake fiberoptic nasotracheal intubation was performed for ventilation support. Femoral and internal jugular vein were catheterized to facilitate possible VV-ECMO deployment. During tracheostomy, progressive desaturation developed and VV-ECMO was instituted immediately. After tumor resection and tracheal stenting, VV-ECMO was weaned smoothly, and the patient was sent for intensive postoperative care. Two days later, he was transferred to the ward for palliative immunotherapy and subsequently discharged uneventfully. CONCLUSION: In a difficult airway patient with severe airway obstruction, emergency tracheostomy for rigid bronchoscopy access and standby VV-ECMO can be life-saving, and ECMO can be weaned smoothly after tumor excision. During anesthesia for patients with tracheal tumors causing critical airway obstruction, spontaneous ventilation should be maintained at least initially, and ECMO deployment should be prepared for high-risk patients, such as those with obstructive symptoms, obstructed tracheal lumen > 50%, or distal trachea location.

Analysis of Anticoagulation Therapy and Anticoagulation-Related Outcomes Among Asian Patients After Mechanical Valve Replacement.

Importance: Current international normalized ratio (INR) guidelines are based on trials involving European and US populations. To our knowledge, no adequate study involving Asian patients has been conducted to date. Objective: To evaluate the association between INR and anticoagulation-related outcomes in an Asian population after mechanical aortic valve replacement (AVR) or mitral VR (MVR). Design, Setting, and Participants: This retrospective cohort study was conducted between 2001 and 2018, with follow-up until December 31, 2018, among patients who underwent AVR, MVR, or combined AVR-MVR at 3 medical centers and 4 regional hospitals and contributed electronic medical records to the Chang Gung Research Database. Exclusion criteria were missing demographic characteristics, younger than 20 years, fewer than 2 INR records, and having died during the hospitalization of the index surgery. Main Outcomes and Measures: Bleeding and thromboembolic complications were analyzed. The possibility of nonlinearity and cutoff potential for the INR were explored using a logistic regression model, which considered the INR a restricted cubic spline (RCS) variable. Results: The study population consisted of 900 patients, with 525 (58.3%) men and 375 (41.7%) women and a mean (SD) age of 52.0 (12.5) years. Overall, 474 (52.7%) received AVR alone, 329 (36.6%) received MVR alone, and 97 (10.8%) received combined AVR-MVR. All patients had at least 2 INR examinations after discharge, providing 16 676 INR records for the AVR group and 18 207 for the MVR and combined AVR-MVR groups. In the AVR group, the RCS model showed that higher risks of composite thromboembolic events were associated with an INR of less than 2.0 or greater than 2.6 vs an INR of 2.0, and a higher risk of bleeding events was associated with an INR of less than 1.8 or greater than 2.4 vs an INR of 2.0. When treating the INR as a categorical variable, the risk of composite thromboembolic and composite bleeding events was significantly higher among patients with INRs less than 1.5 (adjusted odds ratio [aOR], 2.55; 95% CI, 1.37-4.73) and with INRs of 3.0 or greater (aOR, 3.48; 95% CI, 1.95-6.23) vs those with INRs between 2.0 and 2.5.In the MVR and combined AVR-MVR groups, higher risks of composite thromboembolic events were associated with an INR of less than 2.1 or greater than 2.7 vs an INR of 2.5, and a higher risk of bleeding events was associated with an INR of less than 2.1 or greater than 2.8 vs an INR of 2.5. When treating the INR as a categorical variable, the risk of a composite bleeding events was significantly higher among patients with INRs of 3.5 or greater (aOR, 2.25; 95% CI, 1.35-3.76) vs those with INRs between 2.5 and 3.0. Conclusions and Relevance: Among Asian patients in this study, the incidence of thromboembolic events in the MVR group with INRs in the range of 2.0 to 2.5 was not significantly higher than that among those with INRs in the range of 2.5 to 3.0; in the AVR group, the incidence for those with INRs in 1.5 to 2.0 range was not significantly higher than for those with INRs in the range of 2.0 to 2.5.

Sex-related differences on the risks of in-hospital and late outcomes after acute aortic dissection: A nationwide population-based cohort study.

OBJECTIVE: The aim of this study is to evaluate the sex-related differences on the risks of perioperative and late outcomes for adult acute aortic dissection (AAD) patients following surgical management. METHODS AND RESULTS: By using Taiwan National Health Insurance Research Database, totally 1,410 female and 3,432 male patients were identified to first-ever receive type A AAD open surgery or type B AAD stenting treatment from 2004 to 2013. We assessed the sex-related difference on outcomes, including in-hospital mortality, all-cause mortality, aortic death, redo aortic surgery, ischemic stroke, and depression during the follow-up period. The analysis was done separately for type A and type B surgeries. RESULTS: On average, female patients diagnosed with AAD were older than males. There was no significant sex difference of in-hospital mortality or all-cause mortality for both type A open and type B stent surgeries. The risk of redo aortic surgery was significantly greater in males than females (7.8% vs. 4%; unadjusted subdistribution hazard ratio [SHR] 0.51, 95% CI 0.38-0.69) for type A open surgery, but not for type B stent surgery. Noticeably, the risk of newly-diagnosed depression was significantly greater in females than males (8% vs. 5.1%; unadjusted SHR 1.6, 95% CI 1.24-2.06) for type A open surgery, but not for type B stent surgery. CONCLUSIONS: No significant sex-related difference was found for the in-hospital mortality or accumulative all-cause mortality. However, there were more redo aortic surgeries for males and more postoperative depression for females in type A AAD population.

Effects of dexmedetomidine on surgery for type A acute aortic dissection outcome.

No study has evaluated the effect of dexmedetomidine in patients who received surgery for type A aortic dissection. This is the first study to evaluate the effect of dexmedetomidine in aortic dissection patients. This study was executed using data from the Chang Gung Research Database in Taiwan. The CGRD contains the multi-institutional standardized electronic medical records from seven Chang Gung Memorial hospitals, the largest medical system in Taiwan. We retrospectively evaluate patients who received surgery for acute type A aortic dissection between January 2014 and December 2018. Overall, 511 patients were included, of whom 104 has received dexmedetomidine infusion in the postoperative period. One-to-two propensity score-matching yielded 86 cases in the dexmedetomidine group and 158 cases in the non-dexmedetomidine group. The in-hospital mortality and composite outcome including all-cause mortality, acute kidney injury, delirium, postoperative atrial fibrillation, and respiratory failure, were considered primary outcomes. The in-hospital mortality and composite outcome were similar between groups. The risk of Acute Kidney Injury Network stage 3 acute kidney injury was significantly lower in the dexmedetomidine group than in the non-dexmedetomidine group (8.1% vs 19.0%; OR, 0.38; 95% CI, 0.17-0.86; p = 0.020. The risk of newly-onset dialysis was also significantly lower in the dexmedetomidine group than in the non-dexmedetomidine group (4.7% vs 13.3%; OR, 0.32; 95% CI, 0.11-0.90; p = 0.031). Post-operative dexmedetomidine infusion significantly reduced the rate of severe acute kidney injury and newly-onset dialysis in patients who received surgery for acute type A aortic dissection.

Sex differences in risks of in-hospital and late outcomes after cardiac surgery: a nationwide population-based cohort study.

OBJECTIVES: Outcomes of sex differences in major cardiac surgery remain controversial. A comprehensive understanding of sex differences in major adult cardiac surgery could provide better knowledge of risk factors, management strategy and short-term or long-term outcomes. The present study aimed to investigate sex differences in the risks of outcomes of major cardiac surgeries and subgroup analyses of different valve types. DESIGN: Population-based nationwide cohort study. SETTING: Data were obtained from National Health Insurance Research Database (NHIRD) in Taiwan. PARTICIPANTS: A total of 66 326 adult patients (age ≥20 years; 30.3% women) who underwent a first major cardiac surgery (isolated coronary artery bypass graft (CABG), isolated valve or concomitant bypass/valve) from 2000 to 2013 were identified via Taiwan NHIRD. MAIN OUTCOME MEASURES: Outcomes of primary interest were in-hospital death and all-cause mortality during follow-up period. Propensity score matching was conducted as a secondary analysis for the sensitivity test. RESULTS: Women who underwent isolated CABG tended to have greater risks of both in-hospital (OR 1.37; 95% CI 1.26 to 1.49) and late outcomes (HR 1.26; 95% CI 1.22 to 1.31). Women after concomitant CABG/valve also had a greater in-hospital (OR 1.19; 95% CI 1.01 to 1.40) and long-term mortality (HR 1.14; 95% CI 1.05 to 1.24). Women after isolated mitral valve repair have a non-favourable outcome of in-hospital mortality (OR 1.70; 95% CI 1.01 to 2.87). Women who did not receive an isolated aortic valve replacement had more favourable all-cause mortality outcome (HR 0.90; 95% CI 0.84 to 0.96). Secondary analysis in the propensity score-matching cohort demonstrated results similar to the primary analysis. CONCLUSIONS: Female patients who underwent procedures involving CABG (with or without concurrent valvular intervention) had generally worse outcomes. However, the results of isolated valve surgery were variable on the basis of the type of intervened valve.

Zoledronic acid inhibits osteoclastogenesis and bone resorptive function by suppressing RANKL­mediated NF­κB and JNK and their downstream signalling pathways.

Targeting excessive osteoclast differentiation and activity is considered a valid therapeutic approach for osteoporosis. Zoledronic acid (ZOL) plays a pivotal role in regulating bone mineral density. However, the exact molecular mechanisms responsible for the inhibitory effects of ZOL on receptor activator of nuclear factor (NF)­κB ligand (RANKL)­induced osteoclast formation are not entirely clear. The present study aimed to investigate the role of ZOL in osteoclast differentiation and function, and to determine whether NF­κB and mitogen­activated protein kinase, and their downstream signalling pathways, are involved in this process. RAW264.7 cells were cultured with RANKL for differentiation into osteoclasts, in either the presence or absence of ZOL. Osteoclast formation was observed by tartrate­resistant acid phosphatase staining and bone resorption pit assays using dentine slices. The expression of osteoclast­specific molecules was analysed using reverse transcription­quantitative polymerase chain reaction and western blotting assays to deduce the molecular mechanisms underlying the role of ZOL in osteoclastogenesis. The results showed that ZOL significantly attenuated osteoclastogenesis and bone resorptive capacity in vitro. ZOL also suppressed the activation of NF­κB and the phosphorylation of c­Jun N­terminal kinase. Furthermore, it inhibited the expression of the downstream factors c­Jun, c­Fos and nuclear factor of activated T cells c1, thereby decreasing the expression of dendritic cell­specific transmembrane protein and other osteoclast­specific markers. In conclusion, ZOL may have therapeutic potential for osteoporosis.

Association Between Volume and Outcomes of Infective Endocarditis Surgery: A Nationwide Cohort Study.

BACKGROUND: To determine the relationship between hospital surgical volume and mortality risk and valve repair rate in infective endocarditis (IE) surgery. METHODS: Using the Taiwan National Health Insurance Research Database, 3873 patients were identified who underwent surgery between 2000 and 2013. The cumulative hospital volume of valve surgery for IE was calculated, and patients were divided into 4 subgroups according to the quartile. Outcomes were mortality and valve repair rate and the cut point of referral excellence. RESULTS: The distribution of IE surgery has been shifting to lower-volume hospitals over the years. The global disease severity (Charlson Comorbidity Index score) of patients was greater in the lowest-volume hospital than in the highest-volume hospital (2.4 vs 2.0). The crude in-hospital mortality rate was 15.8% and 9.4% for the lowest- and highest-volume hospitals, respectively, with a significant difference (adjusted odds ratio: 1.86, 95% confidence interval: 1.22-2.85) after adjustment of baseline characteristics including the Charlson Comorbidity Index score. The mitral valve repair rate increased with the increase in cumulative volume. During a mean follow-up period of 4.4 years, 324 (41.9%) and 254 (30.9%) patients died in the lowest- and highest-volume subgroups, respectively, and the difference was significant (adjusted hazard ratio: 1.59, 95% confidence interval: 1.21-2.10). CONCLUSIONS: A higher cumulative volume of IE surgery is associated with a lower risk of mortality and a higher likelihood of successful mitral valve repair. Therefore, interfacility transfer to a high-volume hospital may improve outcomes of IE surgery.

Mitral valve repair versus replacement in patients with rheumatic heart disease.

BACKGROUND: Rheumatic heart disease remains a major cause of cardiovascular death worldwide. Limited real-world nationwide data are available to compare the long-term outcomes between mitral valve repair and replacement in rheumatic heart disease. METHODS: We identified adult patients with rheumatic heart disease who underwent mitral valve repair or replacement surgery between 2000 and 2013 from Taiwan's National Health Insurance Research Database. Outcomes of interest included operation-related complications, all-cause mortality, and mitral valve reoperation rate. Propensity score matching at a 1:1 ratio was conducted to mitigate possible confounding factors. RESULTS: A total of 5086 patients with rheumatic heart disease who underwent mitral valve surgery were identified. Of those, 489 (9.6%) and 4597 (90.4%) underwent mitral valve repair and mitral valve replacement, respectively. After propensity score matching was applied, each group had 467 patients. No difference in risk of in-hospital mortality was observed between groups. With a mean follow-up of 6 years, the mitral valve repair group had comparable risks of all-cause mortality with the mitral valve replacement group (33.4% vs 32.5%; hazard ratio, 1.01; 95% confidence interval, 0.81-1.25). However, higher risks of mitral valve reoperation were observed in the mitral valve repair group (subdistribution hazard ratio, 4.32; 95% confidence interval, 2.02-9.23). Previous percutaneous transvenous mitral commissurotomy was identified as a risk factor of mitral valve reoperation in the repair group. CONCLUSIONS: Among patients with rheumatic heart disease, mitral valve repair is not associated with superior long-term outcomes. Patients should be carefully selected for mitral valve repair because of its higher reoperation rate, particularly those with previous percutaneous transvenous mitral commissurotomy.