Diagnosis and Surgical Outcomes of Patients with Anomalous Left Coronary Artery from the Pulmonary Artery: A Single Taiwanese Medical Center Experience.

BACKGROUND: Anomalous left coronary artery from the pulmonary artery (ALCAPA), a very rare congenital cardiac anomaly, is associated with a high mortality rate among infants who are not diagnosed or treated in a timely manner. Surgical intervention with the reconstruction for a two-coronary-system circulation is the main treatment; however, there have been very few reported cases from Taiwan. In this study, we aim to describe the clinical manifestations, diagnostic methods, surgery types, and surgical outcomes in patients with ALCAPA from a single Taiwanese medical center. METHODS: We retrospectively reviewed patients diagnosed with ALCAPA who underwent surgery at our institution between January 2001 and October 2018. Clinical presentations, noninvasive and invasive study results, surgical methods, and postoperative follow-up results were assessed from medical records. Moreover, literature on this particular cardiovascular anomaly was reviewed. RESULTS: The study included 6 patients (5 children and 1 adult). The diagnosis was confirmed using cardiac catheterization and coronary angiography in four patients and only echocardiography in two patients. All patients underwent surgical correction and survived. Four patients showed improvements in left ventricular function and mitral regurgitation (MR). CONCLUSION: Early diagnosis and timely surgical intervention could avoid mortality regardless of the method of operation. ALCAPA can be definitively diagnosed using noninvasive echocardiography. Both left ventricular systolic function and mitral insufficiency could improve after the surgical intervention in pediatric patients. Repair or replacement of the mitral valve could be reserved for persistent MR complicated with congestive heart failure, particularly in patients who received the initial operation beyond infancy.

Cost-utility analysis of direct ventricular assist device vs double bridges to heart transplantation in patients with refractory heart failure.

OBJECT: This study compared the cost-utility of direct ventricular assist device (VAD) vs double bridges, extracorporeal membrane oxygenation (ECMO) before VAD, to heart transplantation in patients with refractory heart failure. MATERIALS AND METHODS: From a health payer perspective, a Markov model was developed. The cycle length was 1 month, and the time horizon was a lifetime. Probabilities and direct cost data were calculated from a nationwide claim database. Utility inputs were adopted from published sources. The utility was expressed as quality-adjusted life years (QALYs). Both costs and utility were discounted by an annual rate of 3%. Deterministic and probabilistic sensitivity analyses were performed to test the stability of the model. RESULTS: The direct VAD group had less lifetime costs (USD 95 910 vs USD 129 516) but higher lifetime QALYs than the double bridges group (1.73 vs 0.89). The sensitivity analysis revealed that the direct VAD group consistently had lower cost and higher QALYs during all variations in model parameters. The probability that direct VAD was cost-effective exceeded 75% at any levels of willing-to-pay. CONCLUSION: From a health insurance payer perspective, direct VAD bridge to heart transplantation appeared to be more cost-effective than double bridges in patients with refractory heart failure.

Procedural Characteristics and Outcomes of Transcatheter Aortic Valve Implantation: A Single-Center Experience of the First 100 Inoperable or High Surgical Risk Patients with Severe Aortic Stenosis.

BACKGROUND: This is the first study of a Taiwanese population reporting transcatheter aortic valve implantation (TAVI) outcomes of the first 100 cases from a single center offering two different transcatheter heart valve technologies via six types of approaches. We herein report the 30-day and one-year outcomes in our first 100 TAVI patients at Taipei Veterans General Hospital. METHODS: From May 2010 to April 2016, 100 consecutive patients with severe aortic stenosis (AS) who were considered unsuitable or at high risk for surgical aortic valve replacement underwent TAVI. Patient outcomes were classified according to the Valve Academic Research Consortium-2 (VARC-2) definitions. The device performance was assessed using transthoracic echocardiography by independent investigators. RESULTS: The mean patient age was 81.1 years, where 54% were female, and the mean Logistic EuroSCORE was 21.5%. The Medtronic CoreValve was used in 84 patients and the Edwards Sapien or Sapien XT valve (ESV) in 16. The transfemoral approach was the most frequently used route (83%), followed by transapical (9%) access. Overall, there was no procedural death. The VARC-2 outcomes were as follows: device success, 95%; stroke, 1%; major vascular complication, 3%; a need for pacemaker implantation, 5.1%. At discharge, the incidence of postoperative mild, moderate or severe paravalvular leak was 30%, 3% and 0%, respectively. At one year, the all-cause mortality rate was 14.0%, and no valve-related dysfunction was observed. Through multivariable analysis, non-transfemoral access [hazard ratios (HR) 4.81; 95% confidence interval (CI) 1.66-14.09; p = 0.004] and advanced chronic kidney disease (stages 4-5), (HR 3.13; 95% CI 1.07-9.09; p = 0.036) were independently associated with an increased risk of one-year mortality. CONCLUSIONS: We demonstrated that TAVI shows good early and mid-term outcomes in terms of survival, technical success, valve-related adverse events and haemodynamic performance in high-risk patients with severe AS.

The role of adenosine in preconditioning by brief pressure overload in rats.

BACKGROUND/PURPOSE: Brief pressure overload of the left ventricle reduced myocardial infarct (MI) size in rabbits has been previously reported. Its effects in other species are not known. This study investigates effects of pressure overload and the role of adenosine in rats in this study. METHODS: MI was induced by 40-minute occlusion of the left anterior descending coronary artery followed by 3-hour reperfusion. MI size was determined by triphenyl tetrazolium chloride staining. Brief pressure overload was induced by two 10-minute episodes of partial snaring of the ascending aorta. Systolic left ventricular pressure was raised 50% above the baseline value. Ischemic preconditioning was elicited by two 10-minute coronary artery occlusions. RESULTS: The MI size (mean ± standard deviation), expressed as percentage of area at risk, was significantly reduced in the pressure overload group as well as in the ischemic preconditioning group (17.4 ± 3.0% and 18.2 ± 1.5% vs. 26.6 ± 2.4% in the control group, p < 0.001). Pretreatment with 8-(p-sulfophenyl)-theophylline (SPT), an inhibitor of adenosine receptors, did not significantly limit the protection by pressure overload and ischemic preconditioning (18.3 ± 1.5% and 18.2 ± 2.0%, respectively, p < 0.001). SPT itself did not affect the extent of infarct (25.4 ± 2.0%). The hemodynamics, area at risk and mortality were not significantly different among all groups of animals. CONCLUSION: Brief pressure overload of the left ventricle preconditioned rat myocardium against infarction. Because SPT did not significantly alter MI size reduction, our results did not support a role of adenosine in preconditioning by pressure overload in rats.

Intraportal injection of insulin-producing cells generated from human bone marrow mesenchymal stem cells decreases blood glucose level in diabetic rats.

We studied the process of trans-differentiation of human bone marrow mesenchymal stem cells (hBM-MSCs) into insulin-producing cells. Streptozotocin (STZ)-induced diabetic rat model was used to study the effect of portal vein transplantation of these insulin-producing cells on blood sugar levels. The BM-MSCs were differentiated into insulin-producing cells under defined conditions. Real-time PCR, immunocytochemistry and glucose challenge were used to evaluate in vitro differentiation. Flow cytometry showed that hBM-MSCs were strongly positive for CD44, CD105 and CD73 and negative for hematopoietic markers CD34, CD38 and CD45. Differentiated cells expressed C-peptide as well as ß-cells specific genes and hormones. Glucose stimulation increased C-peptide secretion in these cells. The insulin-producing, differentiated cells were transplanted into the portal vein of STZ-induced diabetic rats using a Port-A catheter. The insulin-producing cells were localized in the liver of the recipient rat and expressed human C-peptide. Blood glucose levels were reduced in diabetic rats transplanted with insulin-producing cells. We concluded that hBM-MSCs could be trans-differentiated into insulin-producing cells in vitro. Portal vein transplantation of insulin-producing cells alleviated hyperglycemia in diabetic rats.

Transplantation of insulin-producing cells from umbilical cord mesenchymal stem cells for the treatment of streptozotocin-induced diabetic rats.

BACKGROUND: Although diabetes mellitus (DM) can be treated with islet transplantation, a scarcity of donors limits the utility of this technique. This study investigated whether human mesenchymal stem cells (MSCs) from umbilical cord could be induced efficiently to differentiate into insulin-producing cells. Secondly, we evaluated the effect of portal vein transplantation of these differentiated cells in the treatment of streptozotocin-induced diabetes in rats. METHODS: MSCs from human umbilical cord were induced in three stages to differentiate into insulin-producing cells and evaluated by immunocytochemistry, reverse transcriptase, and real-time PCR, and ELISA. Differentiated cells were transplanted into the liver of diabetic rats using a Port-A catheter via the portal vein. Blood glucose levels were monitored weekly. RESULTS: Human nuclei and C-peptide were detected in the rat liver by immunohistochemistry. Pancreatic ß-cell development-related genes were expressed in the differentiated cells. C-peptide release was increased after glucose challenge in vitro. Furthermore, after transplantation of differentiated cells into the diabetic rats, blood sugar level decreased. Insulin-producing cells containing human C-peptide and human nuclei were located in the liver. CONCLUSION: Thus, a Port-A catheter can be used to transplant differentiated insulin-producing cells from human MSCs into the portal vein to alleviate hyperglycemia among diabetic rats.

Various modalities for evaluation of a fused heart in conjoined twins.

Conjoined twins are a rare congenital anomaly with an estimated incidence of 1/50,000 to 1/100,000. Among thoracopagus conjoined twins, 75% have a fused heart. We compare the usefulness of various modalities for evaluating cardiovascular structure in fused-heart conjoined twins. We report a series of 20 sets of thoracopagus conjoined twins as well as the results of a PubMed database literature review literature from 1982 to 2009. Twenty sets of fused-heart thoracopagus conjoined twins were evaluated by echocardiography, cardiac catheterization, magnetic resonance image (MRI), and three-dimensional computed tomography angiography (3D-CTA). Imaging results were compared to findings at surgery or autopsy. All sets of conjoined twins underwent postnatal echocardiography; 11 sets (55%) underwent cardiac catheterization; 4 sets (20%) underwent MRI; and 1 set (5%) underwent 3D-CTA. All intracardiac anatomy (ICA) was identified by echocardiography. Cardiac catheterization, MRI, and 3D-CTA were able to identify extracardiac vascular structures as well as the ICA. 3D-CTA, which can be performed as early as the first week of life, is a noninvasive, less expensive, and the safe examination with minimal risk due to its short procedural time. Three-dimensional CTA is an effective and safe modality for evaluating the cardiovascular anatomy of fused-heart conjoined twins before surgery.

Implantation of monocusp valve prolongs the duration of chest tube drainage in children with tetralogy of fallot after corrective surgery.

BACKGROUND: Right ventricular outflow tract obstruction relief is one of the major procedures during the total correction of tetralogy of Fallot (TOF). Pulmonary insufficiency (PI) is usually inevitable after a transannular incision with a patch repair is performed. Therefore, some surgeons advocate to place a monocusp valve within the transannular patch (TAP) in order to decrease the severity of the PI. However, the monocusp valve seemed not be very effective in some patients who underwent the complete TOF repair. METHODS: Patients who had the classic form of TOF between January 2009 and January 2017 and underwent the corrective surgery with a TAP by the same cardiovascular surgeon were identified for further analysis. Clinical information including demographics at operation, perioperative data, and postoperative outcome were collected retrospectively and compared between the group with and without a monocusp valve. RESULTS: A total of 24 TOF cases were included in the final analysis, and 16 (66.7%) patients received a monocusp valve placement. The patients' characteristics before and during the surgery were similar between the two groups. The median duration of chest tube drainage after the total correction in the monocusp group was longer than those without the valve (p = 0.04). There was no difference in the immediate postoperative data, including the inflammation/infection status, the duration of mechanical ventilation, and the length of ICU and hospital stay. CONCLUSION: Implantation of a monocusp valve during the total TOF correction using a TAP did not bring benefit to improve the immediate postoperative outcomes, especially the duration of the pleural drainage. Further study with a prospective design and a larger number of cases is needed.

A right-sided aortic arch with Kommerell's diverticulum of the aberrant left subclavian artery presenting with syncope.

A right-sided aortic arch with an aneurysm of the aberrant subclavian artery is a rare disease. We report a case of Kommerell's diverticulum of an aberrant left subclavian artery in a patient with a right-sided aortic arch. Fewer than 50 cases have been reported in the literature. A number of operative strategies are described. Right thoracotomy provides good exposure and avoids the morbidity associated with bilateral thoracotomy or sternotomy and thoracotomy. In our patient with symptoms of dysphagia, syncope, and left subclavian steal syndrome, a left thoracotomy was used. The repair was accomplished by division of a left ligamentum arteriosum, obliteration of the Kommerell's aneurysm, and an aorto-subclavian bypass. Postoperative complications included left vocal cord palsy and Horner's syndrome. Hoarseness and left ptosis recovered spontaneously 3 months after surgery, and the patient remained symptom-free at the 1-year follow-up. We believe a left thoracotomy for direct repair of Kommerell's diverticulum is a simple and safe method without the increased morbidity found in other procedures.

Prenatal diagnosis of tetralogy of Fallot with pulmonary atresia.

Tetralogy of Fallot involves an abnormal embryological development in which an unequal conotruncal division results in a small pulmonary artery and a great aortic artery. In its most severe form, the infundibulum of the right ventricle and the pulmonary artery can be atretic with the anomaly commonly referred to as pulmonary atresia with ventricular septal defect. Reported here is a case of prenatal diagnosis of tetralogy of Fallot with pulmonary atresia. The characteristic ultrasonographic findings included a small pulmonary artery, a large aorta, and a ventricular septal defect. The search for an atretic pulmonary valve and a ductus arteriosus with reversed blood flow was emphasized in the presence of asymmetrically dilated fetal heart. After birth, the newborn received single-stage total correction for the tetralogy of Fallot and was discharged a month later in stable condition. In this case report, the neonatal angiogram is added for confirming the prenatal diagnosis, which is of value in teaching fetal echocardiography to novice practitioners. We believe a prenatal diagnosis of tetralogy of Fallot can improve neonatal outcome.

Cardiac myocyte progenitors from adult hearts for myocardial regenerative therapy.

BACKGROUND: The heart is a highly vascular organ and prolonged interruption of myocardial blood flow initiates events that culminate in cardiac myocyte death. Proposed experimental reparative strategies include harvesting potent cells followed by direct injection into ischemic myocardium to achieve myogenesis and angiogenesis. METHODS: Accordingly, we set out to isolate and expand a purified population of adult rat putative cardiomyocyte precursors, and to identify their characteristics in vitro. By using an acute myocardial infarction model and direct cell implantation, we further tested the hypothesis that these cells are an ideal cell source for myocardial regeneration and can enhance cardiac repair after implantation into the ischemic rat heart. RESULTS: We describe here the identification of a subpopulation of primitive cells from rat heart, processing stem cell marker, c-kit and myogenic transcriptional factors, GATA-4 and MEF 2C, and cardiac specific proteins, troponin-I, alpha-sarcomeric actinin and connexin-43. They exhibited a high in vitro proliferative potential. These findings strongly suggest that these cells are putative cardiomyocyte precursors. After transplantation, they were able to be retained and proliferate (13.63 +/- 5.97% after 2 weeks) within the ischemic heart. Progeny of implanted cells migrated along the infarcted scar, reconstituted regenerated cardiomyocytes with incorporation into host myocardium, and inhibited cardiac remodeling with decreased scar formation. CONCLUSION: Our findings suggest that putative cardiomyocyte precursors isolated from adult heart could potentially be an autologous cell source for myocardial regeneration cell therapy.

Prenatal diagnosis of dextrotransposition of the great arteries.

Dextrotransposition of the great arteries (DTGA) is a common cardiac cause of cyanosis in newborn infants that can cause acidosis and death within a short period of time unless there is a large atrial-level shunt or a patent ductus arteriosus. Here, we report a case of prenatal diagnosis of DTGA at 24+1 gestational weeks. In a tilted 4-chamber view, the pulmonary trunk branched to the left and the right pulmonary, with its root connected to the left ventricle outflow tract. In the short-axis view, the pulmonary trunk was shown to be parallel with the ascending aortic root. Cesarean section was performed due to the nonreassuring fetal status at 38+5 gestational weeks. The male neonate appeared to have mild cyanotic symptoms and weighed 3,108 g. Apgar scores were 8 and 9 at 1 and 5 minutes, respectively. Neonatal echocardiography was performed immediately after birth and the findings confirmed DTGA associated with atrial septal defect secundum. Postnatally, angiography confirmed the echocardiographic diagnosis of DTGA with a large atrial septal defect secundum and a large patent ductus arteriosus. Jatene arterial switch operation and atrial septal defect closure with Gore-Tex patch were performed. The neonate withstood the operation well and was discharged 27 days after birth weighing 2,950 g and in a stable condition. Prenatal diagnosis of DTGA can greatly aid to prepare the patient's family and the surgeon and significantly improve the outcome of complex heart disease in the neonatal period.

Coronary artery spasm after off-pump coronary artery bypass grafting.

BACKGROUND: Coronary artery spasm (CAS) in the immediate postoperative period has been recognized as a possible cause for perioperative myocardial ischaemia after off-pump coronary artery bypass grafting (CABG). It varies in severity and can be associated with circulatory collapse and death. The purpose of this study was to present our experiences on CAS after off-pump CABG and detail its management. METHODS: The case reports of three patients with similar clinical presentations of ischaemic heart disease who underwent CABG using an off-pump technique are reviewed. Severe manifestations of CAS in the immediate postoperative period with documented angiographic findings are presented. RESULTS: Three patients (two men and one woman) with angina pectoris were diagnosed with coronary artery disease using coronary angiography. The elective off-pump CABG was uneventful; however, severe manifestation of myocardial ischaemia with abrupt onset developed at the intensive care unit. All three patients underwent immediate coronary angiography to verify the diagnosis of CAS. Apart from intracoronary nitroglycerine infusion and medical support with inotropic agents, extracorporeal membranous oxygenation was carried out because of severe haemodynamic deterioration in one case, while support was required with intraaortic balloon pumping in another. All three patients made a full recovery. CONCLUSION: Coronary artery spasm can severely complicate the postoperative course for patients undergoing off-pump CABG, leading to myocardial ischaemia or infarction, life-threatening arrhythmias, persistent hypotension and even cardiac arrest. Early awareness and diagnosis of CAS with the establishment of appropriate management strategies may prevent its potentially lethal consequences.

Coronary artery bypass grafting in patients with left ventricular dysfunction.

BACKGROUND: Coronary artery bypass grafting surgery (CABG) remains a challenge for patients with coronary artery disease and left ventricular (LV) dysfunction. The aim of this study was to evaluate the result of CABG in patients with LV dysfunction. METHODS: Medical records of 1,847 patients who underwent primary, isolated CABG at Taipei Veterans General Hospital from January 1, 1991 to December 31, 2002, were reviewed. The mortality rate associated with clinical and operative variables was compared between patients with LV ejection fraction (LVEF) > or = 35% and patients with LVEF < 35%. RESULTS: Patients with LVEF < 35% had more episodes of myocardial infarction (57.5% vs 28.9%, p < 0.001) and history of congestive heart failure (18.1% vs 3.2%, p < 0.001), higher New York Heart Association (NYHA) class, and higher angina class. Longer cardiopulmonary bypass time (147 +/- 44 minutes vs 137 +/- 40 minutes, p < 0.001) but fewer left internal mammary artery (LIMA) grafts (46.8% vs 65.7%, p < 0.001) were used in patients with LVEF < 35%. Patients with LVEF < 35% had significantly higher hospital mortality (6.6% vs 2.2%, p < 0.001), higher major morbidity (23.3% vs 16.1%, p < 0.01), and longer hospital stay (25 +/- 23 days vs 21 +/- 16 days, p < 0.01). CONCLUSION: Although patients with LV dysfunction had higher mortality and morbidity, CABG could be done in these high-risk patients with acceptable results.

Comparisons of Differentiation Potential in Human Mesenchymal Stem Cells from Wharton's Jelly, Bone Marrow, and Pancreatic Tissues.

Background. Type 1 diabetes mellitus results from autoimmune destruction of ß-cells. Insulin-producing cells (IPCs) differentiated from mesenchymal stem cells (MSCs) in human tissues decrease blood glucose levels and improve survival in diabetic rats. We compared the differential ability and the curative effect of IPCs from three types of human tissue to determine the ideal source of cell therapy for diabetes. Methods. We induced MSCs from Wharton's jelly (WJ), bone marrow (BM), and surgically resected pancreatic tissue to differentiate into IPCs. The in vitro differential function of these IPCs was compared by insulin-to-DNA ratios and C-peptide levels after glucose challenge. In vivo curative effects of IPCs transplanted into diabetic rats were monitored by weekly blood glucose measurement. Results. WJ-MSCs showed better proliferation and differentiation potential than pancreatic MSCs and BM-MSCs. In vivo, WJ-IPCs significantly reduced blood glucose levels at first week after transplantation and maintained significant decrease till week 8. BM-IPCs reduced blood glucose levels at first week but gradually increased since week 3. In resected pancreas-IPCs group, blood glucose levels were significantly reduced till two weeks after transplantation and gradually increased since week 4. Conclusion. WJ-MSCs are the most promising stem cell source for ß-cell regeneration in diabetes treatment.

IL-1ß-Induced Mesenchymal Stem Cell Migration Involves MLCK Activation via PKC Signaling.

Mesenchymal stem cells (MSCs) migrate via the bloodstream to sites of injury, possibly attracted by inflammatory cytokines. Although many cytokines can induce stem cell migration, the underlying mechanism is not fully understood. We found that tail vein-injected MSCs migrate to the pancreas in nonobese diabetic (NOD) mice. An ELISA assay revealed that hyperglycemic NOD mice have higher pancreatic levels of interleukin-1ß (IL-1ß) than normal NOD mice and that IL-1ß stimulates MSC migration in a Transwell assay and electric cell-substrate impedance sensing system. Microarray analysis showed that myosin light chain kinase (MLCK) is involved in IL-1ß-induced MSC migration, while Western blots showed that IL-1ß stimulates MLCK expression and activation and that MLCK-siRNA transfection reduces MSC migration. Kinase inhibitors, chromatin immunoprecipitation, and a knockdown study revealed that IL-1ß-induced MLCK expression is regulated by the PKCδ/NF-κB signaling pathway, and a kinase inhibitor study revealed that IL-1ß-induced MLCK activation occurs via the PKCα/MEK/ERK signaling pathway. These results show that IL-1ß released from the pancreas of hyperglycemic NOD mice induces MSC migration and that this is dependent on MLCK expression via the PKCδ/NF-κB pathway and on MLCK activation via the PKCα/MEK/ERK signaling cascade. This study increases our understanding of the mechanisms by which MSCs home to injury sites.

Undifferentiated Wharton's Jelly Mesenchymal Stem Cell Transplantation Induces Insulin-Producing Cell Differentiation and Suppression of T-Cell-Mediated Autoimmunity in Nonobese Diabetic Mice.

Type 1 diabetes mellitus is caused by T-cell-mediated autoimmune destruction of pancreatic ß-cells. Systemic administration of mesenchymal stem cells (MSCs) brings about their incorporation into a variety of tissues with immunosuppressive effects, resulting in regeneration of pancreatic islets. We previously showed that human MSCs isolated from Wharton's jelly (WJ-MSCs) represent a potential cell source to treat diabetes. However, the underlying mechanisms are unclear. The purpose of this study was to discern whether undifferentiated WJ-MSCs can differentiate into pancreatic insulin-producing cells (IPCs) and modify immunological responses in nonobese diabetic (NOD) mice. Undifferentiated WJ-MSCs underwent lentiviral transduction to express green fluorescent protein (GFP) and then were injected into the retro-orbital venous sinus of NOD mice. Seven days after transplantation, fluorescent islet-like cell clusters in the pancreas were apparent. WJ-MSC-GFP-treated NOD mice had significantly lower blood glucose and higher survival rates than saline-treated mice. Systemic and local levels of autoaggressive T-cells, including T helper 1 cells and IL-17-producing T-cells, were reduced, and regulatory T-cell levels were increased. Furthermore, anti-inflammatory cytokine levels were increased, and dendritic cells were decreased. At 23 days, higher human C-peptide and serum insulin levels and improved glucose tolerance were found. Additionally, WJ-MSCs-GFP differentiated into IPCs as shown by colocalization of human C-peptide and GFP in the pancreas. Significantly more intact islets and less severe insulitis were observed. In conclusion, undifferentiated WJ-MSCs can differentiate into IPCs in vivo with immunomodulatory effects and repair the destroyed islets in NOD mice.

Operative results of coronary artery bypass grafting in women.

BACKGROUND: The relative mortality of coronary artery bypass grafting (CABG) surgery in women is not certain. The purpose of this study was to examine the results of primary, isolated CABG in a series of Taiwanese female patients. METHODS: Medical records of 2055 patients (188 women and 1867 men), who underwent primary, isolated CABG at Taipei Veterans General Hospital from January 1, 1991 to December 31, 1999, were reviewed. The mortality rate, associated with clinical and operative variables, was compared between female and male patients. RESULTS: The female patients had more diabetes (51.6% vs. 29.9%, P<0.01), more hypertension (77.1% vs. 65.0%, P<0.01), and more hypercholesterolemia (39.4% vs. 29.6%, P<0.01), as compared with men. Fewer women consumed cigarette smoking (17.0% vs. 52.1%, P<0.001). Fewer internal mammary artery grafts were used in women (43.1% vs. 57.3%, P<0.001). Nine female (4.8%) and 93 male patients (5.0%) died. There was no significant difference in hospital mortality between women and men. Other variables, including age, angina class, NYHA class, incidence of peripheral arterial occlusive disease, stenosis of left main coronary artery, number of stenotic coronary arteries, incidence of emergent operations, anastomosis number, aortic cross-clamping time, cardiopulmonary bypass time, and left ventricular ejection fraction, were not significantly different between female and male patients. CONCLUSIONS: Although the female patients were more frequently diabetic, hypertensive, and hypercholesterolemic, the hospital mortality of CABG in women was not significantly different from that in men. This result supports an aggressive surgical treatment for women with coronary artery disease.

Transcatheter implantation of intravascular stents for postoperative residual stenosis of peripheral pulmonary artery stenosis.

This is a prospective study of transcatheter implantation of 11 intravascular stents in 7 patients with status/post (S/P) surgical correction of major cardiovascular lesions. The safety and efficacy of balloon-expandable stents for treatment of peripheral pulmonary artery stenosis (PPAS) is evaluated and analyzed. Although the transcatheter implantation of intravascular stents has been reported as a possible treatment for stenotic peripheral pulmonary arteries, the results of intermediate follow-up studies on patients with S/P surgical correction for residual PPAS need to be evaluated. From June 1998 to December 2001, a total of 15 patients with PPAS having S/P surgery for major cardiovascular lesions were enrolled in this study. Eight of them had redo surgery after complete evaluation and the other 7 patients who might be at higher risk of mortality or morbidity from redo surgery, underwent transcatheter implantation of stents to dilate significant PPAS. Tetralogy of Fallot, S/P total correction, was done in 6 and transposition of great vessels, S/P Jatene operation, was done in 1. There were 10 stents (P 308 Palmaz stent x8 and Intrastent x2) implantation for 10 sites of the stenotic PPAS in these 7 patients, who were aged from 3.6 to 17.3 (10.1 +/- 5.6) years and had body weights ranging from 17 to 72.5 (37.1 +/- 23.0) kg. The narrowest diameter of the stenotic peripheral pulmonary arteries and pressure gradients across the stenosis were measured before and after implantation of stents. A follow-up catheterization and pulmonary angiography was performed 1 year later to evaluate the intermediate efficacy of stents implantation. All the stenotic peripheral pulmonary arteries of these 7 patients had a significant reduction of pressure gradients immediately after the procedure. The narrowest mean diameter of pulmonary arteries increased from 6.7 +/- 3.4 to 11.3 +/- 3.0 mm (p < 0.001), and the mean pressure gradient dropped from 31 +/- 9.9 to 11.4 +/- 4.6 mm Hg (p < 0.001). The follow-up catheterization 1 year later revealed a persistent effect in all but 1 patient. Only a young male presented with a recurrent stenosis with a pressure gradient of > or = 20 mm Hg, which was relieved by redilation with implantation of another stent. There was no immediate or intermediate complication. Transcatheter stent implantation for treatment of a significant residual PPAS after surgical correction of complicated congenital heart disease is a safe and effective procedure. Since children are growing with age, a long-term follow-up study to evaluate the effects and possible problems of stent implantation is mandatory.

Surgical techniques for emergent repair of post-infarction ventricular septal defect: compare endocardial patch and infarct exclusion method with traditional method.

BACKGROUND: The traditional surgical repair of post-infarction ventricular septal defect (VSD) includes excision of necrotic myocardium and approximation of the remaining of healthy ventricular wall and septal portion. The exclusion method emphasizes no excision of infarcted myocardium, preservation of the left ventricular geometry and exclusion of infarction area. We discuss our experiences in 13 patients and compared the results obtained from 2 different surgical methods. METHODS: From July 1996 to December 2001, 13 patients with post-infarction VSD received emergent repair. Seven patients were repaired in the traditional way and the other 6 with infarct exclusion method. There were 9 men and 4 women, ranging in age from 57 to 79. In the traditional group, all 7 patients were classified as NYHA IV and supported by intra-aortic balloon counter-pulsation (IABP) and 4 patients were for synchronous coronary bypass grafting. Patients using exclusion method were the 1 classified as NYHA III and 5 as IV with cardiogenic shock and supported by IABP. Coronary bypass grafting was performed concomitantly in 2 patients. RESULTS: Five patients died within 30 days after the surgery. Four patients (mortality rate = 57.1%) had reconstruction in traditional way and 1 (mortality rate = 16.6%) in exclusion way. The complication rate was higher in the traditional group (= 100%, n = 7, p = 0.005). In the traditional group, 1 patient received heart transplantation due to persistent severe pump failure and recovered well. Two received tracheostomy due to respiratory failure and 1 died 2 months later. In the group of exclusion method, 1 patient suffered recurrent VSD 2 days after the first surgery and died due to ventricular arrhythmia. CONCLUSIONS: The surgical mortality caused by acute post-infarction VSD has decreased with endocardial patch and infarction exclusion method. Rapid diagnosis, appropriate preoperative management and delicate surgical repair improve the overall results and help to attain long-term survival.