Intra-Coronary Administration of Tacrolimus Improves Myocardial Perfusion and Left Ventricular Function in Patients with ST-Segment Elevation Myocardial Infarction (COAT-STEMI) Undergoing Primary Percutaneous Coronary Intervention.

BACKGROUND: Ischemia-reperfusion injury following acute ST-segment elevation myocardial infarction (STEMI) is strongly related to inflammation. However, whether intracoronary (IC) tacrolimus, an immunosuppressant, can improve myocardial perfusion is uncertain. METHODS: A multicenter double-blind randomized controlled trial was conducted in Taiwan from 2014 to 2017. Among 316 STEMI patients with Killip class ≤ 3 undergoing primary percutaneous coronary intervention (PCI), 151 were assigned to the study group treated with IC tacrolimus 2.5 mg to the culprit vessel before first balloon inflation, and the remaining 165 were assigned to the placebo group receiving IC saline only. The primary endpoint was percentage of post-PCI TIMI-3 flow. The primary composite endpoints included achievement of TIMI-3 flow, TIMI- myocardial perfusion (TMP) grade, or 90-min ST-segment resolution (STR). The secondary endpoints were left ventricular ejection fraction (LVEF) and 1-month/1-year major adverse cardio-cerebral vascular events (MACCEs) (defined as death, myocardial infarction, stroke, target-vessel revascularization or re-hospitalization for heart failure). RESULTS: Although post-PCI TIMI-3 epicardial flow and MACCE rate at 1 month and 1 year did not differ between the two groups, TMP grade (2.54 vs. 2.23, p < 0.001) and 90-min STR (67% vs. 61%, p < 0.001) were significantly higher in the tacrolimus-treated group than in the placebo group. The STEMI patients treated with tacrolimus also had significantly higher 3D LVEF and less grade 2 or 3 LV diastolic dysfunction at 9 months compared to those without. CONCLUSIONS: IC tacrolimus for STEMI improved coronary microcirculation and 9-month LV systolic and diastolic functions. However, the benefit of tacrolimus on clinical outcomes remains inconclusive due to insufficient patient enrollment.

Acute pericarditis following treatment of a metastatic liver tumor with radiofrequency ablation: a case report.

BACKGROUND: Radiofrequency ablation is a common and minimally invasive procedure used to treat liver tumors. However, the potential threat of heat injury to adjacent structures if the hepatic lesion is near the diaphragm is often overlooked and misunderstood. Rare cardiovascular complications have been reported. How best to identify the patients at risk to allow for prompt treatment is an important issue. CASE PRESENTATION: A 56-year-old man with underlying oral cancer received radiofrequency ablation for a metastatic liver tumor at segment II. Pleuritic chest pain developed on the day after radiofrequency catheter ablation. Diffuse ST elevation and echocardiography showed the new onset of small to moderate pericardial effusion without tamponade sign. Inflammatory markers were also elevated. Acute pericarditis due to heat penetration and stimulation was favored. His symptoms and signs resolved after treatment with anti-inflammatory medication. CONCLUSION: Potential cardiovascular complications are possible after radiofrequency catheter ablation for liver tumors located at segment II. Artificial ascites with normal saline before radiofrequency ablation may separate the liver and diaphragm to prevent cardiac complications. During the procedure, electrocardiographic monitoring and close observation of the patient's symptom are required. Echocardiography can be used to confirm cardiac complications.

Risk of acute coronary syndrome after parathyroidectomy in patients with end-stage renal disease: A population-based cohort study in Taiwan.

AIM: Patients with end-stage renal disease (ESRD) who received parathyroidectomy (PTX) had persistently reduced levels of parathyroid hormone. This study investigated the risk of acute coronary syndrome (ACS) in patients with ESRD who underwent PTX using a nationwide health insurance claims database. METHODS: Of all ESRD patients, we selected 1047 individuals who had undergone PTX between 2000 and 2008 as the PTX group and 4188 patients who did not undergo PTX (non-PTX group) matched by propensity score. Multivariable Cox proportional hazards regression analysis was conducted for assessing the excess ACS risk for the PTX group compared to the non-PTX group. RESULTS: The mean follow-up periods were 4.63 and 4.04 years for the PTX and non-PTX groups, respectively. A significant reduction in the risk of ACS (adjusted hazard ratio = 0.74, 95% confidence interval = 0.57-0.96) was observed for the ESRD patients after PTX. CONCLUSIONS: Parathyroidectomy is associated with reduced risk of ACS in patients with ESRD.

Comparison of Clinical Features between Typical and Atypical Takotsubo Cardiomyopathy: A Single Center, Retrospective, Case-Controlled Study.

BACKGROUND: The incidence and possible differences between typical and atypical Takotsubo cardiomyopathy (TTC) in Taiwanese patients have not yet been assessed. METHODS: We reviewed the records of 2171 patients who underwent left heart catheterization for suspected acute coronary syndrome (ACS) between January 2003 and March 2011 to identify TTC. Demographic, clinical presentations, laboratory data, and electrocardiographic, echocardiographic and angiographic findings were assessed in all patients. RESULTS: We found that fourteen patients had typical TTC, and six had atypical TTC. There were no differences in the clinical presentations, ejection fraction and in-hospital course of illness between patients with typical TTC (the TT group) and patients with atypical TTC (the AT group). However, the patients in the AT group were relatively younger than those in the TT group (mean ages 60 vs. 73 years, respectively, p = 0.018), and fewer patients had hypertension in the AT group than in the TT group (33% vs. 86%, respectively, p = 0.037). In electrocardiography, ST segment elevation was noted less frequently in the AT group than in the TT group (33% vs. 86%, respectively, p = 0.037). CONCLUSIONS: Atypical TTC and typical TTC may be the same syndrome with different manifestations. They seemed to have different patient characteristics and electrocardiographic changes. KEY WORDS: Acute coronary syndrome; Takotsubo cardiomyopathy; Transient left ventricular apical ballooning.

Association of anxiety and depression with chronic liver diseases in patients with noncardiac chest pain: A cross-sectional study.

Causes of chest pain can vary from benign to life-threatening conditions, and in many cases not necessary of cardiac origin. A possible reason for noncardiac chest pain could be anxiety or depression caused by chronic liver diseases. The aim of this study was to investigate the association of anxiety and depression with chronic liver disease in patients with noncardiac pain. Patients with chest tightness or pain referred for treadmill exercise testing were recruited from a regional hospital in southern Taiwan. Medical records of the patients were used to define the presence and type of chronic liver disease. Multiple logistic regression analyses were conducted to assess the association of anxiety and depression with chronic liver disease. A total of 2537 patients with liver function test results and abdominal sonography data were analyzed, and 1965 patients showed a negative treadmill exercise testing. The mean age of these 1965 patients was 51.9 years and 54.2% were male. The prevalence of alcoholic liver disease, hepatitis B, hepatitis C, and fatty liver disease was 10.6%, 10.9%, 3.7%, and 27.0%, respectively. Results from multiple logistic regression analyses showed that the risk of anxiety (adjusted odds ratio [aOR] = 1.83, P < .001) and depression (aOR = 1.85, P < .001) was significantly higher in patients with alcoholic liver disease. Anxiety was significantly higher in patients with fatty liver disease (aOR = 1.30, P = .031), and the risk of depression was significantly higher in patients with chronic hepatitis C (aOR = 2.18, P = .005). In conclusion, in patients with noncardiac chest pain, alcoholic liver disease was significantly associated with anxiety and depression, while those with fatty liver and chronic hepatitis C were associated with anxiety and depression, respectively. Clinicians should be vigilant to these correlations in their practice.

Effects of Tai Chi on adiponectin and glucose homeostasis in individuals with cardiovascular risk factors.

The aim of this study was to evaluate the acute effect of a single bout of Tai Chi (TC) exercise on adiponectin and glucose homeostasis in individuals with cardiovascular risk factors. Twenty-six individuals (mean age 60.2 years) with at least one cardiovascular risk factor who had been practicing Yang's style TC exercise for at least 3 months were recruited from a regional hospital in Taiwan. A one-group repeated measured quasi-experimental design was used. Participants completed a 60-min Yang's style TC exercise routine including warm up, stretching exercises, and TC followed by a 30-min resting period. After a 1-week washout period, the same group of participants underwent a control condition in which they were instructed to remain seated for 90 min at the study location. Blood samples were collected both before and after the TC intervention or the sitting condition. The difference between pre-post measurements for adiponectin was 0.58 ± 1.42 µg/ml in the TC trial and -0.46 ± 0.99 µg/ml in the sitting trial. The differences between the two trials were statistically significant (P = 0.004). The changes from pretrial to posttrial were significantly greater for glycerol (P < 0.001), cholesterol (P = 0.046), and LDL-C (P = 0.038) in the TC trial compared with those in the sitting trial. Conversely, the changes were significantly lesser for HOMA-IR (P = 0.004), log (HOMA-IR) (P = 0.001), and glucose (P = 0.003) in TC trial compared with those in the sitting trial. In conclusion, a single bout of TC exercise had a significant positive effect on blood adiponectin concentrations in individuals with cardiovascular risk factors.

Patient satisfaction with dabigatrean and warfarin for stroke prevention in atrial fibrillation: Taiwan PASSION study.

BACKGROUND: Patient satisfaction with oral anticoagulant (OAC) therapy is an important metric of care quality and has been associated with higher medication persistence. Among OACs, dabigatran has been shown to be non-inferior to vitamin K antagonists (VKAs) with increased ease of use for stroke prevention in patients with atrial fibrillation (AF). In this study, we sought to evaluate the expectations, convenience, and satisfaction of Taiwanese AF patients on dabigatran and VKA therapies as well as associated clinical outcomes. METHODS: Patients with AF (paroxysmal, persistent, or permanent) receiving OAC medication from outpatient facilities were enrolled in 24 hospitals across Taiwan. Cohort A consisted of 139 patients switched from VKA to dabigatran, while cohort B was comprised of 1113 patients on newly initiated OAC therapy (VKA, 54). The Perception of Anticoagulant Treatment Questionnaire was distributed, and responses on a five-point Likert scale were aggregated and analyzed across demographic groups. RESULTS: In cohort A, convenience and satisfaction scores continued to increase at follow-up and significantly higher, compared to baseline, but both treatments scored similarly in cohort B. In cohort B, the two highest expectation scores were that the OAC would be "easy to take" and could be "taken independently." On the other hand, the patients were relatively less concerned about the side effects and cost of therapy before taking the OAC. For dabigatran-receiving patients, there were 1.1 stroke-related events per 100 patient-years and 3.0 bleeding-related events per 100 patient-years. CONCLUSION: In Taiwanese patients with AF and initially treated with VKA, switched to dabigatran resulted in higher convenience and treatment satisfaction. For those patients on newly initiated OAC treatment, VKA and dabigatran convenience and satisfaction scores were similar.

Takotsubo cardiomyopathy as an underlying mediator of myocardial infarction with normal coronary arteries.

OBJECTIVE: The purpose of the present study was to describe our experience with myocardial infarction with normal coronary arteries (MINCA) with regards to the prevalence, clinical characteristics, possible underlying etiologies (including Takotsubo cardiomyopathy, TCM) and the short- and long-term outcomes associated with this condition. METHODS: We retrospectively analyzed the records of 596 consecutive patients presenting with acute myocardial infarction over a 4-year period and identified 24 patients (14 female, 10 male) with angiographically normal coronary arteries. Demographic and clinical variables and outcomes were reviewed. RESULTS: Mean patient age was 59 +/- 20 years. The presumed MINCA mechanism was TCM in 10 patients (41.7%), probable myocarditis in 5 (20.8%), coronary spasm in 4 (16.7%), coronary thrombus in 3 (12.5%) and aortic dissection in 2 patients (8.3%). After a mean follow-up of 19 +/- 14 months, 2 patients with probable myocarditis had died of cardiovascular causes, 1 patient with aortic dissection had died due to sepsis after surgery and 1 patient with TCM had died of noncardiovascular causes 2 years after discharge. CONCLUSION: In this study, we found that MINCA occurred in 4% of patients with acute myocardial infarction undergoing emergent coronary angiography, with the most frequent underlying mechanism being TCM.

Association between renal function impairment and multivessel involvement in patients with acute ST-elevation myocardial infarction.

The aim of this study was to evaluate the association between acute ST-elevation myocardial infarction (STEMI) involving multivessel and the severity of renal function impairment. We reviewed medical records of patients with acute STEMI admitted to a regional teaching hospital in southern Taiwan between March 1999 and October 2013. A total of 1215 patients who underwent coronary angiography were included. Multiple logistic regression analysis showed that multivessel involvement (at least two) with significant stenosis was significantly associated with stage 4 chronic kidney disease (adjusted odds ratio [aOR]=2.14, 95% confidence interval [CI]=1.09-4.20) and stage 5 chronic kidney disease (aOR=2.35, 95% CI=1.13-4.89), adjusting for age, sex, type 2 diabetes mellitus, hyperlipidemia, and systolic blood pressure at admission in patients with acute STEMI. In addition, multivessel total occlusion was significantly associated with stage 4 chronic kidney disease (aOR=3.68, 95% CI=1.27-10.70) and stage 5 chronic kidney disease (aOR=3.43, 95% CI=1.08-10.82), adjusting for heart rate at admission and systolic blood pressure at admission in patients with acute STEMI. In conclusion, severe renal function impairment was significantly associated with multivessel significant stenosis and multivessel total occlusion in patients with acute STEMI.

Association between heart rate recovery after exercise and renal function in patients referred for treadmill exercise test.

INTRODUCTION: Heart rate recovery (HRR) is a marker of parasympathetic activity recovery after exercise, and it is associated with cardiovascular mortality and total mortality. Impaired renal function is also associated with cardiac mortality. The aim of this study was to investigate the association between HRR after exercise and renal function in patients referred for a treadmill exercise test. PATIENTS AND METHODS: This cross-sectional study was conducted at a regional hospital in southern Taiwan. Patients who completed a symptom-limited treadmill exercise test from January 2015 to February 2018 were recruited. Before the treadmill exercise test, patients were asked to complete a questionnaire on the past disease history and lifestyle factors. Serum creatinine measurement within two years prior to or after the date of the treadmill exercise test of the patients was also obtained from the medical records for these patients. Estimated glomerular filtration rate (eGFR) was calculated. Simple and multiple linear regression analyses were performed to investigate the association between one-minute HRR and eGFR. RESULTS: A total of 2,825 patients completed the treadmill exercise test, and serum creatinine measurement was identified from medical records for 2,153 patients (76.2%). Multiple linear regression analysis revealed that a lower eGFR was significantly associated with lower one-minute HRR (P< 0.001), adjusting for other significant independent factors, including age, waist circumference, type 2 diabetes mellitus, and smoking. CONCLUSIONS: In this cross-sectional observational study, a lower eGFR was significantly and independently associated with decreased one-minute HRR, suggesting that parasympathetic activity recovery after exercise could be impaired by a decrease in renal function.

Optimal initial treatment and clinical outcome of type A aortic intramural hematoma: a clinical review.

Intramural hematoma (IMH) of the aorta is a well-known variant of aortic dissection; however, the optimal initial treatment strategy for type A IMH remains controversial. An English language search of Medline for manuscripts on the treatments and outcomes of IMH with the keywords 'intramural hematoma', 'ascending aorta or type A', 'aortic disease' with cross-references was performed for articles dating from January 1986 to September 2006. Primary outcomes of interest were initial treatment strategies as well as the early and overall mortality rates. Earlier publications studying overlapping patient groups from the same institutions were excluded. Case reports and small series of less than 10 patients were not enrolled. Data from 328 reported cases in 12 studies were extracted. Initial surgery and medical treatment were performed for 168 (51.2%) and 160 (48.8%) patients, respectively. Nine out of 12 studies (75%) came from Asia. The early mortality rate was 10.1% (17/168) and 14.4% (23/160) in patients who received initial surgery and medical treatment, respectively (p=0.37). The optimal initial treatment strategy for type A IMH may still be individualized. Initial medical treatment and timed surgical therapy seems to be associated with higher early mortality rates in patients with type A IMH, even in a primarily Asian cohort. The impact of either initial treatment strategy on long-term survival must be evaluated in further study.

Isolated right ventricular intracavitary metastasis of hepatocellular carcinoma in a 74-year-old woman.

A 74-year-old woman with a history of chronic hepatitis C and transcatheter arterial chemoembolization for an unresectable hepatocellular carcinoma (HCC) 2 years previously presented with progressive exertional dyspnea of 1 month's duration. Two-dimensional echocardiography revealed a huge right ventricular mass with right atrial and right ventricular outflow tract extension. Palliative resection of the tumor and adjunctive chemotherapy was performed. However, the right ventricular mass recurred 1 month later and the patient died 4 months after the operation. To our knowledge, this is the oldest patient reported with isolated right ventricular intracavitary metastasis of HCC, and this report reemphasizes the lower surgical indication in patients with metastatic cardiac tumors.

Comparison of the risk of left ventricular free wall rupture in Taiwanese patients with ST-elevation acute myocardial infarction undergoing different reperfusion strategies: A medical record review study.

Ventricular free wall rupture (VFWR) is the second most common cause of death in patients with acute ST-elevation myocardial infarction (STEMI). Nevertheless, few reports have investigated the factors, including different treatment strategies, associated with VFWR in Taiwanese patients. Therefore, the aim of this study was to compare the risk of VFWR in Taiwanese patients with acute STEMI who had received primary percutaneous coronary intervention (PCI), rescue PCI, scheduled PCI, thrombolytic therapy, and pharmacologic treatment. In this medical records review study, records of patients with acute STEMI admitted to a regional hospital in south Taiwan between March 1999 and October 2013 were screened. Multivariate stepwise logistic regression analysis was used to evaluate the association between the risk of VFWR and its independent factors. The overall incidence of VFWR among the 1545 patients with acute STEMI in this study was 1.6%. Compared with primary PCI, the risk of VFWR was significantly higher in patients who had received thrombolysis (adjusted odds ratio = 6.83, P = 0.003) or pharmacologic treatment alone (adjusted odds ratio = 3.68, P = 0.014). The risk of VFWR in patients receiving rescue PCI or scheduled PCI was not significantly different from that in patients receiving primary PCI. In addition, older age and Killip class >I were associated with an increased risk of VFWR in patients with acute STEMI, whereas the use of angiotensin-converting enzyme inhibitors was associated with a lower risk of VFWR. In conclusion, findings from this medical record review study provide support for the use of primary PCI, rescue PCI, and scheduled PCI over thrombolytic therapy and pharmacologic treatment in reducing the risk of VFWR in Taiwanese patients with acute STEMI.

Nontraumatic avulsion of aortic valve commissure as a cause of acute aortic valve regurgitation: A case report.

BACKGROUND: Avulsion of the aortic valve commissure as a cause of acute aortic valve regurgitation is mostly due to trauma, infective endocarditis, or ascending aortic dissection. Nontraumatic avulsion of the aortic valve commissure is very rare. We reviewed the literature and analyzed potential risk factors of nontraumatic avulsion. CASE PRESENTATION: An 80-year-old male with hypertension was seen in the emergency department with acute onset dyspnea. Echocardiogram revealed left ventricular hypertrophy with adequate systolic function, prolapse of the noncoronary cusp, and incomplete coaptation of the right coronary and noncoronary cusps with severe aortic valve regurgitation. Surgery revealed an avulsion between the left coronary and noncoronary cusps. Histopathology examination of the aortic valve showed myxoid degeneration, fibrosis, and calcification. Examination of the ascending aorta revealed myxoid degeneration and fragmentation of elastic fibers. Aortic valve replacement was performed, and the patient was alive and well 4 years after surgery. A review of the literature showed that more than three-fourths of the similar cases occurred in males, and about half in patients with hypertension and those 60 years of age or older. CONCLUSIONS: In the case of acute aortic regurgitation without a history of trauma, infection, or valvotomy, when 2 prolapsed aortic cusps are observed by echocardiography in the absence of an intimal tear of the ascending aorta, an avulsion of the aortic commissure should be suspected, especially in males with hypertension who are 60 years of age or older.

Effects of habitual t'ai chi exercise on adiponectin, glucose homeostasis, lipid profile, and atherosclerotic burden in individuals with cardiovascular risk factors.

OBJECTIVES: A single bout of t'ai chi (TC) exercise was previously found to be associated with a significant increase in post-exercise adiponectin levels in individuals with cardiovascular risk factors. The objective of this study was to examine the long-term effects of 24-month habitual TC exercise on adiponectin levels, glucose homeostasis, lipid profile, and atherosclerotic burden in individuals with cardiovascular risk factors. DESIGN: This was a prospective observational study. SETTINGS/LOCATION: The study was conducted at a regional hospital in south Taiwan. SUBJECTS: Participants of a TC exercise program held by the clinics of cardiology and cardiovascular surgery for individuals with cardiovascular diseases were recruited to the TC group. Individuals who did not join the program were recruited as controls. All study subjects had at least one cardiovascular risk factor. INTERVENTIONS: Ninety-minute session of Yang's style TC at least once a week. OUTCOME MEASURES: Measurements on adiponectin, glucose homeostasis, lipid profile, and atherosclerotic burden were made at three time points-baseline, 12 months, and 24 months. Two-way repeated-measures general linear model was used to assess the changes over the study period between the TC and control groups. RESULTS: Thirty-seven patients in both the TC and control groups completed the study. The TC group showed a greater increase in natural logarithmic transformed (Ln) adiponectin values than the control group over the study period (interaction effect p=0.009). Glucose homeostasis, lipid profile, risk of atherosclerosis, and atherosclerotic burden did not showed significant changes with TC compared with the controls over the 24-month period. CONCLUSIONS: The results of the present study indicate that for individuals with at least one cardiovascular risk factor, engaging in habitual TC exercise could lead to favorable changes in levels of adiponectin. The association between habitual TC and cardiovascular events and diabetic complications will require further investigations.

Oxaliplatin-induced acquired long QT syndrome with torsades de pointes and myocardial injury in a patient with dilated cardiomyopathy and rectal cancer.

A 67-year-old woman presented with a history of dilated cardiomyopathy with congestive heart failure since 2003, who subsequently developed lower rectal cancer (adenocarcinoma) with liver, bone, and lymph node metastasis. Abdominoperineal resection and hepatectomy were performed. The patient received two rounds of intravenous chemotherapy, including 12 and six courses of FOLFOX4 (5-fluorouracil, leucovorin, and oxaliplatin; 85 mg/m(2) per cycle). She underwent a third round of intravenous FOLFOX4 because of tumor progression. During the 21(st) course of FOLFOX4 regimen, the patient developed ST segment depression in lead II and prolongation of QT interval with polymorphic ventricular tachycardia, torsades de pointes right after the start of oxaliplatin infusion. Immediate defibrillation and cardiopulmonary resuscitation were administered, and the patient regained spontaneous circulation and consciousness. Twelve-lead electrocardiogram showed ST segment elevation in III, aVF, and ST segment depression in V4-6 after resuscitation. To our knowledge, prolongation of QT interval with torsades de pointes and coronary spasm with myocardial injury that were stabilized in one patient following oxaliplatin infusion has not been reported. We present a patient with these rare complications.

Ruptured aortic dissection presenting with new onset atrial fibrillation.

We report this type A aortic dissection in both ascending and descending thoracic aorta presenting with new onset atrial fibrillation. CT images confirmed the final diagnosis. The mechanism may be due to compression of the left atrium by a large haematoma.

Intravenous thrombolysis of occlusion in the middle cerebral and retinal arteries from presumed ventricular myxoma.

Background. Although thrombolytic therapy has been shown to be beneficial to stroke patients, the effectiveness of intravenous thrombolysis in ischemic stroke patients with ventricle myxoma is unknown. Case Description. A 22-year-old woman with left hemiplegia was sent to the emergency department at a teaching hospital. The magnetic resonance angiography showed occlusion of the right middle cerebral artery, and the echocardiography showed a mass in the left ventricle. Intravenous recombined tissue plasminogen activator (rt-PA) was administrated, and the postthrombolysis transcranial Doppler exam showed that her right middle cerebral artery was circulative. The patient's condition improved gradually, and no complication was observed up to 16 months of follow-up. Conclusion. Intravenous rt-PA is a reasonable treatment for stroke patients with ventricle myxoma.

Postinfarction left ventricular rupture salvaged by resuscitation induced pericardial tear.

A 73-year-old diabetic, hypertensive man sustained acute inferolateral wall myocardial infarction 2 days before a syncopal episode, and he was resuscitated on the way to the hospital and during the preoperative examination. An extensive tear of the left posterolateral pericardium with massive left hemothorax and left ventricular free wall rupture with pulsatile bleeding were found during surgery. Iatrogenic pericardial tear due to vigorous cardiac massage could temporarily relieve the pericardial tamponade due to the postinfarction ventricular rupture and allowed the timely surgery to be conducted.