Determinants of Prosthesis-Patient Mismatch after Aortic Valve Replacement-Ten-Year Cohort Data in Single Center of Taiwan.

Background: Patient-prosthesis mismatch (PPM) after surgical aortic valve replacement for severe aortic stenosis has a significant effect on survival. Few studies have identified the risk factors for PPM and related outcomes. This study investigated these risk factors and clarified the outcomes. Methods: This study enrolled consecutive patients who underwent aortic valve replacement surgery between January 2010 and June 2020 in our hospital. Data on clinical profiles, prosthesis types, echocardiographic parameters before and after surgery, and clinical outcomes including the composite of all-cause mortality and redo valve replacement were collected. We defined moderate and severe PPM as an effective orifice area index value of ≤ 0.85 and ≤ 0.65 cm2/m2, respectively, measured postoperatively through echocardiography. Potential risk factors for PPM and clinical outcomes were evaluated. Results: A total of 185 patients were enrolled. Body surface area (BSA; 1.68 ± 0.02 vs. 1.62 ± 0.01 m2, p = 0.036), renal insufficiency (32.50% vs. 11.70%, p = 0.026), and aortic annulus diameter (1.99 ± 0.05 vs. 2.17 ± 0.03 cm, p = 0.013) were statistically significant risk factors for severe PPM. The primary outcome was observed in 30.00% and 15.86% of the patients with and without severe PPM, respectively (log-rank p = 0.023). Multivariate Cox proportional hazards analysis indicated that severe PPM was a risk factor for the primary outcome (hazard ratio: 2.688, 95% confidence interval: 1.094-6.622, p = 0.031). Conclusions: Our study demonstrated that large BSA, renal insufficiency, and small annulus diameter were risk factors for severe PPM after aortic valve replacement surgery. Severe PPM was associated with worse clinical outcomes.

Underestimating the Risk of an Inconclusive Result in Exercise Treadmill Tests for Patients With Suspected Ischemic Heart Disease.

BACKGROUND: The exercise stress test is a widely used noninvasive test for diagnosing ischemic heart disease. Patients with a "positive" result have a higher risk than those with a "negative" result. However, the outcomes of patients with an "inconclusive" result remain uncertain.Methods and Results: We retrospectively collected the data of patients who underwent an ECG-based treadmill stress test between August 2009 and March 2020. Propensity score matching (PSM) was performed to adjust for confounders. Clinical outcomes were compared in terms of all-cause death and cardiovascular (CV) death. Subgroup analysis evaluated treatment interactions, including medication and examinations. In total, 25,475 patients were recruited, and after exclusion and PSM, 4,847 (1,621 with a positive result, 1,606 with a negative result, and 1,621 with an inconclusive result) remained. Compared with the negative group, the inconclusive group, but not the positive group, had a significantly worse outcome in terms of all-cause death (hazard ratio [HR]: 1.834, 95% confidence interval [CI]: 1.34-2.511 and HR: 1.327, 95% CI: 0.949-1.857, respectively); however, CV death was not significantly different in the inconclusive and positive groups (HR: 1.728, 95% CI: 0.413-7.232 and HR: 2.067, 95% CI: 0.517-8.264, respectively). CONCLUSIONS: Clinicians must not underestimate the potential for worse outcomes in patients with an inconclusive stress test result.

Application of genetic risk score for in-stent restenosis of second- and third-generation drug-eluting stents in geriatric patients.

BACKGROUND: The second-and third-generation drug-eluting stents (DESs) in-stent restenosis (ISR) genetic risk score (GRS) model has been previously validated. However, the model has not been validated in geriatric patients. Therefore, we conducted this study to test the feasibility of the DES-ISR GRS model in geriatric patients with coronary artery disease (CAD) in Taiwan. METHODS: We conducted a retrospective, single-center cohort study and included geriatric patients (age ≥ 65 years) with CAD and second-or third-generation DES(s) deployment. Patients undergoing maintenance dialysis were excluded. ISR was defined as ≥ 50% luminal narrowing on the follow-up coronary arteriography. The DES-ISR GRS model included five selected exonic single-nucleotide polymorphisms (SNPs): CAMLG, GALNT2, C11orf84, THOC5, and SAMD11. The GRS was defined as the sum of the five selected SNPs for the risk allele. RESULTS: We enrolled 298 geriatric patients from January 2010 and December 2019 in this study. After propensity score matching, there were 192 geriatric patients with CAD in the final analysis, of which 32 patients had ISR. Patients were divided into two groups based on their GRS values: low (0-2) and high (≥ 3) GRS. A high GRS was significantly associated with DES-ISR in geriatric patients. CONCLUSION: Those geriatric patients with a high GRS had significantly higher second-or third-generation DES ISR rates. The five SNP-derived DES-ISR GRS model could provide genetic information for interventional cardiologists to treat geriatric patients with CAD. TRIAL REGISTRATION: The primary study protocol was registered with clinicaltrials.org. with registration number: NCT03877614; on March 15, 2019. ( http://clinicaltrials.gov/ct2/show/NCT03877614 ).

Management of Restenosis after Stenting in Left Main Coronary Artery Disease.

Background: The optimal alternative treatment strategy to coronary artery bypass graft surgery (CABG) for in-stent restenosis (ISR) in left main (LM) coronary artery disease remains uncertain. Methods: We retrospectively screened all intervention reports from an intervention database and extracted those mentioning an LM stent. We then manually confirmed reports involving LM ISR and divided them into two groups, those in which the patient received a new drug-eluting stent (new-DES) strategy, and those in which the patient received a drug-coated balloon (DCB) only. A composite endpoint of major adverse cardiovascular events (MACEs) and each individual endpoint were compared. We also performed a brief analysis of similar designed studies. Results: Between the new-DES (n = 40) and DCB-only (n = 22) groups, during median respective follow-up times of 581.5 and 642.5 days, no significant statistical differences were detected in MACEs (50.0% vs. 50.0%, p = 0.974), cardiovascular death (27.5% vs. 13.6%, p = 0.214), nonfatal myocardial infarction (30.0% vs. 31.8%, p = 0.835), or target lesion revascularization (35.0% vs. 45.5%, p = 0.542). We analyzed four similar studies and found comparable MACE findings (odds ratio: 0.85, 95% CI: 0.44-1.67). Conclusions: Our findings support both DCB angioplasty and repeat DES implantation for LMISR lesions in patients who were clinically judged to be unsuitable for CABG; the treatments achieved comparable clinical results in terms of MACEs in the medium term.

Risk Factors for QT Prolongation in Patients with Chronic Hydroxychloroquine Use.

Background: Hydroxychloroquine is used as an antimalarial and immunomodulator, however it can induce QT prolongation that could potentially lead to fatal arrhythmia. We investigated changes in QT interval in long-term hydroxychloroquine users, and identified possible risk factors associated with significant QTc prolongation. Methods: We retrospectively enrolled 3603 patients who received long-term hydroxychloroquine treatment from 2009 to 2019, of whom 167 had electrocardiography (ECG) results before and during hydroxychloroquine therapy. Baseline characteristics, laboratory data, comorbidities, concurrent medications, and related clinical outcomes were reviewed. Results: Overall, 225 patients (6.2%) died within the study period, with 50 patients (1.4%) continuously receiving hydroxychloroquine treatment until death. Three patients had fatal ventricular arrhythmia. No significant change in corrected QT interval (QTc) was noted before and during hydroxychloroquine treatment (451.1 ± 39.9 ms vs. 456.0 ± 37.3 ms, P = 0.140) in the ECG cohort. Multivariable logistic regression showed that diabetes mellitus [odds ratio (OR): 9.55, 95% confidence interval (CI): 2.02-45.22; P = 0.005] and use of additional QT-prolonging drugs (OR: 2.89, 95% CI: 1.40-5.94; P = 0.004) were independent risk factors for significant QTc prolongation. Multiple linear regression, with the number of QT-prolonging drugs and comorbidities including diabetes mellitus, hypertension, and atrial fibrillation as explanatory variables, predicted QTc response (adjusted R2 = 0.385) in the long-term hydroxychloroquine users. Conclusions: In the long-term users of hydroxychloroquine, those with diabetes mellitus and concurrent use of additional QT-prolonging drugs were at a higher risk of significant QTc prolongation. Baseline QTc interval, concurrent medications, and comorbidities predicted QTc response.

Automated Recognition of Regional Wall Motion Abnormalities Through Deep Neural Network Interpretation of Transthoracic Echocardiography.

BACKGROUND: Automated interpretation of echocardiography by deep neural networks could support clinical reporting and improve efficiency. Whereas previous studies have evaluated spatial relationships using still frame images, we aimed to train and test a deep neural network for video analysis by combining spatial and temporal information, to automate the recognition of left ventricular regional wall motion abnormalities. METHODS: We collected a series of transthoracic echocardiography examinations performed between July 2017 and April 2018 in 2 tertiary care hospitals. Regional wall abnormalities were defined by experienced physiologists and confirmed by trained cardiologists. First, we developed a 3-dimensional convolutional neural network model for view selection ensuring stringent image quality control. Second, a U-net model segmented images to annotate the location of each left ventricular wall. Third, a final 3-dimensional convolutional neural network model evaluated echocardiographic videos from 4 standard views, before and after segmentation, and calculated a wall motion abnormality confidence level (0-1) for each segment. To evaluate model stability, we performed 5-fold cross-validation and external validation. RESULTS: In a series of 10 638 echocardiograms, our view selection model identified 6454 (61%) examinations with sufficient image quality in all standard views. In this training set, 2740 frames were annotated to develop the segmentation model, which achieved a Dice similarity coefficient of 0.756. External validation was performed in 1756 examinations from an independent hospital. A regional wall motion abnormality was observed in 8.9% and 4.9% in the training and external validation datasets, respectively. The final model recognized regional wall motion abnormalities in the cross-validation and external validation datasets with an area under the receiver operating characteristic curve of 0.912 (95% CI, 0.896-0.928) and 0.891 (95% CI, 0.834-0.948), respectively. In the external validation dataset, the sensitivity was 81.8% (95% CI, 73.8%-88.2%), and specificity was 81.6% (95% CI, 80.4%-82.8%). CONCLUSIONS: In echocardiographic examinations of sufficient image quality, it is feasible for deep neural networks to automate the recognition of regional wall motion abnormalities using temporal and spatial information from moving images. Further investigation is required to optimize model performance and evaluate clinical applications.

Post cardiac injury syndrome successfully treated with medications: a report of two cases.

BACKGROUND: Post cardiac injury syndrome (PCIS) is induced by myocardial infarction or cardiac surgery, as well as minor insults to the heart such as percutaneous coronary intervention (PCI), or insertion of a pacing lead. PCIS is characterized by pericarditis after injury to the heart. The relatively low incidence makes differential diagnosis of PCIS after PCI or implantation of a pacemaker a challenge. This report describes two typical cases of PCIS. CASE PRESENTATION: The first patient presented with signs of progressive cardiac tamponade that occurred two weeks after implantation of a permanent pacemaker. Echocardiography confirmed the presence of a moderate amount of newly-formed pericardial effusion. The second patient underwent PCI for the right coronary artery. However, despite an uneventful procedure, the patient experienced dyspnea, tightness of chest and cold sweats, and bradycardia two hours after the procedure. Echocardiography findings, which showed a moderate amount of newly-formed pericardial effusion, suggested acute cardiac tamponade, and compromised hemodynamics. Both patients recovered with medication. CONCLUSION: These cases illustrated that PCIS can occur after minor myocardial injury, and that the possibility of PCIS should be considered if there is a history of possible cardiac insult.

Carotid vascular strain predicts cardiovascular events in patients with hypertension.

BACKGROUND: We aim to investigate prognostic effects of carotid strain (CS) and strain rate (CSR) in hypertension. METHODS: We prospectively recruited 120 patients being treated for hypertension (65.8 ± 11.8 years, 58% male) in this observational study. Peak circumferential CS and peak CSR after ejection were identified using two-dimensional speckle tracking ultrasound. Major cardiovascular events were any admission for stroke, acute coronary syndrome, and heart failure. RESULTS: After a mean follow-up period of 63.6 ± 14.5 months, 14 (12%) patients had cardiovascular events. Age (75.3 ± 9.2 vs 64.6 ± 11.6 years; p = 0.001), systolic blood pressure (131.8 ± 15.5 vs 143.1 ± 16.6 mm Hg; p = 0.021), diastolic blood pressure (74.6 ±11.4 vs 82.1 ± 12.2 mm Hg; p = 0.039), use of diuretics (71 vs 92%; p = 0.014), carotid CS (2.17 ± 1.02 vs 3.28 ± 1.14 %; p = 0.001), and CSR (.28 ± .17 vs .51 ± .18 1/s; p < 0.001) were significantly different between the patients who did and did not reach the end-points. Multivariate Cox regression analysis controlling for age, systolic blood pressure, diastolic blood pressure, and use of diuretics showed that CS (HR .425, 95%CI .223-.811, p = 0.009) and CSR (HR .001, 95%CI .000-.072, p = 0.001) were independent predictors for cardiovascular events. CONCLUSION: In conclusions, decreased CS and CSR were associated with cardiovascular events in hypertension.

Reduced-Dose Prasugrel versus Clopidogrel for Patients Undergoing Percutaneous Coronary Intervention.

Whether reduced-dose prasugrel has a better efficacy or safety than standard-dose clopidogrel remains unknown in patients undergoing percutaneous coronary intervention (PCI).A systematic search of PubMed, EMBASE, Google Scholar, and Cochrane Library from database inception to May 1, 2020 was performed to compare the clinical outcomes in patients with acute coronary syndrome or stable coronary artery disease undergoing PCI between those treated with reduced-dose prasugrel and clopidogrel. The pooled odds ratio (OR) and 95% confidence interval (CI) were calculated using the fixed-effect or random-effect model if significant heterogeneity was observed. The primary efficacy endpoint was major adverse cardiovascular events (MACE), including cardiovascular (CV) death, myocardial infarction (MI), or ischemic stroke. The primary safety endpoint was all bleeding events.Overall, seven studies with 32,951 patients with PCI were included in the analysis. Reduced-dose prasugrel was associated with a lower risk of MACE than clopidogrel (OR 0.80, 95% CI 0.67-0.97). Except for MI (OR 0.74, 95% CI 0.56-0.98), the secondary efficacy endpoints of CV death, ischemic stroke, all-cause death, and stent thrombosis were similar. For the primary safety endpoint of all bleeding events, there was no significant difference between reduced-dose prasugrel and clopidogrel (OR 1.31, 95% CI 0.87-1.98), but the risk of minor bleeding was significantly higher in reduced-dose prasugrel (OR 1.73, 95% CI 1.25-2.41).In patients undergoing PCI, a lower risk of MACE was found in patients receiving reduced-dose prasugrel than in those with clopidogrel, but a higher risk of minor bleeding events was noted.

Asclepius and Yellow Ribbon techniques: Efficacious alternative strategies for advancing a coronary sinus electrophysiology catheter.

BACKGROUND: Inserting an electrophysiological (EP) catheter into the coronary sinus (CS) via the femoral vein can be difficult and time-consuming in patients with variants of the CS orifice or lumen curve. Our experience with such patients inspired us to develop two new techniques: the Asclepius and Yellow Ribbon techniques. METHODS: Data from a 4-year period were retrieved from records of patients undergoing radiofrequency ablation for paroxysmal supraventricular tachycardia (PSVT) or Wolff-Parkinson-White (WPW) syndrome. Data were analyzed to determine the success and complication rates of conventional and alternative techniques for catheter placement. RESULTS: The success rate of the Asclepius technique was 96.7% (30/31) and that of the Yellow Ribbon technique was 100.0% (7/7). The overall success rate of these two techniques was 97.3% (37/38). CONCLUSIONS: With a high success rate, shorter procedure time, and no complications, the Asclepius and Yellow ribbon techniques may be safe, inexpensive, and effective alternative strategies for EP catheter placement in patients with difficult coronary sinus orifice access.

Application of an Artificial Intelligence Trilogy to Accelerate Processing of Suspected Patients With SARS-CoV-2 at a Smart Quarantine Station: Observational Study.

BACKGROUND: As the COVID-19 epidemic increases in severity, the burden of quarantine stations outside emergency departments (EDs) at hospitals is increasing daily. To address the high screening workload at quarantine stations, all staff members with medical licenses are required to work shifts in these stations. Therefore, it is necessary to simplify the workflow and decision-making process for physicians and surgeons from all subspecialties. OBJECTIVE: The aim of this paper is to demonstrate how the National Cheng Kung University Hospital artificial intelligence (AI) trilogy of diversion to a smart quarantine station, AI-assisted image interpretation, and a built-in clinical decision-making algorithm improves medical care and reduces quarantine processing times. METHODS: This observational study on the emerging COVID-19 pandemic included 643 patients. An "AI trilogy" of diversion to a smart quarantine station, AI-assisted image interpretation, and a built-in clinical decision-making algorithm on a tablet computer was applied to shorten the quarantine survey process and reduce processing time during the COVID-19 pandemic. RESULTS: The use of the AI trilogy facilitated the processing of suspected cases of COVID-19 with or without symptoms; also, travel, occupation, contact, and clustering histories were obtained with the tablet computer device. A separate AI-mode function that could quickly recognize pulmonary infiltrates on chest x-rays was merged into the smart clinical assisting system (SCAS), and this model was subsequently trained with COVID-19 pneumonia cases from the GitHub open source data set. The detection rates for posteroanterior and anteroposterior chest x-rays were 55/59 (93%) and 5/11 (45%), respectively. The SCAS algorithm was continuously adjusted based on updates to the Taiwan Centers for Disease Control public safety guidelines for faster clinical decision making. Our ex vivo study demonstrated the efficiency of disinfecting the tablet computer surface by wiping it twice with 75% alcohol sanitizer. To further analyze the impact of the AI application in the quarantine station, we subdivided the station group into groups with or without AI. Compared with the conventional ED (n=281), the survey time at the quarantine station (n=1520) was significantly shortened; the median survey time at the ED was 153 minutes (95% CI 108.5-205.0), vs 35 minutes at the quarantine station (95% CI 24-56; P<.001). Furthermore, the use of the AI application in the quarantine station reduced the survey time in the quarantine station; the median survey time without AI was 101 minutes (95% CI 40-153), vs 34 minutes (95% CI 24-53) with AI in the quarantine station (P<.001). CONCLUSIONS: The AI trilogy improved our medical care workflow by shortening the quarantine survey process and reducing the processing time, which is especially important during an emerging infectious disease epidemic.

Comparison of Minimally Invasive Thrombectomy with Percutaneous Balloon Angioplasty for Organized Thrombi in Hemodialysis Access.

BACKGROUND: Thrombi are an important challenge when establishing hemodialysis access for hemodialysis. We developed a minimally invasive thrombectomy (MIT) salvage treatment to solve this problem when traditional percutaneous transluminal angioplasty (PTA) fails. OBJECTIVES: The study aimed to investigate the safety and patency rate following MIT as a rescue procedure for traditional PTA with organized thrombi obstructing hemodialysis access. METHODS: This was a prospective study of MIT as a rescue procedure for traditional PTA to remove organized thrombi and establish hemodialysis access. We included patients with (1) stenotic lesions, (2) vascular access thrombi, (3) high venous pressure, (4) vascular collapse and suction. Nephrologists evaluated hemodialysis access immediately post-thrombi removal and patency at 7, 30, 60, 120, and 180 days post-removal, in addition to complications. Kaplan-Meier survival analysis was performed to analyze the primary and secondary patency rates after clinical procedural success. RESULTS: From June 2014 to May 2015, 746 patients underwent PTA in our hospital, and 425 patients consented to participate in this study. Of these patients, we enrolled 46 who underwent simultaneous PTA and MIT. Immediate clinical success was achieved in 100% of the patients in the MIT group. No complications were observed in any of the 46 patients, including major bleeding, shock, or hospitalization. The primary and secondary patency rates did not differ between MIT and PTA alone (p = 0.93 and p = 0.28, respectively). CONCLUSIONS: MIT can be considered a safe rescue procedure for removing organized thrombi to establish vascular access for hemodialysis when initial and traditional PTA fails.

The Efficacy and Safety of Using Extension Catheters in Complex Coronary Interventions: A Single Center Experience.

BACKGROUND: The extension catheter was originally developed to facilitate stent delivery to challenging lesions. We evaluated the efficacy and safety of using an extension catheter in patients undergoing percutaneous coronary interventions (PCI). METHODS: Two interventional cardiologists reviewed the records of all consecutive patients who, between November 2011 and October 2015, had undergone PCI with a GuideLiner or Heartrail ST-01 extension catheter. Clinical demographics, vessel characteristics, procedural details, and outcomes were recorded. RESULTS: We identified 136 (3.7%) eligible patients (male: 81.6%; mean age: 66.2 ± 11.2 years) in 3665 PCI procedures. Seventy-two (52.9%) cases required increased support to cross severely calcified lesions. The remainder were coronary tortuosity [47 (34.6%)], chronic total occlusions [35 (25.7%)], previously deployed proximal stents [16 (11.8%)], and anomalous origin of coronary artery [9 (6.6%)]. There were 43 type B and 91 type C lesions. The success rate was 86.8% (118) and the complication rate was 6.6% (7 coronary dissections, 1 thrombus formation, and 1 stent dislodgement). All complications were successfully managed using endovascular interventions. The failure rate significantly (25.5%) increased if more than 3 of 6 peri-procedural factors coexisted: 1) long lesions (> 30 mm), 2) tortuosity, 3) calcification, 4) chronic total occlusion, 5) previous intervention history, and 6) previously deployed proximal stents. CONCLUSIONS: Using an extension catheter for challenging complex PCIs is safe and highly successful if the practitioner has adequate experience manipulating extension catheters.

Aortic dissection extending into the interventricular septum following redo aortic valve replacement surgery in a patient with Takayasu's arteritis: a rare case report.

Background: Takayasu's arteritis is an infrequent manifestation of vasculitis affecting the aorta and its primary branches with numerous symptoms. This report details a rare case wherein a patient developed interventricular septal dissection following aortic valve replacement. Case summary: A middle-aged woman diagnosed with Takayasu's arteritis previously underwent aortic valve replacement with a mechanical valve owing to severe aortic regurgitation. Subsequently, she received a redo aortic valve replacement following an episode of prosthetic valve infective endocarditis with paravalvular leak. Heart failure symptoms emerged during follow-up, revealing aortic root dissection extending into the interventricular septum, causing significant prosthetic valve movement. A Trido Bentall operation and interventricular septum repair were performed, and the patient recovered smoothly. Discussion: Interventricular dissection, although uncommon, may be due to factors such as infection, myocardial infarction, congenital anomalies, trauma, or post-surgical shear stress. Timely diagnosis is imperative to prevent life-threatening complications; surgery remains the primary treatment. The present case report describes a rare presentation that was successfully managed through a Bentall operation and underscores the necessity of prompt intervention in treating this condition.

High premature atrial complex burden and risk of renal function decline.

Background: Atrial arrhythmia, particularly atrial fibrillation (AF), is known to be associated with renal function decline and increased risk of end-stage kidney disease. In recent years, premature atrial complexes (PACs) as subclinical arrhythmia have been proposed to be a marker of atrial cardiomyopathy and associated with poor clinical outcomes. However, the relationship between excessive daily PAC burden and renal outcomes remains unexplored. Methods: This retrospective, all-comers cohort study analyzed 30 488 consecutive Holter monitoring records obtained from a validated Holter databank at a referral medical center in Taiwan between 2011 and 2018. After exclusion, 10 981 patients were categorized into three groups: high daily PAC burden (≥100 beats per day), low PAC burden (<100 beats per day) and the AF group. We used parallel propensity score matching to balance confounding factors between groups. The primary study interest was major adverse kidney events, including an estimated glomerular filtration rate (eGFR) decline of 40%, eGFR <15 mL/min/1.73 m2 or the initiation of hemodialysis. Results: After a mean follow-up of 4.07 ± 3.03 years, patients with high PAC burden had a 1.24-fold higher incidence of major adverse kidney events compared with the low PAC burden group [95% confidence interval (CI) 1.03-1.50]. The risk of major adverse kidney events was similar between patients with AF and those with high PAC burden [adjusted hazard ratio (HR) 1.05, 95% CI 0.87-1.25], but significantly higher in the AF group than in the low PAC burden group (adjusted HR 1.29, 95% CI 1.07-1.56). Conclusion: Excessive daily PAC burden is associated with a higher risk of major adverse kidney events and has a comparable impact as AF.

Significance of strictly defined idiopathic tricuspid regurgitation.

BACKGROUND: Moderate to severe tricuspid regurgitation (TR) is known to cause right ventricular (RV) failure and death. Although TR is traditionally classified as primary or secondary, recently, a new class of TR called idiopathic TR has been proposed, with varying definitions among different studies. METHODS: The data were retrospectively collected for the period of January to June 2018 for 8711 patients from the patient cohort of the National Cheng Kung University Hospital echocardiography laboratory. A total of 670 patients (7.7%) with moderate-to-severe TR were included. Idiopathic TR was diagnosed strictly using a new systematic approach. RESULTS: The distribution of significant TR included 74 (11.0%) primary TR cases, 48 (7.2%) with pacemaker-related TR, 267 (39.9%) with left heart disease, 24 (3.6%) with congenital heart disease, 6 (0.9%) with RV myopathy, 105 (15.7%) with pulmonary hypertension, and 146 (21.8%) with idiopathic TR. The mean age in primary and idiopathic TR groups was older ( p = 0.004), with lower estimated pulmonary pressure ( p < 0.001), higher RV fraction area change (FAC, p < 0.001), and tricuspid annulus systolic velocity (S', p = 0.004) compared with functional TR group. Multivariate analysis showed that idiopathic TR ( p = 0.002) and primary TR ( p = 0.008) had better RV FAC than functional TR. CONCLUSION: Idiopathic TR was associated with better RV function than the other secondary TRs. Thus, idiopathic TR should be strictly defined and regarded as a distinct type of TR.

The Beneficial Effects of Beta Blockers on the Long-Term Prognosis of Patients With Premature Atrial Complexes.

AIMS: Premature atrial complexes (PACs) have been reported to increase the risk of adverse cardiovascular outcomes. Beta blockers at low dosages may help to reduce PAC symptoms, but it is unclear whether they can improve long-term outcomes. METHODS: Patients enrolled from a Holter cohort in a medical referral center were stratified into high-burden (≥100 beats/24 h) and low-burden (<100 beats/24 h) sub-cohorts, and propensity score matching between treatment groups and non-treatment groups was conducted for each sub-cohort. RESULTS: In the high-burden sub-cohort, after propensity score matching, the treatment group and non-treatment group respectively had 208 and 832 patients. The treatment group had significantly lower mortality rates than the non-treatment group [hazard ratio (HR) = 0.521, 95% confidence interval (CI) = 0.294-0.923, p = 0.025], but there was no difference in new stroke (HR = 0.830, 95% CI = 0.341-2.020, p = 0.681), and new atrial fibrillation (HR = 1.410, 95% CI = 0.867-2.292, p = 0.167) events. In the low-burden sub-cohort, after propensity score matching, there were 614 patients in the treatment group and 1,228 patients in the non-treatment group. Compared to the non-treatment group, up to 40% risk reduction in mortality was found in the treatment group (HR = 0.601, 95% CI = 0.396-0.913, p = 0.017), but no differences in new stroke (HR =0.969, 95% CI = 0.562-1.670, p = 0.910) or atrial fibrillation (HR = 1.074, 95% CI = 0.619-1.863, p = 0.800) were found. CONCLUSIONS: Beta blockers consistently decreased long-term mortality in high-burden and low-burden patients. Interestingly, this effect was not achieved through reduction of new-onset stroke or AF, and further research is warranted.

Higher premature atrial complex burden from the Holter examination predicts poor cardiovascular outcome.

Premature atrial complexes (PACs) have been suggested to increase the risk of adverse events. The distribution of PAC burden and its dose-response effects on all-cause mortality and cardiovascular death had not been elucidated clearly. We analyzed 15,893 patients in a medical referral center from July 1st, 2011, to December 31st, 2018. Multivariate regression driven by ln PAC (beats per 24 h plus 1) or quartiles of PAC burden were examined. Older group had higher PAC burden than younger group (p for trend < 0.001), and both genders shared similar PACs distribution. In Cox model, ln PAC remained an independent risk factor for all-cause mortality (hazard ratio (HR) = 1.09 per ln PAC increase, 95% CI = 1.06‒1.12, p < 0.001). PACs were a significant risk factor in cause-specific model (HR = 1.13, 95% CI = 1.05‒1.22, p = 0.001) or sub-distribution model (HR = 1.12, 95% CI = 1.04‒1.21, p = 0.004). In ordinal PAC model, 4th quartile group had significantly higher risk of all-cause mortality than those in 1st quartile group (HR = 1.47, 95% CI = 1.13‒1.94, p = 0.005), but no difference in cardiovascular death were found in competing risk analysis. In subgroup analysis, the risk of high PAC burden was consistently higher than in low-burden group across pre-specified subgroups. In conclusion, PAC burden has a dose response effect on all-cause mortality and cardiovascular death.

The impact of permanent pacemaker implantation on thallium myocardial perfusion examination detecting ischemic heart disease.

OBJECTIVES: Patients with permanent pacemaker (PPM) implantation may have altered coronary perfusion patterns that may influence the accuracy of myocardial perfusion examination modalities, which was observed in previous studies but with limited statistic power. Our aim was to examine the performance of thallium-201 (TL-201) myocardial perfusion examination in patients with implanted PPM. METHODS: Data of consecutive patients from our institution who had coronary angiography examination followed by TL-201 myocardial perfusion examination in pairs within 1 year were collected between January 2010 and December 2016 and were divided into PPM and control groups. Propensity score matching (PSM) was performed to compare the positive predictive value (PPV) of perfusion examinations. RESULTS: A total of 934 pairs of studies were evaluated, with 81 in the PPM group and 853 controls. The PPV decreased significantly in the PPM group (28.2 vs. 62.9%, P < 0.001). The finding of large (>20%) ischemic areas correlated significantly with all-cause mortality in the control group (OR, 2.34; P = 0.001), but not in the PPM group (OR,1.05; P = 0.943). After PSM, the PPV was still significantly lower in the PPM group than in the non-PPM group (28.6 vs. 66.2%, P < 0.001). CONCLUSION: Study results do not support the appropriateness of using TL-201 perfusion examinations for risk stratification in patients with implanted PPM.Video Abstract: http://links.lww.com/NMC/A181.

Genetic risk model for in-stent restenosis of second-and third-generation drug-eluting stents.

The new generation, i.e., second- and third-generation, drug-eluting stents (DESs) remain a risk of in-stent restenosis (ISR). We evaluated the power of a genetic risk score (GRS) model to identify high-risk populations for new generation DES ISR. We enrolled patients with coronary artery disease (CAD) treated with new generations DESs by a single-center cohort study in Taiwan and evaluated their genetic profile. After propensity score matching, there were 343 patients and 153 patients in the derivation and validation cohorts, respectively. Five selected single-nucleotide polymorphisms (SNPs), i.e., SNPs in CAMLG, GALNT2, C11orf84, THOC5, and SAMD11, were included to calculate the GRS for new generation DES ISR. In the derivation and the validation cohorts, patients with a GRS greater than or equal to 3 had significantly higher new generation DES ISR rates. We provide biological information for interventional cardiologists prior to percutaneous coronary intervention by specific five SNP-derived GRS.