Vericiguat suppresses ventricular tachyarrhythmias inducibility in a rabbit myocardial infarction model.

BACKGROUND: The VICTORIA trial demonstrated a significant decrease in cardiovascular events through vericiguat therapy. This study aimed to assess the potential mechanisms responsible for the reduction of cardiovascular events with vericiguat therapy in a rabbit model of myocardial infarction (MI). METHODS: A chronic MI rabbit model was created through coronary artery ligation. Following 4 weeks, the hearts were harvested and Langendorff perfused. Subsequently, electrophysiological examinations and dual voltage-calcium optical mapping studies were conducted at baseline and after administration of vericiguat at a dose of 5 µmol/L. RESULTS: Acute vericiguat therapy demonstrated a significant reduction in premature ventricular beat burden and effectively suppressed ventricular arrhythmic inducibility. The electrophysiological influences of vericiguat therapy included an increased ventricular effective refractory period, prolonged action potential duration, and accelerated intracellular calcium (Cai) homeostasis, leading to the suppression of action potential and Cai alternans. The pacing-induced ventricular arrhythmias exhibited a reentrant pattern, attributed to fixed or functional conduction block in the peri-infarct zone. Vericiguat therapy effectively mitigated the formation of cardiac alternans as well as the development of reentrant impulses, providing additional anti-arrhythmic benefits. CONCLUSIONS: In the MI rabbit model, vericiguat therapy demonstrates anti-ventricular arrhythmia effects. The vericiguat therapy reduces ventricular ectopic beats, inhibiting the initiation of ventricular arrhythmias. Furthermore, the therapy successfully suppresses cardiac alternans, preventing conduction block and, consequently, the formation of reentry circuits.

Comparing Artificial Intelligence-Enabled Electrocardiogram Models in Identifying Left Atrium Enlargement and Long-term Cardiovascular Risk.

BACKGROUND: The role of P-wave in identifying left atrial enlargement (LAE) with the use of artificial intelligence (AI)-enabled electrocardiography (ECG) models is unclear. It is also unknown if AI-enabled single-lead ECG could be used as a diagnostic tool for LAE surveillance. We aimed to build AI-enabled P-wave and single-lead ECG models to identify LAE using sinus rhythm (SR) and non-SR ECGs, and compare the prognostic ability of severe LAE, defined as left atrial diameter ≥ 50 mm, assessed by AI-enabled ECG models vs echocardiography. METHODS: This retrospective study used data from 382,594 consecutive adults with paired 12-lead ECG and echocardiography performed within 2 weeks of each other at Chang Gung Memorial Hospital. UNet++ was used for P-wave segmentation. ResNet-18 was used to develop deep convolutional neural network-enabled ECG models for discriminating LAE. External validation was performed with the use of data from 11,753 patients from another hospital. RESULTS: The AI-enabled 12-lead ECG model outperformed other ECG models for classifying LAE, but the single-lead ECG models also showed excellent performance at a left atrial diameter cutoff of 50 mm. AI-enabled ECG models had excellent and fair discrimination on LAE using the SR and the non-SR data set, respectively. Severe LAE identified by AI-enabled ECG models was more predictive of future cardiovascular disease than echocardiography; however, the cumulative incidence of new-onset atrial fibrillation and heart failure was higher in patients with echocardiography-severe LAE than with AI-enabled ECG-severe LAE. CONCLUSIONS: P-Wave plays a crucial role in discriminating LAE in AI-enabled ECG models. AI-enabled ECG models outperform echocardiography in predicting new-onset cardiovascular diseases associated with severe LAE.

Machine learning-based prediction of acute mortality in emergency department patients using twelve-lead electrocardiogram.

Background: The risk of mortality is relatively high among patients who visit the emergency department (ED), and stratifying patients at high risk can help improve medical care. This study aimed to create a machine-learning model that utilizes the standard 12-lead ECG to forecast acute mortality risk in ED patients. Methods: The database included patients who visited the EDs and underwent standard 12-lead ECG between October 2007 and December 2017. A convolutional neural network (CNN) ECG model was developed to classify survival and mortality using 12-lead ECG tracings acquired from 345,593 ED patients. For machine learning model development, the patients were randomly divided into training, validation and testing datasets. The performance of the mortality risk prediction in this model was evaluated for various causes of death. Results: Patients who visited the ED and underwent one or more ECG examinations experienced a high incidence of 30-day mortality [18,734 (5.42%)]. The developed CNN model demonstrated high accuracy in predicting acute mortality (hazard ratio 8.50, 95% confidence interval 8.20-8.80) with areas under the receiver operating characteristic (ROC) curve of 0.84 for the 30-day mortality risk prediction models. This CNN model also demonstrated good performance in predicting one-year mortality (hazard ratio 3.34, 95% confidence interval 3.30-3.39). This model exhibited good predictive performance for 30-day mortality not only for cardiovascular diseases but also across various diseases. Conclusions: The machine learning-based ECG model utilizing CNN screens the risks for 30-day mortality. This model can complement traditional early warning scoring indexes as a useful screening tool for mortality prediction.

Long-term efficacy of sodium-glucose cotransporter 2 inhibitor therapy in preventing atrial fibrillation recurrence after catheter ablation in type 2 diabetes mellitus patients.

Background: Sodium-glucose cotransporter 2 inhibitors (SGLT2i) reduce new-onset atrial fibrillation (AF) in patients with type 2 diabetes mellitus (T2DM). We aimed to determine the long-term effects of SGLT2i on atrial tachyarrhythmia recurrence after catheter ablation (CA) in T2DM patients. Methods: This retrospective study enrolled consecutive patients with T2DM undergoing CA for AF between January 2016 and December 2021. Patient baseline demographic characteristics and use of anti-diabetic and anti-arrhythmic medications were analyzed. Echocardiographic parameters were obtained one day and 6 months after CA. Results: Our study population comprised 122 patients (70% paroxysmal AF). The baseline patient characteristics were similar between the SGLT2i-treated group (n = 45) and the non-SGLT2i-treated group (n = 77) except for stroke. At 6-month follow-up, body-mass index (BMI) was significantly decreased and left ventricular ejection fraction (LVEF) was significantly increased only in the SGLT2i group. E/e' was decreased 6 months after CA in both groups. During a mean follow-up of 33.7 ± 21.6 months, 22 of 122 patients had atrial tachyarrhythmia recurrence. The long-term atrial tachyarrhythmia-free survival rate was significantly higher in the SGLT2i-treated patients, and multivariate analysis revealed that AF type and SGLT2i use were independently associated with atrial tachyarrhythmia recurrence after CA. Conclusion: The use of SGLT2i and AF type were independent risk factors associated with atrial tachyarrhythmia recurrence after CA in T2DM patients with AF. This result was at least partly due to the pleiotropic effects of SGLT2i on BMI reduction and left ventricular function improvement.

Artificial intelligence-enabled electrocardiographic screening for left ventricular systolic dysfunction and mortality risk prediction.

Background: Left ventricular systolic dysfunction (LVSD) characterized by a reduced left ventricular ejection fraction (LVEF) is associated with adverse patient outcomes. We aimed to build a deep neural network (DNN)-based model using standard 12-lead electrocardiogram (ECG) to screen for LVSD and stratify patient prognosis. Methods: This retrospective chart review study was conducted using data from consecutive adults who underwent ECG examinations at Chang Gung Memorial Hospital in Taiwan between October 2007 and December 2019. DNN models were developed to recognize LVSD, defined as LVEF <40%, using original ECG signals or transformed images from 190,359 patients with paired ECG and echocardiogram within 14 days. The 190,359 patients were divided into a training set of 133,225 and a validation set of 57,134. The accuracy of recognizing LVSD and subsequent mortality predictions were tested using ECGs from 190,316 patients with paired data. Of these 190,316 patients, we further selected 49,564 patients with multiple echocardiographic data to predict LVSD incidence. We additionally used data from 1,194,982 patients who underwent ECG only to assess mortality prognostication. External validation was performed using data of 91,425 patients from Tri-Service General Hospital, Taiwan. Results: The mean age of patients in the testing dataset was 63.7 ± 16.3 years (46.3% women), and 8,216 patients (4.3%) had LVSD. The median follow-up period was 3.9 years (interquartile range 1.5-7.9 years). The area under the receiver-operating characteristic curve (AUROC), sensitivity, and specificity of the signal-based DNN (DNN-signal) to identify LVSD were 0.95, 0.91, and 0.86, respectively. DNN signal-predicted LVSD was associated with age- and sex-adjusted hazard ratios (HRs) of 2.57 (95% confidence interval [CI], 2.53-2.62) for all-cause mortality and 6.09 (5.83-6.37) for cardiovascular mortality. In patients with multiple echocardiograms, a positive DNN prediction in patients with preserved LVEF was associated with an adjusted HR (95% CI) of 8.33 (7.71 to 9.00) for incident LVSD. Signal- and image-based DNNs performed equally well in the primary and additional datasets. Conclusion: Using DNNs, ECG becomes a low-cost, clinically feasible tool to screen LVSD and facilitate accurate prognostication.

Obstetric and fetal/neonatal outcomes in pregnant women with frequent premature ventricular complexes and structurally normal heart.

BACKGROUND: High premature ventricular complex (PVC) burden may increase the risk of left ventricular dysfunction and all-cause mortality. We aimed to evaluate maternal and neonatal outcomes of pregnant women with structurally normal heart having PVC burden ≥1%. METHODS: This retrospective cohort study used data from Chang Gung Research Database. Pregnancies from January 1, 2005, through June 30, 2020, with documented maternal PVC burden ≥1% by 24-h Holter monitor were identified. Pregnant women with a diagnosis of structural heart disease or arrhythmias other than PVC were excluded. We used propensity score matching (PSM) to balance the covariates between the PVC group and normal control group. The PVC group was classified into low-PVC (<10%) and high-PVC burden subgroups. The maternal and neonatal outcomes were assessed through 6 months after delivery or termination. RESULTS: After PSM, there were 214, 61, and 46 pregnant women enrolled in the normal control group, low-PVC burden, and high-PVC burden subgroups, respectively. The high-PVC and low-PVC burden subgroups had composite adverse maternal and neonatal events similar to the control group without use of antiarrhythmic drugs (AADs), but a higher proportion of placental abruption was observed in the high-PVC burden subgroup. Maternal age, diabetes, and overweight were significant predictors of composite adverse maternal events, whereas only maternal age was a significant predictor of composite adverse neonatal events. CONCLUSIONS: High PVC burden was not associated with poor composite adverse maternal and neonatal outcomes with no need of AADs therapy in pregnant women with structurally normal heart.

Left atrial booster-pump function as a predictive parameter for atrial fibrillation in patients with severely dilated left atrium.

Background: Left atrial (LA) dimension ≥50 mm had approximately four times the risk of developing atrial fibrillation (AF). The aim of this study was to investigate whether the application of clinical and echocardiographic parameters could differentiate between the patients having severely dilated left atrium with and without AF. Methods: This retrospective cross-sectional study enrolled consecutive patients with LA dimension ≥50 mm and divided them into three groups: no AF (no-AF), paroxysmal AF (PAF) and non-paroxysmal AF (non-PAF) groups. For PAF and non-PAF groups, all patients underwent radiofrequency ablation, and the echocardiographic parameters were obtained on the next day after ablation. Results: Our study population comprised 160 patients, including 80, 53, and 27 patients in the non-AF, PAF and non-PAF groups, respectively. The no-AF group had a significantly higher body mass index (kg/m2) (29.31±6.27, 27.58±4.12 and 26.57±2.81, P=0.01), and a higher prevalence of diabetes mellitus (DM) [31 (38.80%), 13 (25.00%) and 4 (14.80%), P=0.01] and hypertension [67 (83.80%), 34 (65.40%), and 19 (70.40%), P=0.04], but a lower prevalence of rheumatic heart disease (RHD) [3 (3.80%), 6 (11.50%) and 5 (18.50%), P=0.02] and sick sinus syndrome [0 (0.00%), 6 (11.50%) and 4 (14.80%), P=0.045]. Echocardiographic studies showed that the non-AF group had significantly smaller LA minimal volume index (24.89±9.74, 34.06±19.38 and 42.83±17.44 mL/m2, P<0.01), higher LA emptying fraction (51.99%±13.97%, 38.40%±15.96% and 33.89%±10.73%, P<0.01), longitudinal strain (23.87%±7.72%, 17.11%±8.52% and 12.38%±4.28%, P<0.01) and strain rate than the AF groups. The multivariate analysis showed that the late diastolic component of LA strain rate was the only independent factor associated with the presence of AF (odds ratio, 21.69; 95% CI, 9.77-48.13, P<0.01). Conclusions: LA function plays an important role in the absence of AF in patients with LA dimension ≥50 mm; the late diastolic component of LA strain rate was the only independent variable on multivariate analysis.

Clinical Outcomes of low-voltage area-guided left atrial linear ablation for non-paroxysmal atrial fibrillation patients.

BACKGROUND: The therapeutic effect of low-voltage area (LVA)-guided left atrial (LA) linear ablation for non-paroxysmal atrial fibrillation (non-PAF) is uncertain. We aimed to investigate the efficacy of LA linear ablation based on the preexisting LVA and its effects on LA reverse remodeling in non-PAF patients. METHODS: We retrospectively evaluated 145 consecutive patients who underwent radiofrequency catheter ablation for drug-refractory non-PAF. CARTO-guided bipolar voltage mapping was performed in atrial fibrillation (AF). LVA was defined as sites with voltage ≤ 0.5 mV. If circumferential pulmonary vein isolation couldn't convert AF into sinus rhythm, additional LA linear ablation was performed preferentially at sites within LVA. RESULTS: After a mean follow-up duration of 48 ± 33 months, 29 of 145 patients had drugs-refractory AF/LA tachycardia recurrence. Low LA emptying fraction, large LA size and high extent of LVA were associated with AF recurrence. There were 136 patients undergoing LA linear ablation. The rate of linear block at the mitral isthmus was significantly higher via LVA-guided than non-LVA-guided linear ablation. Patients undergoing LVA-guided linear ablation had larger LA size and higher extent of LVA, but the long-term AF/LA tachycardia-free survival rate was higher than the non-LVA-guided group. The LA reverse remodeling effects by resuming sinus rhythm were noted even in patients with a diseased left atrium undergoing extensive LA linear ablation. CONCLUSIONS: LVA-guided linear ablation through targeting the arrhythmogenic LVA and reducing LA mass provides a better clinical outcome than non-LVA guided linear ablation, and outweighs the harmful effects of iatrogenic scaring in non-PAF patients.

P wave duration ≥150 ms predicts poor left atrial function and ablation outcomes in non-paroxysmal atrial fibrillation.

BACKGROUND: It remains unknown whether P wave duration (PWD) ≥ 150 ms measured after extensive radiofrequency catheter ablation (RFCA) can identify non-paroxysmal atrial fibrillation (non-PAF) patients at increased risk of atrial tachyarrhythmia recurrence. We investigated the predicting power of PWD and its association with left atrial (LA) reverse remodeling in patients with non-PAF undergoing pulmonary vein isolation with LA linear ablation. METHODS: We retrospectively evaluated 136 patients who underwent RFCA for drug-refractory non-PAF. Electroanatomic mapping was acquired during AF. Low-voltage area (LVA) was defined as an area with bipolar voltage ≤0.5 mV. Electrocardiography and echocardiography were performed during sinus rhythm 1 day and 3 months after RFCA. PWD was measured using amplified 12­lead electrocardiography. Prolonged PWD was defined as maximum PWD ≥ 150 ms. RESULTS: Over a mean follow-up duration of 48 ± 35 months, 28 patients experienced atrial tachyarrhythmia recurrence. PWD was positively correlated with LVA (r = 0.527, p < 0.001) and inversely correlated with LA emptying fraction (r = -0.399, p < 0.001). PWD was shortened and LA emptying fraction (LAEF) was increased in patients without atrial tachyarrhythmia recurrence during follow-up. Atrial tachyarrhythmia-free survival was significantly more likely in patients without a prolonged PWD (83.5% vs 60.7%, p = 0.002). Multivariate analysis showed that LAEF and PWD were independent predictors of atrial tachyarrhythmia recurrence. CONCLUSIONS: PWD ≥ 150 ms measured after RFCA can identify patients with non-PAF at increased risk of atrial tachyarrhythmia recurrence. PWD is correlated with LVA and LAEF and reflects LA reverse remodeling.

Beneficial Electrophysiological Effects of Rotigaptide Are Unable to Suppress Therapeutic Hypothermia-Provoked Ventricular Fibrillation in Failing Rabbit Hearts With Acute Ischemia-Reperfusion Injury.

Aims: Whether therapeutic hypothermia (TH) is proarrhythmic in preexisting failing hearts with acute ischemia-reperfusion (IR) injury is unknown. Additionally, the effectiveness of rotigaptide on improving conduction slowing in hearts with IR injury is ambiguous. We investigated the electrophysiological effects of TH and rotigaptide in failing rabbit hearts with acute IR injury and determined the underlying molecular mechanisms. Methods and Results: Heart failure was induced by right ventricular pacing (320 beats/min, 4 weeks). Rabbits with pacing-induced heart failure were randomly divided into TH (n = 14) and non-TH (n = 7) groups. The IR rabbit model was created by ligating the coronary artery for 60 min, followed by reperfusion for 15 min in vivo. Then, the hearts were excised quickly and Langendorff-perfused for simultaneous voltage and intracellular Ca2+ (Cai) optical mapping. Electrophysiological studies were conducted, and vulnerability to ventricular fibrillation (VF) was evaluated using pacing protocols. TH (33°C) was instituted after baseline studies, and electrophysiological studies were repeated. Rotigaptide (300 nM) was infused for 20 min, and electrophysiological studies were repeated under TH. Cardiac tissues were sampled for Western blotting. TH increased the dispersion and beat-to-beat variability of action potential duration (APD), aggravated conduction slowing, and prolonged Cai decay to facilitate spatially discordant alternans (SDA) and VF induction. Rotigaptide reduced the dispersion and beat-to-beat variability of APD and improved slowed conduction to defer the onset of arrhythmogenic SDA by dynamic pacing and elevate the pacing threshold of VF during TH. However, the effect of rotigaptide on TH-enhanced VF inducibility was statistically insignificant. TH attenuated IR-induced dysregulation of protein expression, but its functional role remained uncertain. Conclusion: Therapeutic hypothermia is proarrhythmic in failing hearts with acute IR injury. Rotigaptide improves TH-induced APD dispersion and beat-to-beat variability and conduction disturbance to defer the onset of arrhythmogenic SDA and elevate the VF threshold by dynamic pacing, but these beneficial electrophysiological effects are unable to suppress TH-enhanced VF inducibility significantly.

Takotsubo Syndrome Associated with a New Onset Manic Episode: A case report.

Takotsubo syndrome is a condition that mimics acute coronary syndrome. The exact pathogenesis of the condition is unclear but it tends to occur more frequently in elderly women and a large proportion of cases have acute, former, or chronic neurologic or psychiatric disorders. Here we describe a 55-year-old female patient, who was brought to the emergency department presenting with a new-onset manic episode characterized by grandiosity, distractibility, decreased need for sleep, and increased goal-directed behaviours. She experienced chest pain approximately two days later, and non-ST elevation myocardial infarction was observed. The emergent coronary angiogram showed patent coronary arteries, and a diagnosis of Takotsubo syndrome was made. We suggest clinical multidisciplinary vigilance for somatic complaints, especially cardiac ones, in people with psychiatric disorders in order to make timely therapeutic interventions.

Mechanisms of ranolazine pretreatment in preventing ventricular tachyarrhythmias in diabetic db/db mice with acute regional ischemia-reperfusion injury.

Studies have demonstrated that diabetic (db/db) mice have increased susceptibility to myocardial ischemia-reperfusion (IR) injury and ventricular tachyarrhythmias (VA). We aimed to investigate the antiarrhythmic and molecular mechanisms of ranolazine in db/db mouse hearts with acute IR injury. Ranolazine was administered for 1 week before coronary artery ligation. Diabetic db/db and control db/+ mice were divided into ranolazine-given and -nongiven groups. IR model was created by 15-min left coronary artery ligation and 10-min reperfusion. In vivo electrophysiological studies showed that the severity of VA inducibility was higher in db/db mice than control (db/ +) mice. Ranolazine suppressed the VA inducibility and severity. Optical mapping studies in Langendorff-perfused hearts showed that ranolazine significantly shortened action potential duration, Cai transient duration, Cai decay time, ameliorated conduction inhomogeneity, and suppressed arrhythmogenic alternans induction. Western blotting studies showed that the expression of pThr17-phospholamban, calsequestrin 2 and voltage-gated sodium channel in the IR zone was significantly downregulated in db/db mice, which was ameliorated with ranolazine pretreatment and might play a role in the anti-arrhythmic actions of ranolazine in db/db mouse hearts with IR injury.

One-Year Mortality Risk Stratification in Patients Hospitalized for Acute Decompensated Heart Failure: Construction of TSOC-HFrEF Risk Scoring Model.

BACKGROUND: Most previous risk prediction models in patients hospitalized for heart failure (HF) are derived from populations in Western countries, and it is unclear whether these models are applicable to Asian populations. This study aimed to construct a risk score system for predicting one-year mortality risk in Asian patients and to compare the applicability of this risk score system with the 3C-HF score system. METHODS: We used the population in the Taiwan Society of Cardiology-Heart Failure with Reduced Ejection Fraction (TSOC-HFrEF) registry, which is a prospective cohort of patients admitted for acute decompensated heart failure (ADHF) in Taiwan. The risk score system was constructed using multivariate Cox-model derived coefficients. A bootstrapping procedure was also used for bias-corrected evaluations. Comparisons between this constructed model and the 3C-HF score prediction model were evaluated using calibration plots and area under curve (AUC)/receiver operating characteristic (ROC) curve. RESULTS: Patients with complete data (n = 1127) in the TSOC-HFrEF registry were analyzed. During one year of follow-up, 14.5% (n = 163) of the patients died. A risk score system was constructed with the following predictors: body mass index, diastolic blood pressure, dyslipidemia, diabetes, aortic regurgitation, QRS duration, hemoglobin concentration, and digoxin usage. Compared to the 3C-HF score system, this risk score system had a similar discriminatory ability (AUC/ROC values of 0.675 and 0.636, p = 0.127) and both were well-calibrated in the Taiwan population. CONCLUSIONS: The proposed risk score system for predicting one-year all-cause mortality in Taiwanese patients with ADHF may facilitate risk stratification in Asian patients with HF.

A Novel Approach for Predicting Atrial Fibrillation Recurrence After Ablation Using Deep Convolutional Neural Networks by Assessing Left Atrial Curved M-Mode Speckle-Tracking Images.

Aims: Curved M-mode images of global strain (GS) and strain rate (GSR) provide sufficiently detailed spatiotemporal information of deformation mechanics. This study investigated whether a deep convolutional neural network (CNN) could accurately classify these images in patients with atrial fibrillation (AF) who underwent radiofrequency catheter ablation (RFCA) with different outcomes. Methods and Results: We retrospectively evaluated 606 consecutive patients who underwent RFCA for drug-refractory AF. Patients were divided into AF-free (n = 443) and AF-recurrent (n = 163) groups. Transthoracic echocardiography was performed within 24 h after RFCA. Left atrial curved M-mode speckle-tracking images were acquired from randomly selected 163 patients in AF-free group and 163 patients in AF-recurrent group as the dataset for deep CNN modeling. We used the ReLu activation function and repeatedly performed CNN model for 32 times to evaluate the stability of hyperparameters. Logistic regression models with the left atrial dimension, emptying fraction, and peak systolic GS as predictor variables were used for comparisons. Images from the apical 2-chamber (2-C) and 4-chamber (4-C) views had distinct features, leading to different CNN performance between settings; of them, the "4-C GS+4-C GSR" setting provided the highest performance index values. All four predictor variables used for logistic regression modeling were significant; however, none of them, individually or in any combined form, could outperform the optimal CNN model. Conclusion: The novel approach using deep CNNs for learning features of left atrial curved M-mode speckle-tracking images seems to be optimal for classifying outcome status after AF ablation.

Modified biweekly oxaliplatin and capecitabine for advanced gastric cancer: a retrospective analysis from a medical center.

BACKGROUND: We modified 3-week XELOX regimen with oxaliplatin to 85 mg/m 2 on Day 1 and capecitabine 1000 mg/m 2 BID for 10 days every 14 days to be more practical in clinical practice for advanced gastric cancer. The aim of this retrospective analysis is to evaluate the safety profile and efficacy of the modified oxaliplatin plus capecitabine (XELOX) regimen as the first-line treatment for patients with advanced gastric cancer in a medical center in Taiwan. METHODS: From March 2009 to December 2010, among the 614 patients diagnosed with gastric cancer in a medical center, 49 patients with unresectable advanced or metastatic gastric adenocarcinoma were treated with oxaliplatin (85 mg/m 2 ) on Day 1 and capecitabine (1000 mg/m 2 BID) for 10 days every 2 weeks (mXELOX). CT scan was performed for tumor response evaluation. Clinical outcome and adverse events after mXELOX treatment were analyzed retrospectively. RESULTS: A total of 354 mXELOX sessions (median: 6) were administered in 49 patients. The overall tumor response rate was 39.1% among 46 evaluated patients: three complete response (6.5%) and 15 partial response (32.6%). Seven patients had stable disease (15.2%) and 21 (45.7%) patients had progressive disease. The median progression-free survival and median overall survival were 4.37 months and 12.26 months, respectively. The most common grade III/IV hematologic toxicity was anemia (10.2%), and non-hematologic toxicity effects were numbness (8.2%), hand-foot syndrome (10.2%), diarrhea (6.1%), thrombocytopenia (6.1%), and abdominal pain (6.1%). CONCLUSION: This modified biweekly oxaliplatin and capecitabine combination chemotherapy is practical and effective for unresectable advanced or metastatic gastric cancer in our daily practice.