Comparison of cardiovascular outcomes and all-cause mortality in patients with chronic hepatitis B and C: A 13-year nationwide population-based study in Asia.

BACKGROUND AND AIMS: Viral hepatitis infection has been linked to increased atherosclerosis. We therefore investigated cardiovascular outcomes in patients with hepatitis B virus (HBV) and hepatitis C virus (HCV) infection. METHODS: Electronic medical records during 2000-2012 were retrieved from the Taiwan National Health Insurance Research Database. Exclusion criteria were age <18, history of coexisting HBV and HCV infection, acute coronary syndrome, coronary intervention, venous thromboembolism, peripheral artery disease, stroke, major or gastrointestinal bleeding, malignancy, and a follow-up period <180 days. Patients with HBV and HCV infection were propensity-matched then compared for outcomes. Primary outcomes were cardiovascular events at the 1-year follow-up, 3-year follow-up, 5-year follow-up, and at the end of follow-up. RESULTS: 41,554 patients with diagnosis of HBV or HCV were retrieved from 2000 to 2012. After exclusion criteria, 31,943 patients were eligible for analysis and propensity score matched. The study population consisted of 6030 patients with HBV infection and 6030 patients with HCV infection. Risk of composite arterial events (acute coronary syndrome, peripheral artery disease, and acute ischemic stroke) was significantly higher in patients with HCV infection compared with patients with HBV infection (p = 0.012 at 5-year follow-up and p = 0.003 at the end of follow-up). All-cause mortality was significantly higher in patients with HCV infection compared with patients with HBV infection (p < 0.001 at 3-year follow-up, 5-year follow-up, and at the end of follow-up). CONCLUSIONS: In patients with chronic viral hepatitis, subjects with HCV infection had a significantly higher risk of composite arterial events and all-cause mortality compared with those with HBV infection.

Clinical outcomes of peripartum cardiomyopathy: a 15-year nationwide population-based study in Asia.

Peripartum cardiomyopathy (PPCM) is the development of heart failure during late pregnancy to months postpartum with potential fatal outcome. However, the disease is not well-studied in Asia.We aimed to investigate the epidemiology and clinical outcomes of PPCM in Taiwan.Electronic medical records were retrieved from Taiwan National Health Insurance Research Database from 1997 to 2011. Patients with PPCM were separated into 3 groups based on the timing of diagnosis. Early: PPCM diagnosed first to ninth month of pregnancy. Traditional: PPCM diagnosed last month of pregnancy till fifth month post-delivery. Late: PPCM diagnosed sixth to twelfth month post-delivery. Primary outcomes defined as cardiac death, all-cause mortality, and major adverse cardiovascular events (MACE) within 1 year.A total of 3,506,081 deliveries during 1997 to 2011 were retrieved and 925 patients with PPCM were identified. Overall incidence of PPCM was 1:3,790 during the 15 years. Early, Traditional, and Late group each had 88, 742, and 95 patients. Cardiac death occurred in 31 patients, all-cause mortality in 72 patients, and MACE in 65 patients. Late group had 2- to 3-fold event rates in cardiac death, all-cause mortality, and MACE compared with Early and Traditional groups. Cumulative incidence showed significant differences for cardiac death (P = .0011), all-cause mortality (P = .0031), and MACE (P = .0014) among 3 groups. Multivariate Cox model showed Late group had significantly worse outcomes after adjusted for clinical variables compared with 2 other groups.Our study is the largest national cohort among Asian countries that showed timing of diagnosis of PPCM had different outcomes. Late diagnosis portended significantly increased morbidity and mortality, even after adjusted for clinical variables.

Reversal of hoarseness with recognition of Ortner syndrome in a patient with severe mitral regurgitation.

Loss of voice due to vocal cord paralysis, as in Ortner syndrome, is secondary to left recurrent laryngeal nerve palsy. Cardiovascular cause should be listed as a differential diagnosis of hoarseness and is incumbent upon the diagnostic physician to be familiar with the condition. A 56-year-old male presented to our emergency department with shortness of breath due to severe mitral regurgitation. Incidental finding of aggravating hoarseness during the past six months was suspected to be related to his cardiac condition with hugely dilated left atrium. After an ear nose and throat specialist confirmed left vocal cord paralysis, a cardiac surgeon was consulted for surgical management. The operation consisted of mitral valve repair, tricuspid valve repair, left atrial reduction, and Cox maze procedure. Three days after surgery the patient had noticeable improvement in his voice, and 3 months later he had complete resolution of the hoarseness. Awareness of Ortner syndrome and a search for treatable cause of vocal cord palsy therefore is imperative before the nerve injury becomes irreversible. .

Entrapment of permanent pacemaker lead as the cause of tricuspid regurgitation.

Transthoracic 2-dimensional (D) echocardiography (echo) is often used to assess tricuspid regurgitation (TR) after implantation of permanent pacemakers. However, its ability to define the precise anatomical relationship between the tricuspid valve and the pacemaker lead is quite limited. This report presents a 58-year-old male with aggravation of TR after pacemaker implantation for heart block. Three-D echo precisely depicted the entrapment of the lead shaft in the fused and fibrotic septal and posterior tricuspid leaflets. The patient underwent tricuspid valve annuloplasty and the symptoms of right heart failure improved soon after the operation.

Thrombolytic therapy for acute left atrial thrombus formation in one patient with heart failure and atrial fibrillation.

Patients with a left atrial (LA) thrombus are considered at high risk of thromboembolic events. Reports about thrombolytic therapy are limited and optimal guidelines are lacking. In this report, a large, pedunculated, highly mobile thrombus of the LA attached via a short stalk to the LA appendage brim in a 59-year-old female with atrial fibrillation is described. The patient was treated with 100 mg intravenous tissue plasminogen activator for 2 h after the ineffective administration of herapin. The thrombus soon dissolved. However, the patient developed a transient ischemic embolism 12 h later when the post hoc heparin effect was at its nadir. Based on this and other reports, thrombolytic therapy may be effective and safe in patients with acute, non-organized LA thrombi and post hoc heparinization should be sufficient to prevent thromboembolism from rebound coagulation.

Acute and long-term clinical and angiographic outcomes of coronary stenting using Palmaz-Schatz stent and ACS Multi-Link stent.

Acute and long-term (>/= 3 years) outcomes of coronary artery stenting using Palmaz-Schatz and Multi-Link stent implantations between November 1995 and October 1999 were analyzed. There were 655 Palmaz-Schatz stent implantations in 577 lesions on 477 patients (group A) and 428 Multi-Link stent implantations in 381 lesions on 326 patients (group B). The baseline characteristics were similar in the two groups. Group B had more complex lesions, longer stenotic lesions, and larger reference vessel sizes than group A. However, both groups had a similar in-hospital cardiac events. Four hundred and two patients with 488 lesions in group A and 260 patients with 307 lesions in group B underwent a 6-month follow-up coronary angiography. The restenotic rate per lesion was 16% in both groups (P = 0.872). A 3-year angiographic follow-up was performed in 262 patients of group A (301 lesions) and 139 patients of group B (162 lesions), and restenosis was noted in only 3 patients (1.36%) in group A and 5 patients (4%) in group B, in which the lesion was patent at the 6-month angiographic follow-up. Significant increase in minimal luminal diameter was noted from 2.23 +/- 0.66 mm at 6 months to 2.33 +/- 0.64 mm in group A (P < 0.01), and insignificant increase from 2.23 +/- 0.77 to 2.28 +/- 0.82 mm was noted in group B (P = 0.27). No differences were noted between the two groups in mortality, reinfarction, recurrent angina, target lesion angioplasty, or elective coronary artery bypass surgery during a follow-up period of 60 +/- 3 months. Forty-five patients (9.4%) in group A and 18 patients (5.5%) in group B received additional stenting procedures for newly developed lesions. The overall cardiac event-free survival was 66% in group A and 72% in group B (P = 0.844). In conclusion, the procedural success rate, in-hospital morbidity, 6-month angiographic results, and long-term (>/= 3 years) clinical and angiographic outcomes were similar with coronary stenting using either Palmaz-Schatz or Multi-Link stent. The stented lesions were stable; however, late regression of minimal luminal diameter was noted in both groups, and progression of atherosclerotic change in the nonstented site was noted during long-term follow-up.

Evaluation of shunt flow by multiplane transesophageal echocardiography in adult patients with isolated patent ductus arteriosus.

The role of multiplane (M) transesophageal echocardiography (TEE) in the diagnosis of isolated patent ductus arteriosus (PDA) in adults and its effectiveness in the assessment of the pulmonary to systemic flow ratio were evaluated and compared with those obtained from cardiac catheterization examination. Eleven consecutive patients, ranging from 17 to 56 years old (mean of 29.5 +/- 12.0), with clinically suspected PDA were subjects of this study. A complete transthoracic echocardiographic study was performed in each patient before MTEE. MTEE with Doppler color flow mapping showed clear visualization of a ductal structure between the descending aorta and pulmonary artery with a continuous turbulent mosaic flow suggestive of PDA in all 11 patients. The pulmonary/systemic flow and vascular resistance ratios obtained by echocardiography and cardiac catheterization correlated well (r = 0.8732, P =.0004; r = 0.623, P =.04, respectively). This study demonstrated that MTEE combined with transthoracic echocardiography examination is an accurate noninvasive means in the diagnosis of PDA and assessment of the pulmonary to systemic flow and vascular resistance ratios in adult patients.

Acute ingestion poisoning with insecticide formulations containing the pyrethroid permethrin, xylene, and surfactant: a review of 48 cases.

BACKGROUND: Forty-eight patients poisoned with insecticide formulations containing permethrin (a Type I pyrethroid insecticide), xylene, and surfactants are reported here. These patients were diagnosed and treated in the Chang Gung Memorial Hospital in Taiwan from January 1987 to June 1999. Ten patients ingested permethrin in error and 38 patients attempted suicide. Gastrointestinal tract signs and symptoms were most common (35/48; 73%), and included sore throat, mouth ulcerations, dysphagia, epigastric pain, and vomiting. Pulmonary abnormalities were documented in 29% (14/48) of patients. Aspiration pneumonitis occurred in eight patients, including onefatal case. Pulmonary edema was observed in two patients. Sixteen patients (33%) had central nervous system involvement including confusion (6/48; 13%), coma (10/48; 21%), and seizures (4/48; 8%). Cardiovascular symptoms in 3/48 (7%) patients were limited to arrhythmias and shock. Mild renal and hepatic dysfunction was found in 5/48 (10%) and 3/48 (6%) of patients, respectively. Leukocytosis occurred in 16 patients (33%) but was not associated with infection. Only one death occurred during this 12.5-year period. CONCLUSION: Poisoning caused by ingesting insecticides containing permethrin, xylene, and surfactant manifests primarily gastrointestinal tract symptoms and signs. The involvement of the central nervous system and lungs were less common, but clinically more significant. The relative contributions of the 20% permethrin, 70% xylene, and 10% surfactant to these toxic manifestations, however, is uncharacterized.

Analysis of left atrial volume change rate during left ventricular diastolic phase with M-mode echocardiography for differentiation between normal and pseudonormal mitral inflow.

Pseudonormalization of mitral inflow is a diagnostic problem in clinical practice. An excellent correlation exists between the change in the left atrial (LA) angiographic area and posterior aortic wall motion. Therefore, we sought to define the role of LA wall motion, indicating LA volume change rate, in patients with normal and pseudonormal mitral inflow. We performed echocardiography after cardiac catheterization in 62 patients with a velocity ratio of early-to-late mitral inflow (E/A ratio) >1. Study patients were classified into 2 groups according to the response of mitral inflow to phase II of the Valsalva maneuver: patients with E/A >1 after the Valsalva maneuver (n = 31, control group), and patients with <1 after the Valsalva maneuver (n = 31, pseudonormal group). The slopes (slope E and A) of early diastolic and late diastolic motion of the LA wall were derived from M-mode analysis together with the time constant of left ventricular (LV) isovolumic relaxation from cardiac catheterization. The values of slope E (41 plus minus 11 vs 61 plus minus 12 mm/s, p <0.001) and slope E/A (0.69 plus minus 0.13 vs 1.32 plus minus 0.35, p <0.001) were significantly lower in the pseudonormal group and were inversely correlated with the time constant of LV isovolumic relaxation (r = 0.64, p <0.001 and r = 0.73, p <0.001, respectively). Using slope E/A <1 as an indicator of relaxation abnormality, the sensitivity, specificity, positive predictive value, and negative predictive value for the detection of pseudonormalization were 94%, 100%, 100%, and 94%, respectively. The slope of LA wall motion, indicating LA volume change rate, during the LV diastolic phase is useful for evaluating pseudonormal LV diastolic dysfunction in the selected patient population.

Rigid spine syndrome with chronic respiratory failure.

Rigid spine syndrome (RSS) is a rare myopathic ailment characterized by mild axial and proximal muscle weakness. Muscle contraction in these patients causes limitation of neck and trunk flexion, scoliosis, and mild joint deformity. We report the case of a 30-year-old man with RSS who presented with severe restrictive ventilatory defect (forced vital capacity, 1.53 L, 39% of predicted), mild scoliosis (Cobb's angle 12), proximal muscle weakness and stiff back. Creatine phosphokinase was 986 IU/L. Muscle biopsy of the right vastus lateralis revealed increased variation in muscle fiber diameter, proliferation of endomysium, and type I fiber atrophy. Round and whorled fibers indicating myopathic change were found on sections stained with nicotinamide adenine dinucleotide dehydrogenase and succinate dehydrogenase. RSS was diagnosed based on myopathic findings and clinical presentation. Nocturnal chronic respiratory failure and fragmented sleep developed. He was treated with continuous positive airway pressure and had recovered his normal daily activity by 1-year follow-up. We suggest that patients with RSS should be assessed for possible ventilatory failure; treatment with nasal continuous positive airway pressure or bilevel continuous positive airway pressure therapy should be considered.