Transcatheter Edge-to-Edge Repair for a Patient With Severe Mitral Regurgitation of Carpentier IIIa Classification.

Whether patients diagnosed with mitral regurgitation of Carpentier class IIIa (rheumatic origin) can possibly be treated with balloon mitral commissurotomy followed by transcatheter edge-to-edge repair remains unclear. Here, we report on such a case who was successfully treated with balloon mitral commissurotomy and then transcatheter edge-to-edge repair without aggravating mitral stenosis. (Level of Difficulty: Intermediate.).

Atrial fibrillation, liver disease, antithrombotics and risk of cerebrovascular events: A population-based cohort study.

BACKGROUND: Whether patients with atrial fibrillation (AF) and liver disease are also prone to cerebrovascular events and respond similarly favorably to antithrombotic therapy remains under-investigated. METHODS: Patients ≥18years with newly-diagnosed AF in the period 2005 to 2009 were scrutinized from the "Longitudinal Health Insurance Database 2005" (1 million beneficiaries) of Taiwan's National Health Insurance Institute. Patients were categorized into the Liver (N=433) or the Non-liver (N=3490) cohort according to whether they had a diagnosis of advanced liver disease. Patients were then followed to determine cumulative incidence of hospitalization-requiring cerebrovascular events, preventive effects of antithrombotics, and predictors of cerebrovascular events by Cox regression analysis. RESULTS: Within a mean follow-up of 3.3±1.4years, ischemic stroke (89.2 vs. 50.3 per 1000 person-years, adjusted HR 1.502, 95% CI 1.207-1.868, p<0.001) and overall cerebrovascular events (102.3 vs. 56.4 per 1000 person-years, adjusted HR 1.535, 95% CI 1.251-1.883, p<0.001) occurred significantly more often in the Liver than in the Non-liver cohort. Cox models identified aging (≥65years), DM, and CHA2DS-VASc score≥2 points as risk factors for overall cerebrovascular events in the Liver cohort, whereas antiplatelet agents (HR 0.932, 95% CI 0.128-6.803, p=NS) and vit-K antagonistic anticoagulants (HR 1.087, 95% CI 0.150-7.862, p=NS) showed no correlation. CONCLUSION: AF patients comorbid with advanced liver disease are more vulnerable to ischemic and therein overall cerebrovascular events, especially in those with old age, DM, or high CHA2DS-VASc scores. This propensity to cerebrovascular events, however, can't be altered by antithrombotic therapy.

Efficacious and safe orotracheal intubation for laboratory mice using slim torqueable guidewire-based technique: comparisons between a modified and a conventional method.

BACKGROUND: Tracheal intubation of laboratory mice remains essential yet challenging for most researchers. The aim of this study was to investigate whether this procedure can be more efficiently and safely accomplished by a novel method using slim and torqueable guidewires to guide access to the trachea. METHODS: This study was carried out in an animal laboratory affiliated to a tertiary medical center. Mice weighing 22 to 28 g were subjected to various open-chest experiments after being anesthetized with intraperitoneal ketamine (100 mg/kg) and lidocaine hydrochloride (10 mg/kg). The oropharyngeal cavity was opened with angled tissue forceps, and the trachea was transilluminated using an external light. The vocal cords were then crossed using either the Conventional method with a 38-mm-long, end-blunted stiff needle as a guide for insertion of a 22-gauge, 25-mm-long intravenous catheter into the trachea, or the Modified method utilizing using a 0.014-inch-thin torqueable wire as the guide to introduce an identical tube over it into the trachea. The epithelial integrity of the trachea was later examined histologically when the animals were sacrificed either immediately after the surgery or at 28 days post-surgery, depending on the corresponding research protocols. RESULTS: Orotracheal intubation was successfully completed in all mice using either the Conventional (N = 42) or the Modified method (N = 50). With the Modified method, intubation took less time (1.73 vs. 2.17 min, Modified vs. Conventional, p < 0.001) and fewer attempts (1.0 vs. 1.33, p < 0.001), and there were fewer procedural difficulties (0% vs. 16.7%, p = 0.009) and complications (0% vs. 11.9%, p = 0.041) compared with the Conventional method. Histological analysis revealed a significantly lower incidence of immediate (0% vs. 39%, p < 0.001) and late (0% vs. 58%, p < 0.001) injuries to the tracheal epithelial lining with the Modified method compared to the Conventional method. CONCLUSIONS: Tracheal intubation for laboratory mice can be completed efficiently, safely and atraumatically using the proposed Modified method employing readily available inexpensive instruments.

Atrial fibrillation, CHA2DS2-VASc score, antithrombotics and risk of non-traffic-, non-cancer-related bone fractures: A population-based cohort study.

BACKGROUND: Accidental bone fractures are a major cause of premature disabilities and death. Whether atrial fibrillation (AF) treated with or without antithrombotics correlates with occurrence of such events remains under-investigated. METHODS: Patients ≥18 years with newly diagnosed AF between 2005 and 2009 without previous cancers or traffic injury were identified from the "Longitudinal Health Insurance Database 2005" (1 million beneficiaries) of Taiwan's National Health Research Institutes and served as the AF group. A fourfold number of age-, gender-, and comorbidity-matched patients but without AF served as the non-AF controls. Patients were followed, and cumulative incidence of hospitalization-requiring bone fractures was compared between groups. Predictors of accidental bone fractures were determined by Cox regression analysis. RESULTS: Within a mean follow-up of 3.6 years, bone fractures, especially those involving neck/trunk and lower limbs, were significantly more frequent in patients with AF (N=6925) than in those without (N=27,700) (7.0 vs. 3.8 per 1000 person-years, log-rank p=0.001, adjusted HR=1.85, 95% CI=1.50-2.30, p<0.001). Cox models identified female gender, previous stroke, and CHA2DS2-VASc score≧1 as risk factors for bone fractures in AF patients, whereas oral anticoagulants (HR=0.62, 95% CI=0.35-0.91, p=0.034), especially when used in patients with CHA2DS2-VASc score≧1 but not antiplatelet therapy (p=0.39) as negative predictors. CONCLUSION: Patients with AF are more vulnerable to non-traffic-, non-cancer-related bone fractures especially when with specified characteristics. For those with higher CHA2DS2-VASc scores, the use of anticoagulant but not antiplatelet agents could be associated with lower risk of such events.

Atrial fibrillation, CHA2DS2-VASc score, antithrombotics and risk of traffic accidents: A population-based cohort study.

BACKGROUND: Traffic accidents account for a substantial proportion of premature disabilities and deaths. Whether atrial fibrillation (AF) provokes while antithrombotics prevent from such events remains un-investigated. METHODS: All patients ≥40years with newly diagnosed AF in 2005 were scrutinized from the "Longitudinal Health Insurance Database 2005" (1 million beneficiaries) of Taiwan's National Health Insurance Institute as the AF group. Four-fold number of age-, gender-, and comorbidity-matched patients but without AF served as the Non-AF controls. Patients were followed till occurrence of hospitalization-requiring traffic injury, death, withdrawal from insurance, or the end of 2010. Cumulative incidence of traffic accidents was compared between groups, and predictors and preventive role of antithrombotics for these accidents were identified by Cox regression analysis. RESULTS: Within a mean follow-up of 4.3years, traffic injury occurred significantly more often in patients with AF (N=1724) than those without it (N=6896) (5.4 vs. 4.9 per 1000 person-years, log-rank p=0.012, HR 1.110, 95% CI 1.013-1.572). Cox models identified age ≧65years, hypertension, coronary artery disease, stroke, liver cirrhosis and CHADS2VASC score≧1 as risk factors for traffic injury in AF patients, whereas oral anticoagulants (HR 0.576, 95% CI 0.285-0.791, p=0.002) used in patients with CHADS2VASC score ≧1 but not antiplatelet therapy (p=0.197) as negative predictors. CONCLUSION: Patients with AF are more vulnerable to traffic accidents especially when with higher CHADS2VASC scores and other comorbidities. This tendency to traffic accidents, however, could be ameliorated by oral anticoagulation in specialized cases but not by antiplatelet therapy.

Atrial fibrillation increases medical cost and complicates hospital outcome of traffic accident-related physical trauma--a nationwide population-based study.

BACKGROUND: Traffic accidents account substantially for premature disability and deaths in the modern world. Whether atrial fibrillation complicates the outcome of traffic injury remains under-investigated. METHODS: From 1998 to 2010, all inpatient records stored in the Taiwan National Health Insurance database were screened. Those related with traffic accidents were aggregated to individuals and enrolled. The medical expenses and hospital outcomes were compared between patients with atrial fibrillation (AF group) and either the rest patients (No-AF group) or the propensity-matched patients without atrial fibrillation (No-AF-matched group). Prognostic predictive variables for adverse in-hospital events were further identified by multivariate regression analysis. RESULTS: Within the 13-year time span, of the 776,620 individuals ever admitted for traffic accidents, there were 1233 patients with AF. Compared with No-AF and No-AF-matched groups respectively, AF patients stayed longer in hospital (10.9 ± 10.6 vs. 6.8 ± 7.2 and vs. 8.2 ± 8.7 days, both p < 0.001), more often required surgical operations (73.2% vs. 69.5%, p = 0.006 and vs. 68.9%, p = 0.021), and consumed larger medical expenses (US$ 2384 ± 3174 vs. 1246 ± 2024, or 91.3% higher; and vs. 1406 ± 2172, or 69.6% higher, both p < 0.001), yet developed more postoperative complications (8.8% vs. 1.2% and vs. 3.2%, both p<0.001) and deaths (2.5% vs. 0.9%, p < 0.001 and vs. 1.6%, p = 0.015). Identified by regression analysis, CHA2DS2-VASC score and representative demographic/injury-related variables predict in-hospital adverse events in these AF group patients. CONCLUSIONS: For patients suffering traffic accidents, those with AF consume more surgical resources and medical expenses yet end up with poorer hospital outcome, especially those with higher CHA2DS2-VASC scores and other relevant variables.

Lower serum triglyceride level is a risk factor for in-hospital and late major adverse events in patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention- a cohort study.

BACKGROUND: Whether serum triglyceride level correlates with clinical outcomes of patients with ST segment elevation myocardial infarction (STEMI) treated by primary percutaneous coronary intervention (pPCI) remains unclear. METHODS: From June 2008 to February 2012, all patients with STEMI who were treated with pPCI in this tertiary referral hospital and then had fasting lipid profiles measured within 24 hours were included and dichotomized into lower- (≦ 150 mg/dl) and higher-triglyceridemic (>150 mg/dl) groups. Baseline characteristics, in-hospital outcomes, and late major adverse cardiovascular events (MACE) were compared in-between. Independent predictors for in-hospital death and late adverse events were identified by multivariate logistic and Cox regression analyses. RESULTS: A total of 247 patients were enrolled, including 163 lower-triglyceridemic and 84 higher-triglyceridemic subjects. The angiographic characteristics, pPCI results and in-hospital outcomes were similar between the two groups. However, multivariate logistic analysis identified triglyceride level as a negative predictor for in-hospital death (OR 0.963, 95% CI 0.931-0.995, p = 0.023). At follow-up for a mean period of 1.23 to 1.40 years, compared with the high-triglyceridemic group, low-triglyceridemic patients had fewer cumulative incidences of target vessel revascularization (TVR) (21.7% vs. 9.5%, p = 0.011) and overall MACE (26.1% vs. 11.9%, p = 0.0137). Cox regression analysis confirmed serum triglyceride as a negative predictor for TVR and overall MACE. CONCLUSIONS: Serum triglyceride level inversely correlates with in-hospital death and late outcomes in patients with STEMI treated with pPCI. Thus, when managing such patients, a high serum triglyceride level can be regarded as a benign factor but not a target for aggressive therapy.

Hypoxemia during one-lung ventilation for robot-assisted coronary artery bypass graft surgery.

BACKGROUND: Robot-assisted coronary artery bypass grafting requires continuous one-lung ventilation (OLV) to evacuate the thoracic cavity. Whether this ventilatory mode subjects patients to serious hypoxemia remains underinvestigated. METHODS: From 2005 to 2010, all patients receiving robot-assisted coronary artery bypass graft surgery using OLV with active capnothorax for internal mammary artery harvesting and then passive pneumothorax for minithoracotomy direct-vision coronary bypass graft surgery were included. Patients' variables of oxygenation were monitored and compared throughout the whole surgical period. Persistent oxygen desaturation (arterial oxygen pressure <70 mm Hg) refractory to primary managements was defined as a hypoxemic event, and predictors of such events were identified by multivariate regression analysis. RESULTS: A total of 255 consecutive patients were enrolled. Average oxygen saturation decreased modestly during the first stage of OLV with active capnothorax, causing hypoxemic events in 9 patients (4.3%) leading to death in 2 (0.8%), whereas it dropped drastically in the second stage of OLV with passive pneumothorax, resulting in hypoxemic events in 32 patients (12.6%) and death in 1 (0.4%). Multivariate regression analysis identified high pulmonary vascular resistance and low left ventricular ejection fraction as predictors of hypoxemia during internal mammary artery takedown, whereas prolonged procedure and chronic obstructive pulmonary disease were identified as predictors during minithoracotomy bypass grafting. CONCLUSIONS: Robot-assisted two-stage coronary artery bypass surgery employing OLV could be complicated by serious hypoxemia especially at the minithoracotomy grafting stage and in patients with specific risk factors. Thus, when managing such patients, invasive monitoring and aggressive treatment of arterial desaturation are mandatory to ensure the patient's safety and procedural smoothness.