Objective Stent graft-induced new entry (SINE) has been increasingly observed after thoracic endovascular aortic repair (TEVAR) for aortic dissection. We investigated the mechanism of late distal ...SINE, prevention strategies, proper size selection of the stent graft, and implantation sequence. Methods From November 2006 to May 2011, 99 patients with aortic dissection underwent TEVAR with Zenith TX2 stent grafts (Cook, Bloomington, Ind) at our center. Among them, 27 distal SINEs were recognized. Eight of these patients with complicated distal SINE required intervention with new distal endografts, and all were enrolled for further analysis. Results Eight of the 27 patients with distal SINE underwent a secondary endograft procedure from February 2011 to July 2011. All were successfully treated without any complications or deaths. A high taper ratio (35% ± 11%) and excessive oversizing of the true lumen area at the distal stent level (293% ± 76%) were noted among these patients. Conclusions The incidence of distal SINE seemed to be high; however, there were also low rates of death and complications after TEVAR for aortic dissection using stainless steel-based stent grafts. Complicated distal SINE can successfully be resolved by distal endograft implantation. Excessive oversizing of the distal stent graft, as measured by the true lumen area, may be a significant factor causing delayed distal SINE. Precise size selection is crucial for the distal end of the stent, especially for high taper ratio dissection pathology in which the implantation sequence of a distal small-sized stent graft first might be considered to prevent future distal SINE.
Background Voxel-based morphometry (VBM) studies have demonstrated that grey matter abnormalities are involved in the pathophysiology of late-life depression (LLD), but the findings are inconsistent ...and have not been quantitatively reviewed. The aim of the present study was to conduct a meta-analysis that integrated the reported VBM studies, to determine consistent grey matter alterations in individuals with LLD. Methods A systematic search was conducted to identify VBM studies that compared patients with LLD and healthy controls. We performed a meta-analysis using the effect size signed differential mapping method to quantitatively estimate regional grey matter abnormalities in patients with LLD. Results We included 9 studies with 11 data sets comprising 292 patients with LLD and 278 healthy controls in our meta-analysis. The pooled and subgroup meta-analyses showed robust grey matter reductions in the right lentiform nucleus extending into the parahippocampus, the hippocampus and the amygdala, the bilateral medial frontal gyrus and the right subcallosal gyrus as well as a grey matter increase in the right lingual gyrus. Meta-regression analyses showed that mean age and the percentage of female patients with LLD were not significantly related to grey matter changes. Limitations The analysis techniques, patient characteristics and clinical variables of the studies included were heterogeneous, and most participants were medicated. Conclusion The present meta-analysis is, to our knowledge, the first to overcome previous inconsistencies in the VBM studies of LLD and provide robust evidence for grey matter alterations within fronto–striatal–limbic networks, thereby implicating them in the pathophysiology of LLD. The mean age and the percentage of female patients with LLD did not appear to have a measurable impact on grey matter changes, although we cannot rule out the contributory effects of medication.
Abstract Objective Extracorporeal membrane oxygenation (ECMO) is a widely used technique for treating postcardiotomy cardiogenic shock (PCS); however, no study has compared the long-term outcomes of ...patients who receive ECMO support for PCS with those of the general population post cardiac surgery. Methods A total of 1141 patients who received ECMO after cardiac surgery between 2000 and 2011 were identified by using the Taiwan National Health Insurance Research Database. For each patient, we matched 5 non-ECMO patients who had undergone cardiac surgery by using propensity scores calculated for age, sex, 12 comorbid diseases, Charlson score, hospital level, type of cardiac surgery, and year of index hospitalization. The outcomes included all-cause mortality, readmission for any cause, and medical expenditure. Results The incidence of ECMO use after cardiac surgery in Taiwan was 1.91%. The ECMO group had a significantly higher risk of in-hospital mortality than did the non-ECMO group (61.7% vs 6.8%, odds ratio 22.34, 95% confidence interval 19.06-26.18). The risks of all-cause mortality and first readmission for any cause were greater in the ECMO group than that in the control group ( P < .001, P < .001) in the first year, whereas no difference was observed after the first year of follow-up ( P = .209, P = .474). Similar results were observed regarding the medical expenditure of admission after index admission discharge. Conclusions Patients receiving ECMO for PCS had similar outcomes to those of the non-ECMO group after the first year of follow-up despite significantly poor outcomes during the in-hospital course.
Epicardial adipose tissue (EAT) contains ganglionated plexuses and adipocytes that can affect the pathogenesis of atrial fibrillation (AF). The aim of this study was to quantify the EAT surrounding ...the left atrium (LA) and correlate it with occurrence of AF and outcome after catheter ablation. EAT was evaluated using 64-slice multidetector computed tomography in 68 patients with AF and 34 controls. EAT volume was acquired by semiautomatically tracing axial images from the pulmonary artery to the coronary sinus. Topographic distribution of EAT was assessed by dividing the periatrial space into 8 equal regions. EAT volume significantly increased in patients with AF than in controls (29.9 ± 12.1 vs 20.2 ± 6.5 cm3 , p <0.001). Most EAT was located in regions (1) within the superior vena cava, right pulmonary artery, and right-sided roof of the LA (29.8%), (2) within the aortic root, pulmonary trunk, and left atrial appendage (26.5%), and (3) between the left inferior pulmonary vein and left atrioventricular groove (18.1%). Baseline variables were analyzed in patients with (n = 24) and without (n = 44) AF recurrence after ablation. The recurrent group showed significantly increased EAT (35.2 ± 12.5 vs 26.8 ± 11.1 cm3 , p = 0.007). Multivariate analysis revealed that EAT was an independent predictor of AF recurrence after ablation (p = 0.038). In conclusion, EAT of LA was increased in patients with AF. Large clusters of EAT were observed adjacent to the anterior roof, left atrial appendage, and lateral mitral isthmus. Abundance of EAT was independently related to AF recurrence after ablation.
Objective This study analyzes the experience of a single center using hybrid stainless steel-based endovascular stent graft repair of acute complicated and chronic type B aortic dissection aneurysm, ...and assesses the proximal and distal aortic morphologic changes of the midterm results. Methods Between November 2006 and March 2011, 61 patients with type B aortic dissection underwent stainless steel-based stent graft repair and were divided into an acute complicated dissection group (AD; n = 33) and a chronic dissection aneurysm group (CD; n = 28). Serial computed tomography (CT) images were obtained to evaluate the changes of true and false lumen diameter at four levels during the postoperative period. Results The stent graft was successfully implanted in all patients (100%), with two surgical mortalities in the AD group and low perioperative morbidity (3.6%) of stroke and paraplegia. The cumulative survival rates of the two groups were similar (77.6% and 89.0%; P = .585) in a mean follow-up period of 24.1 ± 15.6 months. Complete thrombosis of the thoracic false lumen down to the diaphragm level was achieved in 80.6% of the patients in the AD group and 88.5% in the CD group without significant difference ( P = .221), but the complete regression rate of the thoracic false lumen down to the diaphragm level showed a tendency of propitious remodeling in the AD group (54.8% vs 30.8%; P = .068). During follow-up, despite the proximal changes of stented true and adjacent false lumen diameter being significantly increased and decreased, respectively, in both acute and chronic settings ( P < .05), they were less prominent at the distal aorta in the CD aneurysm group. Intimomedial erosion of the distal end of the stent graft occurred in both acute (n = 6; 18.9%) and chronic (n = 10; 35.7%; P = .121) dissection settings after mean follow-up of 14.0 ± 4.8 months in the AD group and 24.8 ± 5.9 months in the CD group. Three patients with chronic dissection developed either pseudoaneurysm or true lumen compromise by expanded false lumen thrombi and required re-endografting. Conclusions Endovascular stainless steel-based stent graft implantation with vascular bypass to gain a sufficient proximal landing zone is feasible for type B aortic dissection and has low early and midterm mortality and morbidity in both the acute and chronic phases. Although early intervention might result in more favorable aortic remodeling with a higher possibility of complete regression and lower risk of late distal erosion, longer-term follow-up still necessitates continuous careful surveillance of the entire aorta, especially the distal condition.
Abstract Background Large cohort studies provide conflicting evidence regarding the potential for oral macrolide antibiotics to increase the risk of serious cardiac events. Objectives This study ...performed a meta-analysis to examine the link between macrolides and risk of sudden cardiac death (SCD) or ventricular tachyarrhythmias (VTA), cardiovascular death, and death from any cause. Methods We performed a search of published reports by using MEDLINE (January 1, 1966, to April 30, 2015) and EMBASE (January 1, 1980, to April 30, 2015) with no restrictions. Studies that reported relative risk (RR) estimates with 95% confidence intervals (CIs) for the associations of interest were included. Results Thirty-three studies involving 20,779,963 participants were identified. Patients taking macrolides, compared with those who took no macrolides, experienced an increased risk of developing SCD or VTA (RR: 2.42; 95% CI: 1.61 to 3.63), SCD (RR: 2.52; 95% CI: 1.91 to 3.31), and cardiovascular death (RR: 1.31; 95% CI: 1.06 to 1.62). No association was found between macrolides use and all-cause death or any cardiovascular events. The RRs associated with SCD or VTA were 3.40 for azithromycin, 2.16 for clarithromycin, and 3.61 for erythromycin, respectively. RRs for cardiovascular death were 1.54 for azithromycin and 1.48 for clarithromycin. No association was noted between roxithromycin and adverse cardiac outcomes. Treatment with macrolides is associated with an absolute risk increase of 118.1 additional SCDs or VTA, and 38.2 additional cardiovascular deaths per 1 million treatment courses. Conclusions Administration of macrolide antibiotics is associated with increased risk for SCD or VTA and cardiovascular death but not increased all-cause mortality.
Summary Background Icotinib, an oral EGFR tyrosine kinase inhibitor, had shown antitumour activity and favourable toxicity in early-phase clinical trials. We aimed to investigate whether icotinib is ...non-inferior to gefitinib in patients with non-small-cell lung cancer. Methods In this randomised, double-blind, phase 3 non-inferiority trial we enrolled patients with advanced non-small-cell lung cancer from 27 sites in China. Eligible patients were those aged 18–75 years who had not responded to one or more platinum-based chemotherapy regimen. Patients were randomly assigned (1:1), using minimisation methods, to receive icotinib (125 mg, three times per day) or gefitinib (250 mg, once per day) until disease progression or unacceptable toxicity. The primary endpoint was progression-free survival, analysed in the full analysis set. We analysed EGFR status if tissue samples were available. All investigators, clinicians, and participants were masked to patient distribution. The non-inferiority margin was 1·14; non-inferiority would be established if the upper limit of the 95% CI for the hazard ratio (HR) of gefitinib versus icotinib was less than this margin. This study is registered with ClinicalTrials.gov , number NCT01040780 , and the Chinese Clinical Trial Registry, number ChiCTR-TRC-09000506. Findings 400 eligible patients were enrolled between Feb 26, 2009, and Nov 13, 2009; one patient was enrolled by mistake and removed from the study, 200 were assigned to icotinib and 199 to gefitinib. 395 patients were included in the full analysis set (icotinib, n=199; gefitinib, n=196). Icotinib was non-inferior to gefitinib in terms of progression-free survival (HR 0·84, 95% CI 0·67–1·05; median progression-free survival 4·6 months 95% CI 3·5–6·3 vs 3·4 months 2·3–3·8; p=0·13). The most common adverse events were rash (81 41% of 200 patients in the icotinib group vs 98 49% of 199 patients in the gefitinib group) and diarrhoea (43 22% vs 58 29%). Patients given icotinib had less drug-related adverse events than did those given gefitinib (121 61% vs 140 70%; p=0·046), especially drug-related diarrhoea (37 19% vs 55 28%; p=0·033). Interpretation Icotinib could be a new treatment option for pretreated patients with advanced non-small-cell lung cancer. Funding Zhejiang Beta Pharma (China), the Chinese National Key Special Program for Innovative Drugs, the 863 Project, and Zhejiang Provincial Key Special Program.
Fever is associated with the manifestation of Brugada phenotype and ventricular tachycardia/ventricular fibrillation (VT/VF) in patients with Brugada syndrome (BrS). The thermal effect on the ...pathogenesis of functional substrates in BrS remains unknown.
This study aimed to elucidate the thermal effect on BrS phenotype, VT/VF, and electrophysiological characteristics of epicardial functional substrates in BrS.
We consecutively studied 15 patients with BrS receiving radiofrequency catheter ablation for drug-refractory ventricular tachyarrhythmias. Baseline characteristics, electrocardiographic features, and changes in epicardial functional substrates before and after epicardial warm water instillation (n = 6) were recorded and analyzed.
A total of 15 male patients (mean age 41.3 ± 10.3 years) with type 1 BrS presenting with ventricular tachyarrhythmias were consecutively enrolled. Epicardial mapping in 11 patients demonstrated a significantly larger epicardial scar/low-voltage zone (LVZ) area within the right ventricular outflow tract and anterior right ventricular free wall than within the endocardium (6.32 ± 12.74 cm
vs 52.91 ± 45.25 cm
; P = .007). Epicardial warm water instillation in 6 patients led to a significant enlargement of the functional scar/LVZ area (123.83 ± 35.26 cm
vs 63.53 ± 40.57 cm
; P = .03), accelerated conduction velocity of the endocardium and epicardium without scar/LVZ area, and increased VT/VF inducibility (16.7% vs 100%; P = .02). Ablation by targeting premature ventricular complexes and/or epicardial abnormal substrates rendered noninducibility of VT/VF and prevented the recurrences of VT/VF.
Epicardial warm water instillation enhanced functional epicardial substrates, which contributed to the increased inducibility of ventricular tachyarrhythmias in BrS. Ablation by targeting the triggers and abnormal epicardial substrates provided an effective strategy for preventing ventricular tachyarrhythmia recurrences in BrS.
To investigate the impact on outcomes of changing treatment guideline recommendations by comparing the proportion of patients with atrial fibrillation (AF) recommended oral anticoagulants (OACs) ...under the 2011 and 2014 American College of Cardiology/American Heart Association (ACC/AHA) guidelines.
We used the "National Health Insurance Research Database" in Taiwan, which included 354,649 patients with AF from January 1, 1996 through December 31, 2011. Patients with a CHADS2 (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, and prior stroke or transient ischemic attack) score of 2 or more and a CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, prior stroke or transient ischemic attack, vascular disease, age 65-74 years, female sex category) score of 2 or more were considered to have a definitive indication for receiving OACs according to the 2011 and 2014 ACC/AHA guidelines, respectively.
The percentages of patients with AF recommended OACs increased from 69.3% (n=245,598) under the 2011 guideline to 86.7% (n=307,640) under the new 2014 guidelines, an increment of 17.5% (95% CI, 17.4-17.6). Most women with AF (94.1%) and patients older than 65 years (97.2%) would receive OACs on the basis of the 2014 guidelines. Among patients previously not being recommended OACs in older guidelines, OAC use under the new guidelines was associated with a lower risk of adverse outcomes (ischemic stroke or intracranial hemorrhage or bleeding requiring blood transfusion or mortality) with an adjusted hazard ratio of 0.89 (95% CI, 0.85-0.94).
In this nationwide cohort study, use of the 2014 guidelines led more patients with AF to receive OACs for stroke prevention, and this increased OAC use was associated with better outcomes. Better efforts to implement guidelines would lead to improved outcomes for patients with AF.
Renal dysfunction is a significant risk factor for ischemic stroke in atrial fibrillation (AF). However, the incidence of ischemic stroke and how to predict its occurrence among AF patients with ...end-stage renal disease (ESRD) are unclear.
The purpose of this study was to compare the CHADS2 and CHA2DS2-VASc scores for stroke risk stratification in AF patients with ESRD.
A total of 10,999 AF patients with ESRD undergoing renal replacement therapy who were not receiving oral anticoagulants or antiplatelet agents were identified from Taiwan's National Health Insurance Research Database. The study end-point was occurrence of ischemic stroke.
The median (interquartile) CHADS2 and CHA2DS2-VASc scores for the study cohort were 3 (2-5) and 5 (4-7), respectively. During follow-up, 1217 patients (11.7%) experienced ischemic stroke, with an incidence rate of 6.9 per 100 person-years. In Cox regression models, the CHADS2 and CHA2DS2-VASc scores both were significant predictors of ischemic stroke. C-indexes for CHADS2 and CHA2DS2-VASc were 0.608 and 0.682, respectively (P < .001). CHA2DS2-VASc improved the net reclassification index by 4.8% compared with CHADS2 (P < .0001). Among 1409 patients with a CHADS2 score of 0 or 1, the CHA2DS2-VASc score ranged from 1 to 4, with event rates ranging from 2.1 to 4.7 per 100 person-years.
The CHA2DS2-VASc score was useful in predicting ischemic stroke in AF patients with ESRD undergoing dialysis and was superior to the CHADS2 score. The net clinical benefit balancing stroke reduction against major bleeding with anticoagulation in these high-risk patients remains to be defined.
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