Abstract Objective Abdominal aortic aneurysms (AAAs) are characterized by the destruction of elastin and collagen in the media and adventitia. Dipeptidyl peptidase-4 (DPP-4, an adipokine known as ...CD26) influences cell signaling, cell-matrix interactions, and the regulation of the functional activity of incretins in metabolic and inflammatory disorders. Although the role of DPP-4 in AAA evolution has been demonstrated, the underlying mechanisms of DPP-4-regulated AAA development remains unknown. Methods Patients with AAA (n = 93) and healthy controls (CTL, n = 20) were recruited. Based on computed tomography image analyses, 93 patients were divided into two groups: those with a small AAA (SAA, aortic diameter <5 cm, n = 16) and those with a large AAA (LAA, aortic diameter ≥5 cm, n = 77). Plasma DPP-4, glucagon-like peptide-1 levels, and expression of CD26 on mononuclear cells were analyzed. In addition, phorbol 12-myristate 13-acetate (PMA)-induced THP-1 cells and angiotensin II-infused apolipoprotein EtmlUnc mice were used to explore the underlying mechanisms. Results The levels of DPP-4 (μU/μg) increased while active glucagon-like peptide-1 (pM) decreased in patients with AAA in a diameter-dependent manner CTL: 2.3 ± 1.5 and 3.7 ± 2.4, respectively; SAA: 10.0 ± 10.9 and 2.1 ± 0.9, respectively; LAA: 32.2 ± 15.0 and 1.8 ± 1.1, respectively. A significant decline in monocyte CD26 expression in patients with AAAs was observed relative to the CTL group. In vitro studies demonstrated that the inhibition of DPP-4 promoted PMA-induced monocytic cells differentiation, with increased CD68 and p21 expression, regulated by extracellular signal-regulated protein kinase 1/2 activation. Furthermore, inhibition of DPP-4 significantly increased the phosphorylation of PYK2 and paxillin in PMA-induced THP-1 cell differentiation. Finally, the animal study was used to confirm the in vitro results that LAA mice showed marked macrophage infiltration in the adventitia with a decreased expression of DPP-4 as compared with SAA mice. Conclusions Increased plasma DPP-4 activity may correlate with aneurysmal development. CD26 on monocytes plays a critical role in cell differentiation, possibly mediated by extracellular signal-regulated protein kinase 1/2-p21 axis signaling pathways and cytoskeletal proteins reassembly. Exploring the role of DPP-4 further may yield potential therapeutic insights.
Background Acute respiratory distress syndrome (ARDS) is a life-threatening medical condition. Extracorporeal membrane oxygenation (ECMO) is a salvage therapy for patients with ARDS and refractory ...hypoxia. This study compared the characteristics and outcomes of ARDS patients who did or did not receive ECMO matched with Acute Physiology and Chronic Health Evaluation II (APACHE II) score and age. Methods This retrospective, case-control study enrolled patients with ARDS admitted to the intensive care unit of a tertiary referral hospital between January 2007 and December 2012. Overall, 216 patients with ARDS—81 receiving ECMO (ECMO group) and 135 not receiving ECMO (non-ECMO group)—were enrolled in this study. Patients were paired when the difference in their APACHE II scores was within 3 points and their age difference was 3 years. In total, 126 patients could not be matched and were thus excluded. Eventually, of the 90 patients with ARDS enrolled in this study, 45 ECMO group patients were matched with 45 non-ECMO group patients. The demographic data, reasons for intensive care unit admission, and laboratory variables were evaluated. Results The primary etiology of ARDS was infection (72.2%). The APACHE II score and age-matched group receiving ECMO therapy had higher inhospital survival rates. Moreover, the patients receiving ECMO therapy had significantly lower 6-month mortality rates than did the non-ECMO group. Conclusions Patients with ARDS who received ECMO treatment had higher inhospital survival rates than did those with a similar disease severity and at a similar age who did not receive ECMO.
Background Extracorporeal membrane oxygenation (ECMO) has been utilized for patients in critical condition, including life-threatening respiratory failure and postcardiotomy cardiogenic shock. This ...study analyzed the outcomes of patients with acute respiratory distress syndrome (ARDS) treated by ECMO and identified the relationship between prognosis and urine output (UO) obtained on the first day of ECMO support. Methods This study reviewed the medical records of 81 ARDS patients after ECMO support on a specialized cardiovascular surgery intensive care unit of a tertiary care university hospital between May 2006 and December 2011. Demographic, clinical, and laboratory variables were retrospectively collected as survival predictors. Results The overall mortality rate was 55.5%. A multiple logistic regression analysis indicated that the Acute Physiology and Chronic Health Evaluation II (APACHE II) score, mean arterial pressure, platelet count, and UO on day 1 of ECMO support were independent risk factors for hospital mortality. By using the areas under the receiver operating characteristic (AUROC) curve, UO obtained on the first day of ECMO support demonstrated good discriminative power (AUROC 0.754 ± 0.056, p < 0.001). Urine output had the best discriminative power, the best Youden index, and the highest overall correctness of prediction. Cumulative survival rates at the 6-month follow-up differed significantly ( p < 0.001) for UO 1,432 mL or greater on day 1 of ECMO support versus those with UO less than 1,432 mL on day 1 of ECMO support. Conclusions In ARDS patients receiving ECMO support, UO obtained on the first day of ECMO support showed good prognostic ability in predicting hospital mortality.
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.
Abstract Objective The aim of this study was to explore the relationship between perioperative right ventricular (RV) function and postoperative atrial fibrillation (POAF) in the context of cardiac ...surgery. Design Prospective observational study Setting A single medical center setting Participants Ninety-two patients undergoing elective cardiac surgery Interventions None Measurements and Main Results Consecutive patients without previous history of AF referred for cardiac surgery were prospectively enrolled. Comprehensive transesophageal echocardiography (TEE) was recorded at two specific timeframes: before sternotomy (T1); after sternal closure (T2). Four RV measurements, including RV global longitudinal strain (RVGLS), were performed offline. POAF was defined as any sustained episode of AF recorded within 14 days postoperatively. Ninety-two patients (mean age 61.2 ± 10.8, 63 men) were included in this study, where 25 patients (27%) experienced POAF with a median occurrence of 3 days after cardiac surgery. Multivariable logistic regression models demonstrated that RVGLST1 (OR 1.13, p = 0.047) and RVGLST2 (OR1.38, p = 0.001) were independently associated with POAF. However, changes in RV indices were not correlated to POAF. The optimal cutoff points obtained from the receiver operating characteristic curve analysis were -16.7% of RVGLST1 positive likelihood ratio (LR+) 2.21, negative likelihood ratio (LR-) 0.59 and -16.1% of RVGLST2 (LR+ 2.68, LR- 0.38). Conclusions RV dysfunction is significantly associated with the occurrence of POAF in the context of cardiac surgery, and perioperative RVGLS measured by using TEE is a useful index to predict POAF in patients referred for cardiac surgery.
Background Surgical treatment is an option for both type A aortic dissection and complicated type B aortic dissection. Acute kidney injury (AKI) influences the disease course after surgery. Our ...hypothesis was that AKI should be an important prognostic factor for aortic dissection after surgical treatment. Methods Between July 2005 and October 2010, 268 patients (mean age 53 ± 14 years; range, 16 to 88) underwent open surgery for aortic dissection. We reviewed the clinical presentations, surgical variables, and postoperative outcomes to identify the risk factors of death. The 256 patients were divided into groups, with and without AKI, within 24 hours after operation according to the RIFLE (acronym for risk, injury, failure, loss, end stage) criteria. Results The in-hospital mortality rate was 17.9%, the 1-year mortality rate was 18.7%, and the major adverse cardiac events rate within 1 year was 29.9%. In multivariate analysis, patients more than 70 years of age (hazard ratio HR 2.390, p = 0.029), cardiogenic shock (HR 2.895, p = 0.005), preoperative ventilator use (HR 4.137, p = 0.018), operation at midnight (HR 2.295, p = 0.028), longer bypass time (HR 1.007, p < 0.001), and AKI (HR 2.552, p = 0.041) were clinical predictors of mortality. Kaplan-Meier analysis showed that the survival rate was strongly correlated with the severity of AKI by the RIFLE criteria. The independent predictors of AKI included hypertension (odds ratio 2.340, p = 0.027), sepsis (odds ratio 2.594, p = 0.043), and lower limb malperfusion (odds ratio 4.558, p = 0.022). Conclusions Our study provides outcomes of postoperative aortic dissection. We found that AKI was a predictor of 1-year mortality by using the RIFLE criteria. Factors associated with increased 1-year mortality and AKI should be taken into consideration for surgery and postoperative care.
Abstract Background The success rate of mitral annuloplasty (MA) for functional mitral regurgitation (FMR) varies. This study evaluated the effectiveness of this procedure in nonischemic dilated ...cardiomyopathy (DCM) patients after a selective treatment protocol was followed. Methods and Results This study analyzed 42 patients with nonischemic DCM and FMR (mean regurgitation grade, 3.6 ± 0.3), aged a mean 56.5 ± 15 years (range, 25 to 78 years), who underwent MA from April 2003 to December 2007. The analysis excluded patients with coronary artery disease, or mitral leaflets or subvalvular pathologies. All patients had taken maximal medications for at least 3 months and were still in New York Heart Association (NYHA) functional class III to IV (mean, 3.2 ± 0.4). Mean ejection fraction (EF) was 31.4% ± 12.9% (range, 8% to 58%), and left ventricular end-diastolic diameter (LVEDD) was 66.0 ± 8.3 mm (range, 55 to 85 mm). Downsized Carpentier Physio ring (Carpentier-Edwards, Irvine, California) annuloplasty, mean size 26.3 ± 2.3 (range, 24 to 30), was the preferred procedure. Concomitant procedures included 23 tricuspid valve repairs and 10 Maze operations for atrial fibrillation. Echocardiography was performed at early (≤3 months; mean 1.6 ± 1.5), short-term (6 to 12 months; mean 6.9 ± 3.4), and midterm (>12 months; mean 29.5 ± 13.4 months) follow-up. All late deaths and readmissions were recorded. One (2.4%) in-hospital death occurred due to low cardiac output. Follow-up was completed in 40 of 41 (97.6%) patients (mean duration, 31.9 ± 16.1; range, 3.9 to 59.2 months). Eight (19.5%) patients were readmitted for heart failure, including 2 late MRs due to ring dehiscence and infective endocarditis. Three of 5 deaths during the follow-up period were attributed to cardiac death. Actuarial survival after 1 and 3 years was 88.9% and 79.2%, respectively. The number of patients treated with β-blockers increased after operation, from 52.4% to 75.6% ( P = .028). NYHA class decreased from 3.2 ± 0.4 to 1.3 ± 0.6 ( P < .0001). Echo examination revealed left heart reverse remodeling and improved performance in all follow-up time frames. Conclusion This study shows that MA in patients with non-ischemic DCM and FMR is feasible and associated with reasonable short and long term outcomes.
Background Late tricuspid regurgitation after previous cardiac operation remains controversial in terms of when to repair and who will benefit. We reviewed our surgical experiences and stratified the ...risk factors for death and morbidity. Methods From September 2005 to September 2010, 77 consecutive patients (36 men 47%) underwent redo open heart operations with the tricuspid valve (TV) procedure. Their mean age was 56 ± 13 years (range, 27 to 83 years). TV repair was performed in 44 (57%) and TV replacement in 33 (43%): 23 received bioprostheses; 10 received mechanical prostheses. Results Fourteen (18%) patients died after the operation. Risk factors of hospital death by multivariate analysis were age (>65 years), preoperative renal insufficiency (creatinine >2 mg/dL), and preoperative severe liver cirrhosis (Child classification C). Compared with the group that underwent TV repair, those who underwent TV replacement tended to have had previous TV operations (46% vs 9%; p < 0.001) and preoperative Child class C liver cirrhosis (21% vs 2%; p = 0.018). Although in-hospital mortality was insignificant (24% vs 14%; p = 0.232), postoperative morbidities of tracheotomy, gastrointestinal bleeding, and late death were higher in the replacement group. Conclusions Patients who had previous TV operations and preoperative severe liver cirrhosis were more likely to undergo TV replacement in tricuspid reoperations. Compared with patients in the repair group, patients in the replacement group had higher morbidities and low late survival. Earlier intervention, before decompensated heart failure occurs, is warranted to improve the outcome.
Background Extracorporeal membrane oxygenation (ECMO) can be used as a salvage therapy, but the effectiveness is controversial. The aim of this study was to investigate the predictors of mortality ...and the influence of organ dysfunction scores in severe acute respiratory distress syndrome (ARDS) patients treated with ECMO. Methods The records of adult severe ARDS patients receiving ECMO support from May 2006 to December 2011 at Chang Gung Memorial Hospital were retrospectively analyzed. Results The records of 65 patients with severe ARDS who received venovenous ECMO were analyzed. The hospital survival rate was 47.7%. Survivors were younger than nonsurvivors (41.4 ± 15.4 versus 54.1 ± 16.9 years, respectively; p = 0.002) and had shorter duration of mechanical ventilation before ECMO (52.7 ± 51.1 versus 112.1 ± 101.0 hours, respectively; p = 0.01). Before ECMO, Acute Physiology and Chronic Health Evaluation II, Sequential Organ Failure Assessment, and Multiple Organ Dysfunction scores were significantly lower for survivors than for nonsurvivors. Mortality rate increased with rising predictive score. During 7 days of ECMO use, organ dysfunction scores were significantly lower for survivors than nonsurvivors. Conclusions Severe ARDS patients who are younger, have shorter duration of mechanical ventilation, and lower organ dysfunction scores before ECMO initiation have more favorable survival outcome. Early application of ECMO, especially if predictive score is below 2, may improve survival. Organ dysfunction scores before and during ECMO support are correlated with survival.
Abstract 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. < Learning objective: Hoarseness in unusual clinical setting (i.e. other than in common cold), should raise suspicion and alert physician to search for primary cause of the symptoms. Ortner syndrome, due to left recurrent laryngeal nerve palsy secondary to cardiovascular disease, is an important differential diagnosis of loss of voice. Comprehensive evaluation and timely intervention allow reversal of the damage to left recurrent laryngeal nerve, whereas delay in diagnosis may lead to permanent nerve injury.>
PDF
