Publications by authors named "Li-Wei Lo"

315 Publications

Deep Sedation with Intravenous Anesthesia Is Associated with Outcome in Patients Undergoing Cryoablation for Paroxysmal Atrial Fibrillation.

Int Heart J 2021 Jul 6. Epub 2021 Jul 6.

Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital.

Whether deep sedation with intravenous anesthesia will affect the recurrence after cryoballoon ablation (CBA) of paroxysmal atrial fibrillation (AF) is yet to be examined. Thus, in this study, we hypothesize that there is difference in terms of the recurrence between local anesthesia and deep sedation with intravenous anesthesia after an index ablation procedure.In total, 109 patients were enrolled and received CBA, of which 68 (58.2 years) patients underwent pulmonary vein (PV) isolation with a local anesthesia (group 1) and 41 patients (63.2 years) underwent PV isolation with deep sedation using intravenous anesthesia (group 2).During the index procedure, isolation of all major PVs was achieved in 66 patients in group 1 and in 41 patients in group 2. There was no difference in non-PV triggers between the two groups. The periprocedural complication was found to be similar between the two groups (2.9% in group 1 and 4.9% in group 2). Further, 17 patients in group 1 and 4 patients in group 2 experienced recurrences after a follow-up of 19.3 months (P = 0.019). Repeat procedures revealed similar PV reconnection rates between the two groups. It has also been noted that the number of reconnected PV and incidence of atypical flutter seem to increase in group 1.Deep sedation with intravenous anesthesia during CBA for paroxysmal AF is safe and had a better long-term outcome than those with local anesthesia.
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http://dx.doi.org/10.1536/ihj.20-819DOI Listing
July 2021

Generation of IBMS-iPSC-015, -016, -017 human induced pluripotent stem cells (IBMSi013-A, IBMSi014-A, and IBMSi015-A) derived from patients with atrial fibrillation.

Stem Cell Res 2021 Jul 10;54:102419. Epub 2021 Jun 10.

Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan; Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.

Atrial fibrillation is the most common heart disease in the world, with around 35 million patients in 2020. Here we reported the generation of IBMS-iPSC-015-06, IBMS-iPSC-016-06, and IBMS-iPSC-017-02 as human induced pluripotent stem cell (iPSC) lines from patients' peripheral blood mononuclear cells (PBMCs) with atrial fibrillation. The cell lines expressed properties of pluripotent stem cells, including pluripotent markers and the ability to differentiate into three germ layers. These cell lines served as suitable models for studying alternative therapies of atrial fibrillation.
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http://dx.doi.org/10.1016/j.scr.2021.102419DOI Listing
July 2021

Generation of IBMS-iPSC-021, -022, -023 human induced pluripotent stem cells (IBMSi016-A, IBMSi017-A, and IBMSi018-A) derived from patients with the ALDH2 rs671 polymorphism.

Stem Cell Res 2021 Jul 10;54:102416. Epub 2021 Jun 10.

Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan; Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.

ALDH2 gene is coded for the aldehyde dehydrogenase (ALDH), which is an enzyme involved in alcohol metabolism. Compared to normal aldehyde dehydrogenases, a homozygous point mutation on exon 12 from G to A significantly reduces its efficiency. In this study, we have reported the generation of IBMS-iPSC-021-04, IBMS-iPSC-022-01, and IBMS-iPSC-023-03 as induced pluripotent stem cell (iPSC) lines carrying the homozygous form of ALDH2 with the rs671 genetic polymorphism (E487K mutation). These cell lines were characterized in terms of pluripotency and differentiation potential. They serve as useful platforms to study alcohol metabolism and other chronic diseases associated with alcohol consumption.
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http://dx.doi.org/10.1016/j.scr.2021.102416DOI Listing
July 2021

Mechanism of angiotensin receptor-neprilysin inhibitor in suppression of ventricular arrhythmia.

J Cardiol 2021 May 28. Epub 2021 May 28.

Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan; Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan.

Background: The mechanisms underlying angiotensin receptor-neprilysin inhibitor (ARNi) suppression of ventricular arrhythmia (VA) are unclear. This study aimed to investigate the mechanism of ARNi-related suppression of VA in a heart failure (HF) model.

Methods: New Zealand white rabbits (n = 6 per group) were assigned to normal, HF [4 weeks of left ascending artery (LAD) ligation], angiotensin receptor blocker (ARB, valsartan at 27 mg/kg/day for 3 weeks after 1 week of LAD ligation), and ARNi (sacubitril at 34 mg/kg/day and valsartan at 27 mg/kg/day for 3 weeks after 1 week of LAD ligation) groups. Experiments involving echocardiogram, optical mapping, histological of trichrome stain and immunostain, and flow cytometry were performed.

Results: HF group had larger left ventricular (LV) internal dimensions in diastole and systole, and lower LV ejection fraction and fractional shortening than normal, ARB, and ARNi groups. HF group had a prolonged action potential duration (APD) and decreased conduction velocity (CV), which was mitigated in ARB and ARNi groups. HF group had a prolonged QRS duration, QT and QTc intervals, which was reversed in ARB and ARNi groups. HF group had a steeper maximum slope of APD restitutions, which was attenuated in normal, ARB, and ARNi groups. HF group had increased number of phase singularities (PSs) and VA inducibility than normal, ARB, and ARNi groups. A higher content of fibrosis was found in HF group than that in normal, ARB, and ARNi groups. Compared to ARB group, ARNi had a lower context of fibrosis. HF group had more peripheral blood CD4 and CD8 cells count than normal, ARB, and ARNi group.

Conclusions: In a rabbit model of ischemic HF, ventricular arrhythmogenesis could be suppressed by ARNi treatment. This appears to be mediated by reversing changes in the APD, CV, maximum slope of the APDR, PSs, fibrosis, and inflammation.
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http://dx.doi.org/10.1016/j.jjcc.2021.04.011DOI Listing
May 2021

Efficacy of Patient-Specific Strategy: Catheter Ablation Strategy of Persistent Atrial Fibrillation Based on Morphological Repetitiveness by Periodicity and Similarity.

Circ Arrhythm Electrophysiol 2021 May 17;14(5):e009719. Epub 2021 May 17.

National Yang Ming Chiao Tung University, Hsinchu, Taiwan (C.-Y.L., Y.-J.L., L.K., S.-L.C., L.-W.L., Y.-F.H., T.-F.C., F.-P.C., J.-N.L., T.-Y.C., T.-C.T., C.-I.W., C.-M.L., S.-H.L., W.-H.C., S.-A.C.).

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http://dx.doi.org/10.1161/CIRCEP.121.009719DOI Listing
May 2021

Novel model-based point scoring system for predicting stroke risk in atrial fibrillation patients: Results from a nationwide cohort study with validation.

Int J Cardiol Heart Vasc 2021 Jun 28;34:100787. Epub 2021 Apr 28.

Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.

Background: The stroke risk scoring system for atrial fibrillation (AF) patients can vary considerably based on patients' status while receiving ablation. This study aimed to demonstrate a novel scoring system for stroke risk stratification based on the status of catheter ablation.

Methods: First, 787 patients with AF undergoing ablation were matched according to age, sex, and underlying diseases with the same number of patients not undergoing ablation using the propensity-score (PS)-matched cohort. Multivariate Cox model-derived coefficients were used to construct a simple point-based clinical model using the PS-matched cohort. Thereafter, the novel model (AF-CA-Stroke score) was validated in a nationwide AF cohort.

Results: The AF-CA-Stroke score was calculated based on age (point = 5), ablation status (point = 4), prior history of stroke (point = 4), chronic kidney disease (point = 2), diabetes mellitus (point = 1), and congestive heart failure (point = 1). Risk function to predict the 1-, 5-, 10-year absolute stroke risks was reported. The estimated area under the receive operating characteristic curve of the AF-CA-Stroke score in the PS-matched cohort was 0.845 (95% confidence interval: 0.824-0.865) to predict long-term stroke. A validation study showed that discrimination abilities in the AF-CA-Stroke scores were significantly higher than those in the CHADS/CHADSVASc scores. The best cut-off value of the AF-CA-Stroke score to predict future strokes was ≥ 5.

Conclusions: This novel model-based point scoring system effectively identifies stroke risk using clinical factors and AF ablation status of patients with AF. Various age stratifications and AF ablation should be considered in AF management.
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http://dx.doi.org/10.1016/j.ijcha.2021.100787DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8102915PMC
June 2021

Renal denervation prevents myocardial structural remodeling and arrhythmogenicity in a chronic kidney disease rabbit model.

Heart Rhythm 2021 May 13. Epub 2021 May 13.

Institute of Clinical Medicine and Cardiovascular Research Institute, National Yang Ming Chiao Tung University, Taipei, Taiwan; Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan.

Background: The electrophysiological (EP) effects and safety of renal artery denervation (RDN) in chronic kidney disease (CKD) are unclear.

Objective: The purpose of this study was to investigate the arrhythmogenicity of RDN in a rabbit model of CKD.

Methods: Eighteen New Zealand white rabbits were randomized to control (n = 6), CKD (n = 6), and CKD-RDN (n = 6) groups. A 5/6 nephrectomy was selected for the CKD model. RDN was applied in the CKD-RDN group. All rabbits underwent cardiac EP studies for evaluation. Immunohistochemistry, myocardial fibrosis, and renal catecholamine levels were evaluated.

Results: The CKD group (34.8% ± 9.2%) had a significantly higher ventricular arrhythmia (VA) inducibility than the control (8.6% ± 3.8%; P <.01) and CKD-RDN (19.5% ± 6.3%; P = .01) groups. In the CKD-RDN group, ventricular fibrosis was significantly decreased compared to the CKD group (7.4% ± 2.0 % vs 10.4% ± 3.7%; P = .02). Sympathetic innervation in the CKD group was significantly increased compared to the control and CKD-RDN groups [left ventricle: 4.1 ± 1.8 vs 0.8 ± 0.5 (10 μm/mm), P <.01; 4.1 ± 1.8 vs 0.9± 0.6 (10 μm/mm), P <.01; right ventricle: 3.6 ± 1.0 vs 1.0 ± 0.4 (10 μm/mm), P <.01; 3.6 ± 1.0 vs 1.0 ± 0.5 (10 μm/mm), P <.01].

Conclusion: Neuromodulation by RDN demonstrated protective effects with less structural and electrical remodeling, leading to attenuated VAs. In a rabbit model of CKD, RDN plays a therapeutic role by lowering the risk of VA caused by autonomic dysfunction.
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http://dx.doi.org/10.1016/j.hrthm.2021.05.014DOI Listing
May 2021

Case series on stereotactic body radiation therapy in non-ischemic cardiomyopathy patients with recurrent ventricular tachycardia.

Pacing Clin Electrophysiol 2021 Jun 15;44(6):1085-1093. Epub 2021 May 15.

Heart Rhythm Center, Division of Cardiology, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.

Introduction: The efficacy of stereotactic body radiation therapy (SBRT) as an alternative treatment for recurrent ventricular tachycardia (VT) is still unclear. This study aimed to report the outcome of SBRT in VT patients with nonischemic cardiomyopathy (NICM).

Methods: The determination of the target substrate for radiation was based on the combination of CMR results and electroanatomical mapping merged with the real-time CT scan image. Radiation therapy was performed by Flattening-filter-free (Truebeam) system, and afterward, patients were followed up for 13.5 ± 2.8 months. We analyzed the outcome of death, incidence of recurrent VT, ICD shocks, anti-tachycardia pacing (ATP) sequences, and possible irradiation side-effects.

Results: A total of three cases of NICM patients with anteroseptal scar detected by CMR. SBRT was successfully performed in all patients. During the follow-up, we found that VT recurrences occurred in all patients. In one patient, it happened during a 6-week blanking period, while the others happened afterward. Re-hospitalization due to VT only appeared in one patient. Through ICD interrogation, we found that all patients have reduced VT burden and ATP therapies. All of the patients died during the follow-up period. Radiotherapy-related adverse events did not occur in all patients.

Conclusions: SBRT therapy reduces the number of VT burden and ATP sequence therapy in NICM patients with VT, which had a failed previous catheter ablation. However, the efficacy and safety aspects, especially in NICM cases, remained unclear.
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http://dx.doi.org/10.1111/pace.14254DOI Listing
June 2021

An Inkjet-Printed PEDOT:PSS-Based Stretchable Conductor for Wearable Health Monitoring Device Applications.

ACS Appl Mater Interfaces 2021 May 29;13(18):21693-21702. Epub 2021 Apr 29.

Department of Electrical & Systems Engineering, Washington University in St. Louis, St. Louis, Missouri 63130, United States.

A stretchable conductor is one of the key components in soft electronics that allows the seamless integration of electronic devices and sensors on elastic substrates. Its unique advantages of mechanical flexibility and stretchability have enabled a variety of wearable bioelectronic devices that can conformably adapt to curved skin surfaces for long-term health monitoring applications. Here, we report a poly(3,4-ethylenedioxythiophene) polystyrene sulfonate (PEDOT:PSS)-based stretchable polymer blend that can be patterned using an inkjet printing process while exhibiting low sheet resistance and accommodating large mechanical deformations. We have systematically studied the effect of various types of polar solvent additives that can help induce phase separation of PEDOT and PSS grains and change the conformation of a PEDOT chain, thereby improving the electrical property of the film by facilitating charge hopping along the percolating PEDOT network. The optimal ink formulation is achieved by adding 5 wt % ethylene glycol into a pristine PEDOT:PSS aqueous solution, which results in a sheet resistance of as low as 58 Ω/□. Elasticity can also be achieved by blending the above solution with the soft polymer poly(ethylene oxide) (PEO). Thin films of PEDOT:PSS/PEO polymer blends patterned by inkjet printing exhibits a low sheet resistance of 84 Ω/□ and can resist up to 50% tensile strain with minimal changes in electrical performance. With its good conductivity and elasticity, we have further demonstrated the use of the polymer blend as stretchable interconnects and stretchable dry electrodes on a thin polydimethylsiloxane (PDMS) substrate for photoplethysmography (PPG) and electrocardiography (ECG) recording applications. This work shows the potential of using a printed stretchable conducting polymer in low-cost wearable sensor patches for smart health applications.
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http://dx.doi.org/10.1021/acsami.1c00537DOI Listing
May 2021

The isthmus characteristics of scar-related macroreentrant atrial tachycardia in patients with and without cardiac surgery.

J Cardiovasc Electrophysiol 2021 Jul 19;32(7):1921-1930. Epub 2021 Apr 19.

Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.

Introduction: Identifying the critical isthmus (CI) in scar-related macroreentrant atrial tachycardia (AT) is challenging, especially for patients with cardiac surgery. We aimed to investigate the electrophysiological characteristics of scar-related macroreentrant ATs in patients with and without cardiac surgery.

Methods: A prospective study of 31 patients (mean age 59.4 ± 9.81 years old) with scar-related macroreentrant ATs were enrolled for investigation of substrate properties. Patients were categorized into the nonsurgery (n = 18) and surgery group (n = 13). The CIs were defined by concealed entrainment, conduction velocity less than 0.3 m/s, and the presence of local fractionated electrograms.

Results: Among the 31 patients, a total of 65 reentrant circuits and 76 CIs were identified on the coherent map. The scar in the surgical group is larger than the nonsurgical group (18.81 ± 9.22 vs. 10.23 ± 5.34%, p = .016). The CIs in surgical group have longer CI length (15.27 ± 4.89 vs. 11.20 ± 2.96 mm, p = .004), slower conduction velocity (0.46 ± 0.19 vs. 0.69 ± 0.14 m/s, p < .001), and longer total activation time (45.34 ± 9.04 vs. 38.24 ± 8.41%, p = .016) than those in the nonsurgical group. After ablation, 93.54% of patients remained in sinus rhythm during a follow-up of 182 ± 19 days.

Conclusion: The characteristics of the isthmus in macroreentrant AT are diverse, especially for surgical scar-related AT. The identification of CIs can facilitate the successful ablation of scar-related ATs.
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http://dx.doi.org/10.1111/jce.15034DOI Listing
July 2021

Optimal substrate modification strategies using catheter ablation in patients with persistent atrial fibrillation: 3-year follow-up outcomes.

J Cardiovasc Electrophysiol 2021 Jun 5;32(6):1561-1571. Epub 2021 May 5.

Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan.

Objectives: This study aimed to assess the comparative efficacy of four ablation strategies on the incidence rates of freedom from atrial fibrillation (AF) or atrial tachycardia (AT) through a 3-year follow-up in patients with persistent AF.

Background: The optimal substrate modification strategies using catheter ablation for patients with persistent AF remain unclear.

Methods: Patients with persistent AF were enrolled consecutively to undergo each of four ablation strategies: (a) Group 1 (Gp 1, n = 69), pulmonary vein isolation (PVI) plus rotor ablation assisted by similarity index and phase mapping; (b) Gp 2 (n = 75), PVI plus linear ablations at the left atrium; (c) Gp 3 (n = 42), PVI plus the elimination of complex fractionated atrial electrograms; (d) Gp 4 (n = 67), PVI only. Potential confounders were adjusted via a multivariate survival parametric model.

Results: Baseline characteristics were similar across the four groups. At a follow-up period of 34.9 ± 38.6 months, patients in Gp 1 showed the highest rate of freedom from AF compared with the other three groups (p = .002), while patients in Gp 3 and 4 showed lower rates of freedom from AT than those of the other two groups (p = .006). Independent predictors of recurrence of AF were the ablation strategy (p = .002) and left atrial diameter (LAD) (p = .01).

Conclusion: In patients with persistent AF, a substrate modification strategy using rotor ablation assisted by similarity index and phase mapping provided a benefit for maintaining sinus rhythm compared with the other strategies. Both ablation strategy and baseline LAD predicted the 3-year outcomes of freedom from AT/AF.
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http://dx.doi.org/10.1111/jce.15033DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8252615PMC
June 2021

Effects of Angiotensin Receptor-Neprilysin Inhibitor in Arrhythmogenicity Following Left Atrial Appendage Closure in an Animal Model.

Cardiovasc Drugs Ther 2021 Aug 5;35(4):759-768. Epub 2021 Apr 5.

Heart Rhythm Center and Division of Cardiology, Taipei Veterans General Hospital, Taipei, Taiwan, 11217.

Purpose: Left atrial appendage (LAA) closure decreases atrial natriuretic peptide (ANP) levels, which indirectly increases the risk of arrhythmogenicity. We aimed to determine the effect of a combined angiotensin receptor-neprilysin inhibitor (ARNi) on arrhythmogenicity following LAA closure in an animal model.

Methods: Twenty-four rabbits were randomized into four groups: (1) control, (2) LAA closure (LAAC), (3) heart failure (HF)-LAAC, and (4) HF-LAAC with sacubitril/valsartan (+ARNi). HF models were developed in the HF-LAAC and HF-LAAC+ARNi groups. Epicardial LAA exclusion was performed in the LAAC, HF-LAAC, and HF-LAAC+ARNi groups. ANP levels were measured. An electrophysiological study was performed. The myocardium was harvested for histopathological analysis.

Results: The ANP level decreased in the LAAC group (785 ± 103 pg/mL, p = 0.03), failed to increase in the HF-LAAC group (917 ± 172 pg/mL, p = 0.3), and increased in the HF-LAAC+ARNi group (1524 ± 126 pg/mL, p < 0.01) compared to that in the control group (1014 ± 56 pg/mL). The atrial effective refractory period (ERP) was prolonged in the HF-LAAC group and restored to baseline in the HF-LAAC+ARNi group. Ventricular ERP was the longest in the HF-LAAC group. The atrial fibrillation window of vulnerability (AF WOV) was elevated in the LAAC, HF-LAAC, and HF-LAAC+ARNi groups, with the latter group having lower AF WOV than the two former groups. Ventricular fibrillation (VF) inducibility was the highest in the HF-LAAC group (51 ± 5%, p < 0.001), followed by the LAAC group (30 ± 4%, p = 0.006) and the HF-LAAC+ARNi group (25 ± 5%, p = 0.11) when compared to the control group (18 ± 4%). Atrial and ventricular fibrosis were noted in all groups except the control group.

Conclusion: LAA closure decreased ANP, which in turn increased AF and VF inducibility. Atrial and ventricular arrhythmogenicity was suppressed by ARNi.
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http://dx.doi.org/10.1007/s10557-021-07174-2DOI Listing
August 2021

Clinical significance of J waves with respect to substrate characteristics and ablation outcomes in patients with arrhythmogenic right ventricular cardiomyopathy.

Europace 2021 Mar 18. Epub 2021 Mar 18.

Division of Cardiology, Department of Medicine, Heart Rhythm Center, Taipei Veterans General Hospital, No. 201, Section 2, Shih-Pai Road, Taipei, Taiwan.

Aims: J-wave syndrome in patients with arrhythmogenic right ventricular cardiomyopathy (ARVC) has been linked to an increased risk of ventricular arrhythmia. We investigated the significance of J waves with respect to substrate manifestations and ablation outcomes in patients with ARVC.

Methods And Results: Forty-five patients with ARVC undergoing endocardial/epicardial mapping/ablation were studied. Patients were classified into two groups: 13 (28.9%) and 32 (71.1%) patients with and without J waves, respectively. The baseline characteristics, electrophysiological features, ventricular substrate, and recurrent ventricular tachycardia/fibrillation (VT/VF) were compared. Among the 13 patients with J waves, only the inferior J wave was observed. More ARVC patients with J waves fulfilled the major criteria of ventricular arrhythmias (76.9% vs. 21.9%, P = 0.003). Similar endocardial and epicardial substrate characteristics were observed between the two groups. However, patients with J waves had longer epicardial total activation time than those without (224.7 ± 29.9 vs. 200.8 ± 21.9 ms, P = 0.005). Concordance of latest endo/epicardial activation sites was observed in 29 (90.6%) patients without J waves and in none among those with J waves (P < 0.001). Complete elimination of endocardial/epicardial abnormal potentials resulted in the disappearance of the J wave in 8 of 13 (61.5%) patients. The VT/VF recurrences were not different between ARVC patients with and without J waves.

Conclusion: The presence of J waves was associated with the discordance of endocardial/epicardial activation pattern in terms of transmural depolarization discrepancy in patients with ARVC.
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http://dx.doi.org/10.1093/europace/euab060DOI Listing
March 2021

Enhanced detection of cardiac arrhythmias utilizing 14-day continuous ECG patch monitoring.

Int J Cardiol 2021 06 13;332:78-84. Epub 2021 Mar 13.

Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan.

Background: To evaluate the performance of a single‑lead, 14-day continuous electrocardiogram (ECG) patch for the detection of arrhythmias compared to conventional 24-h monitoring.

Methods: This prospective clinical trial enrolled patients suspected of arrhythmias but not diagnosed by 12‑lead ECGs. Each patient underwent a 24-h Holter and 14-day ECG patch simultaneously. Seven types of arrhythmias were classified: supraventricular tachycardia (SVT, repetitive atrial beats >4 beats), irregular SVT without P wave (>4 beats), AF/AFL (irregular SVT without P wave ≥30 s), pause ≥3 s, atrioventricular block (AVB; Mobitz type II, third-degree, two to one or high degree AVB), ventricular tachycardia (VT), and polymorphic VT.

Results: A total of 158 patients were recruited (mean wear time:12.3 ± 3.2 days). The overall arrhythmia detection rate was higher with 14-day ECG patches (59.5%) compared to 24-h Holter (19.0%, P < 0.001). Up to 87.2% of arrhythmias recorded with 14-day ECG patches were not associated with symptoms. The 14-day ECG patch was associated with higher detection rates compared to the 24-h Holter in patients with SVT (52.5% versus 15.8%, P < 0.001), irregular SVT without P wave (12.7% versus 4.4%, P = 0.002), AF/AFL (9.5% versus 3.8%, P = 0.042), and critical arrhythmias (pause ≥3 s, AVB, VT, polymorphic VT) (16.5% versus 2.5%, P < 0.001). The 14-day ECG patch detected more than 2 types of arrhythmias in 5.1% of patients. No serious adverse events in patients wearing the 14-day ECG patch were reported.

Conclusions: The 14-day ECG patch outperformed 24-h Holter to detect overall, asymptomatic, critical and multiple arrhythmias. It is safe and has the potential to identify individuals with hidden arrhythmias, especially those with critical arrhythmias.
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http://dx.doi.org/10.1016/j.ijcard.2021.03.015DOI Listing
June 2021

Spatiotemporal differences in precordial electrocardiographic amplitude before and after flecainide provocation are associated with a history of unstable ventricular arrhythmia in Brugada syndrome.

J Cardiovasc Electrophysiol 2021 Mar 24;32(3):758-765. Epub 2021 Jan 24.

Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.

Introduction: A drug provocation test (DPT) is important for the diagnosis of Brugada syndrome (BrS). The link, however, between dynamic changes of electrocardiography (ECG) features after DPT and unstable ventricular arrhythmia (VA) in BrS remains unknown.

Methods: Between 2014 and 2019, we assessed 27 patients with BrS (median age: 37.0 [interquartile range, IQR: 22.0-51.0] years; 25 men), including 9 (33.3%) with a history of unstable VA and 18 (66.7%) without. All patients in the study presented with Brugada-like ECG features before DPT. The ECG parameters and dynamic changes (∆) in 12-lead ECGs recorded from the second, third, and fourth intercostal spaces (ICS) before and at 1, 6, 12, 18, and 24 h after DPT (oral flecainide 400 mg) were analyzed.

Results: The total amplitude of V at the third ICS 18 and 24 h after DPT was significantly lower in patients with a history of unstable VA than in those without. Patients with BrS and unstable VAs had a significantly larger ∆ amplitude of V at the second ICS 12 h after DPT than in those without unstable VAs (0.28 [0.18-0.41] mV vs. 0.08 [0.01-0.15] mV, p = .01). A multivariate analysis revealed that the amplitude of V at the third ICS 18 and 24 h after DPT and the ∆ amplitude of V at the second ICS 12 h after DPT were associated with a history of unstable VA.

Conclusion: Nonuniform changes and spatiotemporal differences in precordial ECG features after DPT were observed in patients with BrS and these may be surrogate markers for risk stratification.
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http://dx.doi.org/10.1111/jce.14888DOI Listing
March 2021

Non-Vitamin K Antagonist Oral Anticoagulants in Elderly (≥85 years) Patients With Newly Diagnosed Atrial Fibrillation: Changing Clinical Practice and Outcomes for Stroke Prevention in a Nationwide Cohort Study.

Mayo Clin Proc 2021 01;96(1):52-65

Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan. Electronic address:

Objective: To investigate the influences of non-vitamin K antagonist oral anticoagulants (NOACs) on rates of initiations of oral anticoagulants (OACs) and outcomes among elderly patients with atrial fibrillation (AF).

Methods: From January 1, 2009, to December 31, 2015, 33,539 newly-diagnosed AF patients older than 85 years old who survived more than 180 days after AF diagnosis were studied. Temporal trends regarding OAC initiation rates after incident AF were analyzed. The 1-year risks of ischemic stroke, intracranial hemorrhage, and mortality of incident AF patients diagnosed each year were compared with that of the year 2009.

Results: Initiation rates of OACs after AF was newly diagnosed in the elderly significantly increased from 9.5% to 34.3%, mainly due to the introduction of NOACs (from 0% to 26.2%). Several clinical factors were associated with OACs underuse, including chronic obstructive pulmonary disease, abnormal renal function, anemia, and history of bleeding. Compared with year 2009 (incidence rate, 5.55%/year), the 1-year risk of ischemic stroke after AF diagnosis decreased in the era of NOACs (incidence rate, 4.20%/year; adjusted hazard ratio [aHR], 0.748 in year 2012; 4.39%/year, aHR, 0.789 in 2014; 2.75%/year; aHR, 0.513 in year 2015; all P<.01, except for year 2013, 4.80%/year [P=.07]). Also, the risks of mortality were lower in years 2012 to 2015, while the risk of ICH remained unchanged.

Conclusion: Initiation rates of OACs after AF was newly diagnosed in the elderly significantly increased following the introduction of NOACs. A lower risk of ischemic stroke, mortality, and composite adverse events was observed, which was temporally associated with the increasing prescription rates of OACs.
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http://dx.doi.org/10.1016/j.mayocp.2020.08.042DOI Listing
January 2021

Stature, obesity, and atrial fibrillation: Does appearance matter?

Authors:
Li-Wei Lo

J Arrhythm 2020 Dec 6;36(6):982-983. Epub 2020 Sep 6.

Division of Cardiology Department of Medicine Taipei Veterans General Hospital Institute of Clinical Medicine, and Cardiovascular Research Institute National Yang-Ming University Taipei Taiwan.

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http://dx.doi.org/10.1002/joa3.12423DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7733574PMC
December 2020

Delayed association of acute particulate matter 2.5 air pollution exposure with loss of complexity in cardiac rhythm dynamics: insight from detrended fluctuation analysis.

Environ Sci Pollut Res Int 2021 Mar 26;28(9):10931-10939. Epub 2020 Oct 26.

Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, 201, Sec. 2, Shih-Pai Road, Taipei, Taiwan.

There is a delayed (lag 1 to 2 days) correlation between acute PM 2.5 (particulate matter < 2.5 μm in aerodynamic diameter) exposure and cardiovascular events, but the underlying mechanism remained unclear. We aimed to investigate the delayed impact of acute PM 2.5 exposures on cardiac autonomics through linear and nonlinear heart rate variability (HRV) analyses. Among 6912 patients who had received 24-h Holter ECG between October 1, 2015, to October 31, 2016, 56 patients (31 males, 70.3 ± 12.7 years old) were enrolled. We classified the patients as high (> 35.4 μg/m) or low (< 35.4 μg/m) PM 2.5 groups according to their PM 2.5 exposures on the day of Holter recordings (day 0) lag 1 and lag 2 days. Linear and nonlinear HRV parameters〔Detrended fluctuation analysis (DFA) slopes 1 and 2〕were compared. Baseline characteristics were similar between groups. Linear and nonlinear HRV parameters were similar between high- and low-exposure groups on day 0 and lag 1 day, respectively. However, DFA slope 1 was significantly lower in the high-exposure group on lag 2 days (0.784 ± 0.201 vs. 0.964 ± 0.274, p = 0.021). DFA slope 1 of the high-exposure group was significantly lower on daytime periods (9 am to 9 pm, 8 am to 4 pm and 4 pm to 12 pm) but not on nighttime periods. High lag 2 days PM 2.5 exposure is associated with low DFA slope 1 and the relationship is diurnal. This suggests that air pollution might have a delayed impact on the cardiovascular autonomic system.
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http://dx.doi.org/10.1007/s11356-020-11275-0DOI Listing
March 2021

Catheter ablation of complex atrial tachyarrhythmias in adult patients with cor triatriatum.

J Interv Card Electrophysiol 2020 Oct 19. Epub 2020 Oct 19.

Heart Rhythm Center and Division of Cardiology, Taipei Veterans General Hospital, 201, Sec. 2, Shih-Pai Road, Taipei, 11217, Taiwan.

Purpose: Reports concerning clinical characteristics of cor triatriatum and approaches for catheter ablation of complex atrial tachyarrhythmias remain limited. Here, we describe successful catheter ablation treatments for complex atrial tachyarrhythmias in patients with cor triatriatum and address the clinical caveats.

Methods: Demographic characteristics, electrophysiologic findings, and ablation results in four patients with cor triatriatum were described.

Results: Catheter ablation was performed in four patients with cor triatriatum (three sinister and one dexter) and complex atrial arrhythmias (three with persistent atrial fibrillation (AF) and one with atypical left atrial flutter). A transseptal puncture was selectively directed into the accessory compartment containing the pulmonary veins. A comprehensive preview involving transthoracic echocardiography, transesophageal echocardiography, and computed tomography of the pulmonary veins was critical for proper positioning of ablation catheters. The pulmonary veins remain the major triggers or initiators for AF, and four pulmonary vein isolation procedures were sufficient to achieve successful results with negative inducibility test in the patients with AF. Heterogeneous conduction and complex fractionated signals were observed on the fibromuscular membrane. Atypical flutter was terminated during ablation over the connection between membrane and left atrial roof. The procedure was successfully performed on all patients without complications. No acute recurrences of atrial tachyarrhythmias were observed in any of the patients during short-term follow-up.

Conclusions: Catheter ablation is a feasible and efficient therapeutic strategy for treating complex atrial tachyarrhythmias in patients with cor triatriatum. Atrial remodeling due to anatomical obstruction or heterogeneous conduction of the fibromuscular membrane may serve as an arrhythmic substrate.
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http://dx.doi.org/10.1007/s10840-020-00888-7DOI Listing
October 2020

The Clinical Application of the Deep Learning Technique for Predicting Trigger Origins in Patients With Paroxysmal Atrial Fibrillation With Catheter Ablation.

Circ Arrhythm Electrophysiol 2020 11 6;13(11):e008518. Epub 2020 Oct 6.

Heart Rhythm Center, Division of Cardiology, Department of Medicine (C.-M.L., S.-L.C., Y.-J.L., L.-W.L., Y.-F.H., F.-P.C., T.-F.C., T.-C.T., J.-N.L., C.-Y.L., T.-Y.C., C.-I.W., L.K., Y.-C.S., S.-A.C.), Taipei Veterans General Hospital, Taiwan.

Background: Non-pulmonary vein (NPV) trigger has been reported as an important predictor of recurrence post-atrial fibrillation ablation. Elimination of NPV triggers can reduce the recurrence of postablation atrial fibrillation. Deep learning was applied to preablation pulmonary vein computed tomography geometric slices to create a prediction model for NPV triggers in patients with paroxysmal atrial fibrillation.

Methods: We retrospectively analyzed 521 patients with paroxysmal atrial fibrillation who underwent catheter ablation of paroxysmal atrial fibrillation. Among them, pulmonary vein computed tomography geometric slices from 358 patients with nonrecurrent atrial fibrillation (1-3 mm interspace per slice, 20-200 slices for each patient, ranging from the upper border of the left atrium to the bottom of the heart, for a total of 23 683 images of slices) were used in the deep learning process, the ResNet34 of the neural network, to create the prediction model of the NPV trigger. There were 298 (83.2%) patients with only pulmonary vein triggers and 60 (16.8%) patients with NPV triggers±pulmonary vein triggers. The patients were randomly assigned to either training, validation, or test groups, and their data were allocated according to those sets. The image datasets were split into training (n=17 340), validation (n=3491), and testing (n=2852) groups, which had completely independent sets of patients.

Results: The accuracy of prediction in each pulmonary vein computed tomography image for NPV trigger was up to 82.4±2.0%. The sensitivity and specificity were 64.3±5.4% and 88.4±1.9%, respectively. For each patient, the accuracy of prediction for a NPV trigger was 88.6±2.3%. The sensitivity and specificity were 75.0±5.8% and 95.7±1.8%, respectively. The area under the curve for each image and patient were 0.82±0.01 and 0.88±0.07, respectively.

Conclusions: The deep learning model using preablation pulmonary vein computed tomography can be applied to predict the trigger origins in patients with paroxysmal atrial fibrillation receiving catheter ablation. The application of this model may identify patients with a high risk of NPV trigger before ablation.
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http://dx.doi.org/10.1161/CIRCEP.120.008518DOI Listing
November 2020

Precordial T-Wave Inversions in Patients with Arrhythmogenic Right Ventricular Cardiomyopathy Who Present with the Initial Features of Right Ventricular Outflow Tract Arrhythmia.

Acta Cardiol Sin 2020 Sep;36(5):464-474

Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital.

Background: Precordial T-wave inversion (TWI) is an important diagnostic criterion for arrhythmogenic right ventricular cardiomyopathy (ARVC).

Objective: This study aimed to characterize the initial repolarization features of definite ARVC in patients who first presented with right ventricular outflow tract ventricular arrhythmia (RVOT-VA) and TWI.

Methods: Patients who presented with RVOT-VA and TWI ≥ V were retrospectively assessed. The initial characteristics of repolarization between patients with and without a final diagnosis of definite ARVC during follow-up were compared.

Results: TWI ≥ V was observed in 61 of 553 patients (mean age: 44.1 ± 14.7 years; 14 men) with RVOT-VAs. After an average follow-up time of 54.9 ± 33.7 months, 31 (50.8%) patients were classified into the definite ARVC group and 30 (49.2%) into the non-definite ARVC group. The disappearance of precordial TWI ≥ V was observed in eight (13.1%) patients after the elimination of RVOT-VAs. In a multivariate analysis of the initial electrocardiogram features, only fragmented QRS [odds ratio (OR): 15.45, 95% confidence interval (CI): 1.61-148.26, p = 0.02] and precordial V TpTe interval (OR: 1.03, 95% CI: 1.01-1.06, p = 0.02) could independently predict definite ARVC during longitudinal follow-up. An initial V TpTe cutoff value > 88.5 ms could predict the final diagnosis of definite ARVC, with a sensitivity and specificity of 74.2% and 78.6%, respectively.

Conclusions: Despite the high risk of ARVC in RVOT-VAs and TWI ≥ V, "normalization" of TWI was observed after ventricular arrhythmia elimination in 13.1% of the patients. Fragmented QRS and longer V TpTe interval were associated with definite ARVC during longitudinal follow-up.
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http://dx.doi.org/10.6515/ACS.202009_36(5).20200621ADOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7490609PMC
September 2020

Rhodiola crenulata reduces ventricular arrhythmia through mitigating the activation of IL-17 and inhibiting the MAPK signaling pathway.

Cardiovasc Drugs Ther 2020 Sep 18. Epub 2020 Sep 18.

Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, 201 Sec- 2, Shih-Pai Road, Taipei, Taiwan.

Purpose: Ventricular arrhythmia (VA) is related to inflammatory activity. Rhodiola crenulate (RC) and its main active component, salidroside, have been reported as anti-inflammatory agents. The aim of this study was to demonstrate the effect of RC and salidroside in preventing VA via the inhibition of IL-17 in an ischemic heart failure (HF) model.

Methods: Rabbit HF models were established by coronary artery ligation for 4 weeks. These rabbits were treated with RC (125, 250, 500 mg/kg) and salidroside (9.5 mg/kg) once every 2 days for 4 weeks. WBC, serum biochemistry, ECG, and the expression of CD4 T cells were measured every 2 weeks. The mRNA and protein expressions of IL-17 were measured by real time-PCR, ELISA, and Western blotting after RC and salidroside treatment for 4 weeks. Open-chest epicardial catheter stimulation was performed for VA provocation.

Results: After RC and salidroside treatment in HF left ventricle, (1) the levels of WBC and CD4 T cells decreased, (2) the expression of IL-17 and its downstream target genes, IL-6, TNF-α, IL-1β, IL-8, and CCL20, reduced, (3) the level of NLRP3 inflammasome was decreased, (4) fibrosis and collagen production were significantly downregulated, (5) p38 MAPK and ERK1/2 phosphorylation were attenuated, (6) the inducibility of VA was decreased, and (7) the levels of Kir2.1, Nav1.5, NCX, PLB, SERCA2a and RyR were up-regulated.

Conclusions: RC inhibited the expression of IL-17 and its downstream target genes that were mediated by activation of several MAPKs, which decreased the levels of fibrosis and apoptosis and suppressed VA.
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http://dx.doi.org/10.1007/s10557-020-07072-zDOI Listing
September 2020

Flexible Carbon Nanotube Synaptic Transistor for Neurological Electronic Skin Applications.

ACS Nano 2020 08 27;14(8):10402-10412. Epub 2020 Jul 27.

Electrical and Computer Engineering, Michigan State University, East Lansing, Michigan 48824, United States.

There is an increasing interest in the development of memristive or artificial synaptic devices that emulate the neuronal activities for neuromorphic computing applications. While there have already been many reports on artificial synaptic transistors implemented on rigid substrates, the use of flexible devices could potentially enable an even broader range of applications. In this paper, we report artificial synaptic thin-film transistors built on an ultrathin flexible substrate using high carrier mobility semiconducting single-wall carbon nanotubes. The synaptic characteristics of the flexible synaptic transistor including long-term/short-term plasticity, spike-amplitude-dependent plasticity, spike-width-dependent plasticity, paired-pulse facilitation, and spike-time-dependent plasticity have all been systematically characterized. Furthermore, we have demonstrated a flexible neurological electronic skin and its peripheral nerve with a flexible ferroelectret nanogenerator (FENG) serving as the sensory mechanoreceptor that generates action potentials to be processed and transmitted by the artificial synapse. In such neurological electronic skin, the flexible FENG sensor converts the tactile input (magnitude and frequency of force) into presynaptic action potential pulses, which are then passed to the gate of the synaptic transistor to induce change in its postsynaptic current, mimicking the modulation of synaptic weight in a biological synapse. Our neurological electronic skin closely imitates the behavior of actual human skin, and it allows for instantaneous detection of force stimuli and offers biological synapse-like behavior to relay the stimulus signals to the next stage. The flexible sensory skin could potentially be used to interface with skeletal muscle fibers for applications in neuroprosthetic devices.
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http://dx.doi.org/10.1021/acsnano.0c04259DOI Listing
August 2020

The application of novel segmentation software to create left atrial geometry for atrial fibrillation ablation: The implication of spatial resolution.

J Chin Med Assoc 2020 Sep;83(9):830-837

Department of Medicine, Division of Cardiology, Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan, ROC.

Background: The application of new imaging software for the reconstruction of left atrium (LA) geometry during atrial fibrillation (AF) ablation has not been well investigated.

Methods: A total of 27 patients undergoing AF ablation using a CARTO Segmentation Module system were studied (phase I). High-density LA mapping using PentaRay was merged with computed tomography-based geometry from the auto-segmentation module. The spatial distortion between the two LA geometries was analyzed and compared using Registration Match View. The associated contact force on the two LA shells was prospectively validated in 16 AF patients (phase II).

Results: Of the five LA regions, the roof area had the highest quality score between the two LA shells (1.7 ± 0.6). In addition, among the pulmonary veins (PVs), higher quality scores were observed in bilateral PV carinas (both 1.8 ± 0.1, p < 0.05) than in the anterior or posterior PV regions. Furthermore, surrounding the PV ostium, the on-surface points had a significantly higher contact force when targeting the high-density fast anatomical mapping shell than for the auto-segmentation module (right superior pulmonary vein, 20.7 ± 5.8 g vs 12.5 ± 4.4 g; right inferior pulmonary vein, 19.3 ± 6.8 g vs 11.8 ± 4.8 g; left superior pulmonary vein, 22.5 ± 7.3 g vs 11.2 ± 4.5 g; left inferior pulmonary vein, 15.7 ± 6.9 g vs 9.7 ± 4.4 g, p < 0.05 for each group).

Conclusion: The CARTO Segmentation Module and Registration Match View provide better anatomic accuracy and less regional distortion of the LA geometry, and this can prevent excessive contact and potential procedural complications.
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http://dx.doi.org/10.1097/JCMA.0000000000000390DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7478205PMC
September 2020

Applying the CHADS-VASc score to predict the risk of future acute coronary syndrome in patients receiving catheter ablation for atrial fibrillation.

Int J Cardiol Heart Vasc 2020 Aug 28;29:100567. Epub 2020 Jun 28.

Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.

Objective: It remains unknown whether catheter ablation for atrial fibrillation (AF) reduces future acute coronary syndrome (ACS) risk or whether the CHADS-VASc score has a role in predicting this risk. We aimed to compare very long-term risk of ACS between patients who received catheter ablation to AF or antiarrhythmic medications and controls without AF.

Methods: Propensity scores were calculated for each patient and used to assemble a cohort of 787 patients undergoing AF ablation in 2003-2012. Patients were compared to an equal number of AF patients treated with antiarrhythmic medications and a control group without AF. Patients with previous coronary events were excluded. The primary endpoint was ACS occurrence.

Results: Baseline clinical characteristics were comparable. After a mean 9.1 ± 3.2-year follow-up, the ablation group had lower incidence of new onset ACS than the medication and non-AF control groups (annual incidence: 0.15%. 0.78%, and 0.35%; with 2.67, 4.16, and 10.44 cases/1000 person-years, respectively; P < 0.001). After adjusting for multiple confounders, the ablation group had lower future ACS risk than the medication (hazard ratio [HR]: 0.20, 95% confidence interval [CI]: 0.13-0.30) and control groups (HR: 0.30, 95% CI: 0.20-0.45). The CHADS-VASc score was a strong predictor of ACS (HR: 1.61, 95% CI: 1.47-1.76; AUC: 85.9%, 95% CI: 78.5-93.2%). A baseline CHADS-VASc score ≥ 4 predicted future ACS (positive predictive rate: 14.3%).

Conclusions: This study suggested that catheter ablation for AF may be beneficial to reduce future ACS risk in AF patients, and a high baseline CHADS-VASc score can predict future acute coronary events.
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http://dx.doi.org/10.1016/j.ijcha.2020.100567DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7330062PMC
August 2020

Circadian rhythm dynamics on multiscale entropy identifies autonomic dysfunction associated with risk of ventricular arrhythmias and near syncope in chronic kidney disease.

J Cardiol 2020 12 4;76(6):542-548. Epub 2020 Jul 4.

Division of Cardiology, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang-Ming University, Taipei, Taiwan.

Background: A discordant biological clock could potentially induce sudden cardiac death (SCD). We aimed to evaluate the circadian change of heart rate variability (HRV) and its relationship to the risks of ventricular arrhythmia (VA) and near syncope in patients with chronic kidney disease (CKD).

Methods: In this retrospective study, non-CKD and CKD patients were enrolled and underwent a 24-hour Holter examination for linear and nonlinear HRV analyses. The multiscale entropy (MSE) method was selected for nonlinear HRV analyses. The documented VAs or episodes of near syncope were classified as high-risk SCD group (n=8) and others as low-risk SCD group (n=21).

Results: In linear analyses, time and frequency domains revealed no significant difference between groups. In nonlinear analyses with MSE, MSE, MSE, and MSE were significantly lower (p=0.002, p<0.0001, and p=0.013) in the high-risk SCD group, compared to those in the low-risk SCD group, respectively. Comparing between daytime and nighttime within each group, the MSE revealed no difference in the high-risk SCD group (p=0.128), whereas the daytime was significantly higher in the low-risk SCD group (p=0.048). The area under the curve (AUC) analysis revealed MSE has the best predictive power associated with VAs and near syncope with a cut-off value of ≤24.64 (p<0.001).

Conclusions: Nonlinear analysis with MSE demonstrated the loss of circadian change in CKD patients and was associated with a higher risk for VAs and near syncope. The MSE method demonstrated the diurnal change of rhythm dynamics which identifies potential autonomic dysfunction leading to poor prognosis.
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http://dx.doi.org/10.1016/j.jjcc.2020.05.017DOI Listing
December 2020

Left Ventricular Electromechanical Remodeling Detected by Acoustic Cardiography in Paroxysmal Atrial Fibrillation.

J Cardiovasc Transl Res 2021 Apr 18;14(2):348-354. Epub 2020 Jun 18.

Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, 201 Section 2, Shih-Pai Road, Taipei, Taiwan.

This study aimed to investigate the electromechanical function detected by acoustic cardiography before and after radiofrequency ablation therapy (RFA) in paroxysmal AF (PAF) patients with preserved left ventricular ejection fraction (LVEF). Seventy-five symptomatic PAF patients and 69 patients without arrhythmia were enrolled. Thirty-seven PAF patients received RFA therapy. Acoustic cardiographic exam was performed to check S3 and S4 heart sound, electromechanical activation time (EMAT), LV systolic time percentage (LVST), and systolic dysfunction index (SDI) in all participants. Furthermore, 37 PAF patients also received follow-up acoustic cardiography postRFA. PAF had impaired electromechanical systolic function compared with health participants (%EMAT 14.69 ± 3.62 vs. 10.84 ± 2.62; %LVST 40.83 ± 5.14 vs. 36.70 ± 3.87; SDI 4.75 ± 1.61 vs. 3.26 ± 0.96 all p < 0.001). RFA can improve electromechanical systolic function. Improvement below 13.1% could predict the recurrent AF postcatheter ablation. Higher degree of improved electromechanical systolic function postRFA contribute to lower recurrence of AF. Graphical Abstract Receiver operating characteristic (ROC) curve analysis for % change of systolic dysfunction index (SDI) postRFA in the detection of recurrent AF.
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http://dx.doi.org/10.1007/s12265-020-10047-yDOI Listing
April 2021

Corrigendum to "Renal denervation regulates the atrial arrhythmogenic substrates through reverse structural remodeling in heart failure rabbit model" [international journal of cardiology 235(2017),105-113].

Int J Cardiol 2020 Oct 11;316:188. Epub 2020 Jun 11.

Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taiwan; Institute of Clinical Medicine, Cardiovascular Research Institute, National Yang-Ming University, Taipei, Taiwan.

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http://dx.doi.org/10.1016/j.ijcard.2020.05.096DOI Listing
October 2020

Association of Ischemic Stroke, Major Bleeding, and Other Adverse Events With Warfarin Use vs Non-vitamin K Antagonist Oral Anticoagulant Use in Patients With Atrial Fibrillation With a History of Intracranial Hemorrhage.

JAMA Netw Open 2020 06 1;3(6):e206424. Epub 2020 Jun 1.

Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.

Importance: Current guidelines recommend the use of non-vitamin K antagonist oral anticoagulants (NOACs) for stroke prevention in patients with atrial fibrillation (AF). Data regarding warfarin sodium use compared with NOAC use in patients with AF with a history of intracranial hemorrhage (ICH) are limited.

Objective: To compare the clinical outcomes of warfarin use and NOAC use in patients with AF with a history of ICH using a nationwide cohort with AF.

Design, Setting, And Participants: A nationwide cohort study from January 1, 2012, to December 31, 2016, was performed using data from the Taiwan National Health Insurance Research Database. The dates of analysis were July 1 to September 1, 2019. The study population comprised patients with AF with a history of ICH and a CHA2DS2-VASc score (congestive heart failure, hypertension, age ≥75 years [doubled], diabetes, prior stroke/transient ischemic attack/thromboembolism [doubled], vascular disease [prior myocardial infarction, peripheral artery disease], age 65-74 years, sex category [female]) of at least 1 for men or at least 2 for women who had received warfarin or NOACs. The clinical outcomes were examined using Cox proportional hazards regression analyses among the study population before and after propensity score matching.

Exposures: Oral anticoagulation with warfarin or NOACs.

Main Outcomes And Measures: The clinical outcomes measured were all-cause mortality, ischemic stroke, ICH, major bleeding, and adverse events.

Results: The study cohort included 4540 patients (mean [SD] age, 76.0 [10.5] years; 2653 men [58.4%]), with 1047 patients receiving warfarin (mean [SD] age, 75.1 [11.4] years; 571 men [54.5%]) and 3493 patients receiving NOACs (mean [SD] age, 76.3 [10.2] years; 2082 men [59.6%]). Compared with warfarin use, NOAC use was associated with statistically significantly lower risk of all-cause mortality (adjusted hazard ratio [aHR], 0.517; 95% CI, 0.457-0.585), ICH (aHR, 0.556; 95% CI, 0.389-0.796), and major bleeding (aHR, 0.645; 95% CI, 0.525-0.793), whereas the rate of ischemic stroke was similar in the 2 groups (aHR, 0.879; 95% CI, 0.678-1.141). These results were generally consistent after propensity score matching among 973 patients in each group.

Conclusions And Relevance: Among patients with AF with prior ICH, NOAC use was associated with lower rates of ICH and major bleeding compared with warfarin use, whereas the rate of ischemic stroke was similar in the 2 groups. Among patients with AF with prior ICH, NOACs could be the preferred choice for stroke prevention.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.6424DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7265096PMC
June 2020

Risks and outcomes of gastrointestinal malignancies in anticoagulated atrial fibrillation patients experiencing gastrointestinal bleeding: A nationwide cohort study.

Heart Rhythm 2020 10 26;17(10):1745-1751. Epub 2020 May 26.

Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan. Electronic address:

Background: Oral anticoagulants (OACs) may serve as a "screening test" for gastrointestinal (GI) tract malignancies through the clinical presentation of bleeding.

Objective: The purpose of this study was to investigate the 1-year incidence and predictors of GI cancer after GI bleeding among atrial fibrillation (AF) patients treated with warfarin or non-vitamin K antagonist oral anticoagulants (NOACs). The risks of mortality after GI cancers between patients receiving warfarin and those receiving NOACs were compared.

Methods: A total of 10,845 anticoagulated AF patients hospitalized due to GI bleeding without a previous history of GI cancer were identified from the Taiwan National Health Insurance Research Database. Patients were followed-up for incident GI cancers for up to 1 year.

Results: Within 1 year after GI bleeding, 290 patients (2.67%) were diagnosed with GI tract cancer. More patients treated with NOACs were diagnosed with GI cancer than those treated with warfarin (3.87% vs 2.44%; P <.001; odds ratio [OR] 1.606; P <.001). Age (OR 1.025 per 1-year increment) and male sex (OR 1.356) were associated with the diagnosis of GI cancer. Among patients diagnosed with GI cancer, 45.2% died within 1 year. The risk of mortality was lower in patients treated with NOACs than in those treated with warfarin (23.5% vs 51.8%; adjusted hazard ratio 0.441; P <.001).

Conclusion: Incident GI cancers were diagnosed in 1 of 37 AF patients at 1 year after OAC-related GI bleeding and were more common among patients treated with NOACs (1/26) compared to warfarin (1/41). Detailed examinations for occult GI cancers are necessary, especially among elderly males.
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http://dx.doi.org/10.1016/j.hrthm.2020.05.026DOI Listing
October 2020
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