Publications by authors named "Victor Chien-Chia Wu"

99 Publications

Long-Term Outcomes of Acute Kidney Injury After Different Types of Cardiac Surgeries: A Population-Based Study.

J Am Heart Assoc 2021 May 21;10(9):e019718. Epub 2021 Apr 21.

Division of Thoracic and Cardiovascular Surgery Department of Surgery Chang Gung Memorial Hospital Linkou Medical Center Chang Gung University Taoyuan City Taiwan.

Background Dialysis-requiring acute kidney injury (D-AKI) is a major complication of cardiovascular surgery that results in worse prognosis. However, the incidence and impacts of D-AKI in different types of cardiac surgeries have not been fully investigated. Methods and Results Patients admitted for cardiovascular surgery between July 1, 2004, and December 31, 2013, were identified from the National Health Insurance Research Database of Taiwan. The patients were grouped into D-AKI (n=3089) and non-D-AKI (n=42 151) groups. The outcome was all-cause mortality and major adverse kidney event. The long-term outcomes were worse in the D-AKI group than the non-D-AKI group (hazard ratio [HR], 3.89; 95% CI, 3.79-3.99 for major adverse kidney event; HR, 2.89; 95% CI, 2.81-2.98 for all-cause mortality). Patients who underwent aortic surgery had higher risk for D-AKI than other types of surgeries, but they were also more likely to recover. The long-term dialysis rate for the patients who recovered from D-AKI was also lowest in those who underwent aortic surgery. Among all types of cardiac surgeries with D-AKI, patients who had heart valve surgery exhibited the greatest risks of all-cause mortality (HR, 6.04; 95% CI, 5.78-6.32). Conclusions Compared with other heart surgeries, aortic surgery resulted in a higher incidence of D-AKI but better renal recovery, better short-term outcome, and lower incidences of long-term dialysis.
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http://dx.doi.org/10.1161/JAHA.120.019718DOI Listing
May 2021

Effects of Fluoroquinolones on Outcomes of Patients With Aortic Dissection or Aneurysm.

J Am Coll Cardiol 2021 Apr;77(15):1875-1887

Department of Anesthesiology, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan City, Taiwan. Electronic address:

Background: Recent population-based studies have revealed that the use of fluoroquinolones (FQs) is associated with an increased risk of aortic dissection (AD) and aneurysm (AA). However, no evidence is available on whether FQs increase adverse events in patients who had been diagnosed with AD or AA.

Objectives: This study investigated whether the use of FQs increases the risk of aortic-related adverse events and death in this high-risk population.

Methods: A retrospective cohort study was conducted by using the Taiwan National Health Insurance Research Database. A total of 31,570 adult patients who survived after admission for AD or AA between 2001 and 2013 were identified. We divided each calendar year into 6 data units (2 months) for each patient and each year during follow-up. Covariates and exposure of interest (FQs) were reassessed every 2 months. We used another common antibiotic, amoxicillin, as a negative control exposure.

Results: Exposure to FQs was associated with a higher risk of all-cause death (adjusted hazard ratio: 1.61; 95% confidence interval: 1.50 to 1.73), aortic death (adjusted hazard ratio: 1.80; 95% confidence interval: 1.50 to 2.15), and later aortic surgery. However, amoxicillin exposure was not significantly associated with risk of any of the outcomes. A subgroup analysis revealed that the effect of FQs was not significantly different between the AD and AA groups.

Conclusions: Relative to amoxicillin use, FQ exposure in patients with AD or AA was associated with a higher risk of adverse outcomes. FQs should not be used by high-risk patients unless no other treatment options are available.
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http://dx.doi.org/10.1016/j.jacc.2021.02.047DOI Listing
April 2021

Bioprosthetic versus mechanical mitral valve replacements in patients with rheumatic heart disease.

J Thorac Cardiovasc Surg 2021 Mar 18. Epub 2021 Mar 18.

Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Linkou Medical Center, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan City, Taiwan; Center for Big Data Analytics and Statistics, Linkou Medical Center, Chang Gung Memorial Hospital, Taoyuan City, Taiwan. Electronic address:

Background: Rheumatic heart disease (RHD) remains a critical problem in developed countries. Few studies have compared the long-term outcomes of bioprosthetic valves and mechanical valves in patients with RHD who have received mitral valve (MV) replacement.

Methods: Patients with RHD who received MV replacement with bioprosthetic or mechanical valves were identified between 2000 and 2013 from Taiwan's National Health Insurance Research Database. The primary late outcomes of interest were all-cause mortality and redo MV surgery. Propensity score matching at a 1:1 ratio was performed.

Results: We identified 3638 patients with RHD who underwent MV replacement. Among those patients, 1075 (29.5%) and 2563 (70.5%) chose a bioprosthetic valve and mechanical valve, respectively. After matching, 788 patients were assigned to each group. No significant difference in the risk of in-hospital mortality was observed between groups (P = .920). Higher risks of all-cause mortality (10-year actuarial estimates: 50.6% vs 45.5%; hazard ratio, 1.19; 95% confidence interval, 1.01-1.41; P = .040) and MV reoperation (10-year actuarial estimates: 8.9% vs 0.93%; subdistribution hazard ratio, 4.56; 95% confidence interval, 1.71-12.17; P <.01) were observed in the bioprosthetic valve group. Furthermore, the relative mortality benefit associated with mechanical valves was more apparent in younger patients and the beneficial effect persisted until approximately 65 years of age.

Conclusions: In the patients with RHD who underwent MV replacement, mechanical valves were associated with more favorable long-term outcomes in patients younger than the age of 65 years.
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http://dx.doi.org/10.1016/j.jtcvs.2021.03.033DOI Listing
March 2021

Bleeding associated with co-administration of clopidogrel and ACEi in patients undergoing PCI and DAPT.

Atherosclerosis 2021 May 25;324:76-83. Epub 2021 Mar 25.

Division of Cardiology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan City, Taiwan; Center for Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan City, Taiwan; Graduate Institute of Nursing, Chang Gung University of Science and Technology, Taoyuan City, Taiwan. Electronic address:

Background And Aims: The coprescription of an angiotensin-converting enzyme inhibitor (ACEi) with clopidogrel reportedly increases bleeding risk. However, studies have not described such an increase in cases of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI).

Methods: We analyzed electronic medical records of patients with discharge records of having undergone DAPT after PCI from a national health insurance claims database for January 1, 2006 to December 31, 2014. The date of PCI was the index date, and the primary outcome was major bleeding. The unit of analysis was one person-quarter. We compared patients who were prescribed with those not prescribed an ACEi in the cohort. A Poisson model with inverse probability of treatment weighting was fitted using generalized estimating equations to measure the risk of outcomes.

Results: In total, 193,258 patients underwent DAPT after PCI; 46% had a coprescription of an ACEi. After screening, 170,775 patients (479,263 person-quarters) remained for analysis. The mean patient age was 65 ± 13 years, and 73.43% were men. In total, 79,739 prescriptions of an ACEi were written: 57%, 14.21%, 8.88%, 7.17%, and 4.68% were for captopril, ramipril, enalapril, perindopril, and imidapril, respectively. A concomitant prescription of an ACEi with clopidogrel was not associated with increased bleeding risk (adjusted rate ratio: 1.08, 99% confidence interval: 0.99-1.17).

Conclusions: The coadministration of an ACEi with clopidogrel after PCI is common. In this real-world cohort study, such coadministration was not associated with an increased risk of major bleeding in patients undergoing DAPT after PCI.
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http://dx.doi.org/10.1016/j.atherosclerosis.2021.03.022DOI Listing
May 2021

Effect of Permanent Pacemaker Implantation After Valve Surgery on Long-Term Outcomes.

Circ J 2021 Mar 19. Epub 2021 Mar 19.

Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University.

Background: Patients are prone to permanent pacemaker implantation (PPM) after valve surgery, yet current data on the effects of postoperative PPM are scarce and large-scale studies are lacking. The aim of this study was to determine rates and long-term outcomes of PPM after cardiac valve surgery.Methods and Results:A total of 24,014 patients who received valve surgery from 2000 to 2013 were identified from the Taiwan National Health Insurance Research Database. The number of valve surgeries and the proportion of PPM implantations after valve surgery increased (P<0.001). After 1 : 5 propensity score matching, 602 and 3,010 patients were categorized to the PPM and non-PPM groups, respectively. Late outcomes included all-cause mortality, cardiovascular death, sepsis, and readmission due to any cause. The mean follow up was 4.3 years. PPM was associated with a higher all-cause mortality rate (33.6% vs. 29.8%; hazard ratio [HR], 1.14; 95% confidence interval [CI], 0.98-1.32), though not significant at the threshold of P<0.05. PPM was also associated with higher all-cause mortality rates in subgroups that received mitral valve (MV) replacement surgery, combined aortic valve replacement (AVR) with MV surgeries, and combined AVR with tricuspid valve surgeries.

Conclusions: The PPM rate after valve surgery is increasing, and is associated with short-term adverse effects. Patients with PPM may have a higher long-term mortality rate.
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http://dx.doi.org/10.1253/circj.CJ-20-0905DOI Listing
March 2021

Level of serum soluble lumican and risks of perioperative complications in patients receiving aortic surgery.

PLoS One 2021 4;16(3):e0247340. Epub 2021 Mar 4.

Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan City, Taiwan.

Objective: Several serum biomarkers have been investigated for their potential as diagnostic tools in aortic disease; however, no study has investigated the association between serum biomarkers and outcomes after aortic surgery. This study explored the predictive ability of serum soluble lumican in postoperative outcomes after aortic surgery.

Methods: In total, 58 patients receiving aortic surgery for aortic dissection or aneurysm at Linkou Chang Gung Memorial Hospital in Taiwan in December 2011-September 2018 were enrolled. Blood samples were collected immediately upon patients' arrival in the intensive care unit after aortic surgery. The diagnostic properties of soluble lumican levels were assessed by performing receiver operating characteristic (ROC) curve analysis. The confidence interval (CI) of the area under the ROC curve (AUC) was measured using DeLong's nonparametric method and the optimal cutoff was determined using the Youden index.

Results: The serum soluble lumican level distinguished prolonged ventilation (AUC, 73.5%; 95% CI, 57.7%-89.3%) and hospital stay for >30 days (AUC, 78.2%; 95% CI, 61.6%-94.7%). The optimal cutoffs of prolonged ventilation and hospital stay for >30 days were 1.547 and 5.992 ng/mL, respectively. The sensitivity and specificity were respectively 100% (95% CI, 71.5%-100%) and 40.4% (95% CI, 26.4%-55.7%) for prolonged ventilation and 58% (95% 27.7%-84.8%) and 91.3% (95% CI, 79.2%-97.6%) for hospital stay for >30 days.

Conclusions: The serum soluble lumican level can be a potential prognostic factor for predicting poor postoperative outcomes after aortic surgery. However, more studies are warranted in the future.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0247340PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7932520PMC
March 2021

Association of Long-term Use of Antihypertensive Medications With Late Outcomes Among Patients With Aortic Dissection.

JAMA Netw Open 2021 Mar 1;4(3):e210469. Epub 2021 Mar 1.

Department of Anesthesiology, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan City, Taiwan.

Importance: The associations between long-term treatment of aortic dissection with various medications and late patient outcomes are poorly understood.

Objective: To compare late outcomes after long-term use of β-blockers, angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), or other antihypertensive medications (controls) among patients treated for aortic dissection.

Design, Setting, And Participants: This population-based retrospective cohort study using the National Health Insurance Research Database in Taiwan included 6978 adult patients with a first-ever aortic dissection who survived to hospital discharge during the period between January 1, 2001, and December 31, 2013, and who received during the first 90 days after discharge a prescription for an ACEI, ARB, β-blocker, or at least 1 other antihypertensive medication. Data analysis was conducted from July 2019 to June 2020.

Exposure: Long-term use of β-blockers, ACEIs, or ARBs, with use of other antihypertensive medications as a control.

Main Outcomes And Measures: The primary outcomes of interest were all-cause mortality, death due to aortic aneurism or dissection, later aortic operation, major adverse cardiac and cerebrovascular events, hospital readmission, and new-onset dialysis.

Results: Of 6978 total participants, 3492 received a β-blocker, 1729 received an ACEI or ARB, and 1757 received another antihypertension drug. Compared with patients in the other 2 groups, those in the β-blocker group were younger (mean [SD] age, 62.1 [13.9] years vs 68.7 [13.5] years for ACEIs or ARBs and 69.9 [13.8] years for controls) and comprised more male patients (2520 [72.2%] vs 1161 [67.1%] for ACEIs or ARBs and 1224 [69.7%] for controls). The prevalence of medicated hypertension was highest in the ACEI or ARB group (1039 patients [60.1%]), followed by the control group (896 patients [51.0%]), and was lowest in the β-blocker group (1577 patients [45.2%]). Patients who underwent surgery for type A aortic dissection were more likely to be prescribed β-blockers (1134 patients [32.5%]) than an ACEI or ARB (309 patients [17.9%]) or another antihypertension medication (376 patients [21.4%]). After adjusting for multiple propensity scores, there were no significant differences in any of the clinical characteristics among the 3 groups. No differences in the risks for all outcomes were observed between the ACEI or ARB and β-blocker groups. The risk of all-cause hospital readmission was significantly lower in the ACEI or ARB group (subdistribution hazard ratio [HR], 0.92; 95% CI, 0.84-0.997) and β-blocker group (subdistribution HR, 0.87; 95% CI, 0.81-0.94) than in the control group. Moreover, the risk of all-cause mortality was lower in the ACEI or ARB group (HR, 0.79; 95% CI, 0.71-0.89) and the β-blocker group (HR, 0.82; 95% CI, 0.73-0.91) than in the control group. In addition, the risk of all-cause mortality was lower in the ARB group than in the ACEI group (HR, 0.85; 95% CI, 0.76-0.95).

Conclusions And Relevance: The use of β-blockers, ACEIs, or ARBs was associated with benefits in the long-term treatment of aortic dissection.
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http://dx.doi.org/10.1001/jamanetworkopen.2021.0469DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7930924PMC
March 2021

Effect of medications after cardiac surgery on long-term outcomes in patients with cirrhosis.

Medicine (Baltimore) 2021 Feb;100(5):e23075

Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou Medical Center.

Abstract: The aim of this study was to evaluate the effect of beta-blockers, angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) after cardiac surgery in the liver cirrhosis (LC) patients. We conducted a population-based cohort study using data from the Taiwanese National Health Insurance Research Database (NHIRD) from 2001 to 2013. The outcomes of interest included all-cause mortality, major adverse cardiac and cerebrovascular events (MACCE) and liver and renal outcomes. Among 1470 LC patients, 35.6% (n = 524) received beta-blockers and 33.4% (n = 491) were prescribed ACEIs and/or ARBs after cardiac surgery. The risk of negative liver outcomes was significantly lower in the ARB group compared with the ACEI group (9.6% vs 22.7%, hazard ratio [HR] 0.50, 95% confidence interval [CI] 0.31-0.83). Furthermore, the risk of MACCE (44.2% vs 54.7%, HR 0.79, 95% CI 0.65-0.96), all-cause mortality (35.3% vs 46.4%, HR 0.74, 95% CI 0.60-0.92), composite liver outcomes (9.6% vs 16.5%, HR 0.56, 95% CI 0.38-0.85) and hepatic encephalopathy (2.7% vs 5.7%, HR 0.45, 95% CI 0.21-0.94) were lower in the ARB group than the control group. Our study demonstrated that ARBs provide a greater protective effect than ACEIs in regard to long-term outcomes following cardiac surgery in patients with LC.
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http://dx.doi.org/10.1097/MD.0000000000023075DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7870262PMC
February 2021

Thromboembolic events in atrial fibrillation: Different level of risk and pattern between peripheral artery disease and coronary artery disease.

Arch Cardiovasc Dis 2021 Mar 29;114(3):176-186. Epub 2021 Jan 29.

Division of Cardiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, 123, Ta Pei Road, Niao Sung District, 83301 Kaohsiung City, Taiwan. Electronic address:

Background: The existence of vascular disease in patients with atrial fibrillation (AF) is associated with an increased risk of thromboembolic events. It is unclear whether coronary artery disease (CAD) and/or peripheral artery disease (PAD) have similar presentations and complication rates.

Aim: To investigate thromboembolic events among patients with AF who have CAD, PAD or polyvascular disease.

Methods: Patients with a new diagnosis of AF without anticoagulation (n=306,386) were identified from the National Health Insurance Research Database in Taiwan (2001-2013). Ischaemic stroke (IS), systemic thromboembolism (STE) and their combination (IS/STE) were compared in four groups (No-CAD/PAD, CAD-only, PAD-only, CAD+PAD), and secondarily in patients with only CAD versus only PAD. Last, we compared propensity score-matched patients with only CAD or PAD with those with CAD and PAD.

Results: There were 185,169 patients without CAD or PAD, 8113 patients with only PAD, 105,715 patients with only CAD, and 7389 patients with CAD and PAD eligible for analysis (mean±SD follow-up 3.2±3.2 years). The incidences of STE and IS/STE differed in the four groups, with the highest in the CAD+PAD group and the lowest in the No-CAD/PAD group. The proportions of IS and STE also varied, with higher proportions of STE in patients with PAD, but higher proportions of IS in patients with CAD. After propensity score matching, the PAD-only group had significantly higher incidences of STE and IS/STE than the CAD-only group, across all levels of CHADS-VASc score. Patients with CAD and PAD had a significantly higher incidence of STE and IS/STE than propensity score-matched patients with CAD or PAD.

Conclusions: PAD or CAD in patients with AF did not contribute equally to the risk prediction and presentation of IS and STE. Patients with polyvascular disease should be considered at higher risk than those with either condition.
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http://dx.doi.org/10.1016/j.acvd.2020.11.004DOI Listing
March 2021

Efficacy and safety of NOAC versus warfarin in AF patients with left atrial enlargement.

PLoS One 2020 14;15(12):e0243866. Epub 2020 Dec 14.

Division of Cardiology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan City, Taiwan.

Background: Little is known about the effects of anticoagulation in patients with atrial fibrillation (AF) and left atrial enlargement (LAE).

Methods: Data of patients with AF were retrieved from Chang Gung Research Database during 2007-2016. We excluded patients who were not using oral anticoagulants, used anticoagulants for <30 days, used ≥2 agents concomitantly or switched anticoagulants, had left atrial diameter missing from their data, were aged <65, had received valve surgeries, had mitral stenosis, or had a history of cancer. The primary outcomes were ischemic stroke (IS)/systemic embolism (SE), major bleeding, and death from any cause.

Results: We identified 40,777 patients who received a diagnosis of AF. After the exclusion criteria were applied, 6,445 patients remained, 4,922 with LAE, and they were followed up for 2.4 ±1.9 years. The mean age of the patients was 77.32 ± 0.18 in the NOAC group and 76.58 ± 6.91 in the warfarin group (p < 0.0001); 48.24% of patients in the NOAC group and 46.98% of patients in the warfarin group were men (p > 0.05). The mean CHA2DS2-VASc score was 3.26 ± 1.05 in the NOAC group and 3.07 ± 1.12 in the warfarin group (p < 0.0001). The mean HAS-BLED score was 3.87 ± 3.81 in the NOAC group and 3.86 ± 3.80 in the warfarin group (p > 0.05). Furthermore, the mean LA diameter was 4.75 ± 0.63 cm in the warfarin group and 4.79 ± 0.69 cm in the warfarin group (p > 0.05). Among patients with LAE, NOAC was associated with significantly reduced IS/SE events (CRR = 0.63, 95% CI = 0.52-0.77), no difference in major bleeding (CRR = 0.91, 95% CI = 0.78-1.05), and significantly reduced death from any cause (aHR = 0.65, 95% CI = 0.52-0.80) compared with warfarin.

Conclusions: In elderly patients with AF and LAE, NOAC was associated with reduced IS/SE and death from any cause compared with warfarin, whereas no difference in major bleeding was observed between these treatments.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0243866PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7735599PMC
February 2021

Sodium-glucose cotransporter 2 inhibitor versus metformin as first-line therapy in patients with type 2 diabetes mellitus: a multi-institution database study.

Cardiovasc Diabetol 2020 11 9;19(1):189. Epub 2020 Nov 9.

Division of Cardiology, Linkou Medical Center, Linkou Chang Gung Memorial Hospital, No. 5, Fuxing Street, Guishan District, Taoyuan, 33305, Taiwan.

Background: Sodium-glucose co-transporter 2 inhibitors (SGLT2i) has shown evidence of cardiovascular benefit in patients with type 2 diabetes mellitus (T2DM). Currently metformin is the guideline-recommended first-line treatment. We aimed to investigate the benefit of SGLT2i vs metformin as first-line therapy.

Methods: Electronic medical records from Chang Gung Research Database during 2016-2019 were retrieved for patients with T2DM. Patients aged < 20, not receiving anti-diabetic medication, first-line treatment neither metformin nor SGLT2i were excluded. Primary outcomes were heart failure hospitalization, acute coronary syndrome, ischemic stroke, and all-cause mortality. Patients were followed up for events or December 31, 2019, whichever comes first.

Results: After exclusion criteria, a total of 41,020 patients with T2DM were eligible for analysis. There were 1100 patients with SGLT2i as first-line and 39,920 patients with metformin as first-line treatment. IPTW was used for propensity score matching. During one year follow-up, the hazard ratio (HR) of patients on SGLT2i as first-line treatment to patients on metformin as first-line treatment were HR 0.47 (95% CI 0.41-0.54, p < 0.0001) in heart failure hospitalization, HR 0.50 (95% CI 0.41-0.61, p < 0.0001) in acute coronary syndrome, HR 1.21 (95% CI 1.10-1.32, p < 0.0001) in ischemic stroke, and HR 0.49 (95% CI 0.44-0.55, p < 0.0001) in all-cause mortality.

Conclusions: In patients with T2DM, SGLT2i as first-line treatment may be associated with decreased events of heart failure hospitalization, acute coronary syndrome, and all-cause mortality, compared with metformin as first-line treatment. However, there may be an increased events of ischemic stroke using SGLT2i compared to metformin.
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http://dx.doi.org/10.1186/s12933-020-01169-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7654060PMC
November 2020

Sport disciplines and cardiac remodeling in elite university athletes competing in 2017 Taipei Summer Universiade.

Medicine (Baltimore) 2020 Nov;99(45):e23144

Division of Cardiology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan City, Taiwan.

Cardiac remodeling is common in the athletes. Little data is available regarding the cardiac remodeling on the recently proposed 4 sport disciplines among the elite university athletes.A total of 7639 athletes participated in the 2017 Taipei Summer Universiade. Cardiac evaluation via history, ECG, and echocardiography were performed in 826 athletes who signed up for Check Up Your Heart. Athletes were grouped into one of 4 sport disciplines Skill, Power, Mixed, and Endurance.After excluding 66 participants with missing demographic data, 13 missing echocardiographic data, and 24 inadequate echocardiographic images, a total number of 723 university athletes (mean age 23 ± 3 years, 419 males) from 99 countries engaging in 25 different sporting events were analyzed. Electrocardiograms showed that Endurance group had a slower heart rate and higher percentage of left ventricular (LV) hypertrophy (39%). Echocardiograms showed there were significant differences in LV mass index (P < .001), LV geometry (P < .001), left atrial (LA) dilatation (P = .026), right ventricular (RV) dilatation (P < .001), right atrial (RA) dilatation (P < .0001), and tricuspid annular plane systolic excurse (P = .006). LV ejection fraction, LV strain, RV strain, and LV diastolic function showed no difference in 4 sport disciplines.Eccentric LV hypertrophy was the most common type of cardiac remodeling in the university athletes participated in 2017 Taipei Summer Universiade. Adaptive changes in chamber size were more commonly seen in Endurance sport. RA dilatation was the most sensitive to hemodynamic demand, followed by RV dilatation, LA dilatation, and LV dilatation.
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http://dx.doi.org/10.1097/MD.0000000000023144DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7647536PMC
November 2020

Nationwide cohort study of tricuspid valve repair versus replacement for infective endocarditis.

Eur J Cardiothorac Surg 2021 Apr;59(4):878-886

Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan City, Taiwan.

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Objectives: The aim of this study was to compare the outcomes of tricuspid valve (TV) repair versus replacement for patients with infective endocarditis (IE).

Methods: In this nationwide population-based cohort study, we identified 704 patients from Taiwan National Health Insurance Research Database who underwent TV surgery due to IE between 2000 and 2013. Of them, 412 (58.5%) underwent TV repair and 292 (41.5%) underwent TV replacement, and their perioperative and late outcomes were analysed. Confounding was reduced using the inverse probability of treatment weighting on propensity score.

Results: After inverse probability of treatment weighting, the in-hospital mortality rate between the 2 groups was not significantly different. However, patients who received TV repair had lower rates of perioperative complications, including massive blood transfusion, de novo dialysis and deep wound infection; longer ICU and hospital stays; and higher hospital cost. Regarding late outcomes, TV repair was associated with lower risks of all-cause readmission [subdistribution hazard ratio (HR) 0.68, 95% confidence interval (CI) 0.60-0.78; P < 0.001], readmission for adverse liver outcomes (subdistribution HR 0.75, 95% CI 0.58-0.97; P = 0.025), new permanent pacemaker implantation (subdistribution HR 0.27, 95% CI 0.15-0.48; P < 0.001) and all-cause mortality (HR 0.60, 95% CI 0.51-0.71; P < 0.001) than TV replacement.

Conclusions: For IE, TV repair is associated with better early and late outcomes than TV replacement. A repair-first strategy is recommended for patients with IE for whom TV surgery is indicated.
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http://dx.doi.org/10.1093/ejcts/ezaa390DOI Listing
April 2021

Effect of previous coronary stenting on subsequent coronary artery bypass grafting outcomes.

J Thorac Cardiovasc Surg 2020 Sep 22. Epub 2020 Sep 22.

Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan City, Taiwan; Center for Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan City, Taiwan. Electronic address:

Objectives: The effect of previous coronary stenting on subsequent coronary artery bypass graft is inconclusive.

Methods: We used Taiwan's National Health Insurance Database to retrospectively evaluate patients with multivessel coronary artery bypass graft between January 2000 and December 2013. Overall, 32,335 patients who received coronary artery bypass graft were included, of whom 3028 had previous coronary stenting. Propensity-score matching yielded 2977 cases each for evaluation under the previous stenting and no stenting groups. The 30-day mortality and major adverse cardiac events, including all-cause mortality, acute myocardial infarction, and revascularization, were considered primary outcomes.

Results: The number of coronary artery bypass grafts decreased per year. However, the percentage of patients who had previous coronary stent implantation before coronary artery bypass graft increased steadily (P for trend <.001), and the average number of stents implanted in a patient also increased per year (P for trend <.001). The previous stent group had a significantly greater 30-day mortality rate than did the no-stent group (7.2% vs 5.0%; odds ratio, 1.47; 95% confidence interval, 1.19-1.82). The previous stent group had a greater rate of revascularization (14.4% and 10.0%; subdistribution hazard ratio, 1.50; 95% confidence interval, 1.30-1.74) in the last follow-up at year 13.

Conclusions: Previous coronary stenting before coronary artery bypass graft for multivessel coronary artery disease significantly increased 30-day mortality but did not affect late survival. However, patients who had coronary stenting before coronary artery bypass graft experienced more revascularization events during late follow-up.
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http://dx.doi.org/10.1016/j.jtcvs.2020.09.068DOI Listing
September 2020

Mid-term survival of patients with chronic kidney disease after extracorporeal membrane oxygenation.

Interact Cardiovasc Thorac Surg 2020 11;31(5):595-602

Division of Nephrology, Kidney Research Center, Department of Internal Medicine, Linkou Chang Gung Memorial Hospital, Taoyuan City, Taiwan.

Objectives: Chronic kidney disease (CKD) impairs the elimination of fluids, electrolytes and metabolic wastes, which can affect the outcomes of extracorporeal membrane oxygenation (ECMO) treatment. This study aimed to elucidate the impact of CKD on in-hospital mortality and mid-term survival of adult patients who received ECMO treatment.

Methods: Patients who received first-time ECMO treatment between 1 January 2003 and 31 December 2013 were included. Those with CKD were identified and matched to patients without CKD using a 1:2 ratio and were followed for 3 years. The study outcomes included in-hospital outcomes and the 3-year mortality rate. A subgroup analysis was conducted by comparing the dialytic patients with the non-dialytic CKD patients.

Results: The study comprised 1008 CKD patients and 2016 non-CKD patients after propensity score matching. The CKD patients had higher in-hospital mortality rates [69.5% vs 62.2%; adjusted odds ratio 1.41; 95% confidence interval (CI) 1.15-1.72] than the non-CKD patients. The 3-year mortality rate was 80.4% in the CKD group and 68% in the non-CKD group (adjusted hazard ratio 1.17; 95% CI 1.06-1.28). The subgroup analysis showed that the 3-year mortality rates were 84.5% and 78.4% in the dialytic and non-dialytic patients, respectively. No difference in the 3-year mortality rate was noted between the 2 CKD subgroups (P = 0.111).

Conclusions: CKD was associated with increased risks of in-hospital and mid-term mortalities in patients who received ECMO treatment. Furthermore, no difference in survival was observed between the patients with end-stage renal disease and non-dialytic CKD patients.
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http://dx.doi.org/10.1093/icvts/ivaa168DOI Listing
November 2020

Mitral valve repair versus replacement in patients with rheumatic heart disease.

J Thorac Cardiovasc Surg 2020 Aug 29. Epub 2020 Aug 29.

Department of Cardiology, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan City, Taiwan.

Background: Rheumatic heart disease remains a major cause of cardiovascular death worldwide. Limited real-world nationwide data are available to compare the long-term outcomes between mitral valve repair and replacement in rheumatic heart disease.

Methods: We identified adult patients with rheumatic heart disease who underwent mitral valve repair or replacement surgery between 2000 and 2013 from Taiwan's National Health Insurance Research Database. Outcomes of interest included operation-related complications, all-cause mortality, and mitral valve reoperation rate. Propensity score matching at a 1:1 ratio was conducted to mitigate possible confounding factors.

Results: A total of 5086 patients with rheumatic heart disease who underwent mitral valve surgery were identified. Of those, 489 (9.6%) and 4597 (90.4%) underwent mitral valve repair and mitral valve replacement, respectively. After propensity score matching was applied, each group had 467 patients. No difference in risk of in-hospital mortality was observed between groups. With a mean follow-up of 6 years, the mitral valve repair group had comparable risks of all-cause mortality with the mitral valve replacement group (33.4% vs 32.5%; hazard ratio, 1.01; 95% confidence interval, 0.81-1.25). However, higher risks of mitral valve reoperation were observed in the mitral valve repair group (subdistribution hazard ratio, 4.32; 95% confidence interval, 2.02-9.23). Previous percutaneous transvenous mitral commissurotomy was identified as a risk factor of mitral valve reoperation in the repair group.

Conclusions: Among patients with rheumatic heart disease, mitral valve repair is not associated with superior long-term outcomes. Patients should be carefully selected for mitral valve repair because of its higher reoperation rate, particularly those with previous percutaneous transvenous mitral commissurotomy.
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http://dx.doi.org/10.1016/j.jtcvs.2020.07.117DOI Listing
August 2020

Late outcomes of endovascular aortic stent graft therapy in patients with chronic kidney disease.

Medicine (Baltimore) 2020 Sep;99(37):e22157

Division of Thoracic and Cardiovascular Surgery, Department of Surgery.

Endovascular aneurysm repair (EVAR) and thoracic endovascular aortic repair (TEVAR) are effective and minimally invasive treatment options for high-risk surgical candidates. Nevertheless, knowledge about the management of aortic stent graft therapy in chronic kidney disease (CKD) is scarce. This study aimed to examine outcomes after EVAR and TEVAR in patients with CKD.Utilizing data from the Taiwan National Health Insurance Research Database, we retrospectively assessed patients who underwent EVAR and TEVAR therapy between January 1, 2006, and December 31, 2013. Patients were divided into CKD and non-CKD groups. Outcomes were in-hospital mortality, all-cause mortality, readmission, heart failure, and major adverse cardiac and cerebrovascular events.There were 1019 patients in either group after matching. The CKD group had a higher in-hospital mortality rate than the non-CKD group (15.2% vs 8.3%, respectively; odds ratio, 1.92; 95% confidence interval [CI], 1.46-2.54). Patients with CKD had higher risks of all-cause mortality including in-hospital death (46.1% vs 33.1%; hazard ratio [HR], 1.61; 95% CI, 1.35-1.92), readmission rate (62.6% vs 55.0%; subdistribution HR [SHR], 1.61; 95% CI, 1.32-1.69), redo stent (7.8% vs 6.2%; SHR, 1.50; 95% CI, 1.09-2.07), and major adverse cardiac and cerebrovascular events (13.3% vs 8.8%; SHR, 1.50; 95% CI, 1.15-1.95). The subgroup analysis did not demonstrate a variation in mortality between the TEVAR and EVAR cohorts (P for interaction = .725). The dialysis group had higher risks of all-cause mortality and readmission than the CKD without dialysis and non-CKD groups.Among EVAR/TEVAR recipients, CKD was independently associated with higher in-hospital mortality, postoperative complication, and all-cause mortality rates. Patients with end-stage renal disease on dialysis had worse outcomes than those in the CKD non-dialysis and non-CKD groups.
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http://dx.doi.org/10.1097/MD.0000000000022157DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7489716PMC
September 2020

Outcomes of Acute Aortic Dissection Surgery in Octogenarians.

J Am Heart Assoc 2020 09 11;9(18):e017147. Epub 2020 Sep 11.

Division of Thoracic and Cardiovascular Surgery Department of Surgery Chang Gung Memorial Hospital Linkou Medical Center Chang Gung University Taoyuan City Taiwan.

Background Octogenarians (≥80 years old) are high-risk patients for acute aortic dissection (AAD) surgery. However, no population-based study has investigated the late outcomes of AAD surgery in octogenarians. This study aimed to investigate the late outcomes of AAD surgery in octogenarians. Methods and Results A total of 3998 patients who received AAD surgery from 2005 to 2013 were identified from the Taiwan National Health Insurance Research Database. In-hospital complications and late outcomes including all-cause mortality, major adverse cardiac and cerebrovascular event, respiratory failure, and redo aortic surgery were evaluated. The risks of late outcomes between octogenarians and nonoctogenarians were compared using the multivariable Cox proportional hazard model or Fine and Gray competing model. The numbers of the octogenarians who underwent type A and B AAD surgeries were 206 (6%; 206/3423) and 79 (13.7%; 79/575), respectively. Compared with the nonoctogenarians, the type A octogenarians had higher risks of in-hospital mortality and several in-hospital complications, whereas the type B octogenarians did not. Furthermore, compared with the nonoctogenarians, the type A octogenarians had a higher risk of all-cause mortality (61.7% vs 32.5%; hazard ratio [HR], 2.35; 95% CI, 1.95-2.84) and a higher cumulative incidence of major adverse cardiac and cerebrovascular event and respiratory failure, and the type B octogenarians demonstrated a higher risk of all-cause mortality (44.3% vs 30.4%; HR, 1.74; 95% CI, 1.18-2.55). The octogenarians receiving AAD surgeries had higher mortality rates than the normal octogenarian population. Conclusions Octogenarians receiving AAD surgeries exhibit worse late outcomes than nonoctogenarian counterparts.
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http://dx.doi.org/10.1161/JAHA.120.017147DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7726989PMC
September 2020

Association of Family History With Incidence and Outcomes of Aortic Dissection.

J Am Coll Cardiol 2020 09;76(10):1181-1192

Department of Cardiology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan City, Taiwan. Electronic address:

Background: Aortic dissection (AD) is a life-threatening emergency. However, the heritability and association of family history with late outcomes are unclear.

Objectives: The purpose of this study was to evaluate the effect of family history of AD on the incidence and prognosis of AD and estimate the heritability and environmental contribution in AD in Taiwan.

Methods: Both cross-sectional and cohort studies were conducted using Taiwan National Health Insurance database. A registry parent-offspring relationship algorithm was used to reconstruct the genealogy of this population for heritability estimation. The cross-sectional study included 23,868 patients with a diagnosis of AD in 2015. The prevalence and adjusted relative risks (RRs) were evaluated, and the liability threshold model was used to examine the effects of heritability and environmental factors. Furthermore, a 1:10 propensity score-matched cohort comprising AD patients with or without a family history of AD was included to compare late outcomes in the cohort study.

Results: A family history of AD in first-degree relatives was associated with an RR of 6.82 (95% confidence interval [CI]: 5.12 to 9.07). The heritability of AD was estimated to be 57.0% for genetic factors, and 3.1% and 40.0% for shared and nonshared environmental factors, respectively. After excluding individuals with Marfan syndrome or bicuspid aortic valve, a family history of AD was associated with an RR of 6.56 (95% CI: 4.92 to 8.77) for AD. Furthermore, patients with AD and a family history of AD had a higher risk of later aortic surgery than those with AD without a family history (subdistribution hazard ratio: 1.40; 95% CI: 1.12 to 1.76).

Conclusions: A family history of AD was a strong risk factor for AD. Furthermore, patients with AD with a family history of AD had a higher risk of later aortic surgery than those with no family history of AD.
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http://dx.doi.org/10.1016/j.jacc.2020.07.028DOI Listing
September 2020

The implications of catheter ablation for solitary atrial flutter in preventing stroke risk: a nationwide population-based cohort study.

Europace 2020 10;22(10):1558-1566

College of Medicine, Chang Gung University, Taiwan.

Aims: The implications of ablation for atrial fibrillation in preventing stroke are controversial, and no studies have investigated whether ablation prevents ischaemic stroke (IS) in atrial flutter (AFL).

Methods And Results: This study analysed data contained in the Taiwan National Health Insurance Research Database for 16 765 patients with a first diagnosis of solitary AFL during 2001-2013. Eligible patients were divided into two groups according to whether or not they had received ablation. Propensity score matching (PSM) was performed to mitigate the effects of potential confounding factors. The primary outcome was occurrence of IS during follow-up. After 1:2 PSM, the analysis included 1037 patients in the ablation group and 2074 patients in the non-ablation group. The incidence of IS was lower in the ablation group compared to the non-ablation group [subdistribution hazard ratio (SHR) 0.61, 95% confidence interval (CI) 0.41-0.90] during the 2-year follow-up period but not thereafter (SHR 1.03, 95% CI 0.72-1.48). When grouping by stroke history, it revealed that ablation affected the incidence of stroke in patients without history of stroke (SHR 0.59, 95% CI 0.38-0.91) but not in patients with history of stroke. When each group was stratified by CHA2DS2-VASc score, ablation lowered the incidence of stroke in patients with CHA2DS2-VASc ≤3 (SHR 0.31, 95% CI 0.16-0.60) but not in patients with CHA2DS2-VASc ≥4 in the initial 2-year follow-up.

Conclusion: The different incidence of IS in patients with/without ablation indicates that ablation reduces the risk of IS in AFL patients.
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http://dx.doi.org/10.1093/europace/euaa164DOI Listing
October 2020

Incremental prognostic value of global myocardial work over ejection fraction and global longitudinal strain in patients with heart failure and reduced ejection fraction.

Eur Heart J Cardiovasc Imaging 2021 Feb;22(3):348-356

Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou Medical Center, No. 5, Fu-Shin Street, Kwei-Shan District, Taoyuan City 33305, Taiwan.

Aims : Left ventricular (LV) ejection fraction (EF) and global longitudinal strain (GLS) help identify heart failure (HF) patients who are at risk for adverse outcomes. This study aimed to determine whether global myocardial work (GMW), derived from non-invasive LV pressure-strain loops, can provide incremental prognostic information over EF and GLS in patients with HF and reduced EF (HFrEF).

Methods And Results : We retrospectively analysed 508 patients (age 62.9 ± 15.8 years, 29.1% female) with LVEF ≤40%. The study endpoint was a composite of all-cause death and HF hospitalization. The incremental value of GMW over clinical and echocardiographic variables including EF and GLS for the association with the composite endpoint was assessed using Cox regression analyses. Over a 1-year follow-up, 183 patients reached the endpoint. Baseline variables associated with the endpoint were age, haemoglobin, LV end-systolic volume, New York Heart Association Class III or IV, E/e' ratio, pulmonary artery systolic pressure, EF, and GLS. Cox regression analysis revealed that GMW [hazard ratio (HR) 1.15, 95% confidence interval (CI) 1.05-1.25, per 100-mmHg% decrease] added incremental prognostic value over these variables. Both EF and GLS were not independent variables when GMW was included in the model. Patients with GMW <750 mmHg% were associated with a significantly higher risk of all-cause death and HF hospitalization (HR 3.33, 95% CI 2.31-4.80) than patients with GMW ≥750 mmHg%.

Conclusion : In patients with HFrEF, GMW provides incremental prognostic information over EF and GLS regarding risk of all-cause death and HF hospitalization.
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http://dx.doi.org/10.1093/ehjci/jeaa162DOI Listing
February 2021

Corrigendum to 'Outcome of extracorporeal membrane oxygenation support in patients with liver cirrhosis: a nationwide population-based cohort study'.

Eur J Cardiothorac Surg 2020 09;58(3):665

Department of Surgery, Division of Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan City, Taiwan.

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http://dx.doi.org/10.1093/ejcts/ezaa217DOI Listing
September 2020

Novel oral anticoagulant vs. warfarin in elderly atrial fibrillation patients with normal, mid-range, and reduced left ventricular ejection fraction.

ESC Heart Fail 2020 10 16;7(5):2862-2870. Epub 2020 Jul 16.

Division of Cardiology, Chang Gung Memorial Hospital, Linkou Medical Center, No. 5, Fuxing Street, Guishan District, Taoyuan City, 33305, Taiwan.

Aims: Patients with concomitant atrial fibrillation (AF) and reduced left ventricular ejection fraction (LVEF) have poor prognosis. Outcomes of novel oral anticoagulant (NOAC) in elderly AF patients with normal, mid-range, and reduced LVEF were investigated.

Methods And Results: Data were retrieved from Chang Gung Research Database during 2010-2017 for patients with AF. We excluded patients with venous thromboembolism within 6 months, total knee/hip replacement and heart valve replacement within 6 months, end-stage renal disease, stroke/systemic embolism (SE)/death within 7 days, age <65 years old, or no records of LVEF. Primary outcomes were ischaemic stroke (IS)/SE, major bleeding, and death from any cause. There was a total of 50 035 elderly AF patients retrieved. After exclusion criteria, 9615 patients with normal LVEF ≥ 50%, 737 with mid-range LVEF 41-49%, and 908 with reduced LVEF ≤ 40% were studied. At end of follow-up, patients on NOAC had significantly reduced IS/SE compared with warfarin in LVEF ≥ 50% [adjusted hazard ration (aHR) 0.80, 95% confidence interval (CI) 0.71-0.89] and LVEF 41-49% (aHR 0.57, 95% CI 0.36-0.88) after adjusting for covariates, while there was no difference in LVEF ≤ 40%. Patients on NOAC had significantly reduced major bleeding in all LVEF groups. In addition, patients on NOAC had significantly reduced death compared with warfarin in LVEF ≥ 50% (aHR 0.81, 95% CI 0.67-0.98).

Conclusions: In elderly AF patients ≥65 years, using NOAC was associated with lower IS/SE compared with warfarin in normal and mid-range LVEF but not in reduced LVEF. Using NOACs was associated with lower death compared with warfarin in normal LVEF.
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http://dx.doi.org/10.1002/ehf2.12890DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7524083PMC
October 2020

Impact of massive blood transfusion during adult extracorporeal membrane oxygenation support on long-term outcomes: a nationwide cohort study in Taiwan.

BMJ Open 2020 06 23;10(6):e035486. Epub 2020 Jun 23.

Department of Anesthesiology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan

Objectives: Bleeding is a common problem during adult extracorporeal membranes oxygenation (ECMO) support, requiring blood transfusion for correction of volume depletion and coagulopathy. The goal of this study is to investigate the long-term outcomes for adults under support of ECMO with massive blood transfusion (MBT).

Design: Retrospective nationwide cohort study.

Setting: Data were provided from Taiwan National Health Insurance Research Database (NHIRD).

Participants And Interventions: Totally 2757 adult patients were identified to receive MBT (red blood cell ≥10 units) during ECMO support from 2000 to 2013 via Taiwan NHIRD.

Main Outcome Measures: The outcomes included in-hospital major complications/mortality, all-cause mortality, cardiovascular death, newly onset end-stage renal disease and respiratory failure during the follow-up period.

Results: Patients with MBT had higher in-hospital mortality (65.6% vs 52.1%; OR 1.74; 95% CI 1.53 to 1.98) and all-cause mortality during the follow-up (47.0% vs 35.8%; HR 1.46; 95% CI 1.25 to 1.71) than those without MBT. Not only higher incidences of post ECMO sepsis, respiratory failure and acute kidney injury, but also longer duration of ECMO support, ventilator use and intensive care unit stay were demonstrated in the MBT group. Moreover, a subdistribution hazard model presented higher cumulative of respiratory failure (19.8% vs 16.2%; subdistribution HR 1.36; 95% CI 1.07 to 1.73) for the MBT cohort. Positive dose-dependent relationship was found between the amount of transfused red blood cell product and in-hospital mortality. In the MBT subgroup analysis for the impact of transfused ratio (fresh frozen plasma/packed red blood cell) on in-hospital mortality, ratio ≥1.0 had higher mortality.

Conclusions: Patients with MBT during ECMO support had worse long-term outcomes than non-MBT population. The transfused amount of red blood cell had positive dose-dependent effect on in-hospital mortality.
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http://dx.doi.org/10.1136/bmjopen-2019-035486DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7312286PMC
June 2020

Balloon-expandable versus self-expanding transcatheter aortic valve replacement for bioprosthetic dysfunction: A systematic review and meta-analysis.

PLoS One 2020 1;15(6):e0233894. Epub 2020 Jun 1.

Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan City, Taiwan.

Background: Transcatheter aortic valve-in-valve (VIV) procedure is a safe alternative to conventional reoperation for bioprosthetic dysfunction. Balloon-expandable valve (BEV) and self-expanding valve (SEV) are the 2 major types of devices used. Evidence regarding the comparison of the 2 valves remains scarce.

Methods: A systematic review and meta-analysis was conducted to compare the outcomes of BEV and SEV in transcatheter VIV for aortic bioprostheses dysfunction. A computerized search of Medline, PubMed, Embase, and Cochrane databases was performed. English-language journal articles reporting SEV or BEV outcomes of at least 10 patients were included.

Results: In total, 27 studies were included, with 2,269 and 1,671 patients in the BEV and SEV groups, respectively. Rates of 30-day mortality and stroke did not differ significantly between the 2 groups. However, BEV was associated with significantly lower rates of postprocedural permanent pacemaker implantation (3.8% vs. 12%; P < 0.001). Regarding echocardiographic parameters, SEV was associated with larger postprocedural effective orifice area at 30 days (1.53 cm2 vs. 1.23 cm2; P < 0.001) and 1 year (1.55 cm2 vs. 1.22 cm2; P < 0.001).

Conclusions: For patients who underwent transcatheter aortic VIV, SEV was associated with larger postprocedural effective orifice area but higher rates of permanent pacemaker implantation. These findings provide valuable information for optimizing device selection for transcatheter aortic VIV.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0233894PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7263630PMC
August 2020

Direct aortic route versus transaxillary route for transcatheter aortic valve replacement: a systematic review and meta-analysis.

PeerJ 2020 12;8:e9102. Epub 2020 May 12.

Department of Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan, Taiwan.

Background: The transfemoral route is contraindicated in nearly 10% of transcatheter aortic valve replacement (TAVR) candidates because of unsuitable iliofemoral vessels. Transaxillary (TAx) and direct aortic (DAo) routes are the principal nonfemoral TAVR routes; however, few studies have compared their outcomes.

Methods: We performed a systematic review and meta-analysis to compare the rates of mortality, stroke, and other adverse events of TAx and DAo TAVR. The study was prospectively registered with PROSPERO (registration number: CRD42017069788). We searched Medline, PubMed, Embase, and Cochrane databases for studies reporting the outcomes of DAo or TAx TAVR in at least 10 patients. Studies that did not use the Valve Academic Research Consortium definitions were excluded. We included studies that did not directly compare the two approaches and then pooled rates of events from the included studies for comparison.

Results: In total, 31 studies were included in the quantitative meta-analysis, with 2,883 and 2,172 patients in the DAo and TAx TAVR groups, respectively. Compared with TAx TAVR, DAo TAVR had a lower Society of Thoracic Surgery (STS) score, shorter fluoroscopic time, and less contrast volume use. The 30-day mortality rates were significantly higher in the DAo TAVR group (9.6%, 95% confidence interval (CI) = [8.4-10.9]) than in the TAx TAVR group (5.7%, 95% CI = [4.8-6.8]; for heterogeneity <0.001). DAo TAVR was associated with a significantly lower risk of stroke in the overall study population (2.6% vs. 5.8%, for heterogeneity <0.001) and in the subgroup of studies with a mean STS score of ≥8 (1.6% vs. 6.2%, for heterogeneity = 0.005). DAo TAVR was also associated with lower risks of permanent pacemaker implantation (12.3% vs. 20.1%, for heterogeneity = 0.009) and valve malposition (2.0% vs. 10.2%, for heterogeneity = 0.023) than was TAx TAVR.

Conclusions: DAo TAVR increased 30-day mortality rate compared with TAx TAVR; by contrast, TAx TAVR increased postoperative stroke, permanent pacemaker implantation, and valve malposition risks compared with DAo TAVR.
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http://dx.doi.org/10.7717/peerj.9102DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7227658PMC
May 2020

Association between initial dialytic modalities and the risks of mortality, infection death, and cardiovascular events: A nationwide population-based cohort study.

Sci Rep 2020 05 15;10(1):8066. Epub 2020 May 15.

Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan, Taiwan.

To date, few studies have been conducted to pairwise compare the prognosis of peritoneal dialysis (PD), unplanned PD, and unplanned hemodialysis (HD). We analyzed longitudinal data from Taiwan's National Health Insurance Research Database. We included 45,165 patients whose initial dialytic modality was PD or unplanned HD between January 1, 2001 and December 31, 2013. We divided the patients into three groups according to their initial dialytic modalities. The primary outcomes were all-cause mortality and death from infection during 1-year follow up. The risks of all-cause mortality and infection death were higher in the unplanned PD group than in the planned PD group (hazard ratio [HR] 1.43, 95% confidence interval [CI] 1.28-1.60; HR 1.54, 95% CI 1.32-1.80). Likewise, the risks of all-cause mortality and infection death were higher in the unplanned HD group (HR 1.64, 95% CI 1.48-1.82; HR 1.85, 95% CI 1.61-2.13). Furthermore, the risks of all-cause mortality and infection death were also higher in the unplanned HD group than in the unplanned PD group (HR 1.15, 95% CI 1.07-1.23; HR 1.20, 95% CI 1.09-1.32). In conclusion, our study demonstrates that patients whose initial modality was planned PD or unplanned PD may have better clinical outcomes than those whose initial modality was unplanned HD.
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http://dx.doi.org/10.1038/s41598-020-64986-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7229162PMC
May 2020

Incidence and consequences of resuming oral anticoagulant therapy following hematuria and risks of ischemic stroke and major bleeding in patients with atrial fibrillation.

J Thromb Thrombolysis 2021 Jan;51(1):58-66

Cardiovascular Division, Department of Internal Medicine, Linkou Medical Center, Chang Gung Memorial Hospital, Taoyuan City, Taiwan.

Following hematuria, it is uncertain to what extent a vitamin K antagonist (VKA) or non-VKA oral anticoagulant (NOAC) is resumed, and the risks of ischemic stroke/systemic embolism and major bleeding associated with NOAC and VKA resumption are unknown. A cohort study was conducted using electronic medical records collected from 2009 to 2017 at a multicenter healthcare provider in Taiwan. The cohort included 4155 atrial fibrillation patients receiving anticoagulant therapy with hematuria (age: 71.4 ± 11.2 years; 48.8% female). Within 90 days following hematuria, 3287 patients (79.1%) resumed oral anticoagulants including VKA (n = 1554, 37.4%) and NOACs (n = 1733, 41.7%), whereas 868 patients did not resume anticoagulant. Follow-up was initiated 90 days after the occurrence of hematuria, and time-varying multiple Cox regression analyses were used for comparisons between the resumption of NOAC and VKA. The event rates per 100 person-years in the VKA resumption and NOAC resumption groups were 3.04 and 3.28 for ischemic stroke/systemic embolism, and 2.63 and 2.92 for major bleeding, respectively. Patients resuming NOAC had similar risks of ischemic stroke/systemic embolism (hazard ratio 1.14, 95% CI 0.75-1.74) and major bleeding (hazard ratio 1.12, 95% CI 0.72-1.74) compared with those resuming VKA. Since 2011, the proportion of NOAC resumption has increased, whereas the proportions of VKA resumption and non-resumption have decreased. In conclusion, more and more patients who suffer a hematuria while on oral anticoagulant therapy resume NOAC. Patients resuming NOAC have similar risks of ischemic stroke/systemic embolism and major bleeding compared with those resuming VKA.
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http://dx.doi.org/10.1007/s11239-020-02135-2DOI Listing
January 2021

Late Outcomes of Valve Repair Versus Replacement in Isolated and Concomitant Tricuspid Valve Surgery: A Nationwide Cohort Study.

J Am Heart Assoc 2020 04 17;9(8):e015637. Epub 2020 Apr 17.

Department of Cardiology Chang Gung Memorial Hospital Linkou Medical Center Taoyuan City Taiwan.

Background Surgery for tricuspid valve (TV) diseases is associated with poor prognosis, but few studies have described the long-term outcomes by comparing TV repair and replacement in isolated and concomitant TV surgeries separately. Methods and Results Between 2000 and 2013, adult patients who underwent TV repair or replacement surgeries were identified from the Taiwan National Health Insurance Research Database. Outcomes of interest included all-cause mortality, composite outcome, and readmission attributable to any cause. Inverse probability of treatment weighting was used to reduce confounding effects. A total of 2644 patients with a mean follow-up of 4.9 years were included. Of them, 12.6% and 87.4% underwent isolated and concomitant TV surgery, respectively. The in-hospital mortality rates for isolated and concomitant TV surgery were 8.7% and 8.6%, respectively, whereas all-cause mortality rates were 41.7% and 36.8%, respectively. Compared with TV replacement, TV repair demonstrated significantly lower risks of all-cause mortality (concomitant: hazard ratio [HR], 0.76; 95% CI, 0.59-0.99), composite outcome (isolated: subdistribution HR, 0.55; 95% CI, 0.35-0.89; concomitant: subdistribution HR, 0.63; 95% CI, 0.46-0.86), and readmission (isolated: subdistribution HR, 0.64; 95% CI, 0.46-0.91; concomitant: subdistribution HR, 0.72; 95% CI, 0.60-0.86), except insignificant difference in all-cause mortality in isolated surgery. Conclusions Compared with replacement, TV repair is associated with better short- and long-term outcomes in both isolated and concomitant TV surgery. However, further prospective clinical trials are warranted.
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http://dx.doi.org/10.1161/JAHA.119.015637DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7428522PMC
April 2020

Outcome of extracorporeal membrane oxygenation support in patients with liver cirrhosis: a nationwide population-based cohort study.

Eur J Cardiothorac Surg 2020 09;58(3):519-527

Department of Surgery, Division of Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan City, Taiwan.

Objectives: Extracorporeal membrane oxygenation (ECMO) is used for life support in patients with liver cirrhosis (LC). However, there have been no studies evaluating the outcome of ECMO support in patients with LC.

Methods: Using Taiwan's National Health Insurance (NHI) database, we retrospectively evaluated patients with LC who received veno-venous or veno-arterial ECMO between 1 January 2000 and 31 December 2013. The outcomes included ECMO-related complications, in-hospital mortality, all-cause mortality and long-term outcomes in patients with and without LC.

Results: A total of 7003 patients who received ECMO, of whom 233 (3.3%) had LC, were eligible for analysis. The LC patients who received ECMO support had a significantly higher risk of in-hospital mortality than the non-LC group (76.4% vs 60.7%; odds ratio 1.97; 95% confidence interval 1.44-2.70). The LC group also had a higher risk of complications, including de novo dialysis and massive blood transfusion with >10 units of red blood cells. Patients ≥65 years of age, patients with respiratory disease, patients with hypoalbuminaemia and liver transplant patients had higher in-hospital and 1-year mortality. The mortality rates for patients with 2 or more risk factors were 90.3% and 95.8%, respectively. LC was associated with a higher incidence of all-cause mortality and liver-related outcomes during follow-up.

Conclusions: Our findings raise questions regarding the utility of ECMO for LC patients, especially when >2 risk factors have been identified. ECMO support for LC patients should be used with caution and with careful patient selection.
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http://dx.doi.org/10.1093/ejcts/ezaa089DOI Listing
September 2020