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Chemical conversion of natural graphite into graphene based nanomaterials is achievable and scalable by designed Hummers’ method. Conventionally, high amount of manganyl compound (Mn2O7 or MnO3+) and explosive risk of thermal runaway in the reaction are still the key concerns of efficiency and safety in the production technology. In this manuscript, reaction mechanism and innovative strategy are applied in the cascade design of graphite oxide synthesis. By optimizing the amounts of reactive chemicals (KMnO4, H2SO4 and water), utilizing exothermic energy (for self-heating reaction and exfoliation) and combining reaction divisions (for control of thermal runaway), the principal issues of safety and efficiency are improved for simple and practical preparation of graphene oxide nanomaterials. The cascade synthesis occurs in just 8 h without external supply of thermal energy, producing solid yield of more than 130%wt. Obtained graphene oxide nanosheets have good colloidal property, uniform decoration of functional groups, appropriate C/O atomic ratio of 1.62 and optoelectronic band gap energy of 3.33 eV. Characterization of graphene oxide membranes showed elemental oxygen mapping, C/O atomic ratio of 2.12, ultimate tensile strength of 59.17 MPa and strong elastic modulus of 10.123 GPa. Hydrogel of partially reduced graphene oxide was prepared and analyzed, revealing the C/O atomic ratio of 2.63 and band gap energy of 2.88 eV. The technological improvements open a safe and efficient route of graphene oxide production for scientific and industrial purposes.

In the present study, we attempted to synthesize a novel sorbent from the starch modified montmorillonite for the removal of Pb(II), Cd(II), and Ni(II) ions from aqueous solutions. Structure and properties of the adsorbent were characterized by Fourier-transformed infrared(FT-IR) spectroscopy, X-ray diffraction (XRD), and Field emission scanning electron microscopic (FE-SEM) techniques. Batch experiments were confirmed through the effect of different conditions including pH, contact time, initial metal concentration and adsorbent dose. Specifically, the optimum value of adsorbent dose was achieved as 20 g/l for the removal of almost metal ions. The adsorption data was fitted with the optimum pH value as 5 for all experiments. The contact time at which the uptake of maximum metal adsorption was observed within 45 min for Pb(II), 90 min for Cd(II), and 60 min for Ni(II). In addition, it was revealed in our study that the equilibrium data obeyed the Langmuir model, and the adsorption kinetic followed a pseudo second-order rate model. Obtained results were noticeable for a modified phyllosilicate adsorbent, and with such a simple and low-cost modification for montmorillonite, the potential of this material as an economical and effective adsorbent for the removal of metal ions from aqueous solution was considerably elevated.

Mesoporous LaFeO3 as a visible light-driven photocatalyst was prepared by a nanocasting method using mesoporous silica (SBA-15) as a hard template. The as-prepared LaFeO3 photocatalyst was characterized by X-ray diffraction (XRD), scanning electron microscopy (SEM), transmission electron microscopy (TEM), N2 adsorption-desorption, X-ray photoelectron spectroscopy (XPS), and optical absorption spectra. The characterization studies and experimental results showed that LaFeO3 with porous structure caused by the removal of SBA-15 hard template could enhance the specific surface area of the resulting photocatalyst, which improves the phenol adsorption ability of the photocatalyst and in turn enhances its photo-Fenton catalytic activity. The photo-Fenton catalytic activity of the photocatalyst was investigated by photo-Fenton degradation of aqueous phenol under visible light irradiation. The effects of catalyst dosage, H2O2 concentration, and solution pH on the photo-Fenton catalytic degradation of phenol using mesoporous LaFeO3 were studied and optimized. Under the optimal conditions of 20 mg L−1 phenol, 1.0 g L−1 catalyst, and 10 mM H2O2 at pH = 5, the photo-Fenton degradation of phenol (93.47%) was achieved in 180 min under visible light irradiation. Furthermore, our results proved the stability and reusability of mesoporous LaFeO3 and revealed its catalytic mechanism for the photo-Fenton degradation of phenol.

Flow-based generative models have recently become one of the most efficient approaches to model data generation. Indeed, they are constructed with a sequence of invertible and tractable transformations. Glow first introduced a simple type of generative flow using an invertible 1×1 convolution. However, the 1×1 convolution suffers from limited flexibility compared to the standard convolutions. In this paper, we propose a novel invertible n×n convolution approach that overcomes the limitations of the invertible 1×1 convolution. In addition, our proposed network is not only tractable and invertible but also uses fewer parameters than standard convolutions. The experiments on CIFAR-10, ImageNet and Celeb-HQ datasets, have shown that our invertible n×n convolution helps to improve the performance of generative models significantly.

This study aims to produce novel composite artificial marble materials by bulk molding compound processes, and improve their thermal and mechanical properties. We employed stearic acid as an efficient surface modifying agent for CaCO3 particles, and for the first time, a pretreated, recycled, polyethylene terephthalate (PET) fibers mat is used to reinforce the artificial marble materials. The innovative aspects of the study are the surface treatment of CaCO3 particles by stearic acid. Stearic acid forms a monolayer shell, coating the CaCO3 particles, which enhances the compatibility between the CaCO3 particles and the matrix of the composite. The morphology of the composites, observed by scanning electron microscopy, revealed that the CaCO3 phase was homogeneously dispersed in the epoxy matrix under the support of stearic acid. A single layer of a recycled PET fibers mat was pretreated and designed in the core of the composite. As expected, these results indicated that the fibers could enhance flexural properties, and impact strength along with thermal stability for the composites. This combination of a pretreated, recycled, PET fibers mat and epoxy/CaCO3-stearic acid could produce novel artificial marble materials for construction applications able to meet environmental requirements.

Hydroxy-3-methyl-glutaryl-CoA reductase (HMGR) is the rate-controlling enzyme of cholesterol synthesis, and owing to its biological and pharmacological relevance, researchers have investigated several compounds capable of modulating its activity with the hope of developing new hypocholesterolemic drugs. In particular, polyphenol-rich extracts were extensively tested for their cholesterol-lowering effect as alternatives, or adjuvants, to the conventional statin therapies, but a full understanding of the mechanism of their action has yet to be reached. Our work reports on a detailed kinetic and equilibrium study on the modulation of HMGR by the most-abundant catechin in green tea, epigallocatechin-3-gallate (EGCG). Using a concerted approach involving spectrophotometric, optical biosensor, and chromatographic analyses, molecular docking, and site-directed mutagenesis on the cofactor site of HMGR, we have demonstrated that EGCG potently inhibits the in vitro activity of HMGR (Ki in the nanomolar range) by competitively binding to the cofactor site of the reductase. Finally, we evaluated the effect of combined EGCG-statin administration.

Objective: As the global use of extracorporeal membrane oxygenation (ECMO) treatment increases, survival rates have not correspondingly improved, emphasizing the need for refined patient selection to optimize resource allocation. Currently, prognostic markers at the molecular level are limited., Methods: Thirty-four cardiogenic shock (CS) patients were prospectively enrolled, and peripheral blood mononuclear cells (PBMCs) were collected at the initiation of ECMO (t0), two-hour post-installation (t2), and upon removal of ECMO (tr). The PBMCs were analyzed by comprehensive epigenomic assays. Using the Wilcoxon signed-rank test and least absolute shrinkage and selection operator (LASSO) regression, 485,577 DNA methylation features were analyzed and selected from the t0 and tr datasets. A random forest classifier was developed using the t0 dataset and evaluated on the t2 dataset. Two models based on DNA methylation features were constructed and assessed using receiver operating characteristic (ROC) curves and Kaplan-Meier survival analyses., Results: The ten-feature and four-feature models for predicting in-hospital mortality attained area under the curve (AUC) values of 0.78 and 0.72, respectively, with LASSO alpha values of 0.2 and 0.25. In contrast, clinical evaluation systems, including ICU scoring systems and the survival after venoarterial ECMO (SAVE) score, did not achieve statistical significance. Moreover, our models showed significant associations with in-hospital survival (p < 0.05, log-rank test)., Conclusions: This study identifies DNA methylation features in PBMCs as potent prognostic markers for ECMO-treated CS patients. Demonstrating significant predictive accuracy for in-hospital mortality, these markers offer a substantial advancement in patient stratification and might improve treatment outcomes., (© 2024. The Author(s).)

Background: This study aims to determine whether end-stage renal disease (ESRD) is a true contraindication for extracorporeal membrane oxygenation in adult patients., Materials and Methods: Adult patients who received VA-ECMO at National Taiwan University Hospital between January 2010 and December 2021 were included. Patients who received regular dialysis before the index admission were included in the ESRD group. The primary outcome was in-hospital mortality., Results: 1341 patients were included in the analysis, 121 of whom had ESRD before index admission. The ESRD group was older (62.3 versus 56.8 years; P < 0.01) and had more comorbidities. Extracorporeal cardiopulmonary resuscitation (ECPR) was used more frequently in the ESRD group (66.1% versus 51.6%; P < 0.001). The ESRD group had higher in-hospital mortality rates (72.7% versus 63.3%; P = 0.03). In the ECPR subgroup, there was no difference of survival between ESRD and others(P = 0.56). In the multivariate Cox regression, ESRD was not an independent predictor for mortality (P = 0.20)., Conclusion: ESRD was not an independent predictor of in-hospital mortality after VA-ECMO. The survival of ESRD patients was not inferior to those without ESRD when receiving ECPR. Therefore, ESRD should not be considered a contraindication to VA-ECMO in adults., Competing Interests: Declaration of competing interest none, (Copyright © 2024 Formosan Medical Association. Published by Elsevier B.V. All rights reserved.)

Background: Current adult cardiac surgery guidelines recommend against the routine use of prophylactic intravenous corticosteroids during cardiopulmonary bypass (CPB) due to concerns about myocardial injury, despite their potential to reduce postoperative atrial fibrillation. Traditionally, a high dose of 1,000 mg of methylprednisolone was used to attenuate the inflammatory response associated with CPB. Our institution aligned with guideline recommendations and gradually reduced methylprednisolone dosages; thus, we reevaluated the impact on postoperative clinical outcomes., Methods: Our study reviewed 1341 cases from a total of 1680 adult cardiac surgeries performed between June 2019 and May 2022 after excluding cases with off-pump procedures, ventricular assist device implantations, heart transplants, and aortic surgeries requiring systemic circulatory arrest. The study timely sorted periods including a baseline data from 2018, and other three periods since 2019 to analyze the effects of three different methylprednisolone dosage: 0 mg, 500 mg, and 1000 mg. We assessed the annual trends in methylprednisolone administration and compared morbidity and mortality rates across the groups., Results: We observed a significant decline in steroid use, with no-steroid surgeries increasing from 23% to 66.5% by period 3. Despite the decreased use of steroids, our study showed no increase in mortality, new-onset atrial fibrillation, acute kidney injury, cerebrovascular event and prolonged ventilation when compared to baseline data. Notably, less surgical site infection rate was observed in the no-steroid group., Conclusion: The data indicates that a reduction or discontinuation of steroids during CPB can be performed without compromising patient outcomes. This could support a transition towards a more conservative use of steroids in adult cardiac surgery, aligning with current guidelines, and potentially reducing certain postoperative complications., Competing Interests: Declaration of competing interest None., (Copyright © 2024 Formosan Medical Association. Published by Elsevier B.V. All rights reserved.)

Objectives: Extracorporeal cardiopulmonary resuscitation (ECPR) has emerged as a rescue for refractory cardiac arrest, of which acute coronary syndrome is a common cause. Data on the coronary revascularization strategy in patients receiving ECPR remain limited., Methods: The ECPR databases from two referral hospitals were screened for patients who underwent emergent revascularization. The baseline characteristics were matched 1:1 using propensity score between patients who underwent coronary artery bypass grafting (CABG) and those who received percutaneous coronary intervention (PCI). Outcomes, including success rate of weaning from extracorporeal membrane oxygenation (ECMO), hospital survival, and midterm survival in hospital survivors, were compared between CABG and PCI., Results: After matching, most of the patients (95%) had triple vessel disease. Compared with PCI (n = 40), emergent CABG (n = 40) had better early outcomes, in terms of the rates of successful ECMO weaning (71.1% vs 48.7%, P = 0.05) and hospital survival (56.4% versus 32.4%, P = 0.04). After a mean follow-up of 2 years, both revascularization strategies were associated with favourable midterm survival among hospital survivors (75.3% after CABG vs 88.9% after PCI, P = 0.49), with a trend towards fewer reinterventions in patients who underwent CABG (P = 0.07)., Conclusions: In patients who received ECPR because of triple vessel disease, the hospital outcomes were better after emergent CABG than after PCI. More evidence is required to determine the optimal revascularization strategy for patients who receive ECPR., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

Objectives: Best medical therapy (BMT) for acute uncomplicated type B intramural hematoma (TBIMH) is the current treatment guideline, but there is considerable controversy about subsequent clinical course and outcome, which may be associated with a significant failure rate. The purpose of this study was to identify potential risk factors for BMT failure and to develop a risk score to guide clinical decision making., Methods: Patients with acute uncomplicated TBIMH between 2011 January and 2020 December were retrospectively studied. Logistic regression was applied to univariately assess potential risk predictors, and multivariable model results were then used to formulate a simplified predictive model for BMT failure., Results: In a total of 61 patients, the overall rate of BMT failure was 57.4% (35/61), of which 48.6% (17/35) occurred within 28 days of onset. Logistic regression identified maximum descending aortic diameter (HR ​= ​1.99 CI ​= ​1.16-3.40, p ​= ​0.012), initial IMH thickness (HR ​= ​3.29, CI ​= ​1.28-8.46, p ​= ​0.013) and presence of focal contrast enhancement (HR ​= ​3.12, CI ​= ​1.49-6.54, p ​= ​0.003) as potential risk predictors of BMT failure. A risk score was calculated as follows: [Max DTA diameter (mm)∗0.6876 ​+ ​Max IMH thickness (mm)∗1.1918 ​+ ​PAU/ULP ∗1.1369]. Freedom from BMT failure at 1 year was 72% in patients with a risk score ​< ​4.12, compared with only 35.1% in those with a risk score ​≧ ​4.12., Conclusions: In a substantial proportion of patients with acute uncomplicated TBIMH, initial BMT failed. Based on the three initial computed tomographic imaging variables, this risk score could help stratify patients at high or low risk for BMT failure and provided additional information for early intervention., Competing Interests: Conflicts of interest The authors declare that they have no conflict of interest., (Copyright © 2024 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.)

Background: We used computer-assisted image analysis to determine whether preexisting histological features of the cephalic vein influence the risk of non-maturation of wrist fistulas., Methods: This study focused on patients aged 20-80 years who underwent their first wrist fistula creation. A total of 206 patients participated, and vein samples for Masson's trichrome staining were collected from 134 patients. From these, 94 patients provided a complete girth of the venous specimen for automatic image analysis. Maturation was assessed using ultrasound within 90 days after surgery., Results: The collagen to muscle ratio in the target vein, measured by computer-assisted imaging, was a strong predictor of non-maturation in wrist fistulas. Receiver operating characteristic analysis revealed an area under the curve of 0.864 (95% confidence interval of 0.782-0.946, p < 0.001). The optimal cut-off value for the ratio was 1.138, as determined by the Youden index maximum method, with a sensitivity of 89.0% and specificity of 71.4%. For easy application, we used a cutoff value of 1.0; the non-maturation rates for patients with ratios >1 and ≤ 1 were 51.7% (15 out of 29 patients) and 9.2% (6 out of 65 patients), respectively. Chi-square testing revealed significantly different non-maturation rates between the two groups (X 2 (1, N = 94) = 20.9, p < 0.01)., Conclusion: Computer-assisted image interpretation can help to quantify the preexisting histological patterns of the cephalic vein, while the collagen-to-muscle ratio can predict non-maturation of wrist fistula development at an early stage., Competing Interests: Declaration of competing interest None., (Copyright © 2024 Formosan Medical Association. Published by Elsevier B.V. All rights reserved.)

Objective: The use of RDV in SAVR is associated with risk of conduction abnormality requiring PPM implantation, when compared to conventional bioprosthetic valves. We aimed to evaluate the outcome after selective placement of annular compression sutures during surgical aortic valve replacement (SAVR) using Intuity rapid deployment valve (RDV)., Methods: This is a retrospective study of prospectively enrolled patients receiving SAVR using Intuity RDV. Selective placement of commissural compression suture was assessed for all patients based on their annular morphology. Outcomes including operative mortality, rate of pacemaker rate, paravalvular leak and change in trans-valvular pressure gradient were analyzed., Results: 56 consecutive patients underwent SAVR with the INTUITY RDV at our institution from January 2020 to November 2021. The Mean age of our cohort was 69.9 ± 10.6 years with a EuroSCORE II of 3.4 ± 2.4%. 28.6% (16/56) of patients had notable conduction abnormalities pre-operatively, which included atrial fibrillation and left/right bundle branch block. Compression sutures were selectively applied in 19/56 (33.9%) patients. Of which, 13 were bicuspid aortic valve. Post-operatively, we observed no conduction abnormality requiring PPM implantation. In addition, only 3 of the 56 (5.4%) had any degree of paravalvular leak on post-operative echocardiography (all ≤ mild). The mean reduction in trans-valvular gradient was 29.9 mmHg and the mean pressure gradient at 1 month and 1 year follow-up were 9.3 ± 3.6 mmHg and 10.2 ± 4.1 mmHg, respectively., Conclusions: Selective placement of compression suture helps to avoid unnecessary oversizing, which may reduce the risk of paravalvular leak and post-operative PPM implantation., Competing Interests: Declaration of competing interest A conflict of interest occurs when an individual's objectivity is potentially compromised by a desire for financial gain, prominence, professional advancement or a successful outcome. JFMA Editors strive to ensure that what is published in the Journal is as balanced, objective and evidence-based as possible. Since it can be difficult to distinguish between an actual conflict of interest and a perceived conflict of interest, the Journal requires authors to disclose all and any potential conflicts of interest., (Copyright © 2024 Formosan Medical Association. Published by Elsevier B.V. All rights reserved.)

Background: The European System for Cardiac Operative Risk Evaluation (EuroSCORE II) is a well-established scoring system for predicting mortality in cardiac surgery. This system was derived predominantly from a European patient cohort; however, no validation of this system has been conducted in Taiwan. We sought to assess the performance of EuroSCORE II at a tertiary centre., Methods: The 2161 adult patients receiving cardiac surgery between 2017 and 2020 in our institution were included., Results: Overall, the in-hospital mortality rate was 7.89%. The performance of EuroSCORE II was assessed using the area under the receiver operator curve (AUC) for discrimination and the Hosmer-Lemeshow (H-L) test for calibration. Data were analysed for type of surgery, risk stratification, and status of the operation. EuroSCORE II had good discriminative power (AUC=0.854, 95% Confidence Interval (CI): 0.822-0.885) and good calibration (χ 2 =5.19, p=0.82) for all types of surgery except ventricular assist devices (AUC=0.618, 95% CI: 0.497-0.738). EuroSCORE II also showed good calibration for most types of surgery except coronary artery bypass surgery (CABG) combined procedure (P=0.033), heart transplantation (HT) (P=0.017), and urgent operation (P=0.041). EuroSCORE II significantly underestimated the risk for CABG combined procedure and urgent operations, and overestimated the risk for HT., Conclusion: EuroSCORE II had satisfactory discrimination and calibration power to predict surgical mortality in Taiwan. However, the model is poorly calibrated for CABG combined procedure, HT, urgent operation, and, likely, lower- and higher-risk patients., Competing Interests: Declaration of competing interest None declared., (Copyright © 2023. Published by Elsevier B.V.)

Background: To compare the late outcomes between mechanical and bioprostheses after isolated mitral valve replacement (MVR) in dialysis-dependent patients., Methods: A nationwide propensity-matched retrospective cohort study was conducted involving dialysis patients who underwent primary mitral replacement between 2001 and 2018. Ten-year postoperative outcomes were compared between mitral bioprosthesis and mechanical prosthesis using the Cox proportional hazard model and restricted mean survival time (RMST)., Results: The all-cause mortality was 20.8 and 13.0 events per 100 person-years, with a 10-year RMST of 7.40 and 7.31 years for bioprosthesis and mechanical prosthesis, respectively. Major bleeding was the most common adverse event for both bioprosthesis and mechanical prosthesis, with an incidence rate of 19.5 and 19.1 events per 100 person-years, respectively. The incidence of valve reoperation was higher among those who received bioprosthesis (0.55 events per 100 person-years). After 1:1 matching, the all-cause mortality was 15.45 and 14.54 events per 100 person-years for bioprosthesis and mechanical prosthesis, respectively. The RMST at 10 years was comparable between the two groups after matching (5.10 years for bioprosthesis vs. 4.59 years for mechanical prosthesis), with an RMST difference of -0.03. Further, no difference was observed in the incidence of major adverse valve-related events between bioprosthesis and mechanical valves. However, bioprosthesis was associated with a higher incidence of mitral valve reoperation among all major adverse events (RMST difference -0.24 years, 95% CI -0.48 to -0.01, P =0.047)., Conclusions: This study found no association between valve selection and long-term survival outcomes in dialysis patients after MVR. However, bioprosthetic valves may be associated with a slightly higher incidence of reoperation, while other valve-related adverse events, including major bleeding and stroke, were comparable between the two types of prostheses., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Improved durability of modern biologic prostheses and growing experience with the transcatheter valve-in-valve technique have contributed to a substantial increase in the use of bioprostheses in younger patients. However, discussion of prosthetic valve selection in dialysis patients remains scarce as the guidelines are updated. This study aims to compare long-term outcomes between propensity score-matched cohorts of dialysis patients who underwent primary aortic valve replacement with a mechanical prosthesis or a bioprosthesis., Materials and Methods: Longitudinal data of dialysis patients who underwent primary aortic valve replacement between 1 January 2001 and 31 December 2018, were retrieved from the National Health Insurance Research Database., Results: A total of 891 eligible patients were identified, of whom 243 ideally matched pairs of patients were analyzed. There was no significant difference in all-cause mortality (hazard ratio 1.11, 95% CI: 0.88-1.40) or the incidence of major adverse prosthesis-related events between the two groups (hazard ratio 1.03, 95% CI: 0.84-1.25). In patients younger than 50 years of age, using a mechanical prosthesis was associated with a significantly longer survival time across 10 years of follow-up than using a bioprosthesis (restricted mean survival time) at 10 years: 7.24 (95% CI: 6.33-8.14) years for mechanical prosthesis versus 5.25 (95% CI: 4.25-6.25) years for bioprosthesis, restricted mean survival time difference 1.99 years, 95% CI: -3.34 to -0.64)., Conclusion: A 2-year survival gain in favor of mechanical prostheses was identified in dialysis patients younger than 50 years. The authors suggest mechanical prostheses for aortic valve replacement in these younger patients., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)

The impact of the type, purpose, and timing of prior surgery on heart transplantation (HT) remains unclear. This study investigated the influence of conventional cardiac surgery (PCCS) on HT outcomes. This study analyzed HTs performed between 1999 and 2019 at a single institution. Patients were categorized into two groups: those with and without PCCS. Short-term outcomes, including post-transplant complications and mortality rates, were evaluated. Cox proportional and Kaplan-Meier survival analyses were used to identify risk factors for mortality and assess long-term survival, respectively. Of 368 patients, 29% had PCCS. Patients with PCCS had a higher incidence of post-transplant complications. The in-hospital and 1 year mortality rates were higher in the PCCS group. PCCS and cardiopulmonary bypass time were significant risk factors for 1 year mortality (hazard ratios = 2.485 and 1.005, respectively). The long-term survival rates were lower in the PCCS group, particularly in the first year. In sub-analysis, patients with ischemic cardiomyopathy and PCCS had the poorest outcomes. The era of surgery and timing of PCCS in relation to HT did not significantly impact outcomes. In conclusion, PCCS worsen the HT outcomes, especially in patients with ischemic etiology. However, the timing of PCCS and era of HT did not significantly affect this concern., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Chen, Chou, Chou, Wang, Chi, Huang, Yu, Chen and Hsu.)

Background: Thoracic endovascular aortic repair (TEVAR) can only promote 55-80% false lumen (FL) thrombosis when only the proximal primary tear is covered during the repair of type B aortic dissection (TBAD). This study evaluated the effectiveness and clinical outcome of tailored exclusion of the primary entry tear with TEVAR and distal fenestrations with ancillary devices in patients with subacute or chronic Crawford type III and IV aortic dissection aneurysm., Methods: All patients underwent either TEVAR for primary entry tear; subsequently, various ancillary devices were applied on each distal fenestration. These techniques included covered stent occlusion of detached visceral artery entry tears, TL stenting and FL occlusion with vascular plugs in the common iliac artery dissection, or TEVAR coverage for multiple fenestrations from segmental arteries. This case series included nine patients (seven men and two women; mean age: 63.4 years) during January 2013 to May 2019. Outcome analysis included the rates of technical success and procedure-related complications, completeness of FL occlusion, aortic remodeling, and midterm mortality at 2 years., Results: The mean follow-up duration was 37.7 months without in-hospital mortality. One patient was lost to follow-up at the second month, the rest of patients were all alive during the follow-up period. All patients achieved complete FL thrombosis, and six patients exhibited aneurysm diameter shrinkage., Conclusion: Tailored exclusion of visceral and iliac distal fenestrations with proximal primary tear coverage can promote FL thrombosis and aortic remodeling in the visceral aortic segment in patients with Crawford type III or IV aortic dissection aneurysm., (Copyright © 2022 Formosan Medical Association. Published by Elsevier B.V. All rights reserved.)

Background: With the help of robotic surgical systems and their 3-dimensional, high-resolution imaging, mitral repair with long shaft instruments and endo-wrist functionality has become a feasible reality. Patients benefit from maintained thoracic cage integrity, reduced surgical trauma, and faster return to normal functional activity. We describe National Taiwan University Hospital's 10-year experience with robotic-assisted mitral valve repair procedures for repairing mitral regurgitation., Methods: We performed a retrospective observational cohort study of patients undergoing robotic-assisted mitral valve repair for severe mitral regurgitation at National Taiwan University Hospital. Between January 2012 and September 2022, 450 consecutive patients underwent robotic mitral valve repair with or without additional cardiac procedures. All procedures were completed by a single surgical team., Results: Four hundred and fifty patients, with 272 (60.4%) isolated mitral repairs and 178 (39.6%) combined additional (one or more) cardiac procedures were performed. The Euroscore II estimate mortality was 3.1%±2.7%. The average cardiopulmonary bypass (CPB) time was 124±42 minutes, and the average operation time was 165±51 minutes. Perioperative and 30-day mortality was observed in one (0.22%) patient. Mean intensive care unit stay was 26.5±26.0 hours. Postoperative stroke was observed in one (0.22%) patient and new-onset atrial fibrillation was observed in 71 (15.78%) patients. All patients were in less than mild mitral regurgitation and 422 (93.78%) had none or trace regurgitation at discharge. Freedom from moderate mitral regurgitation was 97.6%, and freedom from mitral valve reoperation was 98% at 10 years., Conclusions: With standardized robotic procedures and non-compromised repair techniques, excellent short-term outcomes and long-term valve repair durability can be achieved in experienced centers., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare., (2022 Annals of Cardiothoracic Surgery. All rights reserved.)

Background: Mechanical circulatory support (MCS) has been widely utilized in critically ill cardiac transplant candidates. Few studies have investigated the impact of duration of MCS before heart transplantation (HTx) on long-term patient survival., Methods: A retrospective HTx database was reviewed between 2009 and 2019. Patients who did not or did undergo MCS before HTx were categorized into two groups: (1) A (did not) and (2) B (did), respectively. A receiver operating characteristic (ROC) curve was plotted to assess the cutoff level of MCS duration before HTx in evaluating 5-year survival., Result: A total of 270 HTx patients (group A: 120, group B: 150) were analyzed. Group B patients had a higher percentage of blood type O, a higher incidence of resuscitation, a shorter listing duration, and a higher likelihood of having United Network for Organ Sharing (UNOS) 1A status than group A. The ROC curve revealed 24 days as a good cut-off level for determining the best MCS before HTx timing. Group B was categorized into two subgroups: (1) B1 (MCS < 24 days, n = 65) and (2) B2 (MCS > 24 days, n = 85). B2 had a higher incidence of cardiopulmonary resuscitation (CPR), hemodialysis, longer waiting time after MCS, and better ventricular assist device implantation than B1. However, the survival curves showed that B1 outcomes were significantly worse than in groups A and B2. Groups A and B2 had similar survival curves without an increased incidence of infection., Conclusion: The preliminary data demonstrated that a longer duration of MCS may be associated with better outcomes than urgent HTx., (© 2022 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Objective: Retrograde arterial perfusion is frequently used in minimally invasive cardiac surgery. However, there are concerns about its safety., Methods: A prospective observational cohort study was conducted in a tertiary university affiliated medical center during 2016-2018. Right side femoral artery and femoral vein are used for bypass route. We set cardiopulmonary bypass flow to 2.5-3.0 L/min/m 2 , and adjust pump flow rate to achieve adequate cerebral oxygenation. The upper limit of arterial cannula pressure was 250 mmHg. We divided our patients into four groups by average pump flow 2.2 L/min/m 2 and average mean arterial pressure 45 mmHg. Compared outcomes included surgical mortality, hospital stay, ventilator use, neurological outcomes, acute kidney injury, distal limb saturations, and post-operative clinical complications., Results: We included 117 patients in this study, and all participants had successful mitral valve repair or replacement. Our longest CPB duration was 210 minutes. Surgical mortality was 1.7%. Hemorrhagic stroke rate was 1.7%, and there was no ischemic stroke event. CPB flow did not affect survival rate, hospital stay, intensive care unit stay, or serum lactate in post-operative day 1, but serum creatinine (mg/dL) level increased transiently in patients with low pump flow group(0.9 ± 0.4 vs 1.3 ± 0.7,p < 0.05). Cannulation limb had decreased oxygenation during CPB, but their oxygenation all recovered after surgery. No limb ischemia event happened., Conclusion: Retrograde arterial perfusion is a safe method for minimally invasive cardiac surgery less than 3.5 hours under mild hypothermic status., Competing Interests: Declaration of competing interest None., (Copyright © 2021. Published by Elsevier B.V.)

Systemic lupus erythematosus (SLE) is associated with multi-organ damage including cardiac valve, which may need valvular operation. However, methods for outcome prediction and prosthetic valve selection are unclear in SLE patients undergoing cardiac valve surgery. Twenty-five SLE patients receiving valvular operation in a single institute between 2002 and 2020 were enrolled. Systemic Lupus International Collaborative Clinics/American College of Rheumatology Damage Index (SLICC/ACR damage index, SDI) was applied to evaluate the damage severity. Clinical outcomes were compared between patients with different SDI. The hospital survival rate was 88%, and long-term survival rate was 59.5% and 40.2% at 5 and 10 years. The median SDI was 4 (interquartile range 3-6) in our study, patients were then grouped into higher SDI (defined as SDI ≥ 5, n = 11) and lower SDI group (defined as SDI < 5, n = 14). The in-hospital survival rate (72.2% vs 100%, P = 0.074) and 5-year survival rate (18.2% vs 92.9%, P < 0.001) were lower in higher SDI group, compared to lower SDI group. SDI score was associated with long-term outcome for SLE patients receiving cardiac valve surgery. SDI ≥ 5 was associated with very poor long-term outcomes. This finding implicates that xenograft might be a reasonable choice for SLE patients with SDI ≥ 5., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

Background: Active bloodstream infection (BSI) is a contraindication for heart transplantation (HT). However, some critical patients with BSI may undergo HT as a life-saving procedure. We aimed to investigate the impact of pre-transplant BSI on the clinical outcomes after HT., Methods: We enrolled 511 consecutive patients who underwent HT between 1999 and 2019. Patients were divided into two groups based on the presence of BSI within 30 days preoperatively. Forty-three patients (8.4%) with BSI who were clinically stable and had no metastatic infection were considered for HT on an individual basis. In-hospital mortality, incidence of early postoperative BSI, length of postoperative hospital stays, and long-term survival were compared between the groups. Logistic and Cox regression analyses were performed to identify risk factors for in-hospital and 1-year mortality., Results: Patients with pre-transplant BSI had a high incidence of previous cardiopulmonary resuscitation, pre-transplant ventilator use, mechanical circulatory support use, renal replacement therapy, United Network for Organ Sharing status 1A, and a prolonged preoperative hospital waiting period. The in-hospital mortality rate was higher in patients with pre-transplant BSI (21% vs. 12%, p = .081), and the mortality rate was very high (33.3%) for those with BSI 0-15 days before HT. In addition, patients with pre-transplant BSI had a significantly longer postoperative hospital stay than patients in the control group. However, long-term survival was similar in both groups., Conclusions: Although pre-transplant BSI was associated with higher in-hospital mortality and prolonged postoperative hospital stay, patients who survived the early period had a similar long-term prognosis., (© 2022 Wiley Periodicals LLC.)

Background/purpose: Sensitization, the presence of preformed anti-human antibody in recipients, restricts access to ABO-compatible donors in heart transplant. Desensitization therapy works by reducing preformed antibodies to increase the chances of a negative crossmatch or permit safe transplantation across positive crossmatch. There is no consensus regarding the desensitization protocol in cardiac patients, and the outcome of desensitization remains under debate., Methods: Twenty-five consecutive sensitized heart transplant recipients received perioperative desensitization in our institution from 2012 to 2019. One-year patient survival and graft rejection rate were analyzed and compared between sensitized recipients and non-sensitized recipients., Results: Within the first year after transplant, patient survival in sensitized recipients was 76%. Infection was the major cause of death. The cumulative incidence of rejection was 8% for antibody-mediated rejection and 16% for acute cellular rejection. No significant difference in 1-year survival or rejection rate could be demonstrated between sensitized and nonsensitized recipients., Conclusion: Acceptable early outcomes in patient survival and graft rejection could be anticipated in sensitized heart transplant recipients under a perioperative algorithm using complement-dependent cytotoxicity crossmatch- or panel-reactive antibody-directed urgent immunomodulation strategies, while infection remains the major concern., Competing Interests: Declaration of competing interest Chen YS was a receipt of the grant of 106-2314-B-002 -234 -MY3, 102-2325-B-009, Ministry of Science and Technology, Taiwan. The other authors declare that there are no conflicts of interest., (Copyright © 2021 Formosan Medical Association. Published by Elsevier B.V. All rights reserved.)

End stage renal disease (ESRD) is a contraindication to isolated heart transplantation (HT). However, heart candidates with cardiogenic shock may experience acute kidney injury and require renal replacement therapy (RRT) and isolated HT as a life-saving operation. The outcomes, including survival and renal function, are rarely reported. We enrolled 569 patients undergoing isolated HT from 1989 to 2018. Among them, 66 patients required RRT before HT (34 transient and 32 persistent). The survival was worse in patients with RRT than those without (65.2% vs 84.7%; 27.3% vs 51.1% at 1- and 10-year, p < 0.001 and p = 0.012, respectively). Multivariate Cox analysis identified pre-transplant hyperbilirubinemia (Hazard ratio (HR) 2.534, 95% confidence interval (CI) 1.098-5.853, p = 0.029), post-transplant RRT (HR 5.551, 95%CI 1.280-24.068, p = 0.022) and post-transplant early bloodstream infection (HR 3.014, 95%CI 1.270-7.152, p = 0.012) as independent risk factors of 1-year mortality. The majority of operative survivors (98%) displayed renal recovery after HT. Although patients with persistent or transient RRT before HT had a similar long-term survival, patients with persistent RRT developed a high incidence (49.2%) of dialysis-dependent ESRD at 10 years. In transplant candidates with pretransplant RRT, hyperbilirubinemia should be carefully re-evaluated for the eligibility of HT whereas prevention and management of bloodstream infection after HT improve survival., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Chen, Chou, Wang, Chi, Huang, Yu, Chen and Hsu.)

Background/purpose: Redo operation for mitral valve surgery carries higher risks than first time cardiac surgery. The adhesion between sternum and heart, and also the complexity of second time operation make the redo operation more difficult. The robotic surgery carries some benefit in terms of magnification, assisted by the scope view and precise movement of the instruments. We compared the results of our robotic redo mitral valve surgeries with those of conventional re-sternotomy., Methods: Medical records of patients who underwent redo mitral valve surgeries between 2012 and 2019 at our hospital were retrospectively analyzed. Demographic data, patients' medical histories, presenting symptoms, image analyses, echocardiogram data, operative procedures and postoperative clinical outcomes were collected through chart review., Results: A total of 67 redo mitral valve surgeries, including 23 robotic and 44 re-sternotomy procedures were performed. There were no differences in age, previous operation times, and intervals to previous surgery. Comorbidities of both groups were similar. There was no surgical mortality in the robotic group, and it was 9.0% in the re-sternotomy group (p = 0.287). Operation time was shorter in the robotic group (176 vs. 321 min; robotic vs. re-sternotomy, p＝0.0279). Blood transfusion was lower in the robotic group (1 vs. 2 units; robotic vs. re-sternotomy, p = 0.01189). The ventilation time, ICU stay time, and recheck bleeding rate were similar in both groups., Conclusion: In select patients, robotic redo mitral valve surgery is safe and feasible. It could offer low operative mortality. It is associated with shorter operative times, than re-sternotomy and provides equal immediate operative results., Competing Interests: Declaration of competing interest The authors have no conflicts of interest relevant to this article., (Copyright © 2021 Formosan Medical Association. Published by Elsevier B.V. All rights reserved.)

Objective: Although the negative impact of immunosuppression on survival in patients with acute respiratory distress syndrome (ARDS) treated by extracorporeal membrane oxygenation (ECMO) is well known, short-term outcomes such as successful weaning rate from ECMO and subgroups benefit most from ECMO remain to be determined. The aims of this study were (1) to identify the association between immunocompromised status and weaning from ECMO in patients of ARDS, and (2) to identify subgroups of immunocompromised patients who may benefit from ECMO. Methods: This retrospective cohort study enrolled patients who received ECMO for ARDS from 2010 to 2020. Immunocompromised status was defined as having a hematological malignancy, active solid tumor, solid organ transplant, or autoimmune disease. Results: This study enrolled 256 ARDS patients who received ECMO, of whom 68 were immunocompromised. The multivariable analysis showed that immunocompromised status was not independently associated with failure to wean from ECMO. In addition, the patients with an autoimmune disease (14/24, 58.3%) and organ transplantation (3/3, 100%) had a numerically higher weaning rate from ECMO than other immunocompromised patients. For causes of ARDS, most patients with pulmonary hemorrhage (6/8, 75%) and aspiration (5/9, 55.6%) could be weaned from ECMO, compared to only a few of the patients with interstitial lung disease (2/9, 22.2%) and sepsis (1/4, 25%). Conclusions: Immunocompromised status was not an independent risk factor of failure to wean from ECMO in patients with ARDS. For patients with pulmonary hemorrhage and aspiration-related ARDS, ECMO may be beneficial as bridge therapy., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Cheng, Chen, Shih, Huang, Tseng, Lai, Lan, Lu, Hsieh, Li, Chi, Yu, Chen and Wang.)

Background: Slow gait, frailty, insufficient postoperative caloric intake, and delirium, although seemingly distinct, can appear simultaneously in patients who underwent cardiac surgery., Objectives: The aim of this study was to evaluate how these 4 factors overlap and how they individually and cumulatively affect cardiac surgery outcomes., Methods: The effects of slowness (gait speed <0.83 m/s), frailty (≥3/5 Fried criteria), insufficient postoperative intake (<800 kcal/d), and delirium (defined by the Confusion Assessment Method) on hospital length of stay (LOS) and 3-month mortality were analyzed in 308 adult patients., Results: Slowness, frailty, insufficient intake, and delirium affected 27.5%, 29.5%, 31.5%, and 13.3% of participants, respectively; only 42.2% (130/308) were free from these risks. Risk overlap was prevalent, as 26.3% (n = 81) had 2 or more risk factors. The most obvious overlap was in delirium (80% of delirious participants had other risks), suggesting that delirium cannot be managed in isolation. Individually, whereas slowness was associated only with longer LOS, frailty, insufficient intake, and delirium all led to longer LOS and higher mortality. When equally weighting each risk factor to analyze their cumulative effects, LOS increased by 4.4 days (95% confidence interval, 3.0-5.7) and 3-month mortality increased by 2.6-fold (95% confidence interval, 1.4-4.6), with each risk factor added, independent of participants' educational level, body mass index, and risk for cardiac surgery (EuroSCORE II ≥6)., Conclusions: Because a clinical overlap of slowness, frailty, insufficient postoperative intake, and delirium was evident in patients who underwent cardiac surgery, and risk of death and longer hospital stay increased with each factor added, care should be revised to consider these overlapping factors to maximize patient outcomes., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: The optimal treatment modality for retrograde type A intramural hematoma (IMH) remains debatable. This study evaluated and compared surgical outcomes and aortic remodeling after open aortic repair and thoracic endovascular aortic repair (TEVAR) in patients with retrograde type A IMH with a primary intimal tear or ulcer like projection in the descending aorta. Methods: A single center, retrospective observational study was performed on patients with retrograde type A IMH undergoing either open aortic repair and TEVAR. From June 2009 and November 2019, 46 patients with retrograde type A IMH who received either open aortic repair or TEVAR at our institution were reviewed for clinical outcomes, including post-operative mortality/morbidity, re-intervention rate and aortic remodeling. Results: 33 patients underwent open aortic repair and 13 underwent TEVAR. Median age was 68 years (interquartile range [IQR] 15.2 years) and 63 years (IQR 22.5 years) for the open repair group and TEVAR group, respectively. The median duration of follow-up for TEVAR patients was 37.6 months and 40.3 months for open aortic repair. No difference in the 5-year estimated freedom from all-cause mortality (82.1 vs. 87.8%, p = 0.34), re-intervention (82.5 vs. 93.8%, p = 0.08), and aortic-related mortality (88.9 vs. 90.9%, p = 0.88) were observed between the TEVAR and open repair group, respectively; however, the open repair group had a significantly higher 30-day composite morbidity (39.4 vs. 7.7%, p = 0.037). All patients from both treatment groups had complete resolution of the IMH in the ascending aorta. With regard to the descending thoracic aorta, TEVAR group had a significantly greater regression in the diameter of the false lumen or IMH thickness when compared to the open repair group [median 14mm (IQR 10.1) vs. 5mm (IQR 9.5), p < 0.001]. Conclusion: TEVAR and open aortic repair were both effective treatments for retrograde type A IMH, in which no residual ascending aortic IMH was observed during follow-up. TEVAR was also associated with lower post-operative composite morbidities and better descending aortic remodeling. In selected patients with retrograde type A IMH, TEVAR might be a safe, effective alternative treatment modality., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Yang, Chi, Yu, Chen, Wang and Wu.)

Background: The number of waitlisted patients requiring mechanical circulatory support (MCS) as a bridge to heart transplantation is increasing. The data concerning the results of the double-bridge strategy are limited. We sought to investigate the post-transplant outcomes across the different bridge strategies., Methods: We retrospectively reviewed a heart transplantation database from Jan 2009 to Jan 2019. Intra-aortic balloon pump (IABP), extracorporeal membrane oxygenation (ECMO), and ventricular assist devices (VAD) were the MCS that we investigated. The pre- and post-transplant characteristics and variables of patients bridged with the different types of MCS were collected. The post-transplant survival was compared using Kaplan-Meier survival analysis., Results: A total of 251 heart transplants were reviewed; 115 without MCS and 136 with MCS. The patients were divided to five groups: Group 1 (no MCS): n = 115; Group 2 (IABP): n = 15; Group 3 (ECMO): n = 33; Group 4 (ECMO-VAD): double-bridge ( n = 59); Group 5 (VAD): n = 29. Survival analysis demonstrated that the 3-year post-transplant survival rates were significantly different among the groups (Log-rank p < 0.001). There was no difference in survival between group 4(ECMO-VAD) and group 1(no MCS)1 ( p = 0.136), or between group 4(ECMO-VAD) and group 5(VAD) ( p = 0.994). Group 3(ECMO) had significantly inferior 3-year survival than group 4(ECMO-VAD) and group 5(VAD)., Conclusion: Double bridge may not lead to worse mid-term results in patients who could receive a transplantation. Initial stabilization with ECMO for critical patients before implantation of VAD might be considered as a strategy for obtaining an optimal post-transplant outcome.

Background: We compared 1-year functional outcomes for 4 cardiac surgery patient groups: comparison (without preoperative frailty or postoperative delirium [POD]), frailty only (with preoperative frailty only), POD only (with POD only), and frailty-POD (combined frailty and POD)., Methods: Consecutive cardiac surgery patients (n = 298) at a university hospital were assessed for preoperative frailty using Fried's phenotype, and POD was assessed daily for 10 days after surgery using the Confusion Assessment Method. Functional outcomes (Barthel Index for activities of daily living [ADL]) and all-cause mortality were evaluated 1-year after surgery., Results: Preoperative frailty presented in 85 of participants (28.5%) and POD in 38 (12.8%). Frail participants were at increased risk for POD (odds ratio = 4.9; P < .001). Overall, 1-year mortality was 4.0% (n = 12) and functional change was 0.4 ± 11.0 Barthel points. Controlling for age, cardiac risk, and baseline ADL, frailty-only and comparison participants had comparable 1-year functional outcomes. The POD-only group had greater mortality (adjusted hazard ratio = 23.9; P = .01), whereas the combined frailty-POD group had the greatest ADL decline (β = -23.7; P = .01) and the highest mortality (adjusted hazard ratio = 30.2; P = .006) compared with the comparison group., Conclusions: Preoperative frailty alone did not negatively affect cardiac surgery patients' functional outcomes up to 1 year, but coexisting frailty and POD led to substantial loss of independence on 3 to 4 ADLs and a 30.2-fold higher likelihood of dying 1 year after surgery. Because frailty led to a 4.9-fold increase in POD risk, frailty may serve as a presurgical screen to identify patients who would likely benefit from delirium prevention and functional recovery programs to maximize 1-year postsurgical outcomes., (Copyright © 2021. Published by Elsevier Inc.)

Background: Extracorporeal membrane oxygenation (ECMO) is an effective support method for acute fulminant myocarditis (AFM) with cardiogenic shock. However, deciding whether to bridge to a left ventricular assist device (LVAD) or to maintain ECMO support until heart recovery is still controversial., Material and Methods: This was a retrospective observational study from a single center. Eighty-eight adults with AFM and ECMO support between 2006 and 2018 were included. The primary endpoint was heart recovery without heart transplantation or long-term LVAD support., Results: The heart recovery group contained 43 patients, of whom 41 were discharged after being weaned off ECMO and the other two after LVAD. Five patients with heart transplants and one with long-term LVAD support were discharged, accounting for an overall survival of 55.7%. Multivariate logistic regression revealed that peak CK-MB level, severe intraventricular conduction disturbance (asystole) and malignant arrhythmia (VT or VF) were prognostic factors for nonrecovery (P = .027 and 0.017, respectively), while early intravenous immunoglobulin (IVIG) use before ECMO was highly likely to have a protective effect with a trend toward statistical significance (P = .079). A risk score was developed: 4 points for VT/VF/asystole, 1 point for every 100 μg/L increase in the peak CK-MB level, up to a maximum of 5 points, and -3 points for early IVIG use. The area under the receiver operating characteristic (ROC) curve (AUC) was 0.818., Conclusion: High CK-MB levels and VT/VF/asystole in patients with AFM are associated with poor heart recovery. Early IVIG use shows a potentially protective effect., Competing Interests: Declaration of Competing Interest On behalf of all authors, the corresponding author states that there are no competing interests., (Copyright © 2020. Published by Elsevier Inc.)

Background: Surgical treatment of infective endocarditis (IE) with aortic periannular abscess (PA) is a challenging issue with high mortality and morbidity rate in the current era. The present study is to review the results of surgical treatment for IE-PA based on an anatomy-guided surgical procedure selection for either aortic valve replacement (AVR) or aortic root reconstruction (ARR)., Methods: Patients with IE-PA received surgical treatment in National Taiwan University Hospital during the years 2001-2017 were retrospectively reviewed. The selection of surgical procedure was based on the intraoperative anatomical finding. The AVR group consisted of isolated AVR or AVR with patch repair if PA involved less than one cusp of the annulus. The ARR group included aortic root replacement if PA involved more than one cusp, causing commissural/sub-commissural destruction. In-hospital mortality and mid-term outcome and the risk factors were examined., Results: In-hospital mortality was 13% in the AVR group (24 patients) and 25% in the ARR group (8 patients) (p = 0.578). The composite adverse events (cardiac death, valve reoperation, or paravalvular leak) rate was 31% in the AVR group and 40% in the ARR group at one year; 48% in the AVR group and 40% in the ARR group at five years; 55% in the AVR group and 40% in the ARR group at ten years., Conclusion: Anatomy-guided surgical procedure selection for IE-PA is feasible. With the appropriate selection, ARR may be associated with fewer adverse events in mid-term follow-up. Careful intraoperative judgment and management and long-term follow-up are warranted for these patients., (Copyright © 2019 Formosan Medical Association. Published by Elsevier B.V. All rights reserved.)

Heart failure is a growing epidemic, especially in Taiwan because of the aging population. The 2016 Taiwan Society of Cardiology - Heart Failure with reduced Ejection Fraction (TSOC-HFrEF) registry showed that the guideline-recommended therapies were prescribed suboptimally both at the time of hospital discharge and during follow-up. We, therefore, conducted this 2019 focused update of the guidelines of the Taiwan Society of Cardiology for the diagnosis and treatment of heart failure to reinforce the importance of new diagnostic and therapeutic modalities of heart failure. The 2019 focused update discusses new diagnostic criteria, pharmacotherapy, non-pharmacological management, and certain co-morbidities of heart failure. Angiotensin receptor neprilysin inhibitor and If channel inhibitor is introduced as new and recommended medical therapies. Latest criteria of cardiac resynchronization therapy, implantable cardioverter-defibrillator, heart transplantation, and ventricular assist device therapy are reviewed in the non-pharmacological management chapter. Co-morbidities in heart failure are discussed including chronic kidney disease, diabetes, chronic obstructive pulmonary disease, and sleep-disordered breathing. We also explain the adequate use of oxygen therapy and non-invasive ventilation in heart failure management. A particular chapter for chemotherapy-induced cardiac toxicity is incorporated in the focused update to emphasize the importance of its recognition and management. Lastly, implications from the TSOC-HFrEF registry and post-acute care of heart failure are discussed to highlight the importance of guideline-directed medical therapy and the benefits of multidisciplinary disease management programs. With guideline recommendations, we hope that the management of heart failure can be improved in our society.

Background: Sarcopenia is linked with poor postoperative outcomes., Aims: To evaluate the effects of sarcopenia on first-year functional changes after cardiac surgery., Methods: In this prospective cohort study, functional changes (physical activity levels in metabolic equivalent hours/week, 6-minute walking distance in metres, and grip strength in kg) from preoperative baseline to 1, 3, 6 and 12 months postoperatively were compared in adult patients with and without sarcopenia undergoing cardiac surgery at a tertiary medical centre. Presurgical sarcopenia was defined as low muscle mass plus either low strength or poor physical performance (i.e. reduced gait speed). Secondary outcomes (length of hospital stay and 1-year mortality) were compared between sarcopenia and non-sarcopenia groups., Results: Sarcopenia presented in 27.7% ( n=67) of 242 participants. Participants with sarcopenia were significantly older, predominantly women, and had lower body mass index and higher cardiac surgery risk (measured by the EuroSCORE II) than those without sarcopenia. For both groups, physical activity levels, walking distance and grip strength steadily improved over the year following cardiac surgery. Independent of EuroSCORE II, changes in physical activity levels, walking distance and grip strength did not differ significantly between the sarcopenia and non-sarcopenia groups 1, 3, 6 and 12 months after surgery. Nevertheless, the sarcopenia group had a significantly longer length of hospital stay than the non-sarcopenia group (19.4 vs. 15.3 days; β=2.9, P=0.02) but 1-year mortality (3.4 vs. 3.9% for non-sarcopenia group) was comparable., Conclusions: Despite a longer length of hospital stay for the sarcopenia group, sarcopenia was not a restriction for cardiac surgery given their comparable functional improvement and mortality 1 year following surgery.

Objectives: Although the benefits and risks of on- and off-pump coronary artery bypass have been compared in several clinical trials, large-scale studies regarding long-term outcomes in patients with diabetes are lacking. We compared long-term outcomes after on- and off-pump coronary artery bypass in patients with diabetes., Methods: We evaluated outcomes in 16,215 patients with diabetes who underwent isolated coronary artery bypass from 2000 to 2011. Clinical data validity was regulated by the single-payer, universal, and nationwide reimbursement systems. Long-term outcomes were compared using propensity score matched analyses., Results: Off-pump surgery was associated with a greater incidence of repeat revascularization (P = .0036) in the long term. Propensity score matching identified 3796 patients in each group. There were no significant differences between on- and off-pump surgery regarding the long-term risks of mortality (hazard ratio [HR], 0.95; 95% confidence interval [CI], 0.87-1.02, P = .1667), stroke (HR, 0.97; 95% CI, 0.87-1.09, P = .6074), and myocardial infarction (HR, 1.05; 95% CI, 0.91-1.20, P = .5207). Off-pump surgery offered a survival benefit within 30 days (HR on vs off , 1.52, 95% CI, 1.24-1.85, P < .0001). In patients with diabetes and end-stage renal disease, on-pump surgery provided a significant long-term survival benefit (HR on vs off , 0.68, 95% CI, 0.51-0.91)., Conclusions: In patients with diabetes undergoing isolated coronary artery bypass, off-pump surgery provided a 30-day benefit in mortality, but both groups had similar long-term survival. In off-pump surgery, repeat revascularization was a concern in the long term. In patients with diabetes and end-stage renal disease, on-pump surgery has long-term survival benefits., (Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

A definitive conclusion regarding whether on-pump or off-pump coronary artery bypass is preferable in young patients is lacking. The aim of our study was to perform a long-term comparison of the two approaches in young patients. We analyzed the National Health Insurance Research Database, using data for patients between 18 and 45 years of age who had undergone isolated coronary artery bypass between 2001 and 2011. The study endpoints were: all-cause death, major adverse cardiac and cerebrovascular events, and repeat revascularization within 30 days, 1 year, 5 years, and the entire 10-year follow-up period. A total of 344 patients received off-pump surgery and 741 patients received on-pump surgery. Preoperative characteristics and comorbidities were similar in both groups, and all-cause mortality was almost equal ( p = 0.716). The 5-year survival rates were 93.9% and 92.2% in the off-pump and on-pump groups, respectively, and the 10-year survival rates were 86.3% and 82.1%, respectively. The repeat revascularization rate was significantly lower in the on-pump group ( p = 0.0407). Both the on-pump and off-pump methods offer equally good long-term outcomes in terms of mortality and major adverse cardiac and cerebrovascular events. However, the need for repeat revascularization is a concern in the long term after off-pump surgery.

Purpose: Caseloads of extracorporeal cardiopulmonary resuscitation (ECPR) have increased considerably, and hospital mortality rates remain high and unpredictable. The present study evaluated the effects of the interplay between age and prolonged low-flow duration (LFD) on hospital survival rates in elderly patients to identify subgroups that can benefit from ECPR., Methods: Adult patients who received ECPR in our institution (2006-2016) were classified into groups 1, 2, and 3 (18-65, 65-75, and > 75 years, respectively). Data regarding ECPR and adverse events during hospitalization were collected prospectively. The primary end point was favorable neurologic outcome (cerebral performance category 1 or 2) at hospital discharge., Results: In total, 482 patients were divided into groups 1, 2, and 3 (70.5%, 19.3%, and 10.2%, respectively). LFDs were comparable among the groups (40.3, 41.0, and 44.3 min in groups 1, 2, and 3, P = 0.781, 0.231, and 0.382, respectively). Favorable neurologic outcome rates were nonsignificantly lower in group 3 than in the other groups (27.6%, 24.7%, and 18.4% for group 1, 2, and 3, respectively). Subgroup analysis revealed that the favorable neurologic outcome rates in group 1 were 36.7%, 25.4%, and 13.0% for LFDs of < 30, 30-60, and > 60 min, respectively (P = 0.005); in group 2, they were 32.1%, 21.2%, and 23.1%, respectively (P = 0.548); in group 3 they were 25.0%, 20.8%, and 0.0%, respectively (P = 0.274)., Conclusion: On emergency consultation for ECPR, age and low-flow duration should be considered together to predict neurologic outcome.

Objectives: An oversized cardiac allograft may have a negative impact on survival outcomes according to previous studies; however, due to the shortage of pediatric donor hearts, the use of oversized cardiac allografts is sometimes inevitable. In this study, we reported the survival outcomes of pediatric patients in relation with the donor-recipient weight ratio., Methods: Twenty-eight children, aged 3 months to 17 years, with dilated cardiomyopathy underwent primary cardiac transplantation at the National Taiwan University Hospital between 1995 and 2012. We analyzed these patients according to the donor-recipient weight ratio: group 1 (n = 19) with donor-recipient weight ratio <2.5 (median 1.1, interquartile range 1.0-1.6), and group 2 (n = 9) with donor-recipient weight ratio ≥2.5 (median 3.0, inter-quartile range 2.87-3.5)., Results: The 30-day survival rate was 100% for both group 1 and group 2 (P = 1). The survival rates for group 1 and group 2 were 95% vs 100% at 1 year, 84% vs 89% at 5 years, and 73% vs 61% at 10 years. The median survival was 14.4 years vs 12.9 years (P = .6313)., Conclusion: In this cohort, the use of oversized cardiac allograft in pediatric patients for dilated cardiomyopathy did not have a negative effect on short-term and long-term survival., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Intravascular leiomyomatosis (IVL) is relatively rare. The optimal surgical method and long-term outcomes are not completely understood., Methods: Medical records between 2007 and 2017 in our hospital were analyzed to identify IVL cases with surgical intervention. Their medical records, operative details, and follow-up were collected by chart review and telephone communication., Results: Eight patients with IVL were included in the study, accounting for 0.26% of all uterine leiomyoma cases. Primary IVL was confined to pelvic cavity in three patients, extended to the inferior vena cava (IVC) below renal vein in one, reached IVC and right atrium in three, and reached main pulmonary artery in one. One-stage operation was performed for seven patients. Cardiopulmonary bypass was done in four patients, and aortic cross-clamp and temporary circulatory arrest was performed in two patients. None of the four patients with intrapulmonary tumors received concomitant pulmonary tumor resection. There was no operative mortality and four morbidities, including ureter injury (2), bladder injury (1), and femoral vein thrombosis (1). During follow-up, two patients exhibited local recurrence of the tumor in the pelvis, and one patient had rapidly growing intrapulmonary tumor three months post-operatively. Intrapulmonary tumors in the other three patients remained stationary at 6, 84, and 120 months post-operatively., Conclusion: One-stage operation to completely remove IVL is feasible and with good long-term outcomes, which is recommended if the patient can tolerate the operation. Concomitant intrapulmonary tumors can be followed up watchfully except when associated with pleural effusion or the pathology indicating trend of increasing malignancy., (Copyright © 2018. Published by Elsevier B.V.)

We report a heart transplantation in a patient with no heart. A 60-year-old man suffered from severe infective endocarditis, and due to extensive involvement of the myocardium, only minimal myocardium was left after debridement of the necrotic myocardium and aortic annulus. We finally excised the entire heart to eradicate the infection source and employed 2 extracorporeal membrane oxygenations for full life support. The infection was controlled with strong antibiotics. The patient underwent successful heart transplantation 16 days following the excision and the patient fully recovered without any complications., (Copyright © 2018 Elsevier Inc. All rights reserved.)