Cyclophilin A (CyPA), secreted by vascular smooth muscle cells in response to oxidative stress, is important in the pathogenesis of progressive peripheral arterial occlusion disease (PAOD), which is common among chronic kidney disease. We explored the prevalence of PAOD in Taiwan’s elderly (≥ 65 years old) population and its association with CyPA and renal function. Residents of Tianliao District, a rural community in southern Taiwan, were surveyed. An ankle-brachial index (ABI) < 0.91 was defined as PAOD. Chronic kidney disease (CKD) was defined based on eGFR levels < 60 mL/min/1.73 m2. Serum CyPA was measured. Of the 473 participants, 68 (14.4%) had PAOD. Multiple logistic regression analysis showed PAOD was significantly associated with lower eGFR, lower BMI, higher glycated hemoglobin and higher pulse pressure. Serum CyPA levels in participants with PAOD were significantly higher than those with normal ABI values (47.3 ± 0.4 vs. 25.5 ± 0.2 ng/mL, p < 0.001). Moreover, eGFR inversely correlated with serum CyPA level (p < 0.05) in participants with CKD, but not in participants with normal renal function. In conclusion, with a prevalence of PAOD as high as 14.4% in an elderly community, CyPA might be the link between PAOD and advanced impaired renal function.

Background Despite limited evidence, postoperative prophylactic antibiotics are often used in the setting of permanent pacemaker implantation or replacement. The aim of this study is to investigate the efficacy of postoperative antibiotics. Hypothesis Postoperative prophylactic antibiotics may be not clinically useful. Methods We recruited 367 consecutive patients undergoing permanent pacemaker implantation or generator replacement at a tertiary referral center. Baseline demographics, clinical characteristics, and procedure information were collected, and all patients received preoperative prophylactic antibiotics. Postoperative prophylactic antibiotics were administered at the discretion of the treating physician, and all patients were seen in follow‐up every 3 to 6 months for an average follow‐up period of 16 months. The primary endpoint was device‐related infection. Results A total of 110 patients were treated with preoperative antibiotics only (group 1), whereas 257 patients received both preoperative and postoperative antibiotics (group 2). After a mean follow‐up period of 16 months, 1 patient in group 1 (0.9%) and 4 patients in group 2 (1.5%) experienced a device‐related infection. There was no significant difference in the rate of infection between the 2 groups (P = 0.624). In the univariate analysis, only the age (60 ± 11 vs 75 ± 12 years, P < 0.001) was significantly different between the infected and noninfected groups. In the multivariate analysis, younger age was an independent risk factor for infective complications (odds ratio = 1.08, P = 0.016). Conclusions Patients treated with preoperative and postoperative antibiotics had a similar rate of infection as those treated with preoperative antibiotics alone. Further studies are needed to confirm these preliminary findings.

Introduction Identifying the critical isthmus (CI) in scar‐related macroreentrant atrial tachycardia (AT) is challenging, especially for patients with cardiac surgery. We aimed to investigate the electrophysiological characteristics of scar‐related macroreentrant ATs in patients with and without cardiac surgery. Methods A prospective study of 31 patients (mean age 59.4 ± 9.81 years old) with scar‐related macroreentrant ATs were enrolled for investigation of substrate properties. Patients were categorized into the nonsurgery (n = 18) and surgery group (n = 13). The CIs were defined by concealed entrainment, conduction velocity less than 0.3 m/s, and the presence of local fractionated electrograms. Results Among the 31 patients, a total of 65 reentrant circuits and 76 CIs were identified on the coherent map. The scar in the surgical group is larger than the nonsurgical group (18.81 ± 9.22 vs. 10.23 ± 5.34%, p = .016). The CIs in surgical group have longer CI length (15.27 ± 4.89 vs. 11.20 ± 2.96 mm, p = .004), slower conduction velocity (0.46 ± 0.19 vs. 0.69 ± 0.14 m/s, p < .001), and longer total activation time (45.34 ± 9.04 vs. 38.24 ± 8.41%, p = .016) than those in the nonsurgical group. After ablation, 93.54% of patients remained in sinus rhythm during a follow‐up of 182 ± 19 days. Conclusion The characteristics of the isthmus in macroreentrant AT are diverse, especially for surgical scar‐related AT. The identification of CIs can facilitate the successful ablation of scar‐related ATs.

BackgroundBoth physical activity and inflammation are important in the pathophysiology of metabolic syndrome (MetS). Our study aim is to explore their associations in an elderly male (≥ 65 years old) cohort.MethodsWe enrolled 309 elderly male residents (mean age: 74.4 ± 6.0 years) in a remote southern Taiwan community. The physical activity was recorded by a standard questionnaire. A high-sensitivity C-reactive protein (hsCRP) level > 3.0 mg/L indicated a high inflammatory status.ResultsThe total prevalence rate of MetS was 27.8% in this male geriatric cohort. Median hsCRP levels were significantly higher in the MetS group (1.60 ± 0.7 vs. 1.0 ± 0.3 mg/L, p < 0.01), and the risk of elevated hsCRP increased with escalating MetS components (p for trend < 0.001). The non-MetS group had higher amount of median weekly physical activity (183.1 ± 19.0 vs. 173.5 ± 10.6 MET-hr/week, p = 0.029), which was also higher among those with lower hsCRP levels (186.1 ± 14.1 vs. 167.8 ± 38.5 MET-hr/week, p = 0.013). Multivariate analysis showed that higher body mass index (ORs: 1.527, 95% CI: 1.319-1.768, p < 0.01) insulin (OR: 1.128, 95% CI: 1.045-1.218, p < 0.01) and physical activity (ORs: 0.997, 95% IC: 0.994-0.999, p < 0.05) were independent predictors of MetS, but not hsCRP level (p > 0.05).ConclusionsReduced physical activity was one major pathophysiological MetS factor in our Asian geriatric participants.

Premature atrial complexes (PACs) have been suggested to increase the risk of adverse events. The distribution of PAC burden and its dose–response effects on all-cause mortality and cardiovascular death had not been elucidated clearly. We analyzed 15,893 patients in a medical referral center from July 1st, 2011, to December 31st, 2018. Multivariate regression driven by ln PAC (beats per 24 h plus 1) or quartiles of PAC burden were examined. Older group had higher PAC burden than younger group (p for trend < 0.001), and both genders shared similar PACs distribution. In Cox model, ln PAC remained an independent risk factor for all-cause mortality (hazard ratio (HR) = 1.09 per ln PAC increase, 95% CI = 1.06‒1.12, p < 0.001). PACs were a significant risk factor in cause-specific model (HR = 1.13, 95% CI = 1.05‒1.22, p = 0.001) or sub-distribution model (HR = 1.12, 95% CI = 1.04‒1.21, p = 0.004). In ordinal PAC model, 4th quartile group had significantly higher risk of all-cause mortality than those in 1st quartile group (HR = 1.47, 95% CI = 1.13‒1.94, p = 0.005), but no difference in cardiovascular death were found in competing risk analysis. In subgroup analysis, the risk of high PAC burden was consistently higher than in low-burden group across pre-specified subgroups. In conclusion, PAC burden has a dose response effect on all-cause mortality and cardiovascular death.

Background Transmural lesion creation is essential for effective atrial fibrillation (AF) ablation. Lesion characteristics between conventional energy and high-power short-duration (HPSD) setting in contact force-guided (CF) ablation for AF remained unclear. Methods Eighty consecutive AF patients who received CF with conventional energy setting (power control: 25–30 W, force–time integral = 400 g s, n = 40) or with HPSD (power control: 40–50 W, 10 s, n = 40) ablation were analyzed. Of them, 15 patients in each conventional and HPSD group were matched by age and gender respectively for ablation lesions analysis. Type A and B lesions were defined as a lesion with and without significant voltage reduction after ablation, respectively. The anatomical distribution of these lesions and ablation outcomes among the 2 groups were analyzed. Results 1615 and 1724 ablation lesions were analyzed in the conventional and HPSD groups, respectively. HPSD group had a higher proportion of type A lesion compared to conventional group (P < 0.01). In the conventional group, most type A lesions were at the right pulmonary vein (RPV) posterior wall (50.2%) whereas in the HPSD group, most type A lesions were at the RPV anterior wall (44.0%) (P = 0.04). The procedure time and ablation time were significantly shorter in the HPSD group than that in the conventional group (91.0 ± 12.1 vs. 124 ± 14.2 min, P = 0.03; 30.7 ± 19.2 vs. 57.8 ± 21 min, P = 0.02, respectively). At a mean follow-up period of 11 ± 1.4 months, there were 13 and 7 patients with recurrence in conventional and HPSD group respectively (P = 0.03). Conclusion Optimal ablation lesion characteristics and distribution after conventional and HPSD ablation differed significantly. HPSD ablation had shorter ablation time and lower recurrence rate than did conventional ablation.

SummaryIt is unknown whether there has been any change in the causes of death for acute ST-segment elevation myocardial infarction (STEMI) in the era of aggressive reperfusion. We analyzed the direct causes of in-hospital death in patients with STEMI treated with primary percutaneous coronary intervention (PCI) in a tertiary referral center over the past 10 years.We retrospectively analyzed 878 STEMI patients treated with primary PCI in our hospital between January 2005 and December 2014. There were no significant changes in the age and sex of patients, but the prevalence of hypertension and smoking decreased. STEMI severity increased with more patients in Killip classification > 2. The number of out-ofhospital cardiac arrest events also increased over the 10 years. Symptom onset-to-door time did not change in the 10-year study period. The care quality was improved with shorter door-to-balloon time for primary PCI and increased use of dual antiplatelet therapy. The all-cause in-hospital mortality was 9.1%, which did not vary over the 10 years. Multivariable analysis showed that Killip classification > 2 was the most important determinant of death. Cardiogenic shock was the major cause of cardiovascular death. There was an increase in non-cardiovascular causes of death in the most recent 3 years, with infection being a major problem.Despite improvement in care quality for STEMI, the in-hospital mortality did not decrease in this tertiary referral center over these 10 years due to increased disease severity and non-cardiovascular causes of death. (Int Heart J 2016; 57: 541-546) Key words: Acute myocardial infarction, Coronary angioplasty, Mortality A cute myocardial infarction is an important public health issue in Taiwan because it carries a high fatality rate and its incidence is still increasing. 1) In acute ST-segment elevation myocardial infarction (STEMI), timely primary percutaneous coronary intervention (PCI) and the use of evidence-based medications significantly decrease mortality, and are strongly recommended in local 2) and international guidelines.3,4) In Taiwan, more than 95% of STEMI patients received primary PCI as the initial reperfusion therapy, and the door-to-balloon (D2B) time has improved. 5,6) A previous observational study demonstrated that early primary PCI could decrease the incidence of cardiogenic shock, which is the major cause of death in STEMI.7) It is unknown whether there has been any temporal change in the causes of death during hospitalization for STEMI with the advent of aggressive reperfusion in recent years. Information on the specific causes of death can reveal the weak points of current treatment and enable the implementation of new strategies to improve the quality of care for STEMI patients treated with primary PCI. The major aims of the present study were to describe the 10-year secular trends in the clinical characteristics and management of STEMI patients treated with primary PCI, and to specifically analyze the causes of death in these patients in a tertiary referral c...

Background: The management of refractory electrical storm (ES) requiring mechanical circulation support (MCS) remains a clinical challenge in structural heart disease (SHD). Objective:The study sought to explore the 30-day and 1-year outcome of rescue ablation for refractory ES requiring MCS in SHD.Methods: A total of 81 patients (mean age: 55.3 ± 18.9, 73 men [90.1%]) undergoing ablation were investigated, including 26 patients with ES requiring MCS (group 1) and 55 patients without (group 2). The 30-day and 1-year outcome, including mortality and recurrent ventricular tachyarrhythmias (VAs) receiving appropriate implantable cardioverter defibrillators therapies, were assessed.Results: The patients in group 1 were characterized by older age, more ischemic cardiomyopathies, worse left ventricular ejection fraction, and more comorbidities.Thirty days after ablation, overall events were seen in 15 patients (mortality in 10 and recurrent VA in 7), including pumping failure-related mortality in 6 (60%). During a 30-day follow-up, higher mortality was noted in group 1. After a 1-year follow-up, in spite of the higher mortality in group 1 (P < .001), the overall events and VA recurrences were similar between these two groups (P = .154 and P = .466, respectively). There was a significant reduction of VA burden in both groups and two patients had recurrent ES.Conclusion: Higher 30-day mortality was observed in patients undergoing rescue ablation for refractory ES requiring MCS, and pumping failure was the major cause of periprocedural death. Rescue ablation successfully prevented VA recurrences and resulted in a comparable 1-year prognosis between ES with and without MCS. K E Y W O R D S electrical storm, mechanical circulation support, pumping failure, rescue ablation, structural heart disease