(Robert) Jeenchen Chen

All Publications

• Differential Serum Proteomic Signatures between Acute Aortic Dissection and Acute Myocardial Infarction Biomedicines Lin, Y., Chen, J., Lin, J., Hsu, C., Wu, C., Kao, S. 2023; 11 (1): 161

  Abstract

  Acute aortic dissection (AAD) and acute myocardial infarction (AMI) are both severe cardiovascular diseases that may cause sudden death. However, whether serum proteins are differentially expressed between AAD and AMI remains unclear. Here, we aimed to explore serum protein profiles between AAD and AMI patients. A total of 75 serum samples were collected, including AAD patients without AMI (n = 25), AMI patients without AAD (n = 25), and normal subjects (n = 25). Protein identities and expression levels were assessed by LC-MS/MS analysis and a label-free quantitation method, respectively. After depletion of albumin and IgG, a total of 117 proteins with differential expression (fold change ≥2 or ≤-2.0, p < 0.05) were identified, of which 60 were upregulated and 57 were downregulated in AAD sera as compared to AMI sera. Bioinformatic analysis revealed that the differentially expressed serum proteins were mainly derived from exosomes and the extracellular space, and their molecular functions and biological processes were primarily involved in the activity of transporters and complements and the immune response. In addition, the serum level of Cadherin-5, an identified protein with significant regulation in AAD, was further evaluated by ELISA and the results showed that Cadherin-5 in AAD sera was higher that in AMI and healthy sera. Collectively, these findings reveal the differential serum protein profiles between AAD and AMI, which may reflect the divergent pathophysiological progression between the two cardiovascular diseases.

  View details for DOI 10.3390/biomedicines11010161

  View details for PubMedCentralID PMC9855332

• The Early Dynamic Change in Cardiac Enzymes and Renal Function Is Associated with Mortality in Patients with Fulminant Myocarditis on Extracorporeal Membrane Oxygenation: Analysis of a Single Center's Experience. Healthcare (Basel, Switzerland) Ho, C., Ju, T. R., Lee, C. C., Lin, H., Wang, A., Chen, R. J., Lin, Y. 2022; 10 (6)

  Abstract

  (1) Background: Fulminant myocarditis (FM) could result in hemodynamic derangement and fatal arrhythmia. Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) is used to maintain organ perfusion in FM patients complicating cardiogenic shock. The present study aims to assess the static and dynamic factors in association with mortality in FM patients on V-A ECMO (2) Methods: Twenty-eight patients were enrolled between 2013 to 2019 for analysis (3) Results: In-hospital survival rate was 78.5%. There was no statistical difference in demographics and baseline laboratory data between survivors and non-survivors. However, within 24 h after ECMO support, CK-MB increased by 96.8% among non-survivors, but decreased by 23.7% among survivors (p = 0.022). Troponin I increased by 378% among non-survivors and 1.7% among survivors (p = 0.032). Serum creatinine increased by 108% among non-survivors, but decreased by 8.5% among survivors (p = 0.005). The receiver operating characteristic curve suggested an increase in serum creatinine by 68% within 24 h after ECMO support was associated with increased mortality with an area under the curve of 0.91. (4) Conclusions: V-A ECMO is an excellent tool to support FM patients with cardiogenic shock. The early dynamic change of renal function and cardiac enzymes may be useful for outcome assessment.

  View details for DOI 10.3390/healthcare10061063

  View details for PubMedID 35742115

• Marker Games: Seeking Better Biomarkers? AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE Chen, R., Yu, W. 2016; 194 (1): 11-13

  View details for DOI 10.1164/rccm.201602-0211ED

  View details for Web of Science ID 000378979100006

  View details for PubMedID 27367885

• Right miniparasternotomy may be a good minimally invasive alternative to full sternotomy for cardiac valve operations: a propensity-adjusted analysis. The Journal of cardiovascular surgery Chiu, K. M., Chen, R. J., Lin, T. Y., Chen, J. S., Huang, J. H., Huang, C. Y., Chu, S. H. 2016; 57 (1): 111-20

  Abstract

  Limited real-world data existed for mini-parasternotomy approach with good sample size in Asian cohorts and most previous studies were eclipsed by case heterogeneity. The goal of this study was to compare safety and quality outcomes of cardiac non-coronary valve operations by mini-parasternotomy and full sternotomy approaches on risk-adjusted basis. METHODS From our hospital database, we retrieved the cases of non-coronary valve operations from 1 January 2005 to 31 December 2012, including re-do, emergent, and combined procedures. Estimated EuroScore-II and propensity score for choosing mini-parasternotomy were adjusted for in the regression models on hospital mortality, complications (pneumonia, stroke, sepsis, etc.), and quality parameters (length of stay, ICU time, ventilator time, etc.). Non-complicated cases, defined as survival to discharge, ventilator use not over one week, and intensive care unit stay not over two weeks, were used for quality parameters.There were 283 mini-parasternotomy and 177 full sternotomy cases. EuroScore-II differed significantly (medians 2.1 vs. 4.7, P<0.001). Propensity scores for choosing mini-parasternotomy were higher with lower EuroScore-II (OR=0.91 per 1%, P<0.001), aortic regurgitation (OR=2.3, P=0.005), and aortic non-mitral valve disease (OR=3.9, P<0.001). Adjusted for propensity score and EuroScore-II, mini-parasternotomy group had less pneumonia (OR=0.32, P=0.043), less sepsis (OR=0.31, P=0.045), and shorter non-complicated length of stay (coefficient=-7.2 (day), P<0.001) than full sternotomy group, whereas Kaplan-Meier survival, non-complicated ICU time, non-complicated ventilator time, and 30-day mortality did not differ significantly.The propensity-adjusted analysis demonstrated encouraging safety and quality outcomes for mini-parasternotomy valve operation in carefully selected patients.

  View details for PubMedID 26771734

• Videoscope-assisted cardiac surgery JOURNAL OF THORACIC DISEASE Chiu, K., Chen, R. 2014; 6 (1): 22-30

  Abstract

  Videoscope-assisted cardiac surgery (VACS) offers a minimally invasive platform for most cardiac operations such as coronary and valve procedures. It includes robotic and thoracoscopic approaches and each has strengths and weaknesses. The success depends on appropriate hardware setup, staff training, and troubleshooting efficiency. In our institution, we often use VACS for robotic left-internal-mammary-artery takedown, mitral valve repair, and various intra-cardiac operations such as tricuspid valve repair, combined Maze procedure, atrial septal defect repair, ventricular septal defect repair, etc. Hands-on reminders and updated references are provided for reader's further understanding of the topic.

  View details for DOI 10.3978/j.issn.2072-1439.2014.01.04

  View details for Web of Science ID 000330625000005

  View details for PubMedID 24455172

  View details for PubMedCentralID PMC3895591

• Cardioplegia Delivery by Transcutaneous Pigtail Catheter in Minimally Invasive Mitral Valve Operations ANNALS OF THORACIC SURGERY Chiu, K., Chen, R., Lin, T., Chen, J., Huang, J., Chu, S. 2013; 95 (3): E77-E78

  Abstract

  For cardioplegia delivery and removing air from the aorta in minimally invasive mitral valve operations, we would like to propose a cost-effective pigtail method. The 8F pigtail punctures the aorta, delivers cardioplegia, and stays in place for removing air from the aorta. We then slide its tip out of the aorta as an accessory drain. With more than 100 successes, we are using it in every case and would like to share it with peer surgeons.

  View details for DOI 10.1016/j.athoracsur.2012.10.065

  View details for Web of Science ID 000315332800010

  View details for PubMedID 23438572

• Short-term outcomes of cadaveric lung transplantation in ventilator-dependent patients CRITICAL CARE Hsu, H., Chen, J., Ko, W., Huang, S., Kuo, S., Huang, P., Chi, N., Chang, C., Chen, R. J., Lee, Y. 2009; 13 (4): R129

  Abstract

  Survival after cadaveric lung transplantation (LTx) in respiratory failure recipients who were already dependent on ventilation support prior to transplantation is poor, with a relatively high rate of surgical mortality and morbidity. In this study, we sought to describe the short-term outcomes of bilateral sequential LTx (BSLTx) under extracorporeal membrane oxygenation (ECMO) support in a consecutive series of preoperative respiratory failure patients.Between July 2006 and July 2008, we performed BSLTx under venoarterious (VA) ECMO support in 10 respiratory failure patients with various lung diseases. Prior to transplantation, 6 patients depended on invasive mechanical ventilation support and the others (40%) needed noninvasive positive pressure ventilation to maintain adequate gas exchange. Their mean age was 40.9 years and the mean observation period was 16.4 months.Except for 1 ECMO circuit that had been set up in the intensive care unit for pulmonary crisis 5 days prior to transplantation, most ECMO (90%) circuits were set up in the operating theater prior to pneumonectomy of native lung during transplantation. Patients were successfully weaned off ECMO circuits immediately after transplantation in 8 cases, and within 1 day (1/10 patients) and after 9 days (1/10 patients) due to severe reperfusion lung edema following transplantation. The mean duration of ECMO support in those successfully weaned off in the operating theater (n = 8) was 7.8 hours. The average duration of intensive care unit stay (n = 10) was 43.1 days (range, 35 to 162 days) and hospital stay (n = 10) was 70 days (range, 20 to 86 days). Although 4 patients (40%) had different degrees of complicated postoperative courses unrelated to ECMO, all patients were discharged home postoperatively. The mean forced vital capacity and the forced expiratory volume in 1 second both increased significantly postoperatively. The cumulative survival rates at 3 months and at 12 months post-transplantation were 100% and 90%.Although BSLTx in this critical population has varied surgical complications and prolonged length of postoperative ICU and hospital stays, all the patients observed in this study could tolerate the transplant procedures under VA ECMO support with promising pulmonary function and satisfactory short-term outcome.

  View details for DOI 10.1186/cc7989

  View details for Web of Science ID 000272225600026

  View details for PubMedID 19660110

  View details for PubMedCentralID PMC2750186

• Tricuspid Valve Regurgitation and Endomyocardial Biopsy After Orthotopic Heart Transplantation TRANSPLANTATION PROCEEDINGS Chen, R., Wei, J., Chang, C., Chuang, Y., Lee, K., Sue, S., Chen, H. 2008; 40 (8): 2603-2606

  Abstract

  Tricuspid valve regurgitation (TR) after heart transplantation (HTx) has been reported to be caused by endomyocardial biopsy (EMB), acute cellular rejection (ACR), or atrial anastomosis. We performed a prospective study of this problem among our HTx cohort.From 1988 to 2006, we performed 274 HTx. Excluding cases within 1 year (2006), there were 178 patients in whom we had records of EMB dates, ACR grades (International Society for Heart and Lung Transplantation [ISHLT], 1990), echocardiography-measured TR, and time-to-TR. Statistical analyses were performed using nonparametric comparisons, Spearman correlation, Kaplan-Meier time to failure curves, and Cox regression model.All 178 patients underwent a biatrial anastomosis and underwent 2631 EMB (median, 15 times per patient; range, 0-42). The median follow-up duration was 66 months (range 2 days-194 months). Up to December 31, 2006, there were 47 patients (47/178 = 26.4%) who developed moderate-to-severe TR, which differed significantly from the prevalence rate (24/39 = 61.5%) reported by another cardiac team (P = .001) that performed bicaval anastomoses in half of the cases (20/39 = 51%). Our 1-, 3-, and 10-year Kaplan-Meier incidence rates of remarkable TR were 14.7% (10.2%-20.8%), 19.4% (14.2%-26.2%), and 36.3% (27.2%-47.3%), respectively. A positive correlation was shown between each patient's EMB times and ACR but not TR grades, in terms of mean, maximum, or minimum over time (all P < .001 for null hypothesis of noncorrelation). Each patient's EMB times and number of definite ACRs (> or = ISHLT grade II) did not differ significantly between the two groups of remarkable versus nonremarkable TR. Remarkable TR was negatively predicted by each patient's EMB times (hazard ratio = 0.93; P = .010) but not by the ACR grades or the numbers of definite ACRs.Our cohort demonstrated that biatrial anastomosis, ACR, or EMB were not associated with the risk of remarkable TR. The protective effect of EMB on remarkable TR needs further investigation.

  View details for DOI 10.1016/j.transproceed.2008.07.108

  View details for Web of Science ID 000260134300047

  View details for PubMedID 18929813

• Analysis and results of prolonged resuscitation in cardiac arrest patients rescued by extracorporeal membrane oxygenation JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Chen, Y. S., Chao, A., Yu, H. Y., Ko, W. J., Wu, I. H., Chen, R. J., Huang, S. C., Lin, F. Y., Wang, S. S. 2003; 41 (2): 197-203

  Abstract

  We conducted this study to determine the result of prolonged cardiopulmonary resuscitation (CPR) with extracorporeal membrane oxygenation (ECMO) and the predictive factors for hospital discharge and ECMO weaning.Prolonged CPR carries considerable associated mortality and morbidity. As yet, ECMO for prolonged CPR has no definite results. Only small groups of patients and no detailed analysis have been reported.Candidates for ECMO resuscitation were patients in cardiac arrest receiving CPR >10 min without return of spontaneous circulation and no absolute contraindication. Venoarterial ECMO was set up during CPR. We reviewed the data of 57 prolonged CPR patients who received ECMO during CPR over a six-year period.The mean duration of CPR was 47.6 +/- 13.4 min and that of ECMO was 96.1 +/- 87.9 h. The rate of weaning was 66.7%, and the survival rate was 31.6%. Multiple-organ failure was the major reason for mortality, despite successful weaning. Among survivors, long-term follow-up revealed 88.9% survival, and only 5.6% had a severe neurologic deficit. The results indicate that a shorter CPR duration, postcardiotomy arrest, myocardial indicators, a hepatic indicator, and lactic acid are significantly correlated with both weaning and survival, whereas late damage (level on the third or seventh day of reperfusion) rather than initial damage (level on the first day) was more predictive of the results.Prolonged CPR rescue by ECMO provides an acceptable survival rate and outcome in survivors. Our results of the selected cases encourage further investigations of the wider application of ECMO in CPR.

  View details for DOI 10.1016/S0735-1097(02)02716-X

  View details for Web of Science ID 000180362800005

  View details for PubMedID 12535808

• A case report of acquired methemoglobinemia rescued by veno-venous extracorporeal membrane oxygenation MEDICINE Lien, Y., Lin, Y., Chen, R. 2021; 100 (15): e25522

  Abstract

  Severe methemoglobinemia (Met-Hb) is rare. The delayed diagnosis and treatment often cause further damage. The management of cellular hypoxemia is challenging and the use of extra-corporeal membrane oxygenation (ECMO) has never been reported.The young patient, healthy with unremarkable past medical history, was sent to emergency room with out-of-hospital circulatory arrest (OHCA) and severe generalized cyanosis. His family reported he ingested sodium nitrite accidentally.After successful resuscitation and return of spontaneous circulation (ROSC), the paradoxically normal arterial blood gas (ABG) with the unusual brownish blood led to the suspicion of Met-Hb. The lab test confirmed it and showed a very high level of 80%.Because of recovered and normal cardiac function, we placed veno-venous extracorporeal membrane oxygenation (VV-ECMO) for tissue hypoxemia in addition to exchange transfusion, vitamin C, and methylene blue.Met-Hb blood level dropped rapidly. After vigorous rehabilitation for weeks, the patient was able to be discharged home without major neurological sequela.VV-ECMO can hyper-oxygenate the hypoxemic tissue regardless the etiology and minimize hypoxemia-reperfusion injury while awaiting the definite diagnosis and therapy.

  View details for DOI 10.1097/MD.0000000000025522

  View details for Web of Science ID 000658956900069

  View details for PubMedID 33847673

  View details for PubMedCentralID PMC8052064

• Lung Transplant Outcomes with Concomitant Heart Donation Bobba, C. M., Keller, B. C., Rosenheck, J., Henn, M. C., Chen, R., Mokadam, N. A., Whitson, B. A., Ganapathi, A. M. ELSEVIER SCIENCE INC. 2021: S329

  View details for Web of Science ID 000631254401057

• Comparison of Waitlist and Post-Transplant All-Cause Mortality in Patients with Hypertrophic Cardiomyopathy before and after the UNOS Allocation System Change Chen, R. J., Vallakati, A., Ganapathi, A. M., Henn, M. C., Whitson, B. A., Mokadam, N. A., Lampert, B., Benza, R., Hasan, A., Kahwash, R., Franco, V., Haas, G., Emani, S. ELSEVIER SCIENCE INC. 2021: S222

  View details for Web of Science ID 000631254400515

• BCL-6 promotes the methylation of miR-34a by recruiting EZH2 and upregulating CTRP9 to protect ischemic myocardial injury BIOFACTORS Lin, J., Hsu, C., Chen, J., Kao, S., Lin, Y. 2021; 47 (3): 386-402

  Abstract

  Acute myocardial infarction (AMI) and the following heart failure are public health problems faced all over the globe. The current study set out to investigate the role of B-cell lymphoma 6 (BCL-6) in cardiac protection after AMI. Initially, AMI mouse models and H9c2 cell oxygen-glucose deprivation (OGD) models were established. The cell models were transfected with the vectors containing oe-BCL-6, oe-EZH2, sh-EZH2, miR-34a mimic, and miR-34a inhibitor. RT-qPCR and Western blot analysis were applied to detect the expression patterns of microRNA-34a (miR-34a), BCL-6, enhancer of zeste homolog 2 (EZH2), and C1q tumor necrosis factor-related protein 9 (CTRP9) in the treated cell models. ChIP-qPCR and co-immunoprecipitation assay were performed to detect EZH2 enrichment and H3K27me3 levels in the miR-34a promoter region and the interaction between BCL-2 and EZH2, respectively. EdU staining, TUNEL staining, and flow cytometry were performed to detect cell proliferation and apoptosis, while ELISA was conducted to detect the oxidative stress levels. It was found that miR-34a was highly expressed in heart tissues of AMI models, while BCL-6 and EZH2 were poorly expressed. BCL-2 overexpression increased the recruitment of EZH2, upregulated H3K27me3 level in the miR-34a promoter region, and inhibited the miR-34a expression. Ctrp9, the downstream negative-regulatory molecule of miR-34a, was upregulated. Besides, miR-34a/CTRP9 expression changes were found to affect cardiomyocyte apoptosis, oxidation stress, and proliferation, and prevent myocardial injury in AMI mice. Our findings indicate that BCL-6 increases the level of H3K27me3 in the promoter region of miR-34a via EZH2 recruitment and CTRP9 upregulation, which inhibits the apoptosis of myocardial cells.

  View details for DOI 10.1002/biof.1704

  View details for Web of Science ID 000612151300001

  View details for PubMedID 33502806

• Down-Regulation of miR-34a-5p Potentiates Protective Effect of Adipose-Derived Mesenchymal Stem Cells Against Ischemic Myocardial Infarction by Stimulating the Expression of C1q/Tumor Necrosis Factor-Related Protein-9 FRONTIERS IN PHYSIOLOGY Weng, C., Wu, C., Kao, S., Chen, J., Lin, H. 2019; 10: 1445

  Abstract

  Adipose-derived stem cells (ADSCs) have shown great promise for the treatment of myocardial infarction (MI), although their potential therapeutic mechanism remains poorly understood. Growing evidence has implicated microRNAs (miRNAs or miRs) in the biological processes whereby ADSCs could ameliorate cardiovascular disease. In this study, we explored the contribution of miR-34a-5p down-regulation to the protective actions of ADSCs against MI. We initially identified the interaction between miR-34a-5p and C1q/tumor necrosis factor-related protein-9 (CTRP9) through in silico analysis. We next tested the effects of miR-34a-5p and CTRP9 on the expression of extracellular signal-regulated kinase 1 (ERK1), matrix metalloproteinase-9 (MMP-9), nuclear factor (erythroid-derived 2)-like 2 (NRF2), and antioxidant proteins [manganese superoxide dismutase (MnSOD), and heme oxygenase-1 (HO-1)] through gain- and loss-of-function tests. In other experiments, we assessed the proliferation, migration, and apoptosis of ADSCs using the EdU assay, scratch test, Transwell assay, and flow cytometry. Finally, we studied whether miR-34a-5p/CTRP9 axis could modulate the protective effect of ADSCs against MI during stem cell transplantation in MI mouse models. miR-34a-5p could target and down-regulate CTRP9 in cardiomyocytes. Down-regulated miR-34a-5p increased the expression of ERK1, MMP-9, NRF2, MnSOD, and HO-1, whereas down-regulation of miR-34a-5p or up-regulation of CTRP9 in vitro promoted ADSC proliferation and migration and inhibited ADSC apoptosis. Moreover, miR-34a-5p down-regulation or CTRP9 up-regulation promoted the protective role of ADSCs against MI damage in vivo. Thus, inhibition of miR-34a-5p may facilitate ADSC's protective function against MI damage by stimulating the expression of CTRP9.

  View details for DOI 10.3389/fphys.2019.01445

  View details for Web of Science ID 000504987000001

  View details for PubMedID 31920683

  View details for PubMedCentralID PMC6927948

• Thromboelastogram Directed Anticoagulation After Left Ventricular Assist Device Implantation Abdou, M., Chen, R. J., Wang, I., Gleissner, E., Pickrell, J., Caccamo, M., Hadi, A. ELSEVIER SCIENCE INC. 2017: S248

  View details for Web of Science ID 000398839800642

• Voltage-Gated Ca2+ Influx into Coronary Artery Smooth Muscle Is Decreased in Ischemic versus Non-Ischemic Cardiomyopathy - The First Evidence from Human Transplant Cardiectomy Samples Chen, R. J., Alloosh, M., Badin, J. K., Sturek, M., Wang, I., Wozniak, T., Hashmi, Z. A. ELSEVIER SCIENCE INC. 2017: S135

  View details for Web of Science ID 000398839800340

• Skirted Cannula Technique for Apical Cannulation in Implantation of Centrimag Left Ventricular Assist Device ANNALS OF THORACIC SURGERY Shen, T., Tsai, K., Hu, C., Chen, R. 2016; 101 (6): 2404-2406

  Abstract

  The CentriMag, an extracorporeal short-term ventricular assist device designed for treatment of patients with acute cardiogenic shock, is Conformité Européenne-marked in Europe for use up to 30 days. Extended use beyond the licensed period is not uncommon, however. We have developed a skirted cannula technique for apical cannulation in implantation of the Centrimag. This technique allows easy positioning of the cannula and excellent hemostasis. It also offers secure fixation of the cannula so that patients can ambulate and attend rehabilitation programs should extended use be anticipated.

  View details for DOI 10.1016/j.athoracsur.2016.02.046

  View details for Web of Science ID 000376502600074

  View details for PubMedID 27211964

• Cardiac Myxoma With Unusual Obstructive and Embolic Presentations Concurrent Stroke and Angiography-Negative Myocardial Infarction-A Case Report MEDICINE Chen, R., Chou, H., Tsai, K., Shen, T., Hu, C. 2015; 94 (38): e1602

  Abstract

  We present a case of cardiac myxoma with atypical presentations of concurrent stroke and angiography-negative myocardial infarction. The case emphasizes the importance of basic echocardiography and timely surgery in the management of cardiac myxoma. An elderly woman presented to the emergency department in an unconscious state. Electrocardiogram and elevated cardiac enzymes suggested acute myocardial infarction; however, immediate coronary angiography proved patency. Basic echocardiography revealed an oscillating left atrial myxoma obstructing inflow through the mitral valve. After regaining consciousness while in the intensive care unit, the patient developed respiratory distress and shock, and emergent en bloc resection was performed. Ataxia was noted in her postoperative course and multiple small cerebellar infarcts were found on magnetic resonance imaging. After a 1-month period of rehabilitation, the patient recovered well and continues to be followed as an outpatient. Cardiac myxoma requires timely management and may be missed if not included in the differential diagnoses. Basic echocardiography, also called focused cardiac ultrasound, may aid in the diagnosing of perplexing cardiac cases.

  View details for DOI 10.1097/MD.0000000000001602

  View details for Web of Science ID 000369533200029

  View details for PubMedID 26402823

  View details for PubMedCentralID PMC4635763

• Intraoperative Measurement of Fractional Flow Reserve in Off-Pump Coronary Artery Bypass: A Pilot Study THORACIC AND CARDIOVASCULAR SURGEON Chiu, K., Lin, T., Chen, J., Huang, J., Chen, R., Chu, S. 2015; 63 (4): 288-291

  Abstract

  Fractional flow reserve of myocardium (FFRmyo) is a functional study of significant coronary artery stenosis, defined as the ratio of the pressure distal to the stenosis (poststenosis) divided by the pressure of aortic root (prestenosis). Instead of cath laboratory, we could measure it in operating room for off-pump coronary artery bypass (OPCAB) surgery and here shared our methods in the pilot study.We used needles, catheters, and pressure tracing but without guidewires or fluoroscopy to measure FFRmyo during OPCAB. In February 2010, we conducted the pilot study and collected 32 anastomosis data from 10 patients. Without revising the anastomosis plans based on coronary angiographies, 24 FFRmyo of the 32 anastomoses (75%) were less than 0.75, which represented significant functional stenosis. The FFRmyo measurements did not lead to any adverse events.The measurement of fractional flow reserve in OPCAB is safe and feasible. It can serve as a functional assessment of coronary artery stenosis in adjuvant to conventional coronary angiography.

  View details for DOI 10.1055/s-0034-1383815

  View details for Web of Science ID 000356101000006

  View details for PubMedID 25032723

• Technological Innovations in the Development of Cardiovascular Clinical Information Systems JOURNAL OF MEDICAL SYSTEMS Hsieh, N., Chang, C., Lee, K., Chen, J., Chan, C. 2012; 36 (2): 965-978

  Abstract

  Recent studies have shown that computerized clinical case management and decision support systems can be used to assist surgeons in the diagnosis of disease, optimize surgical operation, aid in drug therapy and decrease the cost of medical treatment. Therefore, medical informatics has become an extensive field of research and many of these approaches have demonstrated potential value for improving medical quality. The aim of this study was to develop a web-based cardiovascular clinical information system (CIS) based on innovative techniques, such as electronic medical records, electronic registries and automatic feature surveillance schemes, to provide effective tools and support for clinical care, decision-making, biomedical research and training activities. The CIS developed for this study contained monitoring, surveillance and model construction functions. The monitoring layer function provided a visual user interface. At the surveillance and model construction layers, we explored the application of model construction and intelligent prognosis to aid in making preoperative and postoperative predictions. With the use of the CIS, surgeons can provide reasonable conclusions and explanations in uncertain environments.

  View details for DOI 10.1007/s10916-010-9561-5

  View details for Web of Science ID 000303825500059

  View details for PubMedID 20703637

• Connective Tissue Growth Factor Acts as a Therapeutic Agent and Predictor for Peritoneal Carcinomatosis of Colorectal Cancer CLINICAL CANCER RESEARCH Lin, B., Chang, C., Chen, R., Jeng, Y., Liang, J., Lee, P., Chang, K., Kuo, M. 2011; 17 (10): 3077-3088

  Abstract

  Here, we aimed to investigate the role of connective tissue growth factor (CTGF) in peritoneal carcinomatosis (PC) associated with colorectal cancer (CRC) and to characterize the underlying mechanism of CTGF mediating adhesion.A cohort of 136 CRC patient specimens was analyzed in this study. CRC cell lines were used for in vitro adhesion assay and in vivo peritoneal dissemination experiment. Recombinant CTGF protein treatment, transfection of CTGF expression plasmids, and knockdown of CTGF expression in CRC cells were utilized to evaluate the integrin α5, which served as a target of CTGF in inhibiting peritoneal seeding.The analysis of CRC tissues revealed an inverse correlation between CTGF expression and prevalence of PC. Lower CTGF level in CRC patients was associated with higher peritoneal recurrence rate after surgery. Inducing CTGF expression in cancer cells resulted in decreased incidence of PC and increased rate of mice survival. The mice received intraperitoneal injection of recombinant CTGF protein simultaneously with cancer cells or following tumor formation; in both cases, peritoneal tumor dissemination was found to be effectively inhibited in the mouse model. Functional assay revealed that CTGF significantly decreased the CRC cell adhesion ability, and integrin α5 was confirmed by reverse transcriptase PCR and functional blocking assay as a downstream effector in the CTGF-mediated inhibition of CRC cell adhesion.CTGF acts as a molecular predictor of PC and could be a potential therapeutic target for the chemoprevention and treatment of PC in CRC patients.

  View details for DOI 10.1158/1078-0432.CCR-09-3256

  View details for Web of Science ID 000290610000004

  View details for PubMedID 21558398

• Effect of Coronary Artery Disease on the Outcomes of the Patients with Ischemic Stroke in Taiwan Yin, J., Chen, R. J. LIPPINCOTT WILLIAMS & WILKINS. 2011: E336

  View details for Web of Science ID 000287479401384

• Associations of exposure to noise with physiological and psychological outcomes among post-cardiac surgery patients in ICUs CLINICS Hsu, S., Ko, W., Liao, W., Huang, S., Chen, R. J., Li, C., Hwang, S. 2010; 65 (10): 985-989

  Abstract

  This study sought to study the associations of noise with heart rate, blood pressure, and perceived psychological and physiological responses among post-cardiac surgery patients in ICUs.Forty patients participated in this study after recovering from anesthesia. A sound-level meter was placed at bedsides to measure noise level for 42 hours, and patients' heart rate and blood pressure were recorded every 5 minutes. Patients were also interviewed for their perceived psychological/physiological responses.The average noise level was between 59.0 and 60.8 dB(A) at the study site. Annoyance and insomnia were the respective psychological and physiological responses reported most often among the patients. Although noise level, irrespective of measures, was not observed to be significantly associated with the self-assessed psychological and physiological responses, it was significantly associated with both heart rate and blood pressure.Our study demonstrated that the noise in ICUs may adversely affect the heart rate and blood pressure of patients, which warrants the attention of hospital administrators and health care workers.

  View details for DOI 10.1590/S1807-59322010001000011

  View details for Web of Science ID 000284778300011

  View details for PubMedID 21120299

  View details for PubMedCentralID PMC2972598

• Analysis of bicanalicular nasal intubation in the repair of canalicular lacerations JAPANESE JOURNAL OF OPHTHALMOLOGY Wu, S., Ma, L., Chen, R. J., Tsai, Y., Chu, Y. 2010; 54 (1): 24-31

  Abstract

  To analyze the outcomes (success, failure) and complications of surgical repair of canalicular lacerations by bicanalicular nasal intubation in a series of patients treated over a 7-year period.The case records of 98 patients undergoing surgical repair of canalicular lacerations were retrospectively reviewed. Patient characteristics and results of the surgical repair were analyzed to identify factors that may influence the outcomes. Two groups (success and failure) were statistically compared with the Mann-Whitney U test for scale variables and with Fisher's exact test for categorical variables.Of the 98 patients, 78 (79.6%) had patency after irrigation (anatomic success) and 83 (84.7%) were asymptomatic (functional success). Patients age, sex, injury location, anesthetic methods, and timing of surgical repair were not significantly associated with the postoperative patency of the lacerated canaliculus. Having a stent left for more than 90 days was significantly associated with restoration of the canalicular anatomy (P < 0.01). Patients with postoperative anatomic patency had a significantly lower rate of symptomatic epiphora than patients with anatomic obstruction (P < 0.001). Symptomatic epiphora was significantly more frequent in patients with combined upper and lower canalicular injuries (P < 0.01).Our results suggest that retaining bicanalicular silicone nasal intubation for more than 90 days can provide satisfactory results in restoring both canalicular anatomy and function. With an experienced operating team, repair of canalicular lacerations can be delayed for up to 11 days. However, patients with combined upper and lower canalicular lacerations are at an increased risk of developing postoperative symptomatic epiphora.

  View details for DOI 10.1007/s10384-009-0755-7

  View details for Web of Science ID 000274456800005

  View details for PubMedID 20151272

• The Correlation between Right Descending Pulmonary Artery Diameter and Echocardiography-Estimated Systolic Pulmonary Artery Pressure ACTA CARDIOLOGICA SINICA Lin, S., Chen, R., Lee, J. 2009; 25 (4): 213-217

  View details for Web of Science ID 000273167200005

• Risk Factors and Surgical Prognosis in Patients with Infra-Renal Abdominal Aortic Aneurysms ACTA CARDIOLOGICA SINICA Lee, K., Chen, R., Chang, C., Sue, S., Tung, T., Chu, T., Wei, J., Chuang, Y. 2009; 25 (2): 91-97

  View details for Web of Science ID 000267770700005

• Measurement of Human Erythrocyte C4d to Erythrocyte Complement Receptor 1 Ratio in Cardiac Transplant Recipients With Acute Symptomatic Allograft Failure TRANSPLANTATION PROCEEDINGS Lee, K. C., Chang, C. Y., Chuang, Y. C., Sue, S. H., Chu, T. W., Chen, R. J., Chen, S. H., Wei, J., Chen, C. H. 2008; 40 (8): 2638-2642

  Abstract

  Complement activation has been recognized as a contributing factor to cardiac allograft dysfunction. Combined measurement of erythrocyte C4d (E-C4d) and complement receptor 1 (E-CR1) are potential biomarkers to monitor complement activity in patients with autoimmune diseases. We conducted a prospective study using CR1-2B11 monoclonal antibody to detect the E-C4d to E-CR1 ratio among our cardiac transplant recipients with acute symptomatic allograft failure.Eight recipients with acute cardiac allograft failure and 72 healthy controls were included in this study. Levels of E-C4d and E-CR1 were measured by indirect immunofluorescence and flow cytometry. The results were utilized to determine the association between patient C4d staining, histological features, and clinical outcomes.Eight patients with nine episodes of sudden onset of graft failure and suspected antibody-mediated rejection (AMR) were included in this study. One patient who received emergent mechanical circulatory support was treated with plasmapheresis for his unstable hemodynamic status. The mean pretreatment left ventricular ejection fraction was 30.3%. No histological study demonstrated cellular rejection or AMR in any patient. There were two patients with positive C4d immunostaining. Three patients had four episodes of acute rejection with sudden death at home. The mean E-C4d/E-CR1 ratio in the study group (n = 9) was 0.22 +/- 0.07, and 0.12 +/- 0.10 in the control group (n = 72). As comparing both groups, we found the ratios were significant higher in the study group (P = .0003).Measurement of the E-C4d/E-CR1 ratio may be a noninvasive method for detecting acute rejection after cardiac transplantation.

  View details for DOI 10.1016/j.transproceed.2008.08.027

  View details for Web of Science ID 000260134300060

  View details for PubMedID 18929826

• The Influence of Gender on Survival After Heart Transplantation TRANSPLANTATION PROCEEDINGS Tsao, C. I., Chen, R. J., Chou, N. K., Ko, W. J., Chi, N. H., Yu, H. Y., Chen, Y. S., Chen, S. C., Wang, S. S. 2008; 40 (8): 2634-2635

  Abstract

  Because of a shortage of deceased donors, more than one-third of patients die during the waiting period for transplantation. This study was conducted to analyze the influence of gender on survival after heart transplantation. We retrospectively reviewed the recipients after primary orthotopic heart transplantation. According to gender, patients were divided into four groups: male donor to male recipient, male donor to female recipient, female donor to male recipient, and female donor to female recipient. Kaplan-Meier survival curves were plotted with log-rank tests. Cox regression analysis with dummy variables were used to examine the effects of donor gender, recipient gender, and donor-recipient gender combinations on survival after heart transplantation. The data did not show any significant effect of donor gender, recipient gender, or donor-recipient gender combinations on patient survival, using the methods of log-rank test and Cox regression with dummy variables. Based on our results, we concluded that gender was not an important factor in organ allocation.

  View details for DOI 10.1016/j.transproceed.2008.08.025

  View details for Web of Science ID 000260134300058

  View details for PubMedID 18929824

• The Influence of Donor Characteristics on Survival After Heart Transplantation TRANSPLANTATION PROCEEDINGS Tsao, C. I., Chen, R. J., Chou, N. K., Ko, W. J., Chi, N. H., Yu, H. Y., Chen, Y. S., Chen, S. C., Wang, S. S. 2008; 40 (8): 2636-2637

  Abstract

  With improved immunosuppressive regimens, transplantation techniques, and postoperative care, heart transplantation (HTx) has been established as a definite therapy for end-stage heart disease. Because of a donor shortage, we have accepted marginal individuals. In this study, we identified donor-related factors influencing survival after HTx by retrospective analysis of recipient data after primary HTx from February 2002 to December 2006. The Cox regression model was used to examine the effects of the following variables on survival of 112 heart transplant recipients: demographic data of gender, age, body weight, donor-recipient body weight ratio; history of smoking, alcohol drinking, diabetes mellitus, hypertension, hepatitis B surface antigen, anti-hepatitis C virus antibody; donor condication before transplantation including catecholamine doses, hypotension, cardiopulmonary resuscitation, creatine MB isoenzyme of creatine kinase (CK-MB), tropinin I, and cold ischemic time of the allograft. Catecholamines and smoking showed significant influences on HTx survival. In our series, the percentage of donors receiving inotropic support before donation was 88% (n = 99), and the percentage of donors with a history of smoking was 25% (n = 28). There was no influence of donor status of diabetes, hypertension, or hepatitis B or C infection on postoperative survival. Our results showed that inotropic support of and a history of smoking by the donor were significant factors influencing posttransplant survival.

  View details for DOI 10.1016/j.transproceed.2008.08.026

  View details for Web of Science ID 000260134300059

  View details for PubMedID 18929825

• Incidence, risk factors, and prognosis of postoperative hyperbilirubinemia after heart transplantation EUROPEAN JOURNAL OF CARDIO-THORACIC SURGERY Hsu, R., Lin, F., Chen, R. J., Chou, N., Ko, W., Chi, N., Wang, S., Chun, S. 2007; 32 (6): 917-922

  Abstract

  The clinical significance of postoperative hyperbilirubinemia after heart transplantation has not been reported. Here, we sought to evaluate the incidence, risk factors, and prognosis of postoperative hyperbilirubinemia after heart transplantation.Between 1987 and 2005, 256 consecutive patients undergoing heart transplantation were studied prospectively. Postoperative hyperbilirubinemia was defined as occurrence of a serum total bilirubin concentration of more than 3mg/dl in any measurement during the postoperative period. Logistic regression was done to identify possible risk factors for postoperative hyperbilirubinemia and hospital mortality.Overall incidence of postoperative hyperbilirubinemia was 57%. Among all patients, there were 35 hospital deaths (14%). In patients with postoperative hyperbilirubinemia, the mean onset time was 2.4+/-4.4 days after transplantation and the mean peak serum total bilirubin was 10.1+/-10.4 mg/dl. Development of postoperative hyperbilirubinemia was associated with a higher mortality (21% vs 5%, P<0.001 by Fisher's exact test). The onset time of postoperative hyperbilirubinemia, the peak serum total bilirubin level, and the time at which the peak bilirubin level was reached were associated with hospital mortality. Old donor age, valvular heart disease, high right atrial pressure, use of mechanical ventilation before transplant, and ascites at transplant were the significant risk factors for postoperative hyperbilirubinemia.Postoperative hyperbilirubinemia is common in patients undergoing heart transplantation and is associated with high hospital mortality. Patients with valvular heart disease, high preoperative right atrial pressure, and ascites at transplant, who then receive an old donor heart, are at greater risk for development of postoperative hyperbilirubinemia.

  View details for DOI 10.1016/j.ejcts.2007.09.013

  View details for Web of Science ID 000251895700019

  View details for PubMedID 17920286

• Long-term outcome and effects of oral bosentan therapy in Taiwanese patients with advanced idiopathic pulmonary arterial hypertension RESPIRATORY MEDICINE Hsu, H., Chen, J., Chen, R. J., Ko, W., Kuo, S., Wu, E., Wu, M., Wang, J., Lee, Y. 2007; 101 (7): 1556-1562

  Abstract

  We report on the long-term outcome and effects of bosentan treatment in Taiwanese patients with advanced (functional class III or IV) idiopathic pulmonary arterial hypertension (IPAH).IPAH patients on stable bosentan therapy for more than 12 months and regularly monitored were eligible for this prospective uncontrolled study. Patients were evaluated for several clinical parameters, both measured at the time of initiation of bosentan therapy and after 12 months on therapy: New York Heart Association functional class (NYHA FC), change in 6-min walk distance (6MWD), right ventricle ejection fraction (RVEF), cardiothoracic ratio (CTR), and pulmonary functional status.Twelve of 15 patients met eligibility requirements and were enrolled. Their mean age was 37.6+/-12.9 years and 92% were female. Six (50%) patients were in NYHA FC IV and the others were in NYHA FC III at baseline. Three (25%) patients were chronic hepatitis C virus (HCV) carriers, with normal liver function. After 12 months of bosentan treatment, 6-MWD, RVEF, and pulmonary function all increased significantly. CTR and NYHA FC both decreased significantly. Oral bosentan was well tolerated and there was no episode of liver dysfunction that required adjustment of the bosentan dosage or discontinuance of therapy.Long-term treatment with oral bosentan appears to have beneficial effects on functional status, exercise capacity, right heart function, and pulmonary function in Taiwanese patients with advanced IPAH, regardless of whether or not they presented with chronic HCV infection.

  View details for DOI 10.1016/j.rmed.2006.12.007

  View details for Web of Science ID 000247765900027

  View details for PubMedID 17223329

• Effect of connective tissue growth factor on hypoxia-inducible factor 1 alpha degradation and tumour angiogenesis JNCI-JOURNAL OF THE NATIONAL CANCER INSTITUTE Chang, C., Lin, M., Lin, B., Jeng, Y., Chen, S., Chu, C., Chen, R. J., Chang, K., Yang, P., Kuo, M. 2006; 98 (14): 984-995

  Abstract

  Connective tissue growth factor (CTGF) inhibits the metastatic activity of human lung cancer cells in a mouse model; however, the mechanism of this modulation is unclear. We investigated the role of angiogenesis in this process.CL1-5 and A549 human lung adenocarcinoma cells were stably transfected with vectors containing CTGF or hypoxia-inducible factor (HIF) 1alpha or with vector controls. Transfected cells were injected into nude mice (n = 10 per group), and tumor growth, metastasis, and mouse survival were measured. Excised xenograft tumors and primary human lung adenocarcinomas (n = 24) were subjected to immunohistochemistry with antibodies to the endothelial cell marker CD31 and to CTGF. Expression of HIF-1alpha and vascular endothelial growth factor (VEGF) A was assessed in vitro by using reporter gene assays. Cells were transiently transfected with HIF-1alpha mutant and antisense arrest-defective 1 protein (ARD-1), and HIF-1alpha acetylation was assayed by immunoprecipitation. All statistical tests were two-sided.Xenograft tumors derived from CTGF transfectants grew more slowly than those from control-transfected cells and had reduced expression of HIF-1alpha and VEGF-A, vascularization (as assessed by CD31 expression), and metastasis (all P<.001). Xenograft tumors derived from CTGF-overexpressing cells that were transfected with HIF-1alpha had higher VEGF-A expression than CTGF-overexpressing xenografts. Mice with CTGF/HIF-1alpha xenografts had lower survival than mice carrying CTGF-overexpressing xenografts (CL1-5/Neo, mean = 69.6 days, 95% confidence interval [CI] = 53.9 to 85.3 days versus CL1-5/CTGF, mean = 102.1 days, 95% CI = 92.1 to 112.1 days; P = .001, CL1-5/CTGF, mean = 102.1 days, 95% CI = 92.1 to 112.1 days versus CL1-5/CTGF/HIF-1alpha, mean = 81.7 days, 95% CI = 66.5 to 96.9 days; P = .011, CL1-5/Neo, mean = 69.6 days, 95% CI = 53.9 to 85.3 days versus CL1-5/CTGF/HIF-1alpha, mean = 81.7 days, 95% CI = 66.5 to 96.9 days; P = .122). Tumors of patients with the same disease stage but with high CTGF protein expression had reduced microvessel density compared with tumors with low expression. Transfection with antisense-ARD1 decreased the level of acetylated HIF-1alpha and restored HIF-1alpha and VEGF-A expression in CTGF-overexpressing cells.CTGF inhibition of metastasis involves the inhibition of VEGF-A-dependent angiogenesis, possibly by promoting HIF-1alpha protein degradation.

  View details for DOI 10.1093/jnci/djj242

  View details for Web of Science ID 000239279000012

  View details for PubMedID 16849681

• Role of appendectomy in laparoscopic training JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUES Chiu, C. C., Wei, P. L., Wang, W., Chen, R. J., Chen, T. C., Lee, W. J., Huang, M. T. 2006; 16 (2): 113-118

  Abstract

  This study aimed to evaluate whether laparoscopic appendectomy is suitable for training residents to become proficient in laparoscopic surgery.A total of 1574 laparoscopic appendectomies were performed at En-Chu-Kong Hospital between January 1998 and December 2003 (788 men and 786 women). These cases were divided into three groups: 543 cases (in 1998-1999) performed by 5 attending surgeons during the learning and trial stage; 536 cases (in 2000-2001) performed by 5 attending surgeons assisted by 2 senior residents with prior experience in open appendectomy; and 495 cases (in 2002-2003) done by these 2 senior residents, supervised by the attending surgeons. Demographic data, intraoperative findings, operative time, conversion rate, frequency of analgesic injection, timing of oral intake, hospital stay, morbidity, and mortality were analyzed.There were no statistically significant differences in the operations performed by attending surgeons (mature stage) vs. senior residents in terms of intraoperative findings, operative time (60.1 +/- 60.4 minutes vs. 56.3 +/- 25.6 minutes), conversion rate (1.12% vs. 0.81%), frequency of analgesic injection (0.57 +/- 1.37 times/stay vs. 0.43 +/- 0.94 times/stay), timing of oral intake (23.7 +/- 30.2 hours vs. 20.8 +/- 27.5 hours), hospital stay (73.9 +/- 61.8 hours vs. 70.3 +/- 51.6 hours), morbidity, or mortality (0% vs. 0.2%).Laparoscopic appendectomy can be safely incorporated into the training of surgical residents under the supervision of experienced surgeons. Laparoscopic appendectomy also provides knowledge of the basics of laparoscopic technique before going on to more complex operations.

  View details for DOI 10.1089/lap.2006.16.113

  View details for Web of Science ID 000237093800007

  View details for PubMedID 16646699

• Additional minocycline pleurodesis after thoracoscopic surgery for primary spontaneous pneumothorax AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE Chen, J. S., Hsu, H. H., Chen, R., Kuo, S. W., Huang, P. M., Tsai, P. R., Lee, J. M., Lee, Y. C. 2006; 173 (5): 548-554

  Abstract

  Ipsilateral recurrence rates of spontaneous pneumothorax after video-assisted thoracoscopic surgery are higher than rates after open thoracotomy.This study was conducted to determine whether additional minocycline pleurodesis would be effective in diminishing recurrence after video-assisted thoracoscopic surgery treatment of primary spontaneous pneumothorax.Between June 2001 and February 2004, 202 patients with primary spontaneous pneumothorax were treated by conventional or needlescopic video-assisted thoracoscopic surgery. The procedures included resection of blebs and mechanical pleurodesis by scrubbing the parietal pleura. After the operation, patients were randomly assigned to additional minocycline pleurodesis (103 patients) or to observation (99 patients).Patients in the minocycline group had higher intensity chest pain and required a higher accumulated dose of meperidine. Short-term results showed that the two groups had comparable chest drainage duration, postoperative hospital stay, and complication rates. Patients in the minocycline group demonstrated a trend of decreased rate of prolonged air leaks (1.9 vs. 6.1%, p = 0.100). After a mean follow-up of 29 mo (12-47 mo), recurrent ipsilateral pneumothorax was noted in two patients in the minocycline group and eight patients in the observation group (p = 0.044 by the Kaplan-Meier method and log-rank test). Postoperative long-term residual chest pain and pulmonary function were comparable in both groups.Although associated with intense immediate chest pain, additional minocycline pleurodesis is a safe and convenient procedure that can reduce the rate of ipsilateral recurrence after thoracoscopic treatment for primary spontaneous pneumothorax.

  View details for DOI 10.1164/rccm.200509-1414OC

  View details for Web of Science ID 000235618900012

  View details for PubMedID 16357330

• Antimicrobial drug resistance in salmonella-infected aortic aneurysms ANNALS OF THORACIC SURGERY Hsu, R. B., Lin, F. Y., Chen, R. J., Hsueh, P. R., Wang, S. S. 2005; 80 (2): 530-536

  Abstract

  Salmonella infection of the aorta and adjacent arteries is rare, but life-threatening. There is an increasing number of infections caused by antimicrobial drug resistant Salmonella. This study sought to assess the association between antimicrobial drug resistance and clinical outcomes of patients with Salmonella-infected aortic aneurysm.Data were collected by retrospective chart review. Between October 1995 and October 2004, 34 patients with Salmonella-infected aortic aneurysm were included. Aneurysm-related deaths were defined as hospital deaths and late deaths due to prosthetic graft infection. Analysis was performed using the chi2 test, Fisher's exact test, and Mann-Whitney test.Nineteen patients had a suprarenal and 15 patients had an infrarenal aortic infection. The most common responsible pathogen was group C Salmonella (47%). Ciprofloxacin-resistant Salmonella infection occurred since March 2001 and the rate increased from 0 per 15 in the years before March 2001 to 5 per 19 in the years after March 2001 (p = 0.005 by Fisher's exact test). Among the 26 patients who had combined medical and surgical therapy, 4 died in the hospital and 4 died of late prosthetic graft infection 3 to 6 months after operation, whereas 4 of the 8 who had medical therapy alone died of aneurysm rupture during hospitalization. The actuarial survival rates by the Kaplan-Meier method were 64% at 6 months, 61% at 1 year, and 56% at 5 years. The risk factors for aneurysm-related death were old age (78.5 +/- 9.7 years vs 63.5 +/- 11.4 years; p < 0.001) and ciprofloxacin-resistant Salmonella infection (4 of 5 vs 8 of 29; p = 0.042).There was an increased mortality associated with ciprofloxacin resistance in infected aortic aneurysms with Salmonella. With an increasing incidence of ciprofloxacin resistant Salmonella, third generation cephalosporin is the antibiotic of choice for Salmonella-infected aneurysm.

  View details for DOI 10.1016/j.athoracsur.2005.02.046

  View details for Web of Science ID 000230923800024

  View details for PubMedID 16039199

• Renal dysfunction after heart transplantation: Incidence, prognosis and risk factors JOURNAL OF THE FORMOSAN MEDICAL ASSOCIATION Hsu, R. B., Chen, R. J., Lin, C. H., Chou, N. K., Ko, W. J., Wang, S. S., Chu, S. H. 2005; 104 (7): 482-486

  Abstract

  Despite more than 20 years of experience in heart transplantation, the risk factors for development of chronic renal insufficiency in recipients are not well established. This study assessed the incidence, prognosis and risk factors for renal dysfunction after heart transplantation.We conducted a retrospective analysis of all adult patients (n = 132) who survived for more than 1 year after heart transplantation at our institutions from March 1992 through November 2002. Renal dysfunction was defined as serum creatinine of > or = 2.0 mg/dL. The incidence and prognosis of renal dysfunction after heart transplantation was estimated by the Kaplan-Meier method and compared by log rank test. Risk factors for renal dysfunction at 1 year after transplantation were evaluated using a logistic regression model.Renal dysfunction was present in 9 patients (7%) before heart transplantation. The cumulative incidence of renal dysfunction after heart transplantation was 23.0 +/- 3.8%, 36.1 +/- 4.3%, 53.9 +/- 4.9%, and 57.3 +/- 5.8% at 6 months, 1 year, 5 years and 10 years, respectively, after transplantation. The actuarial survival rate in patients without renal dysfunction at 1 year after transplantation was better than for patients with renal dysfunction at 1 year after transplantation (p = 0.046 by log-rank test). Independent risk factors for renal dysfunction at 1 year after transplantation were age at transplantation (odds ratio, 1.07; p = 0.02), pretransplant serum blood urea nitrogen (odds ratio, 1.07; p = 0.048), and serum creatinine at 6 months after transplantation (odds ratio, 17.0; p < 0.001).There was a high incidence of renal dysfunction after heart transplantation. Patients with renal dysfunction had poor long-term prognosis. Serum creatinine at 6 months after transplantation was the most significant major risk factor, followed by age at transplantation and pretransplant blood urea nitrogen.

  View details for Web of Science ID 000232764200008

  View details for PubMedID 16091824

• Influence of ciprofloxacin resistance on risk factors for endovascular infection in patients with infection due to group c nontyphoid salmonellae CLINICAL INFECTIOUS DISEASES Hsu, R. B., Chen, R. J., Lin, F. Y., Chu, S. H. 2005; 40 (9): 1364-1367

  Abstract

  From January 2000 through September 2004, a total of 54 patients with infection due to group C nontyphoid salmonellae were evaluated; 8 patients had gastroenteritis alone, and 46 patients had bacteremia. Of the 46 patients who had bacteremia, 12 had endovascular infection and 34 did not. The number of infections due to ciprofloxacin-resistant Salmonella organisms is increasing. Ciprofloxacin-resistant Salmonella organisms predisposed patients to acquire bacteremia, but they did not seem to predispose patients to acquire endovascular infection.

  View details for DOI 10.1086/429325

  View details for Web of Science ID 000228145600024

  View details for PubMedID 15825041

• Nontyphoid Salmonella bacteremia in patients with liver cirrhosis AMERICAN JOURNAL OF THE MEDICAL SCIENCES Hsu, R. B., Chen, R. J., Chu, S. H. 2005; 329 (5): 234-237

  Abstract

  Bacteremia is reported to occur in 4% to 9% of hospitalized patients with liver cirrhosis. Escherichia coli and Klebsiella pneumoniae are the most commonly isolated organisms. Only sporadic cases of nontyphoid Salmonella bacteremia are reported in the literature. In this study, we sought to determine the clinical features and prognosis of patients with liver cirrhosis and bacteremia due to nontyphoid Salmonella.Data were collected by retrospective chart review.From December 1996 to May 2003, we identified 23 patients (18 males, 5 females) with a median age of 58 years. The Child classification for liver cirrhosis was A in 4, B in 9, and C in 10 patients. Solid organ cancers were present in 14 patients: hepatocellular carcinoma in 13 patients and gastric carcinoma in 1 patient. Hospital death occurred in 11 patients (48%): 7 died of sepsis and 4 of hepatic failure. Using a logistic regression model, the independent risk factors for death in patients with nontyphoid Salmonella bacteremia were young age and an advanced stage of liver cirrhosis.Most nontyphoid Salmonella bacteremia in patients with liver cirrhosis was community-acquired. An advanced stage of liver cirrhosis and hepatocellular carcinoma were common. The prognosis for young patients was unfavorable; this was seemingly due to hepatocellular carcinoma producing more unfavorable results in younger cirrhotic patients.

  View details for DOI 10.1097/00000441-200505000-00004

  View details for Web of Science ID 000229205200004

  View details for PubMedID 15894865

• Association of angiotensin-converting enzyme insertion/deletion polymorphism with serum level and development of pulmonary complications following esophagectomy ANNALS OF SURGERY Lee, J. M., Lo, A. C., Yang, S. Y., Tsau, H. S., Chen, R. J., Lee, Y. C. 2005; 241 (4): 659-665

  Abstract

  Pulmonary complications remain the major cause of postoperative mortality in patients with esophageal cancer undergoing esophagectomy. It was unclear whether this dismal complication has a genetic predisposition. We therefore investigated the role of an angiotensin-converting enzyme (ACE) insertion/deletion polymorphism in developing these complications.We conducted a prospective study including 152 patients with esophageal cancer who underwent esophagectomy in National Taiwan University Hospital between 1996 and 2002. The ACE genotype was determined by polymerase chain reaction amplification of leukocyte DNA obtained before surgery. The serum ACE concentration was determined by enzyme-linked immunosorbent assay.Thirty-five patients (23%) developed pulmonary complications following esophagectomy. As compared with patients with the I/I and I/D genotypes, those with the D/D genotype had a higher risk for pulmonary complications (adjusted odds ratio [OR], 3.12; 95% confidence interval [CI], 1.01-9.65). The risk was additively enhanced by combination of the ACE D/D genotype with other clinical risk factors (old age, hypoalbuminemia, and poor pulmonary function). The circulating ACE level was also dose-dependently with the presence of ACE D allele. As compared with the patients with circulating ACE less than 200 ng/mL, the patients with circulating ACE of 200 to 400 ng/mL and over 400 ng/mL had ORs (95% CI) of 2.75 (1.12-6.67) and 15.00 (4.3-52.34) to present with ACE D allele, respectively.An ACE insertion/deletion polymorphism might modulate the function of ACE gene and play a role in affecting individual susceptibility to pulmonary injury following esophagectomy in patients of esophageal cancer.

  View details for DOI 10.1097/01.sla.0000157132.08833.98

  View details for Web of Science ID 000227857800017

  View details for PubMedID 15798469

  View details for PubMedCentralID PMC1357071

• Low incidence of malignancy after transplantation in Chinese heart allograft recipients TRANSPLANT INTERNATIONAL Hsu, R. B., Chen, R. J., Chou, N. K., Ko, W. J., Wang, S. S., Chu, S. H. 2005; 18 (3): 283-288

  Abstract

  This study sought to assess the incidence of neoplastic disease after transplantation in Chinese heart allograft recipients. A total of 156 patients (130 male and 26 female; mean age, 45.8 +/- 15.7 years), surviving more than 30 days after transplantation, were enrolled in this study. The mean follow up duration was 51.2 +/- 33.0 months. Six patients (3.8%) developed neoplastic diseases after transplantation: post-transplant lymphoproliferative diseases in four and solid tumors in two patients. There was no skin cancer or Kaposi's sarcoma. Solid tumors affected the prostate, liver and urinary bladder in two patients. The cumulative incidence of neoplastic disease was 2.1% at 1 year, 3.6% at 5 years, and 10.1% at 10 years after transplantation. The incidence of post-transplant neoplastic disease was low in Chinese heart allograft recipients. It resulted from a relative paucity of Kaposi's sarcoma and skin cancers in Chinese population.

  View details for DOI 10.1111/j.1432-2277.2004.00029.x

  View details for Web of Science ID 000227714800003

  View details for PubMedID 15730487

• Outcome of medical and surgical treatment in patients with acute type B aortic dissection ANNALS OF THORACIC SURGERY Hsu, R. B., Ho, Y. L., Chen, R. J., Wang, S. S., Lin, F. Y., Chu, S. H. 2005; 79 (3): 790-795

  Abstract

  Optimal treatment of acute type B aortic dissection remain unclear. The aim of this study was to assess the clinical outcome of acute type B aortic dissection.In the last 8 years, 107 patients were admitted for acute type B aortic dissection. We medically treated patients at the time of onset with antihypertensives. Surgery was considered if there is intractable pain, uncontrolled hypertension, severe aortic branch malperfusion, or aneurysm expansion.Twenty-nine patients had pleural effusion (27%), 9 patients had leg ischemia (8%), 5 patients had impending rupture, and 2 patients had aneurysm enlargement exceeding 60 mm on repeated imaging studies. A total of 16 patients (15%) underwent surgical intervention: 8 extra-anatomical bypass for leg ischemia, 1 in situ infrarenal aortoiliac bypass for distal aortic obstruction, and 7 thoracic aortic graft replacement. Of the 8 patients with extra-anatomic bypass, 3 patients died: 2 patients died of catastrophic aortic rupture 2 and 9 days after bypass, and 1 patient died of dissection progression to type A lesion 9 days after bypass. There was no in-hospital death in 92 medically treated patients. Follow-up was 92% complete. The mean follow-up duration was 36.1 months (range, 2 to 96 months). The 6-month, 1-year, and 5-year survival rates of all patients were 96.2 +/- 1.9%, 95.2% +/- 2.1%, and 95.2% +/- 2.1%.Medical treatment of acute type B aortic dissection produced good outcomes. Central aortic procedures such as aortic fenestration and endovascular stenting should be the preferred methods to treat patients with acute type B aortic dissection and leg ischemia because there was high risk of central aortic complications after extra-anatomic bypass.

  View details for DOI 10.1016/j.athoracsur.2004.07.061

  View details for Web of Science ID 000227414400006

  View details for PubMedID 15734378

• Incidence of serum creatine kinase elevation and its relation to medications used after heart transplantation CLINICAL TRANSPLANTATION Hsu, R. B., Chen, R. J., Wang, S. S., Chu, S. H. 2005; 19 (1): 45-50

  Abstract

  Rhabdomyolysis after heart transplantation is well described as a drug-related phenomenon. The incidence of serum creatine kinase (CK) elevation after heart transplantation is not formally reported in previous clinical studies. This study sought to find the incidence of asymptomatic serum CK elevation after heart transplantation and assess its relation to medications that are commonly used after transplantation.Data were collected in outpatient basis between August 2002 and August 2003. Patients with acute rejection, infection or muscle pain were excluded. All patients were followed monthly at a special clinic. Physical examinations and routine blood tests including serum CK were performed monthly. We evaluated the results of 106 asymptomatic patients and 765 serial data to determine the incidence of serum CK elevation after transplantation. Logistic regression was used to identify its risk factors.The incidence of serum CK elevation in asymptomatic heart transplant recipients was 16.2%. Risk factors of its elevation were diabetes mellitus and use of medications including cyclosporine, drugs for hypertriglyceridemia, antihypertensives, and prednisolone. Among the antihypertensives commonly used, angiotensin converting enzyme inhibitors, angiotensin receptor blockers and calcium antagonists were associated with a higher incidence of serum CK elevation, but beta-blockers protected patients from serum CK elevation.The incidence of serum CK elevation in asymptomatic heart transplant recipients was not low. Serum CK measurements should be part of the routine follow-up in transplant recipients, especially when patients had diabetes mellitus. Medications commonly used after heart transplantation significantly affected the incidence of serum CK elevation.

  View details for DOI 10.1111/j.1399-0012.2004.00293.x

  View details for Web of Science ID 000226347700008

  View details for PubMedID 15659133

• Connective tissue growth factor inhibits metastasis and acts as an independent prognostic marker in colorectal cancer GASTROENTEROLOGY Lin, B. R., Chang, C. C., Che, T. F., Chen, S. T., Chen, R. J., Yang, C. Y., Jeng, Y. M., Liang, J. T., Lee, P. H., Chang, K. J., Chau, Y. P., Kuo, M. L. 2005; 128 (1): 9-23

  Abstract

  Connective tissue growth factor (CTGF) has been shown to be implicated in tumor development and progression. The aim of this study was to investigate the role of CTGF in progression of colorectal cancer (CRC).Immunohistochemical staining of specimens from 119 patients with CRC was performed. Liposome-mediated transfection was used to introduce a CTGF expression vector into CRC cell lines. Transfectants were tested in invasive ability and experimental hepatic metastasis in BALB/c mice. Furthermore, a FOPflash/TOPflash reporter assay was performed to investigate CTGF on the beta-catenin/T-cell factor signaling pathway.Patients with stage II and stage III CRC whose tumors displayed high CTGF expression had a significantly higher overall survival and a disease-free advantage over patients with CRC with low CTGF expression. Alterations in the CTGF level in CRC cell lines modulated their invasive ability with an inverse correlation. In addition, a reduction in the CTGF level of CT26 cells after stable transfection with antisense CTGF resulted in increased liver metastasis in BALB/c mice. The activity of the beta-catenin/T-cell factor signaling pathway and its downstream effector gene matrix metalloproteinase 7 in these CTGF-transfected cells was strongly attenuated. Blockage of matrix metalloproteinase 7 with its neutralizing antibodies inhibited increased invasiveness in antisense CTGF-transfected CT26 cells.Our results implicate CTGF as a key regulator of CRC invasion and metastasis, and it appears to be a useful and better prognosis factor for patients with stage II and stage III CRC.

  View details for DOI 10.1053/j.gastro.2004.10.007

  View details for Web of Science ID 000226225400005

  View details for PubMedID 15633118

• Risk factors for recurrent bacteremia in adult patients with nontyphoid salmonellosis AMERICAN JOURNAL OF THE MEDICAL SCIENCES Hsu, R. B., Chen, R. J., Chu, S. H. 2004; 328 (6): 315-318

  Abstract

  This study sought to find the risk factors for recurrent bacteremia in adult patients with nontyphoid salmonellosis.Retrospective chart review.Between September 1984 and December 2003, 235 adult (age > or = 18 years old) patients with bacteremia with nontyphoid salmonellosis were admitted to our hospital. Among them, 130 patients (55%) had immunodeficiency, 31 patients (13%) had systemic lupus erythematosus, 26 patients (11%) had hematologic malignancies, 50 patients (21%) had solid organ cancers, and 39 patients (17%) had endovascular infections. Thirty-seven patients had recurrent bacteremia during the study period. Both univariate and multivariate analysis showed that immunodeficiency was the only predictor of recurrent bacteremia (odds ratio, 2.79; P = 0.013). The overall hospital mortality rate was 26%: 8% for patients with recurrent bacteremia and 29% for patients without recurrence. The independent risk factors of hospital death were old age, not recurrent infection, and solid organ cancers.Old age, systemic lupus erythematosus, malignancies, and immunodeficiency were common in adult patients with nontyphoid Salmonella bacteremia. The incidence of recurrent bacteremia was 16%. Immunodeficiency predisposed patients to recurrent bacteremia. Recurrent bacteremia was associated with a lower hospital mortality rate, however.

  View details for DOI 10.1016/S0002-9629(15)33940-9

  View details for Web of Science ID 000225808600002

  View details for PubMedID 15599326

• Risk factor screening scale to optimize treatment for potential heart transplant candidates under extracorporeal membrane oxygenation AMERICAN JOURNAL OF TRANSPLANTATION Chen, Y. S., Ko, W. J., Chi, N. H., Wu, I. H., Huang, S. C., Chen, R. J., Chou, N. K., Hsu, R. B., Lin, F. Y., Wang, S. S., Chu, S. H., Yu, H. Y. 2004; 4 (11): 1818-1825

  Abstract

  We developed a risk factor-scaling score (RFSS) to select which patients supported by extracorporeal membrane oxygenation (ECMO) were suitable for ventricular assist device (VAD) implantation or heart transplantation (HTx). A total of 78 patients supported with ECMO for more than 48 h due to cardiac origin were included in this study. Patients were categorized into two groups based on the outcomes: the poor outcome group (n = 33) consisted of for those who later died or were later excluded from VAD or HTx; the favorable outcome group (n = 45) consisted of those who were weaned off ECMO finally and survived or were deemed suitable candidates for VAD or HTx. Seven risk factors were significant according to univariate analyses. Based on the regression coefficients of multivariate analysis, the RFSS was developed: (lung dysfunction x 7) + (systemic infection x 3) + (peak lactate > 3 mmole/L x 3) + (kidney dysfunction x 2) + (creatine kinase > 10,000 U/L x 1). Patients with an RFSS of 7 or more were be allocated to the poor outcome group. The RFSS was validated by another group of 30 patients with good correlation. The RFSS provides a way to predict which ECMO-supported patients are suitable candidates for VAD implantation or HTx.

  View details for DOI 10.1111/j.1600-6143.2004.00578.x

  View details for Web of Science ID 000224435000018

  View details for PubMedID 15476482

• Cyclosporine C-2 monitoring is superior to C-0 in predicting acute cellular rejection in heart transplant recipients in Taiwan Chou, N. K., Chen, R. J., Ko, W. J., Lin, H. L., Yu, S. Y., Chen, Y. S., Hsu, R. B., Lee, C. M., Lin, F. Y., Wang, S. S. ELSEVIER SCIENCE INC. 2004: 2393-2395

  Abstract

  The cyclosporine (CsA) blood concentration at 2 hours postdose (C2) has been shown to be better than trough level (C0) to predict acute cellular rejection (ACR) in solid organ transplantations. We tried to assess the superiority of C2 monitoring to C0 in heart transplantation (HTx). Prospective data were collected from the HTx recipients from November 1991 to April 2003. The 100 patients surviving longer than 3 months after HTx, provided 237 sample sets, with ACR graded by endomyocardial biopsy (EMB) and concurrent C0 and C2 levels. ACR was defined as International Society of Heart and Lung Transplantation (ISHLT) grade lb or higher. Nonparametric methods, logistic regression model, and receiver operating characteristic (ROC) analysis were used. There was no significant demographic heterogeneity between ACR and non-ACR groups. C2 was significantly lower in ACR than non-ACR groups (P = .0192) whereas C0 showed no significant difference. In the logistic regression model, C2 was a significant predictor against ACR (P = .026, odds ratio = 0.76 per 100 ng/mL), but C0 was not. ROC analysis showed that C2 of 600 ng/mL might provide the optimal cut-off point, with a sensitivity of 51.23% and a specificity of 71.43%, but C0 did not show this association. In conclusion, C2 monitoring is superior to C0 for predicting ACR in HTx. ACR should be suspected when the C2 value is below 600 ng/mL.

  View details for DOI 10.1016/j.transproceed.2004.08.115

  View details for Web of Science ID 000225476300066

  View details for PubMedID 15561260

• Infected aortic aneurysms: Clinical outcome and risk factor analysis JOURNAL OF VASCULAR SURGERY Hsu, R. B., Chen, R. J., Wang, S. S., Chu, S. H. 2004; 40 (1): 30-35

  Abstract

  Infected aortic aneurysms are difficult to treat, and are associated with significant mortality. Hospital survival is poor in patients with severe aortic infection, Salmonella species infection, Staphylococcus aureus infection, aneurysm rupture, and suprarenal aneurysm location. We reviewed the clinical outcome in 46 patients with primary infected aortic aneurysms and identified clinical variables associated with prognosis.Data were collected by means of retrospective chart review. Univariate and multivariate logistic regression models were used for risk factor analysis.Between August 1995 and March 2003, 48 patients with primary infected aortic aneurysms were treated at our hospitals. Two patients with negative culture results were excluded. Of the remaining 46 patients, 35 patients had aortic aneurysms infected with Salmonella species and 11 patients had aortic aneurysms infected with microorganisms other than Salmonella species. There were 20 suprarenal infections and 26 infrarenal infections. Surgical debridement and in situ graft replacement were performed in 35 patients, with an early mortality rate of 11%. The incidence of late prosthetic graft infection was 10%. The 90-day mortality rate in patients operated on was 0% for elective operation and 36% for nonelective operation (P =.006, Fisher exact test). Independent predictors of aneurysm-related death were advanced age, non-Salmonella infection, and no operation.With timely surgical intervention and prolonged antibiotic treatment, in situ graft replacement provides an excellent outcome in patients with primary infected aortic aneurysms and elective operation. Mortality is still high in patients undergoing urgent operation. Advanced age, non-Salmonella infection, and no operation are major determinants of mortality.

  View details for DOI 10.1016/j.jvs.2004.03.020

  View details for Web of Science ID 000222522300007

  View details for PubMedID 15218459

• Infective endocarditis in patients with liver cirrhosis JOURNAL OF THE FORMOSAN MEDICAL ASSOCIATION Hsu, R. B., Chen, R. J., Chu, S. H. 2004; 103 (5): 355-358

  Abstract

  Infective endocarditis complicating liver cirrhosis is infrequently reported. This study evaluated the clinical features of infective endocarditis in Taiwanese patients with liver cirrhosis.All cases of infective endocarditis occurring in patients with liver cirrhosis from December 1995 to December 2002 were included in this study. Data were collected by retrospective chart review.Twenty six patients (18 males, 8 females) with median age 6 years (range, 43 to 87) were included. The etiology of liver cirrhosis was hepatitis virus infection in 20 patients. There were 7 nosocomial infections. Bacterial pathogens were identified in 25 patients, with Staphylococcus aureus (n = 8), viridans streptococci (n = 4), Streptococcus sanguis (n = 2), Pseudomonas aeruginosa (n = 2), and Enterococcus faecalis (n = 2) the most common isolates. The hospital mortality rate was 27%. Patients with in-hospital death were more likely to have a history of uremia, staphylococcal infection, nosocomial infection and less likely to have aortic valve infection.The prognosis of patients with infective endocarditis and liver cirrhosis was poor. Infection with Staphylococcus species was a dominant cause and methicillin resistance was common.

  View details for Web of Science ID 000223701800005

  View details for PubMedID 15216401

• Effects of additional minocycline pleurodesis after thoracoscopic procedures for primary spontaneous pneumothorax CHEST Chen, J. S., Hsu, H. H., Kuo, S. W., Tsai, P. R., Chen, R. J., Lee, J. M., Lee, Y. C. 2004; 125 (1): 50-55

  Abstract

  To evaluate the safety and efficacy of additional minocycline pleurodesis after thoracoscopic treatment of primary spontaneous pneumothorax.Retrospective comparative study with a historical control.Thoracic surgical division of a university-affiliated tertiary medical center.Between April 1994 and April 2001, 313 consecutive patients (minocycline group) with primary spontaneous pneumothorax were treated by video-assisted thoracoscopic surgery. The procedures included resection of the blebs and mechanical pleurodesis by scrubbing the parietal pleura. After operation, minocycline hydrochloride, 7 mg/kg, was instilled into the pleural space through a thoracostomy tube. The control group consisted of 51 consecutive patients who underwent the same thoracoscopic procedures alone for primary spontaneous pneumothorax between January 1992 and April 1994.There was no significant difference between the two groups in terms of demographic data, operative findings, and operation time. Chest pain was a common complaint after minocycline pleurodesis, but the total doses of requested analgesics were comparable in both groups. The rate of prolonged air leaks was significantly lower in the minocycline group (7.0% vs 17.6%, p = 0.025). Patients treated with minocycline had shorter periods of postoperative chest drainage and hospitalization. The ipsilateral recurrence rate was also significantly lower in these patients (2.9% vs 9.8%, p = 0.033).Minocycline pleurodesis is a safe and convenient procedure that may improve the outcome and reduce the rate of recurrence after thoracoscopic treatment for primary spontaneous pneumothorax. A randomized control study may be needed to confirm the findings.

  View details for DOI 10.1378/chest.125.1.50

  View details for Web of Science ID 000188217700013

  View details for PubMedID 14718420

• Hand-assisted laparoscopic hepatectomy for solid tumor in the posterior portion of the right lobe - Initial experience ANNALS OF SURGERY Huang, M. T., Lee, W. J., Wang, W., Wei, P. L., Chen, R. J. 2003; 238 (5): 674-679

  Abstract

  To prove the feasibility of hand-assisted laparoscopic liver resection for tumors located in the posterior portion of the right hepatic lobe.Use of laparoscopic liver resection remains limited due to problems with technique, especially when the tumor is located near the diaphragm, or in the posterior portion of the right lobe.Between October 2001 and June 2002, a total of 7 patients with solid hepatic tumors involving the posterior portion of the right lobe of liver underwent hand-assisted laparoscopic hepatectomy with the HandPort system at our hospital. Surgical techniques used included CO2 pneumoperitoneum and the creation of a wound on the right upper quadrant of the abdomen for HandPort placement. The location of tumor and its transection margin were decided by laparoscopic ultrasound. The liver resection was performed using the Ultrashear without portal triad control, with the specimens obtained then placed in a bag and removed directly via the HandPort access.The 5 male and 2 female patients ranged in age from 41 to 76 years (mean 62.3 +/- 14.4). Surgical procedures included partial hepatectomy for 6 patients and segmentectomy for one, all successfully completed using a variant of the minimally invasive laparoscopic procedure without conversion to open surgery. The mean duration of the operation was 140.7 +/- 42.2 minutes (90-180). The blood loss during surgery was 257.1 +/- 159 mL (250-500), without any requirement for intraoperative or postoperative transfusion. Pathology revealed hemagioma (n = 2), colon cancer metastasis (n = 2), and hepatocellular carcinoma (n = 3). There were no deaths postoperatively, with 1 patient suffering bile leakage. Mean hospital stay was 5.3 +/- 1.3 days postsurgery.The results of this study suggest that laparoscopic liver resection using the HandPort system is feasible for selected patients with lesions in the posterior portion of the right hepatic lobe requiring limited resection. Individuals with small tumors may benefit; because a large abdominal incision is not required, the wound-related complication rate might be reduced.

  View details for DOI 10.1097/01.sla.0000094301.21038.8d

  View details for Web of Science ID 000186308300006

  View details for PubMedID 14578728

  View details for PubMedCentralID PMC1356144

• Minilaparoscopic and laparoscopic cholecystectomy - A comparative study ARCHIVES OF SURGERY Huang, M. T., Wang, W., Wei, P. L., Chen, R. J., Lee, W. J. 2003; 138 (9): 1017-1023

  Abstract

  To evaluate the feasibility and safety of the minilaparoscopic cholecystectomy (MLC) and to compare the clinical benefits experienced by patients who undergo MLC with those who undergo laparoscopic cholecystectomy (LC) or 5-mm laparoscopic cholecystectomy (5-mm LC).Prospective consecutive study.A tertiary referral center.From September 1, 2000, through June 30, 2001, 90 patients with symptomatic gallstones were randomized to undergo 1 of these 3 procedures.Minilaparoscopic cholecystectomy, LC, and 5-mm LC.Duration of surgery, loss of blood, length of hospital stay, resumption of solid food intake, quantity of analgesic dosage administered, development of complications, degree of pain at ports 24 and 48 hours after surgery, and overall cosmetic result.Subsequent to excluding 6 patients who were converted to LC, there were 30 patients in the LC group, 29 patients in the 5-mm LC group, and 25 patients in the MLC group. The MLC necessitated a longer time to complete the procedure than was the case for the other 2 procedures. There was no notable difference in the mean dosage of the meperidine hydrochloride (Pethidine) administered between the LC and MLC groups, but an apparent increase in the analgesia requirements for the 5-mm LC group was noted when compared with those of the other 2 groups. There was no remarkable difference in terms of blood loss, resumption of solid food intake, hospital stay subsequent to surgery, or surgical-related complication between these 3 groups. The MLC group did have a lower pain score in the subxyphoid port only at 24 hours after surgery compared with the other 2 groups. The cosmetic results were evaluated and no notable difference was noted at 1 week, 1 month, and 6 months after surgery.Although this study has demonstrated the feasibility and safety of the MLC, it does require a longer surgical time and reflects a reasonably high possibility for the conversion to LC. Furthermore, the MLC did not provide any notable clinical benefit for the tested patients compared with those patients in the LC group. We concluded that there is no reason for the MLC to become the universally accepted mode of treatment for symptomatic gallstones before further improvements are made in the technique and instrumentation.

  View details for DOI 10.1001/archsurg.138.9.1017

  View details for Web of Science ID 000185323400020

  View details for PubMedID 12963662

• Soluble inflammatory markers in coronary sinus and peripheral blood of heart transplant recipients CLINICAL TRANSPLANTATION Hsu, R. B., Tsay, Y. G., Lee, C. M., Chen, R. J., Wang, S. S., Chu, S. H. 2003; 17 (4): 331-337

  Abstract

  Cardiac allograft rejection is a focal inflammation and soluble markers are released into coronary sinus (CS). We investigated whether plasma-soluble markers in CS is better to predict the clinical status of transplant recipients than in peripheral blood (PB). Between February 1998 and January 2001, 51 patients admitted for endomyocardial biopsy were included. The clinical events of the transplant recipient were recorded as: early post-transplant, long-term uneventful status, infection, acute rejection and transplant coronary artery disease. The plasma levels of interleukin-2 (IL-2), tumor necrosis factor-alpha (TNF-alpha), ICAM-1, P-selectin, high-sensitive C-reactive protein (CRP) and troponin-I of CS and PB were determined. There were 71 blood samples. In patients within 1 month after heart transplant, there was a higher level of P-selectin, ICAM-1, CRP and troponin-I in CS and PB. In patients with infection, there was a higher level of all soluble markers except IL-2 in CS and PB. Patients with a long-term uneventful status had a lower level of CRP in PB but not in CS. Patients with acute rejection had a higher level of IL-2 in PB but not in CS. Patients with transplant coronary artery disease had a higher level of TNF-alpha in PB but not in CS. Soluble markers in CS failed to predict the occurrence of acute or chronic rejections.

  View details for DOI 10.1034/j.1399-0012.2003.00045.x

  View details for Web of Science ID 000184267600004

  View details for PubMedID 12868989

• Risk factors for primary bacteremia and endovascular infection in patients without acquired immunodeficiency syndrome who have nontyphoid salmonellosis CLINICAL INFECTIOUS DISEASES Hsu, R. B., Tsay, Y. G., Chen, R. J., Chu, S. H. 2003; 36 (7): 829-834

  Abstract

  This study sought to find the risk factors for primary bacteremia, endovascular infection, and in-hospital death for patients without acquired immunodeficiency syndrome who have nontyphoid salmonellosis. From September 1995 through September 2001, 301 patients with nontyphoid salmonellosis were admitted to our hospital; of these patients, 121 had primary bacteremia, and 28 had endovascular infection. Of the 121 patients with primary bacteremia, 64 were aged >50 years, and 26 had endovascular infection. Overall, 90 patients (29.9%) had immunodeficiency. Predictors of primary bacteremia were age; presence of systemic lupus erythematosus; group B, group C, or group D Salmonella infection; and immunodeficiency. The positive predictor of endovascular infection in adult patients with primary bacteremia was group C Salmonella infection, and negative predictors were immunodeficiency and solid-organ cancer. The overall in-hospital mortality rate was 12%; for primary bacteremia, it was 24.8%; for endovascular infection, it was 14.3%. Predictors of in-hospital death were age, extraintestinal infection, and solid-organ malignancy.

  View details for DOI 10.1086/367932

  View details for Web of Science ID 000181761700001

  View details for PubMedID 12652381

• Needlescopic versus conventional video-assisted thoracic surgery for primary spontaneous pneumothorax: A comparative study ANNALS OF THORACIC SURGERY Chen, J. S., Hsu, H. H., Kuo, S. W., Tsai, P. R., Chen, R. J., Lee, J. M., Lee, Y. C. 2003; 75 (4): 1080-1085

  Abstract

  Management of primary spontaneous pneumothorax by needlescopic video-assisted thoracic surgery (VATS) has rarely been attempted and no comparison study with conventional VATS is available. In this study, we compared the clinical outcomes of needlescopic VATS with conventional VATS in treating primary spontaneous pneumothorax. The technique and our experience with needlescopic VATS are reported.Between April 2001 and April 2002, a total of 63 patients with recurrent, persistent, or contralateral primary spontaneous pneumothorax were recruited for this study. Operative procedures included needlescopic VATS in 28 patients and conventional VATS in 35 patients. We used a modified operative technique to improve the poor and narrower vision of the needle-videothoracoscope.There was no mortality or major complications in either of the two groups. Needlescopic and conventional VATS groups had comparable operation times, postoperative pain, requested doses of meperidine hydrochloride, durations of postoperative chest drainage, and length of hospital stay. After a mean follow-up of 8 months, the needlescopic VATS group had less residual neuralgia (p = 0.021) and better wound satisfaction (p = 0.043) than the conventional VATS group. Ipsilateral recurrence of pneumothorax occurred in 1 patient (3.6%) in the needlescopic VATS group but not in any patients in the conventional VATS group.Our experience showed that needlescopic VATS is technically feasible and can be a satisfactory alternative to conventional VATS in treating primary spontaneous pneumothorax. Limited vision of needlescopic VATS can be improved by the modified technique we used. However, conversion to conventional VATS or minithoracotomy is suggested in selected patients to prevent early recurrence.

  View details for DOI 10.1016/S0003-4975(02)04649-0

  View details for Web of Science ID 000181946800003

  View details for PubMedID 12683541

• Attenuation of human-to-pig xenogenic cellular proliferation and Th1 response by expressing the human MHC II DQ exogenes on porcine cells Lee, J. M., Tu, C. F., Huang, S. C., Tsuji, K., Chen, R. J., Hu, C. Y., Hsieh, R. P., Tai, H. C., Weng, C. N., Lee, Y. C., Lee, C. J. ELSEVIER SCIENCE INC. 2003: 527-528

  View details for DOI 10.1016/S0041-1345(02)03858-7

  View details for Web of Science ID 000181017200233

  View details for PubMedID 12591516

• Non-transplant cardiac surgery for end-stage dilated cardiomyopathy in small children JOURNAL OF HEART AND LUNG TRANSPLANTATION Hsu, R. B., Chen, R. J., Wu, M. H., Wang, J. K., Wang, S. S., Chu, S. H. 2003; 22 (1): 94-97

  Abstract

  Between October 1997 and December 2000, a total of 7 pediatric patients with end-stage dilated cardiomyopathy (DCM) were referred to our service for heart transplantation; non-transplant cardiac surgery was offered as a biologic bridge. Two patients died before surgery and the in-hospital surgical mortality rate was 50%: 75% in 4 patients who received emergency surgery and 0% in 2 patients who received urgent surgery. Non-transplant cardiac surgery improved clinical outcome and acted as a biologic bridge, instead of a mechanical bridge, to heart transplantation in small children with DCM and severe heart failure.

  View details for DOI 10.1016/S1053-2498(02)00486-2

  View details for Web of Science ID 000180625500012

  View details for PubMedID 12531419

• Determinants of successful surgical revascularization for failed angioplasty in patients with acute myocardial infarction and cardiogenic shock JOURNAL OF THE FORMOSAN MEDICAL ASSOCIATION Hsu, R. B., Chen, R. J., Wang, S. S., Chu, S. H. 2002; 101 (12): 815-819

  Abstract

  Previous studies have reported encouraging results with percutaneous transluminal coronary angioplasty (PTCA) in patients with acute myocardial infarction (AMI) and cardiogenic shock (CS). However, PTCA fails in many patients and the mortality rate associated with the procedure is very high. This study sought to assess the determinants of successful coronary artery bypass grafting (CABG) in patients with AMI, CS and failed PTCA.From April 1997 to May 2001, 33 patients with a mean age of 62.9 +/- 10.5 years underwent CABG for AMI, CS and failed PTCA. PTCA failed or was not attempted because of primary failure in 13 patients, reocclusion in three, no-reflow in one, and multivessel disease in 18. Patients were initially stabilized with inotropic infusion and mechanical circulatory support. Before June 2000, patients underwent conventional CABG, while after June 2000, patients underwent beating heart CABG. Risk factor analysis was performed using retrospective chart review.The overall in-hospital mortality rate was 30.3%-33.3% in 24 patients who underwent conventional CABG and 22.2% in nine patients who underwent beating heart CABG. Risk factors for death were unstable hemodynamics (p < 0.001), non-right coronary artery as the infarct-related artery (IRA) (p = 0.012), high inotropic dose (p = 0.013), intubation (p = 0.021), cardiopulmonary resuscitation (p = 0.021), and early bypass (p = 0.050).CABG was associated with a high in-hospital mortality rate in patients with AMI, CS and failed PTCA. Patients with unstable hemodynamics and high inotropic dose before surgery had the worst survival rate.

  View details for Web of Science ID 000182333300001

  View details for PubMedID 12632813

• Non-heart-beating donors under extracorporeal membrane oxygenation support Ko, W. J., Chen, Y. S., Chen, R. J., Lai, M. K., Lee, P. H. ELSEVIER SCIENCE INC. 2002: 2600-2601

  View details for DOI 10.1016/S0041-1345(02)03440-1

  View details for Web of Science ID 000179162200036

  View details for PubMedID 12431539

• Needlescopic appendectomy as a routine procedure: "Just because you can?" or "Just because you cannot?" SURGICAL LAPAROSCOPY ENDOSCOPY & PERCUTANEOUS TECHNIQUES Ng, W. T., Kong, C. K., Tse, S., Hui, S. K., Sze, Y. S. 2002; 12 (4): 301-302

  View details for DOI 10.1097/01.SLE.0000025460.43026.E7

  View details for Web of Science ID 000177673700022

  View details for PubMedID 12193832

• Needlescopic, laparoscopic, and open appendectomy: A comparative study (vol 11, pg 306, 2001) SURGICAL LAPAROSCOPY ENDOSCOPY & PERCUTANEOUS TECHNIQUES Huang, M. T., Wei, P. L., Wu, C. C., Lai, I. R., Chen, R. J., Lee, W. J. 2002; 12 (4): CP3

  View details for Web of Science ID 000177673700001

• Needlescopic appendectomy as a routine procedure: "Just because you can?" or "Just because you cannot?" - Reply SURGICAL LAPAROSCOPY ENDOSCOPY & PERCUTANEOUS TECHNIQUES Huang, M. T., Wei, P. L., Wu, C. C., Lee, W. J., Lai, I. R., Chen, R. J. 2002; 12 (4): 302-304

  View details for Web of Science ID 000177673700023

• Successful rescue of sustained ventricular tachycardia/ventricular fibrillation after coronary artery bypass grafting by extracorporeal membrane oxygenation JOURNAL OF THE FORMOSAN MEDICAL ASSOCIATION Chen, R. J., Ko, W. J., Lin, F. Y. 2002; 101 (4): 283-286

  Abstract

  Extracorporeal membrane oxygenation (ECMO) can be set up quickly at the bedside and provides reliable temporary mechanical circulatory support for severe heart failure. We report the case of a 56-year-old female with circulatory collapse due to sustained ventricular tachycardia and ventricular fibrillation (VT/Vf) after coronary artery bypass grafting (CABG) who was successfully resuscitated using ECMO. The sustained VT/Vf might have been secondary to myocardial stunning, ischemia, infarction, or reperfusion. There were 40 cardioversions within the first 5 postoperative days. The patient improved after 8 days of ECMO in addition to use of an intraaortic balloon pump and administration of inotropic agents for profound heart failure. Left ventricular ejection fraction improved from 28% preoperatively to 54.5% on the 20th postoperative day. Cardiogenic shock due to sustained VT/Vf after CABG may be an indication for ECMO support. Immediate establishment of circulatory support using ECMO provides valuable time for spontaneous and interventional correction of reversible causes of sustained VT/Vf.

  View details for Web of Science ID 000176550800007

  View details for PubMedID 12101865

• Extracorporeal membrane oxygenation support for adult postcardiotomy cardiogenic shock ANNALS OF THORACIC SURGERY Ko, W. J., Lin, C. Y., Chen, R. J., Wang, S. S., Lin, F. Y., Chen, Y. S. 2002; 73 (2): 538-545

  Abstract

  Postcardiotomy cardiogenic shock occasionally develops in patients who have undergone cardiac procedures. We report our experience using extracorporeal membrane oxygenation (ECMO) in adult patients with postcardiotomy cardiogenic shock, and analyze the factors that affected outcomes for these ECMO patients.We retrospectively reviewed the medical records of ECMO patients.From August 1994 to May 2000, 76 adult patients (48 men, 28 women; mean age, 56.8+/-15.9 years) received ECMO support for postcardiotomy cardiogenic shock at the National Taiwan University Hospital. The mean ECMO blood flow was 2.53+/-0.84 L/min. The cardiac operations included coronary artery bypass grafting (n = 37), coronary artery bypass grafting and valvular operation (n = 6), valvular operation alone (n = 14), heart transplantation (n = 12), correction of congenital heart defects (n = 3), implantation of a left ventricular assist device (n = 2), and aortic operations (n = 2). Fifty-four patients received ECMO support after intraaortic balloon pumping, but 22 patients directly received ECMO support. Two patients were bridged to heart transplantation and two bridged to ventricular assist devices. Thirty patients died on ECMO support. The causes of mortality included brain death (n = 3), refractory arrhythmia (n = 2), near motionless heart (n = 2), acute graft rejection (n = 1), primary graft failure (n = 1), uncontrolled bleeding (n = 5), and multiple organ failure (n = 16). Twenty-two patients were weaned off ECMO support but presented intrahospital mortality. The cause of mortality included brain death (n = 1), sudden death (n = 4), and multiple organ failure (n = 17). Twenty patients were weaned off ECMO support and survived to hospital discharge. During the follow-up of 33+/-22 months, all were in New York Heart Association functional status I or II except two cases of late deaths. Among the ECMO-weaned patients, "dialysis for acute renal failure" was a significant factor in reducing the chance of survival.The ECMO provided a satisfactory partial cardiopulmonary support to patients with postcardiotomy cardiogenic shock, and allowed time for clinicians to assess the patients and make appropriate decisions.

  View details for DOI 10.1016/S0003-4975(01)03330-6

  View details for Web of Science ID 000173624500039

  View details for PubMedID 11845871

• Reduction of human-to-pig cellular response by alteration of porcine MHC with human HLA DPW0401 exogenes TRANSPLANTATION Lee, J. M., Tu, C. F., Yang, P. W., Lee, K. H., Tsuji, K., Tsai, M. K., Chen, R. J., Hu, C. Y., Hsieh, R. P., Tai, H. C., Chiang, B. L., Weng, C. N., Lee, Y. C., Lee, C. J. 2002; 73 (2): 193-197

  Abstract

  In pig-to-human discordant xenotransplantation, the xenograft can be rejected by a formidable human xenogenic T-cell response, even if the graft has gone through hyperacute rejection or delayed xenograft rejection (acute vascular rejection). We therefore examined, in this study, whether the human-to-pig cellular response could be attenuated through the generation of a transgenic pig for human HLA II.With the technique of microinjection, we produced the HLA DPw0401 transgenic pig. The expression of the HLA DPw0401 gene on peripheral blood mononuclear cells (PBMCs) of the transgenic pig was examined by reverse transcriptase-polymerase chain reaction and flow cytometry. The antigenicity of the transgenic HLA DPw0401 molecule was tested by the HLA DPw0401-primed lymphocyte test reagent. The cellular response was analyzed by xenogenic mixed lymphocyte culture.The mRNA and protein of HLA DPw0401 were expressed in the PBMCs of the transgenic pig. The PBMCs of the HLA transgenic pig induced a stronger cellular reaction to HLA DPw0401-primed lymphocyte test reagents than the nontransgenic littermate pig (n=7, P<0.01). In direct xenogenic mixed lymphocyte culture with responders from HLA DPw0401(+) humans, the PBMCs from the HLA DPw0401 transgenic pig, as compared with those from the normal pig, induced a lower degree of xenogenic cellular response to human PBMCs (n=4, P=0.08).Our preliminary data demonstrated the possibility that the human HLA DPw0401 phenotype can be transferred onto porcine cells through the generation of HLA transgenic pigs and make the PBMCs of humans more tolerant to porcine cells.

  View details for DOI 10.1097/00007890-200201270-00007

  View details for Web of Science ID 000173740800007

  View details for PubMedID 11821729

• Needlescopic, laparoscopic, and open appendectomy: A comparative study SURGICAL LAPAROSCOPY ENDOSCOPY & PERCUTANEOUS TECHNIQUES Huang, M. T., Wei, P. L., Wu, C. C., Lai, I. R., Chen, R. J., Lee, W. J. 2001; 11 (5): 306-312

  Abstract

  The benefits of laparoscopic appendectomy appear to be controversial. Since 1994, several abdominal procedures have been completed by using the needlescopic technique, but there appear to be no prospective studies to demonstrate the perceived benefits of needlescopic appendectomy. The authors compared open, laparoscopic, and needlescopic appendectomy in a randomized fashion with regard to duration of surgery, length of hospitalization, analgesic dosage, and surgery-associated complications. From March to July 1998, 75 patients admitted at the emergency station of the authors' hospital with a final diagnosis of acute appendicitis without tumor formation were randomized to receive one of the three treatment categories: open (OA), laparoscopic (LA), and needlescopic (nLA) appendectomy. Laparoscopic and needlescopic appendectomy were performed by using a three-port technique, although the size of the trocar used varied. There were 26 patients in the OA group, 23 in the LA group, and 26 in the nLA group. The mean operation durations for the OA, LA, and nLA groups were 55.4 +/- 28.0 minutes, 69.1 +/- 48.8 minutes, and 62.3 +/- 26.3 minutes, respectively, and these were not significantly different from one another. The mean number of the analgesic doses (Pethidine 1 mg/kg) required was 1.3 +/- 1.2 mg/kg, 0.5 +/- 0.8 mg/kg, and 0.2 +/- 0.6 mg/kg, respectively. Significant differences were noted when comparing the OA with the LA or nLA groups (OA vs. LA, P = 0.02; OA vs. nLA, P = 0.0002; LA vs. nLA, P = 0.06). The mean oral intake durations were 32.2 +/- 16.9 hours, 21.0 +/- 14.6 hours, and 20.8 +/- 16.4 hours, respectively, after surgery for the OA, LA, and nLA groups, and the between-group differences were statistically significant for the OA versus LA group ( P = 0.004) and for the OA versus nLA group ( P = 0.003). The mean durations of hospitalization for the OA, LA, and nLA groups were 3.6 +/-1.8 days, 2.8 +/- 1.4 days, and 2.4 +/- 0.9 days, and difference was detected between the OA and the nLA groups ( P = 0.02). The OA group rendered a greater wound-complication rate and ileus than did the other two groups, but the differences were not detected between the three categories ( P = 0.065, 0.6935). The result of the current study confirmed that the nLA procedure is a feasible and safe one. The nLA procedure provided substantial advantages over the OA procedure in the contexts of diminished postoperative pain and shorter hospital stay without significant increases in postoperative complication rate or surgical time.

  View details for DOI 10.1097/00019509-200110000-00004

  View details for Web of Science ID 000171741600003

  View details for PubMedID 11668227