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To compare the outcomes of patients requiring extracorporeal membrane oxygenation (ECMO) support who had a restrictive transfusion strategy with those who had a liberal strategy.We retrospectively reviewed all adult patients from 2010 to 2019 who received a minimum of one packed red blood cell (pRBC) during ECMO. Hemoglobin values before each transfusion were retrieved. Restrictive transfusion strategy was defined as a transfusion threshold ≤8.5 g/dl in all transfusion episodes for a single patient, while liberal transfusion strategy was defined as a transfusion threshold8.5 g/dl in any transfusion episode.The analysis included 763 patients, with 138 (18.1%) patients in the restrictive and 625 (81.9%) in the liberal transfusion strategy group. The median hemoglobin level, taking into account all measured hemoglobin values, during ECMO support was 8.3 and 9.9 g/dl, and the average units of pRBC received per day were 0.7 (0.3-1.8) and 1.2 (0.6-2.3), respectively. There were no significant differences in intensive care unit (ICU) mortality (adjusted odds ratio (OR), 0.86; 95% CI 0.56-1.30; p = .47), hospital mortality (adjusted OR, 0.79; 95% CI 0.52-1.21; p = .28), and 90-day mortality (adjusted OR, 0.84; 95% CI 0.55-1.28; p = .42) between the two groups. Among subgroup analyses, a restrictive transfusion strategy was associated with decreased risk of ICU mortality in patients on veno-venous ECMO (adjusted OR, 0.36; 95% CI 0.17-0.73; p = .005). There was no heterogeneity on outcomes across patients stratified by age, APACHE IV score, or need for large volume transfusion.Our data suggested it may be safe to adopt a restrictive red cell transfusion threshold of 8.5 g/dl in patients on ECMO, and highlighted the need for prospective trials in this heavily-transfused population.

BACKGROUND: The utilization of extracorporeal membrane oxygenation (ECMO) has increased rapidly around the world. Being an overall low-volume high-cost form of therapy, the effectiveness of having care delivered in segregated units across a geographical locality is debatable. METHODS: All adult extracorporeal membrane oxygenation cases admitted to public hospitals in Hong Kong between 2010 and 2019 were included. “High-volume” centers were defined as those with >20 extracorporeal membrane oxygenation cases in the respective calendar year, while “low-volume” centers were those with ≤20. Clinical outcomes of patients who received extracorporeal membrane oxygenation care in high-volume centers were compared with those in low-volume centers. RESULTS: A total of 911 patients received extracorporeal membrane oxygenation—297 (32.6%) veno-arterial extracorporeal membrane oxygenation, 450 (49.4%) veno-venous extracorporeal membrane oxygenation, and 164 (18.0%) extracorporeal membrane oxygenation-cardiopulmonary resuscitation. The overall hospital mortality was 456 (50.1%). The annual number of extracorporeal membrane oxygenation cases in high- and low-volume centers were 29 and 11, respectively. Management in a high-volume center was not significantly associated with hospital mortality (adjusted odds ratio (OR) 0.86, 95% confidence interval (CI): 0.61–1.21, P=0.38), or with intensive care unit mortality (adjusted OR 0.76, 95% CI: 0.54–1.06, P=0.10) compared with a low-volume center. Over the 10-year period, the overall observed mortality was similar to the Acute Physiology And Chronic Health Evaluation IV-predicted mortality, with no significant difference in the standardized mortality ratios between high- and low-volume centers (P=0.46). CONCLUSIONS: In a territory-wide observational study, we observed that case volumes in extracorporeal membrane oxygenation centers were not associated with hospital mortality. Maintaining standards of care in low-volume centers is important and improves preparedness for surges in demand.

BackgroundLeft atrial appendage occlusion (LAAO) has emerged as an alternative to oral anti-coagulation therapy for stroke prevention in atrial fibrillation (AF), but data comparing LAAO with direct oral anti-coagulant (DOAC) is sparse.MethodThis cohort study compared LAAO (with or without prior anti-coagulation) with a switch of one DOAC to another DOAC. The primary outcome was a composite of all-cause mortality, ischemic stroke and major bleeding.ResultsA total of 2,350 patients (874 in the LAAO group and 1,476 in the DOAC switch group) were generated by 1:2 propensity score matching. After a mean follow up of 1052 ± 694 days, the primary outcome developed in 215 (24.6%) patients in the LAAO group and in 335 (22.7%) patients in the DOAC switch group (hazard ratio [HR], 0.94; 95% confidence interval [CI], 0.80 to 1.12; P=0.516). The LAAO group had a lower all-cause mortality (HR, 0.49; 95% CI, 0.39 to 0.60; PConclusionsLAAO conferred a similar risk of composite outcome of all-cause mortality, ischemic stroke and major bleeding, as compared with DOAC switch. The risks of all-cause mortality and cardiovascular mortality were lower with LAAO.CLINICAL PERSPECTIVE1)What Is New?Data comparing left atrial appendage occlusion (LAAO) with direct oral anti-coagulant (DOAC) in patient with atrial fibrillation (AF) was sparse.LAAO conferred a similar risk of composite outcome of all-cause mortality, ischemic stroke and major bleeding, as compared with switch of DOAC in patients with AF and intolerant to at least one anti-coagulant.The risks of all-cause mortality and cardiovascular mortality were halved with LAAO.2)What Are the Clinical Implications?This study highlights the potential role of LAAO as a superior alternative to trying another DOAC for patients with AF and intolerant to at least one DOAC.Bleeding events after 6 months post LAAO were significantly reduced by 30% in the LAAO group as compared with the DOAC switch group, coinciding with the de-escalation in anti-thrombotic therapy.Reduction in bleeding during the first 6 months post LAAO represents a potential opportunity to further improve outcomes after LAAO.

BackgroundStroke after acute coronary syndrome (ACS) can be devastating. It is uncertain whether the risks of ischaemic stroke or intracranial haemorrhage (ICH) are associated with different choices of P2Y12 inhibitors (potent P2Y12 inhibitors such as ticagrelor and prasugrel vs clopidogrel). Even though East Asians are known to have different thrombotic and haemorrhagic profiles from Caucasians, data on Chinese patients are sparse.MethodThis was a retrospective cohort study conducting in Chinese patients with ACS who underwent first-ever percutaneous coronary intervention from 14 hospitals in Hong Kong between 2010 and 2017. The primary efficacy endpoint was ischaemic stroke. The secondary efficacy endpoint was a composite outcome of thrombotic events including all-cause mortality, non-fatal myocardial infarction and ischaemic stroke. The primary safety endpoint was ICH. The secondary safety endpoint was a composite of major bleeding events.ResultsAfter adjustment of baseline characteristics by 1:1 propensity score matching, a total of 6220 patients (3110 on each group) were analysed. Compared with clopidogrel, potent P2Y12 inhibitors were associated with a lower risk of ischaemic stroke (HR 0.57; 95% CI 0.37 to 0.87; p=0.008) and a lower risk of thrombotic events (HR 0.77; 95% CI 0.66 to 0.90; p=0.001). Potent P2Y12 inhibitor was associated with similar risk of ICH (HR 0.65; 95% CI 0.34 to 1.25, p=0.20) and major bleeding (HR 0.83; 95% CI 0.68 to 1.01, p=0.069).ConclusionsPotent P2Y12 inhibitors were associated with a lower adjusted risk of ischaemic stroke and thrombotic events, compared with clopidogrel. The risks of ICH and major bleeding were similar.

Background The impact of contrast-induced acute kidney injury (CI-AKI) on long-term major adverse cardiovascular events (MACE) remains controversial. Method This was a retrospective cohort study from 14 hospitals under the Hospital Authority of Hong Kong between 2004 and 2017. Severe CI-AKI was defined as an increase in serum creatinine of >50% from the baseline value, an absolute increase of >1 mg/dL (88 μmol/L) or requiring dialysis after percutaneous coronary intervention (PCI). Mild CI-AKI was defined as an increase in serum creatinine of >25% from the baseline value or an absolute increase of >0.5 mg/dL (44 μmol/L) after PCI but not fulfilling the criteria for severe CI-AKI. The primary endpoint was MACE, defined as a composite outcome of all-cause mortality, non-fatal myocardial infarction after hospital discharge, stroke or any unplanned coronary revascularization, in a time-to-first-event analysis up to 5 years after PCI. The secondary endpoints were individual components of MACE and cardiovascular mortality. Results A total of 34 576 patients were analysed. After adjustment for cardiovascular risk factors, procedural characteristics and medication use, the risk of MACE at 5 years was significantly higher with mild CI-AKI {hazard ratio [HR], 1.18 [95% confidence interval (CI) 1.12–1.26); P Conclusions Among patients undergoing a first-ever PCI, CI-AKI of any severity was associated with a higher adjusted risk of MACE at 5 years. Severe CI-AKI has a stronger association with MACE and its individual components, with an excess of early and late events.

Background: To compare the clinical outcomes of patients requiring extracorporeal membrane oxygenation (ECMO) support who had a restrictive red cell transfusion strategy with those who had a liberal transfusion strategy. Methods: We retrospectively reviewed all adult ECMO cases in Hong Kong from 2010 to 2019. Patients who received a minimum of one packed red blood cell (pRBC) during ECMO were included. Haemoglobin values before each episode of transfusion was retrieved. Restrictive transfusion strategy was defined as a transfusion threshold ≤ 8.5 g/dL in all transfusion episodes for a single patient, while liberal transfusion strategy was defined as a transfusion threshold > 8.5 g/dL in any transfusion episode. Mortality outcomes and other complications were compared.Results: The analysis included 763 patients, with 138 (18.1%) patients in the restrictive and 625 (81.9%) in the liberal transfusion strategy group, and median haemoglobin of 8.3 and 9.9 g/dL, respectively. The average units of pRBC received per day were 0.7 (0.3-1.8) and 1.2 (0.6-2.3) in the two groups. There were no significant differences in ICU mortality (adjusted odds ratio (OR), 0.86; 95% CI 0.56-1.30; P=0.47), hospital mortality (adjusted OR, 0.79; 95% CI 0.52 to 1.21; P=0.28), and 90-day mortality (adjusted OR, 0.84; 95% CI 0.55 to 1.28; P=0.42) between the two groups. Among patients receiving veno-venous ECMO, the ICU mortality was significantly lower with the restrictive transfusion strategy (adjusted OR, 0.36; 95% CI 0.17 - 0.73; P=0.005). Conclusions: Compared with a liberal transfusion strategy, a restrictive red blood cell transfusion threshold of 8.5 g/dL was not associated with worse outcomes in patients on ECMO, with better survival outcomes for patients on veno-venous ECMO.

Background:Peripheral veno-arterial extracorporeal membrane oxygenation (V-A ECMO) is used to support circulatory failure refractory to conventional therapy. However, data on the heart-ECMO interaction at different levels of ECMO blood flow during the immediate period after ECMO initiation are sparse. We evaluated the effects of varying ECMO blood flow rate on left ventricular systolic function.Methods:Adult patients who were supported by peripheral V-A ECMO in a tertiary referral center were recruited. Serial hemodynamic and cardiac performance parameters were measured by transthoracic echocardiogram within the first 48 hours after implementation of V-A ECMO. Measurements at 100%, 120%, and 50% of target blood flow (TBF) were compared.Results:A total of 45 patients were included, 32 (71.1%) were male, and the median age was 57 (50-64) years. The main indications for V-A ECMO were myocardial infarction 25 (55.6%) and myocarditis 6 (13.3%). With a decrease in extracorporeal blood flow from 100% to 50% of TBF, mean arterial pressure dropped from 75±18 to 67±20 mmHg (p2 (pConclusions:In the initial period of V-A ECMO support, left ventricular systolic function quantified bedside echocardiography was inversely related to ECMO blood flow rate. The heart-ECMO interaction should be considered when determining goals of ECMO flow after initiation.

Extracorporeal cardiopulmonary resuscitation (ECPR) is an advanced resuscitation method that has been associated with better outcomes after cardiac arrest compared with conventional cardiopulmonary resuscitation. This is a retrospective analysis of all patients who received ECPR for cardiac arrest in Hong Kong's first ECPR program from 2012 to 2020. The primary outcome was favorable neurologic outcome at 3 months. A new risk prediction model was developed and its performance was compared with published risk scores. One-hundred two patients received ECPR and 19 (18.6%) patients survived with favorable neurologic outcome. Having a shockable rhythm was the strongest predictor of favorable neurologic outcome in multivariate analysis (odds ratio, 9.64; 95% confidence interval [CI], 1.49 to 62.30; P = 0.017). We developed a simple model with three parameters for the prediction of favorable neurologic outcomes - presence of shockable rhythm, mean arterial pressure after extracorporeal membrane oxygenation, and the Acute Physiology And Chronic Health Evaluation IV score, with an area under receiver operating characteristic curve of 0.85 (95% CI, 0.77 to 0.94). In Hong Kong's first ECPR program, 18.6% patients survived with favorable neurologic outcomes, and having a shockable rhythm at presentation was the strongest predictor. Risk scores are useful in predicting important patient outcomes and should be included in clinical decision-making for patients who received ECPR.

BackgroundThere is a significant disparity between randomized controlled trials and observational studies with respect to any mortality benefit with intracoronary imaging during the percutaneous coronary intervention (PCI). This raises a suspicion that the imaging paradox, in which some operators may become over reliant on imaging and less proficient with angiography-guided PCI, might exist.MethodThis was a retrospective cohort study from 14 hospitals under the Hospital Authority of Hong Kong between January 1, 2010 and December 31, 2017. Participants were patients who underwent first-ever PCI. The association between mortality risks of patients undergoing angiography-guided PCI and three tertiles (low, medium, and high) of the proportion of PCI done under intracoronary imaging guidance at a population level (background imaging rate), were evaluated after confounder adjustment by multivariable logistic regression.ResultsIn an adjusted analysis of 11,816 patients undergoing angiography-guided PCI, the risks of all-cause mortality for those were higher in the high-tertile group compared with the low-tertile group (OR, 1.45, 95% CI, 1.10–1.92, P = 0.008), the risks of cardiovascular mortality were higher in the high-tertile group compared with the low-tertile group (OR, 1.51, 95% CI, 1.08–2.13, P = 0.017). The results were consistent with multiple sensitivity analyses. Threshold analysis suggested that the mortality risks of angiography-guided PCI were increased when the proportion of imaging-guided PCI exceeded approximately 50%.ConclusionsThe risks of the all-cause mortality and cardiovascular mortality were higher for patients undergoing angiography-guided PCI in practices with a higher background imaging rate.

BackgroundThe choice of antithrombotic therapy after percutaneous coronary intervention (PCI) is heavily dependent on the relative trade-off between major bleeding (MB) and myocardial infarction (MI). However, the mortality trade-off was mostly described in Western populations and remained unknown in East Asians.MethodThis was a retrospective cohort study from 14 hospitals under the Hospital Authority of Hong Kong between 2004 and 2017. Participants were patients undergoing first-time PCI and survived for the first year. Patients were stratified by the presence of MB and MI during the first year. The primary endpoint was all-cause mortality between 1 and 5 years after PCI. The secondary endpoint was cardiovascular mortality.ResultsA total of 32 180 patients were analysed. After adjustment for baseline characteristics and using patients with neither events as reference, the risks of all-cause mortality were increased in patients with MI only (HR, 1.63; 95% CI 1.45 to 1.84; pConclusionsBoth MB and MI within the first year after PCI were associated with increase in all-cause and cardiovascular mortality in Chinese patients, but the impact was stronger with MB.

The patterns of late major bleeding (MB) after percutaneous coronary intervention (PCI) remain unknown in Chinese patients.This study sought to determine the incidence, prediction, and long-term outcomes of late MB in Chinese patients.This was a retrospective cohort study from 14 hospitals in Hong Kong. Participants were patients undergoing first-time PCI without MB within 30 days or death within 1 year. Patients were stratified by the presence of late MB, defined as MB between 30 and 365 days. The primary endpoint was all-cause mortality. The secondary endpoints were major adverse cardiac events (MACE).A total of 32,057 patients were analyzed. After adjustment for baseline characteristics, periprocedural characteristics, and medications on discharge, the risks of all-cause mortality at 5 years were significantly higher with late MB (HR: 2.15; 95% CI: 1.92-2.41;Late MB was independently associated with a higher risk of mortality, MACE, myocardial infarction, and stroke in patients undergoing PCI. The CARDIAC score is a simple model that can predict MB after PCI. Prevention of MB represents an important strategy to optimize cardiovascular outcomes for patients undergoing PCI.

Background Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) and asthma are associated with a variety of precipitating factors including infection. This study assessed the infective viral etiologies by real-time multiplex polymerase chain reaction of patients hospitalized with AECOPD and asthma exacerbations. In addition, infective etiologies were assessed for association with the clinical outcome of the patients. Methods Adults admitted with AECOPD and asthma exacerbations between August 2016 and July 2017 were recruited. Nasopharyngeal aspirate (NPA) samples were obtained from the patients within 1–2 days of admission and subjected to pathogen detection and human rhinovirus (HRV) typing. Results Altogether 402 patients with AECOPD, 80 stable COPD, 100 asthma exacerbation and 21 stable asthma subjects were recruited. Among those admitted for AECOPD and asthma exacerbations, 141(35.1%) and 45(45.0%) respectively had pathogens identified in the NPA specimens. The commonest virus identified was influenza A followed by HRV. HRV typing identified HRV-A and HRV-C as the more common HRV with a wide variety of genotypes. Identification of pathogens in NPA or HRV typing otherwise did not affect clinical outcomes including the hospital length of stay, readmission rates and mortality except that identification of pathogens in asthma exacerbation was associated with a lower rate of readmissions at 30 and 60 days. Conclusions Many respiratory viruses were associated with AECOPD and asthma exacerbation. HRV-A and HRV-C were the more common HRV associated with exacerbations. Identification of pathogens in NPA was associated with less readmissions for asthma patients at 30 and 60 days. Trial registration ClinicalTrials.gov NCT02866357.

BACKGROUND AND OBJECTIVE Airway inflammation accompanying exacerbations varies among individuals with some having neutrophilic, while others showing eosinophilic inflammation. This study assessed the cut-off values of blood eosinophil count for identifying subjects with longer hospital length of stay (LOS) with acute exacerbations of chronic obstructive pulmonary disease (AECOPD). METHODS Patients were recruited at presentation to the hospital with an AECOPD. Complete blood picture with differential count was taken on admission. Patients were treated with a standard course of systemic corticosteroid and antibiotic and evaluated at 8 weeks post-exacerbation for lung function measurement and 6-min walk. They were followed up in 1 year for any readmissions or mortality. Cut-off values of eosinophils for assessment of longer LOS were calculated using receiver operating characteristic (ROC) curve analysis. RESULTS A total of 346 patients with admission eosinophil count were included in the analysis (333 (96.2%) were males; mean ± SD age: 74.9 ± 7.8 years; mean forced expiratory volume in 1 s (FEV1 ): 43.4 ± 16.3% predicted). The median (interquartile range (IQR)) of the absolute peripheral eosinophil count, percent eosinophil count and LOS were 0.11 (0.25) × 109 /L, 1 (3) % and 5 (7) days, respectively. Using the median LOS of ≥5 days as the cut-off, ROC analysis of the cut-off value of eosinophil count associated with longer LOS was at

Introduction: Pulmonary rehabilitation programme (PRP) varies in duration from a few weeks to more than a year. PRP shorter than 6–8 weeks are generally less effective. Aims: To assess whether a short course PRP with periodic reinforcement exercise training and phone call reminders would help to reduce readmissions for acute exacerbation (AECOPD) and increase activity in COPD patients. Methods: This was a randomized controlled trial. Patients in the invention group received out-patient physiotherapy training for 4-8 sessions, 2 hours each time, 1-2 times weekly. Each subject in the intervention group (IG) would have at least 4-8 weeks supervised training by a trained physiotherapist. Our case manager contacted the subjects by phone every 2 weeks to provide support and reinforcement for continuous exercise at home for one year. The usual care group (UG) received usual care without physiotherapist or case manager intervention. Activities of all patients were assessed by an activity monitor GT3XP (Actigraph, Pensacola, USA). Results: Total 136 subjects were included and randomised (68 in IG and 68 in UG). The age, gender and FEV1% predicted were 75.0±6.7years, 132 males, and 47.0±16.2% respectively. The mean number of readmissions for AECOPD in the IG was less than the UG at 12 months (1.06 vs 1.72 times, p=0.014). Time to first readmission was shorter in the UG than the IG at 12 months (122.4 vs 146.8days, p=0.005). At 12 months, there was no change in activity measured by steps per day between the IG and UG groups. Conclusions: Short course pulmonary rehabilitation could decrease the number of readmissions and lengthen the time of readmissions for AECOPD.