Functional Severity of Coronary Stenosis in Relation to Luminologic Severity in AMI: Comparison with Angina

BACKGROUND AND OBJECTIVES: Positive correlations between quantitative coronary angiography and functional indexes of coronary stenosis are well known in angina pectoris. However, there is little data concerning correlations with acute myocardial infarction (AMI). The objective of this study was to evaluate the differences in correlation of functional severity and luminologic severity between patients with angina and acute myocardial infarction. SUBJECTS AND METHODS: The study population consisted of 23 patients with AMI and 25 patients with angina pectoris. We performed intravascular ultrasound (IVUS) and intracoronary pressure measurement following diagnostic coronary angiography, and measured angiographic diameter stenosis (DST), minimal luminal diameter (MLD), minimal luminal area (MLA), and reference area stenosis (r-AST). Additionally, the fractional flow reserve (FFR) was defined by the ratio of the distal mean coronary pressure (Pd) to the aortic mean pressure (Pa). RESULTS: The IVUS parameters and DST in patients with AMI showed more severe stenosis than seen in patients with angina; MLD (1.37+/-0.30 mm vs 1.73+/-0.63 mm, p0.05). FFR was correlated less with r-AST in patients with myocardial infarction than angina ( - 0.55 vs - 0.84). The r-AST in patients with AMI, in order to be the best cut-off values that fit with a FFR<0.75, was higher than seen in patients with angina (83% vs 67%). CONCLUSION: FFR in AMI was not significantly different from that seen in angina despite the presence of a significant difference of IVUS parameters between the two patient groups. The functional severity of stenosis in relation to its luminologic severity may be lessened following acute myocardial infarction.

Fractional transmural perfusion assessed by myocardial contrast echocardiography according to grades of collateral flow on coronary angiography / 대한내과학회지

BACKGROUND: A collateral flow can be assessed and graded by coronary angiography, however, the technique does not provide any information about perfusion. Myocardial contrast echocardiography (MCE) can assess collateral perfusion and has superior spatial resolution in defining its distribution. OBJECTIVE: To investigate the difference of transmural perfusion according to the angiographical collateral grade in normal myocardium, we performed MCE of collateral artery in 16 patients (m : f = 11 : 5, age: 57+/-13yrs.) with angina and compared the results with the angiographical grades. METHODS: In six patients with preexisting collaterals on baseline angiography, we performed MCE after intracoronary injection of sonicated Hexabrix. For 10 patients without preexisting collaterals on baseline angiography, we performed angiography, MCE for recruited collateral arteries during balloon inflation of stenotic coronary arteries (2 times for 120sec.). For 12 patients who underwent PTCA, we performed pressure wire simultaneously with angiography and MCE for recruited collateral arteries during balloon inflation. Fractional collateral flow(FCF) was defined by the ratio of coronary wedge pressure to proximal pressure(Pw/Pa). Angiographical collaterals were graded according to 'Rentrop' criteria(grade 0-3). Transmural thickness (TMT) and enhanced myocardial thickness (EMT) of an enhanced segment on MCE were measured at diastolic phase. The depth of collateral perfusion was estimated by collateral perfusion index (CPI) that was the ratio of EMT to TMT. RESULTS: There were significant differences of CPI with respect to angiographical grades according to one way ANOVA test (p< 0.05). One of five patients who had no recruited collaterals showed partial enhancement confined to the epicardium with CPI of 0.24. There was significant correlation between the angiographical grade and the CPI with Spearman's Rho value of 0.93(p< 0.0001). The angiographical grades were significantly correlated with FCF with the Spearman's Rho value of 0.87(p=0.0002). There was also significant correlation between FCF and CPI with Pearson's r=0.81 (p=0.0016). CONCLUSION: The higher the angiographical collateral grade is, the higher the collateral pressure and the deeper the fractional transmural perfusion from epicardium into endocardium gets.

The efficacy and safety of irbesartan in treating essential hypertension

BACKGROUND: Irbersatan, an orally active antihypertensive agent, effectively reduce blood pressure by directly blocking angiotensin II receptors without any significant adverse effects. The purpose of this study is to evaluate the efficacy and safety of irbesartan in patients with mild to moderate hypertension. METHODS: This study enrolled 83 patients who had diastolic pressure above 95 mmHg and below 110 mmHg on two measurements. Sixty eight patients were administered 150mg of irbesartan, an angiotensin II receptor blocker, daily for four weeks as an initial dosage. If the sitting diastolic pressure was equal to or greater than 90 mmHg after a 4 week treatment period, the dosage was doubled until the end of 8 weeks. Baseline pressures, antihypertensive effect, side effects, laboratory findings were compared before and after treatment. RESULTS: Fourty two patients out of 53 patients having completed this study showed decreased blood pressure equal to or more than 5 mmHg of the sitting diastolic pressure (response rate=79%). Twenty one patients out of 53 patients showed normalized blood pressure below 90 mmHg of the sitting diastolic pressure (normalization rate=40%). The extent of decrease in diastolic and systolic blood pressure after eight week treatment was an average 11.7+/-10.1 mmHg and 16.3+/-18.9 mmHg, respectively (p<0.05). Nineteen ontoward side effects was observed in 17 patients out of 68 patients with medication (frequency of ontoward effects=25%). Only one case with headache was considered to be related to the medication. Abnormal laboratory findings were observed in eight patients, and only one case with elevation of bilirubin and ALT levels was considered to be related to the medication. CONCLUSION: In conclusion, irbesartan is a safe and effective antihypertensive drug in patients with mild to moderate hypertension with tolerable side effects.

A Case of Stent Migration into Right Ventricle after Percutaneous Transluminal Angioplasty for Budd-Chiari Syndrome

No abstract available.

Echocardiographic Assessment of Left Ventricular Systolic Function in Comparision with Automatic Quantification of 201TI Gated Peerfusion SPECT

BACKGROUND AND OBJECTIVES: Assessment of left ventricular systolic function is an important clinical variable with respect to diagnosis, prognosis and treatment in various clinical situation. Automatic quantification of ventricular volume and ejection fraction by delineating 3 dimensional endocardial boundaries from the gated perfusion SPECT was validated. The purposes of this study were to assess the agreement of left ventricular ejection fraction determined by two-dimensional echocardiography and automatic quantification of perfusion SPECT and compare different echocardiographic methods with the reference method, automatic quantification of perfusion SPECT. METHOD: Twenty seven patients (20 men, 7 women; mean age 60+/-12) with acute myocardial infarction (anterior: 16, inferior: 7, lateral: 4) and twenty one patients (12 men, 9 women; mean age 60+/-12) without myocardial infarction history and regional wall motion abnormality in echocardiography were studied. All patients had two-dimensional echocardiography and 201Tl perfusion SPECT performed within 5 days of each other. Ejection fraction of left ventricle was calculated by echocardiography using modified Simpson's method and M-mode method. Also, ejection fraction of left ventricle was estimated by 201Tl perfusion SPECT using automatic software (quantitative gated SPECT[QGS]; Cedars-Sinai Medical Center, Los Angels, CA). RESULTS: The agreement of ejection fraction between M-mode method and QGS (limit of agreement -3.48, 3.2; average limit of agreement 6.68) in control group was better than that between modified Simpson's method and QGS (limit of agreement 0.04, 8.42; limit of agreement average limit of agreement 8.38). But, The agreement of ejection fraction between modified Simpson's method and QGS in the acute myocardial infarction group (limit of agreement; -15.31, 10.01; average limit of agreement 12.66) was better than that between M-mode method and QGS (limit of agreement -17.82, 13.86; average limit of agreement 15.84). The agreement of ejection fraction between modified Simpson's method and QGS (limit of agreement; -8.49, 5.74; average limit of agreement 7.12) in the anterior myocardial infarction was more accordancy than lateral and inferior wall infarction (limit of agreement; -12.11, 13.74; average limit of agreement 12.92). CONCLUSION: The M-mode method in patients without regional wall motion abnormality and modified Simpson's method in patients with regional wall motion abnormality, especially in anterior wall infarction seen to be useful method for the assessment of left ventricular ejection fraction.

The Evaluation of Diagnostic Validity of ECG for the Subendocardial Infarction by Myocardial Contrast Echocardiography

BACKGROUND AND OBJECTIVES: The pathological findings of Non-Q wave myocardial infarction(NQMI) on ECG did not always correspond to subendocardial infarction(SEMI). The purpose of this study was to evaluate the diagnostic validity of ECG for SEMI by myocardial contrast echocardiography (MCE) in the patients with acute myocardial infarction(AMI). MATERIALS AND METHODS: The study population was 84 patients who underwent MCE under the diagnosis of AMI. MCE was performed by intracoronary injection of sonicated Hexabrix into the infarct related artery and SEMI was diagnosed by inspecting endocardial defect with epicardial enhancement on MCE. RESULTS: (1) Among 19 NQMI cases, 7 cases showed SEMI with MCE score 0.5, 11 cases with score 1, and 1 case with score 0. Among 65 Q-wave MI(QMI) cases, only 5 cases showed SEMI. (2) 7 cases who had NQMI with SEMI showed LV wall motion recovery at follow-up echocardiography except 1 case. Whereas, of 5 QMI cases who had SEMI, only 1 case improve LV wall motion. CONCLUSION: NQMI on ECG does not always imply SEMI on MCE, but the absence of pathologic Q wave in the patients with SEMI is thought to be a predictive factor of the recovery of LV wall motion.

The Evaluation of Diagnostic Validity of ECG for the Subendocardial Infarction by Myocardial Contrast Echocardiography

BACKGROUND AND OBJECTIVES: The pathological findings of Non-Q wave myocardial infarction(NQMI) on ECG did not always correspond to subendocardial infarction(SEMI). The purpose of this study was to evaluate the diagnostic validity of ECG for SEMI by myocardial contrast echocardiography (MCE) in the patients with acute myocardial infarction(AMI). MATERIALS AND METHODS: The study population was 84 patients who underwent MCE under the diagnosis of AMI. MCE was performed by intracoronary injection of sonicated Hexabrix into the infarct related artery and SEMI was diagnosed by inspecting endocardial defect with epicardial enhancement on MCE. RESULTS: (1) Among 19 NQMI cases, 7 cases showed SEMI with MCE score 0.5, 11 cases with score 1, and 1 case with score 0. Among 65 Q-wave MI(QMI) cases, only 5 cases showed SEMI. (2) 7 cases who had NQMI with SEMI showed LV wall motion recovery at follow-up echocardiography except 1 case. Whereas, of 5 QMI cases who had SEMI, only 1 case improve LV wall motion. CONCLUSION: NQMI on ECG does not always imply SEMI on MCE, but the absence of pathologic Q wave in the patients with SEMI is thought to be a predictive factor of the recovery of LV wall motion.

Reproducibility of Gated Myocardial Perfusion SPECT for the Assessment of Myocardial Function : Comparison with Thallium-201 and Technetium-99m-MIBI / 대한핵의학회잡지

PURPOSE: We compared the reproducibility of 201Tl and 99mTc-sestamibi (MIBI) gated SPECT measurement of myocardial function using the Germano algorithm. MATERIALS AND METHODS: Gated SPECT acquisition was repeated in the same position in 30 patients who received 201Tl and in 26 who received 99mTc-MIBI. The quantification of end-diastolic volume (EDV), end-systolic volume (ESV), and ejection fraction (EF) on 201Tl and 99mTc-MIBI gated SPECT was processed independently using Cedars quantitative gated SPECT software. The reproducibility of the assessment of myocardial function on 201Tl gated SPECT was compared with that of 99mTc-MIBI gated SPECT. RESULTS: Correlation between the two measurements for volumes and EF was excellent by the repeated gated SPECT studies of 201Tl (r=0.928 to 0.986; p<0.05) and 99mTc-MIBI (r=0.979 to 0.997; p<0.05). However, Bland Altman analysis revealed the 95% limits of agreement (2 SD) for volumes and EF were tighter by repeated 99mTc-MIBI gated SPECT (EDV: 14.1 ml, ESV: 9.4 ml and EF: 5.5%) than by repeated 201Tl gated SPECT (EDV: 24.1 ml, ESV: 18.6 ml and EF: 10.3%). The root mean square (RMS) values of the coefficient of variation (CV) for volumes and EFs were smaller by repeated 99mTc-MIBI gated SPECT (EDV: 2.1 ml, ESV: 2.7 ml and EF: 2.3%) than by repeated 201Tl gated SPECT (EDV: 3.2 ml, ESV: 3.5 ml and EF: 5.2%). CONCLUSION: 99mTc-MIBI provides more reproducible volumes and EF than 201Tl on repeated acquisition gated SPECT. 99mTc-MIBI gated SPECT is the preferable method for the clinical monitoring of myocardial function.

Left Ventricular Ejection Fraetion Determmed by Cated Tl-201 Perfusion SPECT and Quantitative Software / 대한핵의학회잡지

PURPOSE: We compared estimates of ejection fraction (EF) determined by gated Tl-201 perfusion SPECT (g-TI-SPECT) with those by gated blood pool (GBP) scan. MATERIALS AND METHODS: Eighteen subjects underwent g-TI-SPECT and GBP scan. After reconstruction of g-TI-SPECT, we measured EF with Cedars software. The comparison of the EF with g-TI-SPECT and GHP scan was assessed by correlation analysis and Bland Altman plot. RESULTS: The estimates of EF were significantly different (p<0.05) with g-TI-SPECT (40%+/-14%) and GBP scan (43%+/-14%). There was an excellent correlation of EF between e-TI-SPECT and GBP scan (r=0.94, p<0.001). The mean difference of EF between GRP scan and g-TI- SPECT was +3.2%, Ninety-five percent limits of agreement were +9,8%. EF between g-TI-SPECT and GBP scan were in poor agreement. CONCLUSION: The estimates of EF by g-TI-SPECT was well correlated with those by GBP scan. However, EF of g-TI-SPECT doesn't agree with EF of GBP scan. EF of g-TI-SPECT cant be used interchangeably with EF of GBP scan.

Comparison of Coronary Flow Reserve According to The Degree of Hypokinesia in Dilated Cardiomyopathy With Regional Asynergy

BACKGROUND AND OBJECTIVES: Dilated cardiomyopathy(DCMP) is a primary myocardial disease of unknown cause characterized by left ventricular or biventricular dilatation and impaired myocardial contractility. In 1973, Kreulen et al. classified DCMP into two groups-one with generalized hypokinesia and the other with regional asynergy in addition to generalized hypokinesia. Diminished coronary flow reserve has been reported in DCMP with generalized hypokinesia but its mechanism remains obscure. The aim of this study was to investigate the relationship between the degree of microvascular dysfunction and the difference of regional wall motion abnormality in DCMP with regional asynergy. METHODS: The subjects of this study were 11 patients (M:F=:5, mean age:60 15yrs) a diagnosis of DCMP with regional asynergy, normal sinus rhythm without left bundle branch block and normal coronary angiogram who underwent Doppler wire from September 1997 to December 1999. Left ventricle was divided into three territories according to the coronary arterial distribution by echocardiography(A: coronary artery territory showing regional asynergy, I: coronary artery territory showing intermediate wall motion, P: coronary artery territory showing relatively preserved wall motion). Coronary flow reserve(CFR) was measured at the mid portion of left anterior descending artery(LAD), left circumflex artery(LCX) and right coronary artery(RCA) with 0.014 inch Doppler guide wire before and during intracoronary injection of 12-18 of adenosine. Relative coronary flow reserve(rCFR) was obtained by the ratio of the CFR in coronary artery of the territory showing regional asynergy and relatively preserved wall motion to the CFR in coronary artery of the territory showing intermediate wall motion (CFRA/CFRI, CFRP/CFRI). RESULTS: Regional asynergy was observed in LAD territory in 4(36%) patients, LCX territory in 4(36%) patients, RCA territory in 3(28%) patients (p=s). The mean CFR was 2.5 0.6 in LAD, 2.4 0.5 in LCX, 2.4 0.6 in RCA(p=s). The mean CFR and rCFR in coronary arteries showing regional asynergy were significantly lower than those in coronary arteries showing relatively preserved wall motion(2.1 0.5 vs 2.7 0.6, p<0.05, 0.84 0.12 vs 1.11 0.11, p<0.001). CONCLUSION: Degree of regional hypokinesia in DCMP with regional asynergy seems to be associated with that of microvascular dysfunction.

Clinical Comparison of Coronary Flow Reserve and Fractional Flow Reserve after PTCA in Patients with Coronary Artery Disease / 대한내과학회지

OBJECTIVES: Severity of coronary artery stenosis has been defined in terms of geometric dimensions, pressure gradient-flow relations, resistance to flow and coronary flow reserve(CFR) after maximum arteriolar vasodilation. Myocardial fractional flow reserve(FFR) is a new index of the functional severity of coronary stenosis that is calculated from pressure measurements during coronary angiography. We compared the relationship between FFR and CFR after PTCA and the residual stenosis with FFR and CFR in the patients with acute myocardial infarction (AMI) and angina. METHODS: The study population consisted of 25 patients with AMI and 18 patients with angina. All AMI patients had successful restoration of infarc-related artery by thrombolysis or direct PTCA. Doppler index was measured using 0.014 inch Doppler wire 15 minutes after successful restoration of infarc- related artery. Hyperemic index was measured after intracoronary injection of adenosine(16-18ug). Baseline and hyperemic distal coronary artery pressure was measured using 0.014 inch pressure wire with advancing the wire distal to the lesion and simultaneous proximal aortic pressure was measured using guiding catheter. RESULTS: 1) Post-interventional FFR and CFR were 0.91+/-0.09 and 1.87+/-0.45 in AMI and 0.93+/-0.06 and 2.73+/-0.67 in angina. There was no significant correlation between FFR and CFR in AMI and angina(p=NS). CFR showed the weak correlation with hyperemic distal pressure(hPd) in AMI(p=0.04) and FFR with hDSVR in angina(p=0.04). FFR and CFR were not correlated with mean blood pressure and heart rate(p=NS). 2) FFR and hyperemic pressure gradient had the close correlation with residual stenosis after successful PTCA in AMI and angina(p<0.001). Baseline pressure gradient also showed weak correlation with FFR(p<0.05). 3) CFR was 1.87+/-0.45 in AMI and 2.73+/-0.67 in angina with significant difference between two groups (p<0.001) and FFR was 0.91+/-0.09 in AMI and 0.93+/-0.06 in angina without difference(p=NS). hPa and hPd showed the significant difference between the two groups(p<0.05). CONCLUSION: FFR seems to be a new index of the functional severity of coronary stenosis that is calculated from pressure measurements during coronary angiography.

Contractile Reserve versus Cell Membrane Integrity for Predicting Contractile Recovery after Reperfusion in Acute Myocardial Infarction and Their Relationship

BACKGROUND: Early prediction of functional recovery could have very important prognostic and therapeutic implication. Modalities evaluating functional recovery of dysynergic segments have included metabolic and perfusion imaging as well as assessment of contractile reserve in response to inotropic agent. Dobutamine stress echocardiography(DSE) assesses contractile reserve whereas rest and 24hr delayed Tl-201 SPECT(T1-201) assesses cell membrane integrity. Does contractile reserve always imply cell membrane integrity? If not, which one could be more useful predictor of contractile recovery of the infarcted segment after restoration of the infarct related artery(IRA) in acute myocardial infarction(AMI)? The aim of this study was to evaluate comparative accuracy of contractile reserve and cell membrane integrity in predicting contractile recovery and their relation. METHODS: We prospectively compared DSE with Tl-201 in 22 of 34 patients with acute myocardial infarction from August 1996 to September 1997. AU patients underwent coronary angiography and got revascularization treatment if they had significant stenosis. DSE and Tl-201 were done within 24hrs after successful restoration without flow limiting residual stenosis. An intravenous infusion of dobutamine(5(mg/kg/min) was started with an infusion pump and continued in 3-minute dose increment up to 20(mg/kg/min under continuous ECG and echocardiographic monitoring. Regional wall motion was assessed according to 16-segment model from American Society of Echocardiography recommendation. Wall motion was scored as 1 (normal), 2(mild to moderate hypokinesia), 3(severe hypokinesia), 4(akinesia), 5(dyskinesia). The improvement of wall motion score(WMS) more than 1 from asynergy during dobutmine infusion was considered to have contractile reserve. SPECT images were obtained at rest and 24hours later. The Tl-201 images were analyzed visually according to 16 segment model, scored by grade 0: normal uptake, 1: mild to moderate decreased, 2: severe decreased, 3: defect. Those segments were considered to have a cellular integrity if the defect at rest improved more than grade 1 on delayed images. All patients underwent 1 month follow up echocardiography after discharge. The improvement of WMS more than score 1 from asynergy at follow up was considered to have contractile recovery. RESULTS: 71 akinetic segments out of total of 352 segments were analyzed. There was no significant difference of sensitivity(88 vs 82%), specificity(82 vs 82%), and accuracy(86 vs 81%) in predicting contractile recovery between DSE and Tl-201. The agreement between contractile reserve and cellular integrity was 73% with kappa value of 0.42(p=0.001). CONCLUSION: Contractile reserve has similar sensitivity, specificity and predictive value with cell membrane integrity in predicting contractile recovery. However contractile reserve immediately after restoration does not necessarily imply cell membrane integrity in acute myocardial inFarction.

Comparison between Adaptive Arterial Remodeling and Inadequate Arterial Remodeling Assessed by Intravascular Ultrasound / 대한내과학회지

OBJECTIVES:Adaptive arterial remodeling (AAR) is a process to maintain luminal patency despite atherosclerotic plaque accumulation, whereas some of the lesions undergo a negative remodeling (vessel shrinkage), namely inadequate arterial remodeling (IAR). Histopathologic and intravascular ultrasound (IVUS) studies have shown lumen compromise is delayed until the atherosclerotic lesion occupies more than an estimated 40% to 50% of the potential area within the internal elastic lamina and proposed contributors to lumen compromise are medial and adventitial damage, superficial calcification, apoptosis. However the precise mechanisms and factors leading to these two vascular remodeling patterns are still unclear. The aim of this study is to investigate the effect of plaque accumulation on compensatory dilatation in arterial remodeling and their relationship according to their remodeling patterns. METHODS: Preinterventional intravascular ultrasound images of 56 focal, de novo native and nonosteal lesions on coronary angiography were obtained. Cross sectional area of external elastic membrane (LEEM), Minimal lumen (MLA) and plaque plus media (P&M; P&M=EEM- MLA) in the target lesions were measured. Cross sectional area of external elastic membrane (REEM) and lumen (RLA) in proximal reference segments were measured. The lesions were divided into two groups according to their remodeling patterns ; adequate arterial remodeling (LEEM/REEM>0.78) and inadequate arterial remodeling (LEEM/REEM0.05). CONCLUSION: In adaptive arterial remodeling, the amount of plaque accumulation seems to be an important determinant of compensatory arterial dilatation and contribute weakly to stenosis severity. On the contrary, in inadequate arterial remodeling, it seems to contribute greatly to stenosis severity.

Temporal Changes of Myocardial Capillary Flow after Attempted Reperfusion in Acute Myocardial Infarction

BACKGROUND AND OBJECTIVES: As lack of myocardial perfusion was demonstrated Microvascular function after reperfusion of infarct related artery (IRA) can be changed in convalescent stage for several possible mechanisms such as hyperemia and microvascular stunning. Therefore, myocardial contrast echocardiography (MCE) performed early stage after reperfusion of IRA may cause over or underestimation of the extent of myocardial necrosis. The aims of the study were to demonstrate the temporal changes of myocardial perfusion after revascularization of IRA and to explore the association of late changes of myocardial capillary flow with contractile recovery. METHODS: MCE was performed 5-7days after the attack of acute myocardial infarction (AMI) in 21 patients (M:F=17:4, age: 58+/-12yrs) who underwent successful reperfusion of IRA. MCE was graded by semiquantitative score (0: no opacification, 0.5: partial opacification, 1: homogenous opacification) by 16 segment model. Every patient underwent 1-2months follow up 2D echocardiography and MCE. Improvement of wall motion score more than 1 at follow up was considered to have contractile recovery. RESULTS: Thirty-one of 71 initially akinetic segments were scored as 1, 30 segments as 0.5 and 10 segments as 0 after attempted reperfusion. Twelve of 30 segments with score of 0.5 and 5 of 10 segments with score of 0 showed late improvement of MCE score to 1 and 0.5. Only 1 of 30 segments with score of 0.5 got worse to score of 0. Every segment with late improvement from 0.5 to 1 showed contractile recovery, whereas none of 5 segments with late improvement from 0 to 0.5 showed contractile recovery. There was no significant difference of predictive value between early and late MCE (p=ns). CONCLUSION: Temporal changes of myocardial perfusion from 1week to 2 months in AMI were mainly progressive improvement caused by recovery of microvascular function from stunning rather than progressive microvascular damage or reactive hyperemia. However, it may not significantly affect the validity of MCE in predicting contractile recovery.

Temporal Changes of Myocardial Capillary Flow after Attempted Reperfusion in Acute Myocardial Infarction

BACKGROUND AND OBJECTIVES: As lack of myocardial perfusion was demonstrated Microvascular function after reperfusion of infarct related artery (IRA) can be changed in convalescent stage for several possible mechanisms such as hyperemia and microvascular stunning. Therefore, myocardial contrast echocardiography (MCE) performed early stage after reperfusion of IRA may cause over or underestimation of the extent of myocardial necrosis. The aims of the study were to demonstrate the temporal changes of myocardial perfusion after revascularization of IRA and to explore the association of late changes of myocardial capillary flow with contractile recovery. METHODS: MCE was performed 5-7days after the attack of acute myocardial infarction (AMI) in 21 patients (M:F=17:4, age: 58+/-12yrs) who underwent successful reperfusion of IRA. MCE was graded by semiquantitative score (0: no opacification, 0.5: partial opacification, 1: homogenous opacification) by 16 segment model. Every patient underwent 1-2months follow up 2D echocardiography and MCE. Improvement of wall motion score more than 1 at follow up was considered to have contractile recovery. RESULTS: Thirty-one of 71 initially akinetic segments were scored as 1, 30 segments as 0.5 and 10 segments as 0 after attempted reperfusion. Twelve of 30 segments with score of 0.5 and 5 of 10 segments with score of 0 showed late improvement of MCE score to 1 and 0.5. Only 1 of 30 segments with score of 0.5 got worse to score of 0. Every segment with late improvement from 0.5 to 1 showed contractile recovery, whereas none of 5 segments with late improvement from 0 to 0.5 showed contractile recovery. There was no significant difference of predictive value between early and late MCE (p=ns). CONCLUSION: Temporal changes of myocardial perfusion from 1week to 2 months in AMI were mainly progressive improvement caused by recovery of microvascular function from stunning rather than progressive microvascular damage or reactive hyperemia. However, it may not significantly affect the validity of MCE in predicting contractile recovery.

A Case of Intussusception Induced by Intestinal Tuberculosis / 대한소화기내시경학회지

Although intussusception is primarily a disease of children, about 5 to 10 percent of cases occur in adults. The underlying causes of adult intussusception are tumor, postoperative complication, local bowel ischemia, abnormal motility and rarely intestinal tuberculosis. Recently, we experienced a 62-year-old man with intussusception underlying pulmonary tuberculosis. The postoperative pathologic finding was intestinal tuberculosis. For its rarity, we report this case with review of literatures.

Comparison of Myocardial Fractional and Coronary Flow Reserve after Revascularization in Acute Myocardial Infarction

BACKGROUND AND OBJECTIVE: The aim of this study was to compare the residual diameter stenosis after PTCA with fractional flow reserve (FFR) and coronary flow reserve (CFR), and investigate the correlation between FFR and CFR in patients with acute myocardial infarction (AMI). MATERIALS AND METHOD: The study population consisted of twenty seven patients with myocardial infarction. Baseline and hyperemic average peak velocity (APV) were measured using Doppler wire 15 minutes after restoration of infarct-related artery (IRA). CFR was obtained by the ratio of distal hyperemic APV to baseline APV. Distal coronary arterial pressure (Pd) was measured with advancing the wire distal to the lesion of IRA. Simultaneous proximal aortic pressure (Pa) was measured using guiding catheter. Myocardial FFR was obtained by the ratio of hyperemic Pd to hyperemic Pa. RESULTS: Post-interventional CFR and FFR were 0.85+/-0.44, 0.91+/-0.09. CFR did not show significant correlation with luminal diameter stenosis (%ST). There was no significant correlation between FFR and CFR with a correlation coefficient of 0.29 (p=.25). But, significant correlation was found between %ST and FFR, %ST and hyperemic PG (hPG) with correlation coefficient of -0.70 (p=.0012) and 0.68 (p=.0018). CONCLUSION: In AMI patients, %ST has a significant correlation with FFR and hPG after PTCA. But, there was no significant correlation between FFR and CFR.

A Case of Synchronous Multiple Gastric Cancer ; Quadruple Cancer / 대한소화기내시경학회지

According to Moertel's classification, synchronous multiple gastric cancer is eonsidered to be a sort of multiple primary cancer, The clinical signifieance of multiplicity in gastric cancer was its location relative to the resection line. Compared with patients with single gastric cancer, multiple gastric cancer were more frequently found among the older men, and they were more commonly found in early gastric cancer. The frequency of multifocality in gastric cancer is 2.2-9% in the world literature reports and is increasing recently, with advance in the diagnostic method of gastric cancer. However, synchronous multiple gastric cancer which has more than four foci is rare. In Korea, there has been only one case reported about quadruple gaatric cancer. Recently, we experienced a case of a 58-year-old male patient with synchronously developed-quadruple gastric cancer on the body of stomach, for whom radical total gastrectomy and esophagojejunostomy was done. All of them were moderately differentiated adenocarcinoma. The mapping about four lesions showed that Borrmanin type III AGC extending to the serosa was placed on the posterior wall of higher body; EGC IIc invading the submucosa, the anterior wall of mid body, EGC III confined to the mucosa, the lesser curvature side of mid to lower body; EGC III localizing to the mucosa, the posterior wall of lower body. So we reported this case with a review of literatures.