A Case of Left Atrial Free-Floating Thrombus / 계명의대학술지

A 74-year-old woman who had paroxysmal atrial fibrillation without mitral stenosis was hospitalized for syncope and right-sided weakness. Echocardiography revealed a large free-floating thrombus in the left atrium, sometimes prolapsing partially into the left ventricle in diastole. Because of her poor neurological status, she was managed with anticoagulation. On the 12th day, the thrombus had disappeared on the follow-up echocardiography, and aortoiliac embolization was later detected on computed tomography. Unfortunately, she developed various complications of stroke and limb infarction, and died after 4 months of hospital care. In addition to this case report, we reviewed a total 70 cases of left atrial free-floating thrombus. Atrial fibrillation and mitral pathology were two major causative factors. All the cases, except 1, were confirmed on echocardiography. The most common presentation that led to echocardiography was systemic embolization, followed by heart failure. Others were acute hemodynamic decompensation from mitral obstruction, chest pain, palpitation, and bacteremia. Cardiac thrombectomy was the preferred treatment modality with favorable outcomes.

A Case of Pleural Effusion and Pulmonary Edema Caused by Calcium Channel Blockers in a Patient of Systemic Hypertension

Calcium channel blockers (CCBs) are very popular drugs to lower blood pressure (BP) without significant side effects. A 72-year-old man admitted for uncontrolled hypertension. He had history of hypertension, atrial fibrillation with slow ventricular response, angina, abdominal aortic aneurysm, and stage 3 chronic kidney disease. He had taken several anti-hypertensives, such as amlodipine 5 mg, perindopril 8 mg, and indepamide 1.5 mg. To control BP, nifedipine 120 mg was added. Then pulmonary edema and pleural effusion was developed. Echocardiography showed preserved left ventricular ejection fraction and mild mitral regurgitation. Fluid restriction and high dose furosemide did not cease pleural fluid accumulation. Thus a total of 4 times of thoracentesis were done and all fluid analyses revealed transudate. We thought that pleural effusion and pulmonary edema was induced by CCBs and discontinued the drugs. He recovered quickly and finally discharged in a stable condition.

Coronary artery vasospasm after atrial septal defect surgery / 영남의대학술지

Coronary vasospasm is one of the fatal complications that may occur in patients undergoing open heart surgery. To date, however, there are not many cases in this series and no definite pathophysiology has been documented. We experienced a case of coronary artery vasospasm after atrial septal defect (ASD) surgery and then successfully treated it with both transbrachial intra-aortic balloon pump and percutaneous cardiopulmonary support. Only several hours after ASD surgery, the patient exhibited the cardiovascular collapse, the ST-segment elevation, followed by ventricular fibrillation and normal coronary angiography findings. It is important to make a differential diagnosis of coronary artery vasospasm in patients presenting with ST-segment elevation who had no notable coronary artery diseases. This case indicates that clinicians should be aware of the possibility that the coronary artery vasospasm may also occur in patients undergoing ASD surgery.

A Case of Acute Total Obstruction of the Left Main Coronary Artery Presenting with Atypical Momentary Electrocardiogram Changes

Acute total obstruction of the left main coronary artery (LMCA) is a serious emergency condition requiring prompt diagnosis and treatment. Unless properly treated, it will likely progress to cardiogenic shock and a high mortality rate. We report a case of acute LMCA total obstruction presenting with atypical momentary electrocardiogram (ECG) changes including right bundle branch block with left axis deviation, and ST-segment elevation in aVR and aVL. We focus on the unusual ECG changes associated with LMCA obstruction which should be noted in order to ensure revascularization without delay, especially when this condition is accompanied by cardiogenic shock.

A Case of Primary Cardiac Lymphoma Mimicking Acute Coronary and Aortic Syndrome

Primary cardiac lymphoma (PCL) is a rare disorder, but the incidence is increasing and its clinical manifestations are various. We report a case of PCL, which mimics an acute coronary and aortic syndrome. A 51 year-old female was presented with chest pain radiating to the back. Her initial electrocardiogram revealed T wave inversion in the leads of V 5-6, II, III and aVF. Additionally, cardiac troponin-T was slightly elevated. Chest radiography showed marked mediastinal widening. Computed tomography scan showed a huge pericardial mass. The histopathologic findings of the mass were compatible with diffuse large B cell lymphoma. She died of refractory ventricular tachycardia, probably, due to an extensive infiltration of PCL to the myocardium.

Effect of Aspiration Thrombectomy on Microvascular Dysfunction in ST-Segment Elevation Myocardial Infarction With an Elevated Neutrophil Count

BACKGROUND AND OBJECTIVES: Aspiration thrombectomy (AT) during primary percutaneous coronary intervention (PCI) is an effective adjunctive therapy for ST-segment elevation myocardial infarction (STEMI). An elevated neutrophil count in STEMI is associated with microvascular dysfunction and adverse outcomes. We evaluated whether AT can improve microvascular dysfunction in patients with STEMI and an elevated neutrophil count. SUBJECTS AND METHODS: Seventy patients with STEMI undergoing primary PCI from August 2007 to February 2009 in our institution were classified by tertiles of neutrophil count on admission (7,600/mm3). The angiographic outcome was post-procedural thrombolysis in myocardial infarction (TIMI) flow grade. Microvascular dysfunction was assessed by TIMI myocardial perfusion (TMP) grade and ST-segment resolution on electrocardiography 90 minutes after PCI. The clinical outcome was major adverse cardiac event (MACE), defined as cardiac death, re-infarction, and target lesion revascularization at 9 months. RESULTS: There were no significant differences in the clinical characteristics and pre- and post-procedural TIMI flow grades between the neutrophil tertiles. As the neutrophil count increased, a lower tendency toward TMP grade 3 (83% vs. 52% vs. 54%, p=0.06) and more persistent residual ST-segment elevation (>4 mm: 13% vs. 26% vs. 58%, p=0.005) was observed. The 9-month MACE rate was similar between the groups. On subgroup analysis of AT patients (n=52) classified by neutrophil tertiles, the same tendency toward less frequent TMP grade 3 (77% vs. 56% vs. 47%, p=0.06) and persistent residual ST-segment elevation (>4 mm: 12% vs. 28% vs. 53%, p=0.05) was observed as neutrophil count increased. CONCLUSION: A higher neutrophil count at presentation in STEMI is associated with more severe microvascular dysfunction after primary PCI, which is not improved with AT.

Effect of Aspiration Thrombectomy on Microvascular Dysfunction in ST-Segment Elevation Myocardial Infarction With an Elevated Neutrophil Count

BACKGROUND AND OBJECTIVES: Aspiration thrombectomy (AT) during primary percutaneous coronary intervention (PCI) is an effective adjunctive therapy for ST-segment elevation myocardial infarction (STEMI). An elevated neutrophil count in STEMI is associated with microvascular dysfunction and adverse outcomes. We evaluated whether AT can improve microvascular dysfunction in patients with STEMI and an elevated neutrophil count. SUBJECTS AND METHODS: Seventy patients with STEMI undergoing primary PCI from August 2007 to February 2009 in our institution were classified by tertiles of neutrophil count on admission (7,600/mm3). The angiographic outcome was post-procedural thrombolysis in myocardial infarction (TIMI) flow grade. Microvascular dysfunction was assessed by TIMI myocardial perfusion (TMP) grade and ST-segment resolution on electrocardiography 90 minutes after PCI. The clinical outcome was major adverse cardiac event (MACE), defined as cardiac death, re-infarction, and target lesion revascularization at 9 months. RESULTS: There were no significant differences in the clinical characteristics and pre- and post-procedural TIMI flow grades between the neutrophil tertiles. As the neutrophil count increased, a lower tendency toward TMP grade 3 (83% vs. 52% vs. 54%, p=0.06) and more persistent residual ST-segment elevation (>4 mm: 13% vs. 26% vs. 58%, p=0.005) was observed. The 9-month MACE rate was similar between the groups. On subgroup analysis of AT patients (n=52) classified by neutrophil tertiles, the same tendency toward less frequent TMP grade 3 (77% vs. 56% vs. 47%, p=0.06) and persistent residual ST-segment elevation (>4 mm: 12% vs. 28% vs. 53%, p=0.05) was observed as neutrophil count increased. CONCLUSION: A higher neutrophil count at presentation in STEMI is associated with more severe microvascular dysfunction after primary PCI, which is not improved with AT.

Contrast-induced Nephropathy in Patients Undergoing Percutaneous Coronary Angiography and its Clinical Characteristics / 대한신장학회지

PURPOSE: Contrast media-induced nephropathy (CIN) following coronary angiography is associated with an increased mortality and morbidity. We investigated the incidence of nephrotoxicity, clinical characteristics, laboratory characteristics and risk factors of CIN in patients undergoing coronary angiography. METHODS: We retrospectively evaluated the medical records of 555 patients who had undergone coronary angiography at the Sanggye Paik Hospital, from January 2004 to December 2005. We defined CIN as any increase in the creatinine value of more than 0.5 mg/dL or 50% of baseline value. RESULTS: Among 555 patients, CIN developed in 10 of 48 patients (20.8%) with renal insufficiency (serum creatinine > or =1.4 mg/dL) and in 7 of 507 patients (1.4%) without renal insufficiency (p or =65 years were the significant predictors of CIN. There were no statistical differences in contrast type and volume according to the development of CIN. CONCLUSION: Our data supported the assumption that renal insufficiency, congestive heart failure, hyperuricemia and anemia may be the risk factors of developing CIN.

Combination chemotherapy with topotecan and vincristine for patients with refractory or recurrent small cell lung cancer / 대한내과학회지

BACKGROUDN: Small cell lung cancer (SCLC) is a chemotherapy-sensitive tumor. However, the duration of response is usually short and most patients experience relapses. Topotecan is commonly used for treatment of these patients. Nevertheless, the response rate of topotecan as a single regimen is only about 20% and the resulting severe myelosuppression is troublesome. Vincristine is also an active agent, and it does not compromise the marrow function. In this background, we evaluated the efficacy and toxicities of topotecan and vincristine combination chemotherapy. METHODS: Patients with pathologically confirmed SCLC refractory to or recurrent after platinum-based chemotherapy were eligible for this study. The treatment regimen was as follows; topotecan 1.5 mg/m2/day IV bolus on day 1, 2 and 3 and vincristine 1.5 mg/m2 (maximum 2 mg on day 1 (on every cycle)) and day 2 (on odd cycles only). This regimen was repeated every 3 weeks. The efficacy was evaluated in terms of response rate, time to progression and overall survival duration. The toxicities were assessed according to NCI-CTC version 3.0. RESULTS: A total of 19 patients were entered into this study. The median age was 63 years (range 43-85 years). Partial response was obtained for 3 patients (response rate 15.8%, 95% CI: 0-32.5%). The median time to progression and survival duration was 51 days and 199 days, respectively. For a total of 52 cycles of treatment, grade 3 or 4 neutropenia and thrombocytopenia were observed in 25.0% and 11.5% of the patients, respectively. Grade 2 neurotoxicities were observed in 15.4% of the patients. There was no treatment-related mortality. CONCLUSIONS: The topotecan and vincritine combination is active and safe for patients with recurrence or refractory SCLC. However, the benefit of adding vincristine to topotecan needs to be confirmed in further studies.

A Case of Wegener's Granulomatosis with Colitis / 대한류마티스학회지

Wegener's granulomatosis is an uncommon disease that is characterized by granulomatous necrotizing vasculitis affecting small vessels. It typically targets the upper and lower respiratory tract and the kidney, but gastrointestinal involvement is rare. A 41-year-old man who has been already diagnosed with Wegener's granulomatosis by nasal cavity biopsy was admitted with bloody diarrhea and high fever. He had discontinued taking the immunosuppressive medication. His colonoscopic finding revealed colitis and ulcer lesions which biopsies show vasculitis and ill-defined granuloma. Therefore he was treated with systemic steroid and improved dramatically.

Early Detection of Perforation of the Right Ventricle by a Permanent Pacemaker Lead

Ventricular perforation is a rare complication of permanent cardiac pacemaker implantation. We report here on a 68-year-old woman with a dual chamber permanent pacemaker that had been implanted one month earlier, and she suffered cardiac perforation from the pacemaker lead. Frequent follow-up via12-lead surface electrocardiography and chest radiography and the proper work-up for pacemaker implantation are needed for detecting rare complications after pacemaker implantation.

Growth Changes of Lower Extremities after Pyogenic or Tuberculous Knee Joints in Children / 대한정형외과학회잡지

It is well-known that the infection of bone and joints could produce the shortening by destroying the articuiar cartilage and growth plate, or the lengthening hy increased hlood circulation to the epiphyseal and metaphyseal regions of long bone. Since 1985, we have treated total l7 cases of children s pyogenic or tuberculous children s knee with early arthrotomy and continuous irrigation etc. and followed their long hone growth for average 53 months after surgical intervention. Five patients (group I ) were early treated within 2 weeks and twelve patients(group 3 ) were delayed to treat their knees for more than 2 weeks of symptom development. Total 11 patients out of 17 cases(64.7%) (2 cases of group 1 pyogenic arthritis, and 1 case of group l and 8 cases of group II tuberculous arthritis) revealed growth acceleration. Femoral lengthening was much more greater than that of tibial growth, and the size of patella, distal femoral and proximal tibial epiphysis which were measured by computerized digitizer were also significantly larger than that of opposite knee. The total limb length was increased hy average 7mm in 6 months, l4mm in 1 year and 3mm in 2 years after operation. These results suggest the pyogenic and tuberculous arthritis in children s knee should he treated as early as possible after symptoms developed, and followed them to trace their limh inequality for at least 2 years after surgery. That means the early arthrotomy for tuberculous knee or even in pyogenic arthritis can preserve normal articular cartilage and can also prevent the early epiphyseal closure hy infection. and can get the limh lengthening by increased blood circulation around the knee joint.

Mechanical Properties of Palmar Radiocarpal Ligaments of Wrist and Their Clinical significances / 대한정형외과학회잡지

To study why the palmar capsular connections between radius and lunate remain intact in perilunate ligamentous injury of the wrist joint, and to compare the material properties of the short radiolunate, long radiolunate, and radioscaphoid region of the radioscaphocapitate ligaments (as the extrinsic ligaments) with those of the intrinsic ligaments of the previous papers, the anatomical and mechanical characteristics of those three palmar radiocarpal ligaments of twenty cadavers were measured and tested by a servo-hydraulic test machine. In spite of its small cross-sectional area (24% of short radiolunate ligament), the radioscaphoid ligament demonstrates a failure load of 58% and a stress of 260% of the short radiolunate ligament, and toughness similar to both the short and long radiolunate ligaments. This suggests that the radioscaphocapitate ligament may contribute as an initial constraint to perilunate injury. The failure load of the scapholunate ligament might be smaller than previously reported due to testing strain rate, which coupled with its short initial length may make it more vulnerable to injury at lower applied loads. The short radiolunate ligament, in spite of the largest width and cross-sectional area, has a failure load and toughness similar to the long radiolunate ligament. The material properties of short and long radiolunate ligaments may explain why the rest of the carpals persistently dislocate or fracture about lunate.