An Intra-procedural Stent Thrombosis in a Prasugrel Resistant Patient Treated with Ticagrelor / 계명의대학술지

Stent thromboses due to multifactorial causes including hypercoagulable conditions and high on treatment platelet reactivity (HTPR), which means a low response to anti-platelet therapy, especially clopidogrel. Prasugrel is a third generation thienopyridine and inactive pro-drug requiring metabolic activation in vivo, which improves the rate of HTPR with clopidogrel. This drug is mostly effective, with a potent, fast, and consistent anti-platelet action, but rare cases of inadequate platelet inhibition with prasugrel have been reported. Here we describe the case of a 47-year-old man who presented with a recurrent acute myocardial infarction and ST during an intravascular ultrasound pullback and was resistant to prasugrel, was successfully treated with ticagrelor.

Persistent Truncus Arteriosus with Aortic Dominance in Female Adult Patient

Persistent truncus arteriosus categories associated with different natural histories and various surgical approaches were reported. Although pulmonary overflow and severe heart failure are common, some patients who have hypoplastic pulmonary artery systems may show lesser symptoms of heart failure and remain in relatively stable condition. We experienced a 33-year-old woman with uncorrected type II persistent truncus arteriosus who presented with cyanosis rather than congestive heart failure, and are presenting her images.

The Clinical Impact of Bedside Contrast Echocardiography in Intensive Care Settings: A Korean Multicenter Study

BACKGROUND AND OBJECTIVES: We assessed the ability of portable echocardiography (with contrasts) to clearly delineate the cardiac structure, and evaluated the impact of its use on the diagnosis and management of critically ill patients in Korea. SUBJECTS AND METHODS: We prospectively enrolled 123 patients (mean age 66+/-16 years), who underwent portable transthoracic echocardiography (with contrast) for image enhancement at 12 medical centers. The quality of the global left ventricular (LV) images, the number of the regional LV segments visualized, the ability to visualize the LV apex and the right ventricle (RV), and any changes in the diagnostic procedure and treatment strategy were compared before and after the contrast. RESULTS: Of the 123 patients, 52 (42%) were using mechanical ventilators. The amount of poor or uninterpretable images decreased from 48% to 5% (p<0.001), after the contrast. Before the contrast, 15.6+/-1.1 of 16 LV segments were seen, which improved to 15.9+/-0.6 segments (p=0.001) after the contrast. The ability to visualize the LV apex increased from 47% to 94% (p<0.001), while the inability to clearly visualize the RV decreased from 46% to 19% (p<0.001). Changes in the diagnostic procedure (for example, not requiring other types of imaging studies) were observed in 18% of the patients, and the treatment plan (medication) was altered in 26% of patients after the contrast echocardiography. CONCLUSION: The use of a contrast agent during the portable echocardiography, in intensive care settings, can improve the image quality and impact the diagnostic procedures and treatment for Korean patients.

Acute Myocardial Infarction during the Subacute Phase of Refractory and Incomplete Kawasaki Disease in a Five-year-old Boy / 대한구급학회지

Kawasaki disease (KD) is an acute, systemic vasculitis of childhood. The early mortality of KD results from coronary complications, mainly aneurysmal thrombosis with myocardial infarction, and the subacute phase of KD has the highest risk of mortality. Although there have been reports of ischemic heart disease as late cardiologic sequelae of KD in young adults, acute myocardial infarction caused by coronary complications in the subacute phase of KD is rare. We experienced one pediatric patient who developed coronary artery aneurysm and acute myocardiac infarction (AMI) during the subacute phase of incomplete and intravenous immunoglobulin (IVIG)-nonresponsive KD. The patient was given a good prognosis due to close monitoring and early recognition of AMI. Physicians should carefully monitor KD patients who do not respond to initial IVIG therapy and who show progressive coronary artery dilatation. If such a patient complaints of chest pain and the ECG shows hyperacute T waves, the physician should suspect development of AMI.

A Case of Infective Endocarditis and Meningitis Caused by Streptococcus agalactiae / 대한내과학회지

It is well known that newborns and pregnant women typically show higher rates of Streptococcus agalactiae infection. However, the incidence of group B streptococcal (GBS) disease in nonpregnant adults is increasing, particularly in elderly persons and those with significant underlying diseases, such as diabetes, neurologic impairment, and cirrhosis. Skin infections, osteoarticular infections, and pneumonia are commonly associated with GBS, while meningitis and endocarditis are less common. S. agalactiae endocarditis is an uncommon but important condition with a high mortality rate. Several cases of endocarditis due to S. agalactiae have been reported in the literature, but there have been no reports of S. agalactiae meningitis associated with endocarditis in Korea. Here, we describe a case of S. agalactiae meningitis and endocarditis in a 50-year-old man who was successfully treated with intravenous antibiotics and cardiac surgery.

The Prognostic Implication of Metabolic Syndrome in Patients with Heart Failure

BACKGROUND AND OBJECTIVES: Metabolic syndrome (MetS) increases the risk of heart failure (HF). The purpose of this study was to identify the prevalence of MetS in patients with HF and determine the syndrome's association with HF in clinical and laboratory parameters. SUBJECTS AND METHODS: A total of 3200 HF patients (67.6+/-14.5 years) enrolled in a nationwide prospective Korea HF Registry between Jan. 2005 and Oct. 2009. Patients were divided into two groups according to the presence or absence of MetS at admission: group I (presence, n=1141) and group II (absence, n=2059). RESULTS: The prevalence of MetS was 35.7% across all subjects and was higher in females (56.0%). The levels of white blood cells, platelets, creatinine, glucose, and cholesterol were significantly higher in group I than in group II. Left ventricular dimension and volume was smaller and ejection fraction was higher in group I than in group II. An ischemic cause of HF was more frequent in group I. The rates of valvular and idiopathic cause were lower in group I than in group II. The rate of mortality was lower in group I than in group II (4.9% vs. 8.3%, p<0.001). CONCLUSION: Despite the increased cardiovascular risks in MetS, MetS was found to be associated with decreased mortality in HF.

Two-year Clinical Outcomes of Patients with Long Segments Drug-Eluting Stents: Comparison of Sirolimus-Eluting Stent with Paclitaxel-Eluting Stent

Limited data are available on the long-term clinical efficacy of drug-eluting stent (DES) in diffuse long lesions. From May 2006 to May 2007, a total of 335 consecutive patients (374 lesions) were underwent percutaneous coronary intervention with implantation of long DES (> or = 30 mm) in real world practice. Eight-month angiographic outcomes and 2-yr clinical outcomes were compared between SES (n = 218) and PES (n = 117). Study endpoints were major adverse cardiac events including cardiac death, myocardial infarction, target-lesion revascularization, target-vessel revascularization and stent thrombosis. Baseline characteristics were similar in the two groups as were mean stent length (44.9 +/- 15.2 mm in SES and 47.4 +/- 15.9 in PES, P = 0.121). Late loss at 8 months follow-up was significantly lower in SES than in PES group (0.4 +/- 0.6 mm in SES vs 0.7 +/- 0.8 mm in PES, P = 0.007). Mean follow-up duration was 849 +/- 256 days, and 2-yr cumulative major adverse cardiac events were significantly lower in the SES than in the PES group (5.5% in SES vs 15.4% in PES, P = 0.003). In conclusion, long-term DES use in diffuse long coronary lesions is associated with favorable results, with SES being more effective and safer than PES in this real-world clinical experience.

Predictors of In-Hospital Mortality and Left Ventricular Functional Recovery in Korean Patients with Stress-Induced Cardiomyopathy: Stress-Induced Cardiomyopathy Registry Data / 대한내과학회지

BACKGROUND/AIMS: The reported frequency of stress-induced cardiomyopathy (SCMP, Takotsubo cardiomyopathy) is increasing; however, there are no data regarding predictors of in-hospital mortality and the recovery of left ventricular (LV) systolic function in patients with SCMP. Therefore, in this study, we sought to identify clinical predictors of in-hospital mortality and of the recovery of LV dysfunction in Korean patients with SCMP. METHODS: From November 2004 to November 2010, 155 patients who fulfilled the clinical diagnostic criteria of the Mayo clinic for SCMP were enrolled retrospectively from eight medical centers in Korea. We checked in-hospital deaths and compared the LV ejection fraction (LVEF) and wall-motion score index (WMSI) upon enrollment for each patient with that after 1 week using echocardiograms. A total of 55 continuous variables and 52 nominal variables were analyzed to find variables associated with in-hospital mortality and the recovery of LV dysfunction. All significant variables were entered into a logistic regression analysis. RESULTS: The mean age of the patients was 64 +/- 15 years; 118 (76.1%) patients were female. The in-hospital mortality rate was 5.2% (n = 8). An elevated initial platelet count was identified as a predictor of in-hospital mortality (odds ratio [95% CI]: 0.99 [0.99-1.00]). There were no predictors of the recovery of LVEF. Predictors of the recovery of WMSI were an absence of arrhythmic events (odds ratio [95% CI]: 22.89 [1.98-265.34]) and an elevated initial LV end-systolic diameter (odds ratio [95% CI]: 0.86 [0.74-1.00]). CONCLUSIONS: An initial absence of arrhythmic events and elevated LV end-diastolic pressure in patients with SCMP may be predictors of the timely recovery of LV dysfunction.

Characteristics, Outcomes and Predictors of Long-Term Mortality for Patients Hospitalized for Acute Heart Failure: A Report From the Korean Heart Failure Registry

BACKGROUND AND OBJECTIVES: Acute heart failure (AHF) is associated with a poor prognosis and it requires repeated hospitalizations. However, there are few studies on the characteristics, treatment and prognostic factors of AHF. The aims of this study were to describe the clinical characteristics, management and outcomes of the patients hospitalized for AHF in Korea. SUBJECTS AND METHODS: We analyzed the clinical data of 3,200 hospitalization episodes that were recorded between June 2004 and April 2009 from the Korean Heart Failure (KorHF) Registry database. The mean age was 67.6+/-14.3 years and 50% of the patients were female. RESULTS: Twenty-nine point six percent (29.6%) of the patients had a history of previous HF and 52.3% of the patients had ischemic heart disease. Left ventricular ejection fraction (LVEF) was reported for 89% of the patients. The mean LVEF was 38.5+/-15.7% and 26.1% of the patients had preserved systolic function (LVEF > or =50%), which was more prevalent in the females (34.0% vs. 18.4%, respectively, p<0.001). At discharge, 58.6% of the patients received beta-blockers (BB), 53.7% received either angiotensin converting enzyme-inhibitors or angiotensin receptor blockers (ACEi/ARB), and 58.4% received both BB and ACEi/ARB. The 1-, 2-, 3- and 4-year mortality rates were 15%, 21%, 26% and 30%, respectively. Multivariate analysis revealed that advanced age {hazard ratio: 1.023 (95% confidence interval: 1.004-1.042); p=0.020}, a previous history of heart failure {1.735 (1.150-2.618); p=0.009}, anemia {1.973 (1.271-3.063); p=0.002}, hyponatremia {1.861 (1.184-2.926); p=0.007}, a high level of serum N-terminal pro-B-type natriuretic peptide (NT-proBNP) {3.152 (1.450-6.849); p=0.004} and the use of BB at discharge {0.599 (0.360-0.997); p=0.490} were significantly associated with total death. CONCLUSION: We present here the characteristics and prognosis of an unselected population of AHF patients in Korea. The long-term mortality rate was comparable to that reported in other countries. The independent clinical risk factors included age, a previous history of heart failure, anemia, hyponatremia, a high NT-proBNP level and taking BB at discharge.

Co-expression of CdtA and CdtC subunits of cytolethal distending toxin from Aggregatibacter actinomycetemcomitans / 대한치주과학회지

PURPOSE: Cytolethal distending toxin (CDT) is a family of heat-labile cytotoxins produced by several gram-negative mucosa-associated pathogens, including Aggregatibacter actinomycetemcomitans. CDT is well known to be capable of inducing growth arrest, morphological alterations, and eventually death in various cells. CDT belongs to a tripartite AB2 toxin (CdtB: the enzymatic A subunit ; CdtA and CdtC: the heterodimeric B subunit). Previous studies proposed that CdtA and CdtC together bind to a cell surface receptor and glycolipids act as a receptor for A. actinomycetemcomitans CDT (AaCDT). In this study, recombinant CdtA and CdtC proteins of AaCDT were co-expressed in a bacterial expression system and tested for their affinity for GM1 ganglioside. METHODS: The genes for CdtA and CdtC from A. actinomycetemcomitans Y4 were utilized to construct the expression vectors, pRSET-cdtA and pET28a-cdtC. Both CdtA and CdtC proteins were expressed in Escherichia coli BL21(DE3) and then purified using hexahistidine (His6) tag. The identity of purified protein was confirmed by anti-His6 antibody and monoclonal anti-CdtA antibody. Furthermore, the affinity of recombinant protein to GM1 ganglioside was checked through ELISA. RESULTS: Recombinant CdtA and CdtC proteins were expressed as soluble proteins and reacted to anti-His6 and monoclonal anti-CdtA antibodies. ELISA revealed that purified soluble CdtA-CdtC protein bound to GM1 ganglioside, while CdtA alone did not. CONCLUSIONS: Co-expression of CdtA and CdtC proteins enhanced the solubility of the proteins in E. coli, leading to convenient preparation of active CdtA-CdtC, a critical material for the study of AaCDT pathogenesis.

Analysis on cause of failure of guided bone regeneration during implant placement: A retrospective study / 대한치주과학회지

PURPOSE: The aim of this retrospective study is to evaluate survival rate of implant and bone formation, to analyze failure contribution factor. MATERIAL AND METHODS: A total of 52 consecutive patients(35 male, 17 female, mean age 49 years) with 104 osseous defects were treated during the period from October 2004 to June 2007 with a simultaneous or staged GBR approach using non-resorbable or resorbable membranes combined with autogenous bone grafts or xenograft(Bio-Oss, Bio-cera, BBP). RESULT: A total of 32(30.8%) of 104 GBR-treated sites failed the bone formation and a total of 5(5.6%) of 89 implants were removed. Early exposure of the membrane has significantly affected bone formation(p<0.05). Non-resorbable membrane showed more exposure of the membrane and low success rate of bone formation than resorbable membrane(p<0.05). There were no difference between success rate of bone formation and using autogenous bone or graft materials. There were no statistically significant difference between success rate of bone formation and smoking or using PRP. Mandible showed more success rate of bone formation than maxilla(p<0.05). CONCLUSION: Early exposure of the membrane, membrane type and maxilla/mandible type have influence on success rate of bone formation during GBR.

Survival rate of implant placement in the maxilla treated with sinus elevation by the lateral approach: A retrospective study / 대한치주과학회지

PURPOSE: Osseointegration of implants in patients with pneumatized maxillary sinuses is difficult to achieve due to the deficiency of available bone in the posterior maxilla after loss of teeth. Maxillary sinus elevation is a method to overcome this problem. In this study, we evaluated the implant survival rate and the relationship between implant survival in patients with sinus elevation by the lateral approach. MATERIALS AND METHODS: A total of 48 patients were consecutively treated with sinus elevation by the lateral approach between February 2003 & August 2006 at the dental hospital of Chonbuk National university. A total of 113 implants were placed. The mean healing period was 7.1 months and implants were placed after a mean period of 5.6 months. The mean observation period was 21.8 months. RESULTS: Out of the 113 implants placed, fifteen failed, resulting in a survival rate of 86.7%, 18 cases of sinus membrane perforation were observed out of 65 sinuses treated. 33 implants were placed in a perforated site and 10 failed, representing a 60.7% implant survival. 80 implants were placed in a nonperforated site and 5 failed, representing a 92.6% implant survival. CONCLUSIONS: Implant placement with sinus elevation is an acceptable treatment for short term Results. Sinus membrane perforation and postoperative complications, however, may have an effect on implant failure.

Cloning and protein expression of Aggregatibacter actinomycetemcomitans cytolethal distending toxin C / 대한치주과학회지

PURPOSE: Aggregatibacter actinomycetemcomitans was associated with localized aggressive periodontitis, endocarditis, meningitis, and osteomyelitis. The cytolethal distending toxin (CDT) of A. actinomycetemcomitans was considered as a key factor of these diseases is composed of five open reading frames (ORFs). Among of them, An enzymatic subunit of the CDT, CdtB has been known to be internalized into the host cell in order to induce its genotoxic effect. However, CdtB can not be localized in host cytoplasm without the help of a heterodimeric complex consisting of CdtA and CdtC. So, some studies suggested that CdtC functions as a ligand to interact with GM3 ganglioside of host cell surface. The precise role of the CdtC protein in the mechanism of action of the holotoxin is unknown at the present time. The aim of this study was to generate recombinant CdtC proteins expression from A. actinomycetemcomitans, through gene cloning and protein used to investigate the function of Cdt C protein in the bacterial pathogenesis MATERIALS AND METHODS: The genomic DNA of A. actinomycetemcomitans Y4 (ATCC29522) was isolated using the genomic DNA extraction kit and used as template to yield cdtC genes by PCR. The amplifed cdtC genes were cloned into T-vector and cloned cdt C gene was then subcloned to pET28a expression vector. The pET28a-cdtC plasmid expressed in BL21 (DE3) Escherichia coli system. Diverse conditons were tested to opitimize the expression and purification of functional CdtC protein in E. coli. RESULTS: In this study we reconstructed CdtC subunit of A. actinomycetemcomitans Y4 and comfirmed the recombinant CdtC expression by SDS-PAGE and Western Blotting. The expression level of the recombinant CdtC was about 2% of total bacterial proteins. CONCLUSION: The lab condition of procedure for the purification of functionally active recombinant CdtC protein is established. The active recombinant CdtC protein will serve to examine the role of CdtC proteins in the host recognition and enzyme activity of CDT and investigate the pathological process of A. actinomycetemcomitans in periodontal disease.

Production of the polyclonal subunit C protein antibody against Aggregatibacter actinomycetemcomitans cytolethal distending toxin / 대한치주과학회지

PURPOSE: Cytolethal distending toxin (CDT) considered as a key factor of localized aggressive periodontitis, endocarditis, meningitis, and osteomyelitis is composed of five open reading frames (ORFs). Among of them, the individual role of CdtA and CdtC is not clear; several reports presents that CDT is an AB2 toxin and they enters the host cell via clathrin-coated pits or through the interaction with GM3 ganglioside. So, CdtA, CdtC, or both seem to be required for the delivery of the CdtB protein into the host cell. Moreover, recombinant CDT was suggested as good vaccine material and antibody against CDT can be used for neutralization or for a detection kit. MATERIALS AND METHODS: We constructed the pET28a-cdtC plasmid from Aggregatibacter actinomycetemcomitans Y4 by genomic DNA PCR and expressed in BL21 (DE3) Escherichia coli system. We obtained the antibody against the recombinant CdtC in mice system. Using the anti-CdtC antibody, we test the native CdtC detection by ELISA and Western Blotting and confirm the expression time of native CdtC protein during the growth phase of A. actinomycetemcomitans. RESULTS: In this study we reconstructed CdtC subunit of A. actinomycetemcomitans Y4 and generated the anti CdtC antibody against recombinant CdtC subunit expressed in E. coli system. Our anti CdtC antibody can be interacting with recombinant CdtC and native CDT in ELISA and Western system. Also, CDT holotoxin existed at 24h but not at 48h meaning that CDT holotoxin was assembled at specific time during the bacterial growth. CONCLUSION: In conclusion, we thought that our anti CdtC antibody could be used mucosal adjuvant or detection kit development, because it could interact with native CDT holotoxin.

Purification and refolding of the recombinant subunit B protein of the Aggregatibacter actinomycetemcomitans cytolethal distending toxin / 대한치주과학회지

PURPOSE: Aggregatibacter actinomycetemcomitans is associated with localized aggressive periodontitis. It produces cytolethal distending toxin (CDT), which induces cell cycle arrest in the G2/M phase. The CDT holotoxin is composed of CdtA, CdtB, and CdtC. CdtB has structural homology to human DNase I and is an active component of the CDT complex acting as a DNase. In particular, the pattern homology seen in the CdtB subunit has been associated with specific DNase I residues involved in enzyme catalysis, DNA binding, and metal ion binding. So, to study the functions and regulation of recombinant CdtB, we made up a quantity of functional recombinant CdtB and tested it in relation to the metal ion effect. MATERIALS AND METHODS: We constructed the pET28a-cdtB plasmid from A. actinomycetemcomitans Y4 by genomic DNA PCR and expressed it in the BL21 (DE3) Escherichia coli system. We obtained the functional recombinant CdtB by the refolding system using the dialysis method and then analyzed the DNase activity and investigated the metal ion effect from plasmid digestion. RESULTS: The recombinant CdtB subunit was expressed as the inclusion bodies. We were able to obtain functional recombinant CdtB subunit using refolding system. We confirmed that our refolded recombinant CdtB had DNase activity and was influenced by the metal ions Mg2+ and Ca2+. CONCLUSION: We suggest that the factors influencing recombinant CdtB may contribute to CDT associated diseases, such as periodontitis, endocarditic, meningitis, and osteomyelitis.

Myocardial protective effects of nicorandil and verapamil during ischemia-reperfusion in an isolated perfused rat heart

BACKGROUND: To reduce or prevent myocardial injury during an ischemia-reperfusion episode, some pharmacological interventions, including administering nicorandil or verapamil, have becomepopular in clinical situations. Nicorandil is a N-(2-hydroxyethyl)- nicotinamide nitrate ester, and it's effective mainly by opening the K+ ATP channels in the mitochondrial membrane, and verapamil is useful for reducing the endothelial injury of coronary vessels during ischemia. In this study, we aimed to determine the cardioprotective effect when both drugs are used simultaneously. METHODS: Isolated rat hearts (the Langendorff perfusion model) were perfused with Krebs-Henseleit bicarbonate buffer. After 30 minutes of controlled perfusion, we added nicorandil or verapamil separately and both drugs were administered together in another group (the mixed group) and we then induced ischemia for 30 minutes. We measured the heart rate, the developed ventricularpressure and the dP/dT during the control period during drug infusion and during reperfusion at 15, 30, 45 and 60 minutes. RESULTS: During reperfusion, the mixed group showed more favorable results for the developed left ventricular pressure (LVP), the dP/dT and the rate pressure product (RPP). The heart rate was significantly decreased as reperfusion processed in all the groups. CONCLUSIONS: For myocardial protection during ischemia-reperfusion, a mixed drug regimen is more beneficial than a single drug regimen, and this occurs without inducing a significant decrease of the heart rate.

Guided tissue regeneration using resorbable membrane with or without xenograft in osseous defect / 대한치주과학회지

PURPOSE: In advanced case of periodontitis, surgical treatment without bone contouring may result in residual pockets inaccessible to proper cleaning during post-treatment maintenance. This problem can be avoided or reduced by applying guided tissue regeneration. MATERIALS AND METHODS: All of 3 patients had deep periodontal pocket depth and bleeding on probing, and radiograph revealed osseous defect, so we planned guided tissue regeneration using resorbable membrane with or without xenograft. RESULT: 6 months later, periodontal pocket depth and bleeding on probing was improved and gingiva was stable. CONCLUSION: Guided tissue regeneration using resorbable membrane with or without xenograft in osseous defect is predictable.

A case of aortoesophageal fistula after NSAID use / 대한내과학회지

Aortoesophageal fistula secondary to thoracic aortic aneurysm is an uncommon cause of gastrointestinal bleeding and is uniformly fatal without surgical intervention. We report a case of aortoesophageal fistula in an 83-year-old male who presented with massive hematemesis after 4 days of NSAID use. Endoscopy showed a kissing esophageal ulcer with a pulsating mass lesion in the mid esophagus. HRCT showed a fusiform aortic aneurysm in the descending aorta that was affecting the mid esophagus.

Risk Factors Associated with Hemodynamic Instability during Stent Implantation in Unprotected Left Main Lesions without Routine IABP: Identification of the High Risk Patients

BACKGROUND AND OBJECTIVES: Percutaneous coronary intervention (PCI) of unprotected left main coronary artery (LMCA) stenosis is a promising approach during this era of drug-eluting stents. However, there is no available hemodynamic data on these type patients during the performance of LMCA stenting. The purpose of this study was to determine the risk factors affecting hemodynamic stability during LMCA stenting, and to evaluate whether hemodynamic support such as inotropics or intra-aortic balloon pump (IABP) is needed, based on the risk factors. SUBJECTS AND METHODS: From July 2003 to January 2006, we enrolled 92 study patients (Male=55) who had visited Yeungnam University Hospital, Keimyung University Dongsan Hospital and InJe University Baik Hospital in Busan and they were all were diagnosed with angiographically detected unprotected LMCA stenosis. Group 1 (n=69) included those patients who did not need hemodynamic support during PCI. Group 2 (n=23) included patients who needed hemodynamic support during PCI. All patients had stents deployed in the LMCA lesions without hemodynamic support; the clinical, angiographic and procedural outcomes were compared between the two groups after the procedure. RESULTS: The baseline patient characteristics were not statistically different between the two groups. On univariate analysis, Group 2 had more patients diagnosed with acute myocardial infarction (AMI) than Group 1 (40% vs. 15%, respectively, p=0.014). Group 1 had a greater frequency of an increased left ventricular (LV) ejection fraction than Group 2 (60+/-10 vs. 47+/-11, respectively, p=0.01). Regarding the lesion location in the LMCA, Group 2 had relatively more lesions at bifurcated locations than Group 1 (44% vs. 78%, respectively, p=0.004). Group 2 required more complex techniques to repair lesions, such as kissing or crush stenting, than did Group 1 (19% vs. 48%, respectively, p=0.006). Multivariate logistic regression analysis showed that the presence of AMI (Odds Ratio (OR)=3.74, p=0.014), a complex stenting procedure such as kissing or crushing (OR=3.99, p=0.006), a bifurcated lesion (OR=4.58, p=0.004) and poor LV function (OR=9.95, p=0.0001) were independent risk factors for hemodynamic instability during LMCA stenting. CONCLUSION: The most important risk factor for hemodynamic instability during LMCA stenting was LV function. Therefore, preparation for hemodynamic support, including IABP before the procedure, is necessary for the high risk patients.

Impact of Optimal Stent Expansion on Late Outcomes after Sirolimus-Eluting Stent Implantation: An Intravascular Ultrasound Study

BACKGROUND AND OBJECTIVES: Sirolimus-eluting stents (SESs) have a considerably lower optimal minimal stent area (MSA) threshold compared to bare metal stents (BMSs). In the SIRIUS IVUS sub study, the absolute optimal stent expansion (OSE) of SESs was described as > or =5.0 mm2. The purpose of this study was to evaluate the impact of the OSE on long-term outcomes following SES implantation using absolute IVUS criteria. SUBJECTS AND METHODS: The study included 157 patients (BMS: 57; SES; 100), who underwent 6-month follow-up angiography and 18-month clinical follow-up after bare metal stent or drug-eluting stent (DES) implantation. According to the absolute measurement IVUS criteria, patients were divided into two groups: OSE and non-OSE. The IVUS criteria for OSE were MSA > or =6.5 mm2 for BMS implantation and MSA > or =5.0 mm2 for SES implantation. RESULTS: Angiographic binary restenosis was higher in the non-OSE than the OSE group with BMS (33.3% vs. 11.4%; p<0.039), but the rates were similar between the two groups with SES (4.5% vs. 3.2%; p=1.00). With the BMS, the MACE rates were 5.7% and 30% in the OSE and non-OSE group, respectively (p=0.017). However, with the SES, the MACE rates were similar between the two groups (OSE group, 3.2% vs. non-OSE group, 4.5%, p=1.00). CONSLUSION: After SES implantation, there were no significant differences in the late outcomes in relation to the achievement of absolute OSE. A variety of restenosis related factors should be considered for better outcomes after DES implantation. Therefore, the concept of OSE in the era of DESs might need to be revisited.