Clinical Effects of Additional Cilostazol Administration After Drug-Eluting Stent Insertion

BACKGROUND AND OBJECTIVES: Cilostazol, a selective inhibitor of phosphodiesterase III (PDE III), prevents inactivation of the intracellular second messenger cyclic adenosine monophosphate (cAMP) and irreversibly inhibits platelet aggregation and vasodilation. Hence, we performed this prospective randomized study to evaluate the clinical effects of additional cilostazol administration in patients receiving dual antiplatelet therapy after drug-eluting stent (DES) insertion. SUBJECTS AND METHODS: Between December 2003 and June 2006, we enrolled a total 603 consecutive patients who underwent successful percutaneous coronary intervention (PCI) with DES insertion at Dong-A University Hospital. Study patients received dual antiplatelet therapy (aspirin and clopidogrel, n=301) for at least six months or dual antiplatelet therapy (six months) combined with cilostazol medication for one month (triple therapy, n=302) after PCI. We investigated the incidence of major adverse cardiac events (MACE) at one month and six months after the initiation of medical therapy. MACE was defined as a composite of death, myocardial infarction (MI), stent thrombosis, and target lesion revascularization (TLR). Platelet function was evaluated in 66 patients (dual therapy group, n=40; triple therapy group, n=26) using a Chrono-Log platelet aggregometer and the VerifyNow P2Y12 assay system. RESULTS: The MACE rate was 0.66% in the triple therapy group (death only, 0.67%) and 1.67% in the dual therapy group (death, 0.67%; MI, 0.67%; stent thrombosis, 0.99%; TLR, 0.99%) at one month after PCI (p=0.087). At six months, there were no differences in the MACE rate between the two groups (triple group vs. dual group=2.65% vs. 3.99%, p=0.864). In laboratory tests, platelet aggregation induced by agonists of ADP (27.92+/-13.04% vs. 40.9+/-15.78%, p=0.0008), collagen (13.73+/-6.95% vs. 27.43+/-14.87%, p=0.03), and epinephrine (10.38+/-7.82% vs. 15.5+/-10.45%, p=0.0000) were lower in the triple therapy group versus the dual therapy group. However, platelet aggregation induced by agonists of arachidonic acid (3.23+/-1.07% vs. 3.78+/-2.12%, p=0.23) and ristocetin (29.19+/-35.55% vs. 44.78+/-32.65%, p=0.07) and aspirin reaction unit (412.96+/-96.25 vs. 427.93+/-76.24, p=0.48) measured by VerifyNow were not different in the triple group versus the dual group. CONCLUSION: Additional administration of cilostazol did not decrease the MACE rate when compared to dual therapy six months after PCI in patients with DES.

Comparison between the Portable Prothrombin Time Self Monitor CoaguChek XS and a Standard Laboratory Method, Sysmex CA-1500 for Monitoring Anticoagulant Therapy of Outpatients

BACKGROUND AND OBJECTIVES: Patients on oral anticoagulation therapy (OAT) require regular monitoring of the prothrombin time (PT) and dosage adjustment to prevent thromboembolic diseases without the risk of hemorrhage. Portable self PT monitors have been recently developed because the standard PT measurements are complicated and take considerable time. This study compared the International normalized ratio (INR) results that were obtained with using the CoaguChek XS device (Roche Diagnostic, Mannheim, Germany) with those obtained using a standard laboratory method Sysmex CA-1500 (Sysmex Corporation, Kobe, Japan) in the patients on OAT and also a healthy control group. SUBJECTS AND METHODS: 100 outpatients on OAT and 20 healthy controls were enrolled on a volunteer basis after providing informed consent at the Dong-A University Hospital. The outpatients and the healthy control group provided us the INR measurements with using both the CoaguChek XS and the Sysmex CA-1500. RESULTS: The coefficients of variation for CoaguChek XS and Sysmex CA-1500 were less than 10%. The PT (INR) results of CoaguChek XS and Sysmex CA-1500 were 2.0+/-0.7 and 2.2+/-0.7, respectively (p<0.001). There was a good correlation between CoaguChek XS and Sysmex CA-1500 (r=0.974, p<0.001). On the regression analysis, the slope of the regression line was 0.9197 and the y-intercept was 0.0058. On the Bland-Altman analysis, the INR mean difference (bias) between the two methods (CoaguChek XS INR-Sysmex CA-1500 INR) was -0.2 and the limit of agreement was +0.168~-0.568. CONCLUSION: The measurement with using CoaguChek XS has high repeatability, rapid availability and good accuracy that are comparable to the standard laboratory method. Therefore, CoaguChek XS can be a valuable tool for the self-monitoring of patients on OAT.

Giant Coronary Sinus Caused by Absent Right and Persistent Left Superior Vena Cava and Severe Tricuspid Regurgitation

Dilated coronary sinus is often visualized on echocardiography in patients with right sided heart disease as well as with persistent left superior vena cava. We observed a case of markedly dilated coronay sinus caused by persistent left superior vena cava and severe tricuspid regurgitation. The diagnosis was made by transthoracic echocardiography with intravenous injection of agitated saline into both arm.

Comparisons of the Short-Term Angiographic Outcomes of Cypher and Taxus Stents Implanted in the Same Patient

BACKGROUND AND OBJECTIVES: Drug-eluting stents (DES) have been shown to substantially reduce both angiographic and clinical restenosis. Cypher(R) (sirolimus-eluting stent, Cordis, Johnson and Johnson, Florida, USA) and Taxus(R) (paclitaxel-eluting stent, Boston Scientific, Boston, USA) are the two most widely used DESs, and they both have distinct pharmacological properties and release kinetics. It has been not studied whether these two DESs show different angiographic outcomes when they are simultaneously implanted in the same patient. SUBJECTS AND METHODS: We retrospectively analyzed the angiographic findings of the short-term follow-up in 34 patients (average age: 63 year old, 9 women) in whom both Cypher and Taxus stents were implanted at the same time for the treatment of obstructive coronary lesion. RESULTS: There was no significant difference in the basal angiographic characteristics of the lesions that had two stents deployed in terms of the AHA/ACC classification, reference diameter, the percent diameter stenosis and minimal luminal diameter. The post-procedure results were similar between the two stents. At 6 months follow-up, the Cypher stent displayed significantly less in-stent lumen loss compared with the Taxus stent (0.16+/-0.04 mm vs 0.27+/-0.04 mm; respectively, p=0.040) and a smaller percent diameter stenosis (15.9+/-1.3% vs 19.9+/-2.2%, respectively, p=0.049). CONCLUSION: The Cypher stent showed significantly less luminal loss during short term follow-up compared with the Taxus stent when implanted in the same patient. This result suggests that in a given individual patient, the Cypher stent induces less neointimal proliferation than does the Taxus stent.

The clinical course of idiopathic membranoproliferative glomerulonephritis type 1 / 대한내과학회지

BACKGROUND: The manifestation of Membranoproliperative glomerulonephritis (MPGN) is variable from asymptomatic hematuria, nephrotic syndrome to advanced chronic kidney disease. The etiology, pathogenesis, and treatment of MPGN are unclear. The incidence of idiopathic MPGN is also rare in Korea, and the clinical course was rarely studied. So we investigated clinical course of idiopathic MPGN type 1. METHODS: From March 1990 to November 2004, renal biopsy was done in about 1500 patients in Dong-A universty hospital. Among them, 16 patients were diagnosed as idiopathic MPGN. Fourteen patients were observed over 6 months. We analyzed clinical data of these patients retrospectively. RESULTS: Male to female ratio of total 16 patients is 2.2:1. Mean age of patients was 37.6 years (14-76 years) at the time of diagnosis. Thirteen cases (81%) had nephrotic range proteinuria, 8 cases (50%) had hypertention, 12 cases (75%) had edema, and 4 cases (25%) had decreased renal fuction (serum creatinine>1.2 mg/dL) at the time of diagnosis. Average observation time was 55.7+/-37.4 (6-122)months. Six cases ended up with progressive renal failure. Three cases achieved complete remission. Renal survival time for 50% of cases was 92 months. In our study, edema and decreased renal fucntion at the time of diagnosis were related with later development of progressive renal failure (p<0.05). Of the total 14 cases, 4 cases ware treated conservatively, 6 cases were treated with anti-platelet agents, and 4 cases were treated with anti-platelet agents and prednisone. In conservative treatment group, 1 case ended up with progressive renal failure and 1 case achieved complete remission. In anti-platelet agents treatment goup, 4 cases ended up progressive renal failure. In combined anti-platelet agents and prednisone treatment group, 1 case ended up progressive renal failure and 2 cases achieved complete remission. However, the effect of each treatment is inconclusive because the number of the patients are too small. CONCLUSIONS: We suspect that deceased renal function and edema at the time of diagnosis may be risk factor predicting progressive renal failure in patients with idiopathic MPGN type 1.

A Case of Aorto-femoral bypass Graft Infection Complicated with Infective Endocarditis

Prosthetic vascular graft infection (PVGI) is a relatively uncommon complication of peripheral vascular surgery and although rare, is the most severe complication in reconstructive vascular surgery. The early diagnosis of this complication can reduce the mortality. We report a case of aorto-femoral bypass graft infection, which was diagnosed by Tc-99m HMPAO WBC scan, complicated with infective endocarditis. A 60-year-old man had been operated with aortofemoral bypass graft because of aortojejunal fistula due to abdominal aortic aneurysm. Nine months later, he was admitted with fever of two months' duration. On echocardiolography, aortic regurgitation and vegetation were observed, and then he was diagosed with infective endocarditis. He was treated with antibiotics for 6 weeks. Recurrent bacteremia of unknown origin persisted despite antibiotic therapy. Multiple microorganisms were separately isolated from the blood cultures. He complained of intermittent right groin pain. Imaging study (CT, MRI, US) showed no definite evidence of graft infection. However, Tc-99m HMPAO WBC scan demonstrated uptake in the aortofemoral bypass graft site. The patient underwent emergent aortofemoral graft removal with axillobifemoral bypass and right femoropopliteal bypass.

A Case of Aorto-femoral bypass Graft Infection Complicated with Infective Endocarditis

Prosthetic vascular graft infection (PVGI) is a relatively uncommon complication of peripheral vascular surgery and although rare, is the most severe complication in reconstructive vascular surgery. The early diagnosis of this complication can reduce the mortality. We report a case of aorto-femoral bypass graft infection, which was diagnosed by Tc-99m HMPAO WBC scan, complicated with infective endocarditis. A 60-year-old man had been operated with aortofemoral bypass graft because of aortojejunal fistula due to abdominal aortic aneurysm. Nine months later, he was admitted with fever of two months' duration. On echocardiolography, aortic regurgitation and vegetation were observed, and then he was diagosed with infective endocarditis. He was treated with antibiotics for 6 weeks. Recurrent bacteremia of unknown origin persisted despite antibiotic therapy. Multiple microorganisms were separately isolated from the blood cultures. He complained of intermittent right groin pain. Imaging study (CT, MRI, US) showed no definite evidence of graft infection. However, Tc-99m HMPAO WBC scan demonstrated uptake in the aortofemoral bypass graft site. The patient underwent emergent aortofemoral graft removal with axillobifemoral bypass and right femoropopliteal bypass.

Feasibility of Transradial Coronary Angiography Using a Single Judkins Left Catheter

BACKGROUND AND OBJECTIVES: Transradial coronary angiography and intervention are getting more popularity throughout the world because of lower incidence of puncture site complications and the patients have displayed early ambulation. However, radial arterial spasms and possible endothelial injury due to the small size of radial artery are troublesome. To overcome this problem, we investigated the usefulness of performing transradial coronary angiography using a single Judkins left catheter (JL). SUBJECTS AND METHODS: A total of 268 patients who underwent right transradial coronary angiography from June 2003 to December 2003 were enrolled for this prospective study. The Judkins Left 3.5(JL3.5), the Multipurpose (MP) and Amplatz Left (AL2 for males, AL1 for females) were assigned to be used in patients with a randomized protocol. The technical/angiographic success rate, procedural/fluoroscopic time and the frequency of stiffwire usage were assessed. RESULTS: Technical success was accomplished in 87 (96.7%) of the patients with a single JL3.5, in 90 (97.8%) of the patients with the MP and in 83 (96.5%) of the patients with the AL catheter. Successful angiography success was achieved in 77 (85.6%) of the patients using the JL3.5, in 71 (77.2%) of the patients using the MP and in 66 patients (76.7%) using the AL. The technical success rate (p=0.270) and the angiographic success rate (p= 0.162) showed no significant difference among the three catheters. The procedural time was 8.1+/-4.0 min in the JL3.5 group, 8.1+/-3.7 min in the MP group and 7.3+/-3.4 min in the AL group, respectively (p=0.431). Also, the fluoroscopic time was not different among the three groups. CONCLUSION: The JL3.5 catheter is an excellent tool for both coronary imaging and it is equally successful as compared with the MP and AL catheters. Therefore, the JL3.5 may be considered as the initial catheter that can be used, including for those difficult cases having tortuous vasculature of the subclavian artery and the ascending aorta, during transradial coronary angiography.

Clinical significance of chromosomal abnormality in multiple myeloma / 대한내과학회지

BACKGROUND: Multiple myeloma is a clonal B-cell malignancy manifested by the accumulation of terminally differentiated plasma cells. The disease is characterized by clinical heterogeneity, with survival ranging from a few months to more than 10 years. The purpose of this study is to evaluate the prognostic value of specific chromosomal abnormality in multiple myeloma. METHODS: We analyzed the clinical records of 40 patients who were diagnosed as multiple myeloma, between April, 1995 and August, 2004. Cytogenetic analysis was conducted by metaphase karyotype analysis. Patients were grouped into normal cytogenetic group (arm A), complete or partial deletion of chromosome 13 and hypodiploidy group (arm B) and other cytogenetic abnormality group (arm C). RESULTS: Median follow up duration was 13.1 months (range 1.5-92.1). Overall response rate to chemotherapy was 58.8% and response rate among arm A, B and C were 56.3%, 33.3% and 75%, respectively (p=0.229). The prognostic factors affecting survival were clinical stage, performance status, serum creatinine level, sex and chromosomal abnormality. The median overall survival was significantly different among arm A, B and C (34.9 months, 8.5 months and 19.8 months, respectively, p=0.0125). CONCLUSION: chromosomal abnormality, especially, complete or partial deletion of chromosome 13 and hypodiploidy at initial diagnosis is significantly associated with survival duration.