A Rare Cause of Spontaneous Echo Contrast in Echocardiography

No abstract available.

Two-year Clinical Outcomes Following Everolimus-eluting Stent Use for Off-label Versus On-label Indications: From the Korean Multicenter Drug-eluting Stent Registry / 계명의대학술지

BACKGROUND: Everolimus-eluting stent (EES) implantations have a relatively low rate of major adverse cardiac event (MACE) and target lesion revascularization (TLR) in patients with off-label use. However, the clinical outcome in the Korean population regarding EES in patients with off-label use is not well known. OBJECTS: The aim of the current analysis was to compare the clinical outcomes of on-label and off-label EES use over a 2-year follow-up period. METHODS: Using patient-level data from a stent-specific, prospective, all-comer registry, we evaluated 987 patients (1,342 lesions) who received an EES (XIENCE V®, Abbott Vascular, Santa Clara, CA, USA) implantation between February 2009 and April 2011. The primary outcome was assessed: 2-year MACE (a composite endpoint of death from any cause, spontaneous myocardial infarction (MI), and any repeat revascularization). The clinical outcomes in the on- and off-label groups were compared at 2 years. RESULTS: The majority of patients (79.0%) were treated for ≥1 off-label indication. The median duration of the clinical follow-up in the overall population was 2.0 years (interquartile range 1.9–2.1). At 2-years after the EES implantation in the enrolled patients, MACE occurred in 71 (7.9%) patients, cardiac death in 12 (1.3%), MI in 4 (0.5%), target vessel revascularization (TVR) in 33 (3.8%), TLR in 22 (2.5%), and definite or probable stent thrombosis (ST) in 1 (0.1%). Off-label EES implantations tend to increase the risk of 2-year MACE (4.7% vs. 8.8%, p = 0.063) without statistical significance. However, the rates of TLR were higher in the off-label EES implantations (0.0% vs. 3.2%, p = 0.013). In the multivariable analysis, renal failure, previous bypass surgery, previous cerebrovascular accident, and left main lesions were associated with 2-year MACE in patients with EES implantations. CONCLUSIONS: The incidence of 2-year MACE was 7.9%, which that might be acceptable in all-comer patients treated with EES implantations. Although the off-label use of EES was not statistically associated with an increased risk of MACE, the TLR rate was higher in the off-label group, suggesting that physicians need to pay attention to high risk patients with the use of EES implantations.

Clinical and Genetic Features of Korean Patients with Recurrent Fever and Multi-System Inflammation without Infectious or Autoimmune Evidence

Autoinflammatory disease (AID) is a newly proposed category of disorders characterized by unprovoked episodes of inflammation without any infectious or autoimmune evidence. We aimed to characterize the clinical and genetic features of patients who had recurrent fever and multi-system inflammation but remain unclassified for any established AIDs. Medical records of 1,777 patients who visited our Rheumatology Clinic between March 2009 and December 2010 were reviewed to identify those who met the following criteria; 1) presence of fever, 2) inflammation in two or more organ systems, 3) recurrent nature of fever or inflammation, 4) no evidence of infection or malignancy, 5) absence of high titer autoantibodies, and 6) failure to satisfy any classification criteria for known AIDs. Genotyping was performed for common missense variants in MEFV, NOD2/CARD15, and TNFRSF1A. A small number of patients (17/1,777, 0.95%) were identified to meet the above criteria. Muco-cutaneous and musculoskeletal features were most common, but there was a considerable heterogeneity in symptom combination. Although they did not satisfy any established classification criteria for AIDs, substantial overlap was observed between the clinical spectrum of these patients and known AIDs. According to the newly proposed Eurofever criteria for periodic fevers, eleven of them were classified as TNF receptor-associated periodic syndrome and two as mevalonate kinase deficiency. However, no examined genetic variants including those in TNFRSF1A were found in these patients. A new set of classification criteria needs to be developed and validated for Asian patients with unclassified AIDs.

Clinical and Genetic Features of Korean Patients with Recurrent Fever and Multi-System Inflammation without Infectious or Autoimmune Evidence

Autoinflammatory disease (AID) is a newly proposed category of disorders characterized by unprovoked episodes of inflammation without any infectious or autoimmune evidence. We aimed to characterize the clinical and genetic features of patients who had recurrent fever and multi-system inflammation but remain unclassified for any established AIDs. Medical records of 1,777 patients who visited our Rheumatology Clinic between March 2009 and December 2010 were reviewed to identify those who met the following criteria; 1) presence of fever, 2) inflammation in two or more organ systems, 3) recurrent nature of fever or inflammation, 4) no evidence of infection or malignancy, 5) absence of high titer autoantibodies, and 6) failure to satisfy any classification criteria for known AIDs. Genotyping was performed for common missense variants in MEFV, NOD2/CARD15, and TNFRSF1A. A small number of patients (17/1,777, 0.95%) were identified to meet the above criteria. Muco-cutaneous and musculoskeletal features were most common, but there was a considerable heterogeneity in symptom combination. Although they did not satisfy any established classification criteria for AIDs, substantial overlap was observed between the clinical spectrum of these patients and known AIDs. According to the newly proposed Eurofever criteria for periodic fevers, eleven of them were classified as TNF receptor-associated periodic syndrome and two as mevalonate kinase deficiency. However, no examined genetic variants including those in TNFRSF1A were found in these patients. A new set of classification criteria needs to be developed and validated for Asian patients with unclassified AIDs.

Embolization of Inferior Epigastric Artery for Treatment of Rectus Sheath Hematoma Caused by Insulin Injection During Anticoagulation and Antiplatelet Therapy

Rectus sheath hematoma, caused by rupture of epigastric vessel or muscle tear, is most frequently encountered in association with anticoagulation therapy, trauma, operation, and hematologic disorder. It rarely occurs spontaneously. Rectus sheath hematoma related to subcutaneous injection of insulin is very rare. We report a case of percutaneous catheterbased coil embolization for treatment of rectus sheath hematoma caused by subcutaneous injection of insulin on abdomen during anticoagulation and antiplatelet therapy in an 83-year-old thin woman with diabetes.

Usefulness of the Doppler Flow of the Ophthalmic Artery in the Evaluation of Carotid and Coronary Atherosclerosis

BACKGROUND AND OBJECTIVES: There is little information about the relationship between the Doppler flow of the ophthalmic artery (OA) and carotid and coronary atherosclerosis. The aim of the investigation was to assess the clinical usefulness of the Doppler flow of the OA to estimate the severity of carotid and coronary atherosclerosis. SUBJECTS AND METHODS: The study was a retrospective analysis of the findings in 140 patients (mean age: 60 years, male: 64%) who underwent coronary angiography (CA) for the evaluation of typical angina between July 2010 and October 2011 in our single center. The severity of coronary artery stenosis was based on the Gensini score (GS). Significant coronary artery disease (CAD) was defined as the obstruction of over 75% of the major coronary arteries confirmed with CA. The pulsed Doppler flow of the OA and carotid ultrasound were performed before CA. RESULTS: The mean systolic velocity/mean diastolic velocity (MSV/MDV), pulsatile index and resistance index in the Doppler flow of the OA were identified as significant and independent correlations with carotid intima-media thickness, and MSV/MDV was identified to have a significant and independent correlation with the GS. MSV/MDV >2.1 was the independent predictor for significant CAD {odds ratio (OR) 3.8, 95% confidence interval (CI) 1.5-9.7, p=0.005} and carotid plaque (OR 2.8, 95% CI 1.1-7.0, p=0.028), after adjustment for CAD-associated factors. CONCLUSION: The Doppler flow of the OA might be a useful predictor of the severity of carotid and coronary atherosclerosis.

Free Floating Left Atrial Thrombus Disappearing during Echocardiography

No abstract available.

Anomalous Origin of the Left Coronary Artery from the Pulmonary Artery Initially Visualized by Echocardiography and Multidetector Computed Tomography Coronary Angiography

Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital anomaly associated with very high mortality during infancy. We report a 35-year-old female patient with ALCAPA initially visualized by echocardiography. She visited outpatient department presenting with intermittent chest discomfort for 3 weeks. Transthoracic echocardiography showed left coronary artery arising from main pulmonary artery and abundant septal color flow Doppler signals. Transesophageal echocardiography clearly revealed markedly dilated and tortuous right coronary artery showing windsock appearance. Multidetector computed tomography and coronary angiography enabled visualization of anomalous left coronary artery originating from left side of main pulmonary trunk. After treadmill exercise test which showed ST-segment depression presenting inducible myocardial ischemia, patient underwent direct re-implantation of the anomalous coronary artery into the aorta without any complication.

Reversible Pulmonary Hypertension in Adolescent with Left Atrial Myxoma

We report a patient of left atrial huge myxoma presenting with severe pulmonary hypertension in adolescents. A patient was a 14-year-old boy presented with sudden onset dyspnea. Transthoracic echocardiographic study revealed the presence of a nodular, 4.34 x 8.11 cm sized, mobile, hyperechoic mass in the left atrium and severe pulmonary hypertension with tricuspid insufficiency. After surgical therapy, tricuspid regurgitation and pulmonary hypertension was decreased and the patient was stabilized and had an uneventful clinical course.

Effect of Valsartan on N-Terminal Pro-Brain Natriuretic Peptide in Patient With Stable Chronic Heart Failure: Comparison With Enalapril

BACKGROUND AND OBJECTIVES: The plasma concentration of N-terminal pro-brain natriuretic peptide (NT-pro-BNP) is a st-rong prognostic indicator for patients with heart failure (HF) across all stages of the condition. Several clinical trials have de-monstrated convincingly that neurohormonal modulation on the renin angiotensin system (RAS) decreases plasma NT-pro-BNP level and results in favorable outcomes. But there are still limited comparative data on the neuro-hormonal modulatory effects of two RAS inhibitors: angiotensin converting enzyme inhibitor and angiotensin receptor blocker. SUBJECTS AND METHODS: This study was a prospective, multi-center, randomized, open-label, controlled, and non-inferiority study involving 445 patients with left ventricular ejection fraction (LVEF) less than 45%. Patients were assigned to receive either valsartan (target dose of 160 mg bid) or enalapril (target dose of 10 mg bid) for 12 months. We compared plasma NT-pro-BNP, high sensitive C-reactive protein (hs-CRP) level and echocardiographic parameters before and after treatment with valsartan or enalapril. RESULTS: The NT-pro-BNP and hs-CRP levels were significantly decreased after 12 months of treatment with valsartan and enalapril. The percentage change was similar between both groups. LVEF improved and left ventricular internal dimensions were decreased in both groups, and there were no significant differences between two groups. CONCLUSION: Valsartan is as effective on improving plasma NT-pro-BNP level as enalapril in patients with stable chronic HF.

Effect of Valsartan on N-Terminal Pro-Brain Natriuretic Peptide in Patient With Stable Chronic Heart Failure: Comparison With Enalapril

BACKGROUND AND OBJECTIVES: The plasma concentration of N-terminal pro-brain natriuretic peptide (NT-pro-BNP) is a st-rong prognostic indicator for patients with heart failure (HF) across all stages of the condition. Several clinical trials have de-monstrated convincingly that neurohormonal modulation on the renin angiotensin system (RAS) decreases plasma NT-pro-BNP level and results in favorable outcomes. But there are still limited comparative data on the neuro-hormonal modulatory effects of two RAS inhibitors: angiotensin converting enzyme inhibitor and angiotensin receptor blocker. SUBJECTS AND METHODS: This study was a prospective, multi-center, randomized, open-label, controlled, and non-inferiority study involving 445 patients with left ventricular ejection fraction (LVEF) less than 45%. Patients were assigned to receive either valsartan (target dose of 160 mg bid) or enalapril (target dose of 10 mg bid) for 12 months. We compared plasma NT-pro-BNP, high sensitive C-reactive protein (hs-CRP) level and echocardiographic parameters before and after treatment with valsartan or enalapril. RESULTS: The NT-pro-BNP and hs-CRP levels were significantly decreased after 12 months of treatment with valsartan and enalapril. The percentage change was similar between both groups. LVEF improved and left ventricular internal dimensions were decreased in both groups, and there were no significant differences between two groups. CONCLUSION: Valsartan is as effective on improving plasma NT-pro-BNP level as enalapril in patients with stable chronic HF.

Comparative Study of Low Doses of Rosuvastatin and Atorvastatin on Lipid and Glycemic Control in Patients with Metabolic Syndrome and Hypercholesterolemia

BACKGROUND/AIMS: This multicenter, open-labeled, randomized trial was performed to compare the effects of rosuvastatin 10 mg and atorvastatin 10 mg on lipid and glycemic control in Korean patients with nondiabetic metabolic syndrome. METHODS: In total, 351 patients who met the modified National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) criteria for metabolic syndrome with low-density lipoprotein cholesterol (LDL-C) levels > or = 130 mg/dL were randomized to receive either rosuvastatin 10 mg (n = 173) or atorvastatin 10 mg (n = 178) for over 6 weeks. RESULTS: After 6 weeks of treatment, greater reductions in total cholesterol (- 35.94 +/- 11.38 vs. - 30.07 +/- 10.46%, p < 0.001), LDL-C (48.04 +/- 14.45 vs. 39.52 +/- 14.42%, p < 0.001), non-high-density lipoprotein cholesterol (- 42.93 +/- 13.15 vs. - 35.52 +/- 11.76%, p < 0.001), and apolipoprotein-B (- 38.7 +/- 18.85 vs. - 32.57 +/- 17.56%, p = 0.002) levels were observed in the rosuvastatin group as compared to the atorvastatin group. Overall, the percentage of patients attaining the NCEP ATP III goal was higher with rosuvastatin as compared to atorvastatin (87.64 vs. 69.88%, p < 0.001). Changes in glucose and insulin levels, and homeostasis model assessment of insulin resistance index were not significantly different between the two groups. The safety and tolerability of the two agents were similar. CONCLUSIONS: Rosuvastatin 10 mg was more effective than atorvastatin 10 mg in achieving NCEP ATP III LDL-C goals in patients with nondiabetic metabolic syndrome, especially in those with lower NCEP ATP III target level goals.

Clinical experience with primary cardiac tumors / 대한내과학회지

BACKGROUND/AIMS: In Korea, few studies have examined primary cardiac tumors, which have a reported incidence of 0.0017~0.19% in autopsy series. This study surveyed the status of primary cardiac tumors over the past 7 years in one region. METHODS: A retrospective review examined all patients with primary cardiac tumors, except for confirmed thrombus, using hospital medical records from 2000 to 2006 at six community hospitals. Identified cases undergoing biopsy and surgery were selected for the study. RESULTS: The operative mortality was 7.7%. Of the 71 patients (26 males) with identified primary cardiac tumors, 65 (91.5%) tumors were benign and 6 (8.5%) were malignant. The benign tumors were myxoma (78.9%), rhabdomyoma (4.2%), fibroelastoma (2.8%), fibroma (1.4%), and leiomyoma (1.4%). Two of the myxomas were present at multiple locations. The malignant tumors included sarcomas (67%) and lymphomas (33%). Most of the tumors were located in the left atrium (76%). The majority of patients presented with chest pain and dyspnea. During follow-up for an average of 26.8+/-21.3 months, all but one patient with benign tumors was alive; one myxoma patient died perioperatively (1.5%). Four of the patients with malignant tumors (67%) died. CONCLUSIONS: Cardiac myxomas and sarcomas were the most common primary benign and malignant tumors, respectively. Benign tumors had excellent postoperative survival rates, while malignant tumors had high mortality.

Reference Values for the Augmentation Index and Pulse Pressure in Apparently Healthy Korean Subjects

BACKGROUND AND OBJECTIVES: Arterial stiffness is a precursor to premature cardiovascular disease. The augmentation index (AI) and pulse pressure (PP) are cardiovascular risk factors. The aim of this study was to define the diagnostic values of the AI and PP from the peripheral arterial and central aortic waveforms in healthy subjects. SUBJECTS AND METHODS: We recruited 522 consecutive subjects (mean age 46.3+/-9.6 years, 290 males) who came to our facility for a comprehensive medical testing. We measured the body mass index (BMI), blood pressure, peripheral and central PP, and a pulse wave analysis that included the central and peripheral AI. RESULTS: The peripheral and central AIs in the female subjects were significantly higher than that in the male subjects (p<0.001). The peripheral and central PPs in the subjects with hyperlipidemia were significantly higher than subjects with normal lipid profiles (p<0.001). The peripheral and central PPs and peripheral and central AIs significantly increased with age. CONCLUSION: Pending validation in prospective outcome-based studies, a peripheral PP of 70 mmHg, central PP of 50 mmHg, peripheral AI of 100%, and central AI of 40% may be preliminary values in adult subjects.

Assessment of Non-Calcified Coronary Plaques Using 64-Slice Computed Tomography: Comparison With Intravascular Ultrasound

BACKGROUND AND OBJECTIVES: Non-invasive detection and characterization of plaque composition may constitute an important step in risk stratification and monitoring of the progression of coronary atherosclerosis. Multislice computed tomography (MSCT) allows for accurate, non-invasive detection and characterization of atherosclerotic plaques, as well as determination of coronary artery stenosis. The aim of this study was to determine the usefulness of MSCT for characterizing non-calcified coronary plaques previously classified by intravascular ultrasound (IVUS). SUBJECTS AND METHODS: Seventy-one plaques were evaluated in 42 patients undergoing MSCT and IVUS. Coronary plaques were classified as hypoechoic or hyperechoic based on IVUS echogenicity. On MSCT, CT attenuation was measured using circular regions of interest (ROI) and represented as Hounsfield units (HU). RESULTS: MSCT attenuation in hypoechoic plaques was significantly lower than it was in hyperechoic plaques (52.9+/-24.6 HU vs. 98.6+/-34.9 HU, respectively, p<0.001). When comparing CT attenuation between hypoechoic and hyperechoic plaques, 60.2 HU was the cut-off value for differentiating between the two, with a 90.7% sensitivity and a 78.6% specificity. CONCLUSION: MSCT might be a useful tool for non-invasively evaluating the characteristics of coronary artery plaques.

A Case of Aspergillus Endocarditis Presenting as Endophthalmitis

Aspergillus endocarditis is an uncommon, but often fatal, disease that usually occurs in patients who have had prior cardiac surgery. Endophthalmitis is a very rare complication of infective endocarditis, especially at presentation. We report a case of Aspergillus endocarditis in a 68-year-old woman who presented with endophthalmitis.

Left Atrial Mural Endocarditis Diagnosed by Transesophageal Echocardiography in a Patient with Mitral Valve Prolapse

Infective endocarditis (IE) is one of the major complications of the mitral valve prolapse (MVP) syndrome and usually involves mitral valve (MV) and its accessory apparatus. Left atrial (LA) mural endocarditis is a condition of rarely diagnosed and the most feasible mechanism is related to the impact of regurgitant jet that causes endothelial damage and retrograde microorganisms dissemination. Echocardiography is essential in diagnosis and treatment of IE but in mural endocarditis, it may be difficult to find vegetation by standard view of transthoracic echocardiography (TTE). We report a case of LA mural endocarditis which was diagnosed by transesophageal echocardiography (TEE) in a patient with MVP.

A case of spontaneous intracerebral hemorrhage in neurofibromatosis type 1 associated with pheochromocytoma / 대한내과학회지

Spontaneous intracerebral hemorrhage is very rare in patients with neurofibromatosis type 1. A 30-year-old woman was referred to our hospital for evaluation of headaches, nausea, and vomiting. She was diagnosed with neurofibromatosis type 1 and a spontaneous intracerebral hemorrhage. She was treated with conservative management, including antihypertensive medications for 32 months. However, because of sustained hypertension, we performed screening tests for a pheochromocytoma. The 24 hr urine VMA and urine metanephrines were elevated. Abdominal CT showed a right adrenal mass, 7.5 x 5.8 cm in size.. After a successful resection of the tumor, the hypertension resolved without medication for > 1 year. This case illustrates that delayed diagnosis and treatment of pheochromocytoma can cause serious complications from hypertension, such as cerebrovascular hemorrhage. Thus, in patients with neurofibromatosis and hypertension, screening for pheochromocytoma is important for the early detection of an adrenal tumor.

Prognostic Significance of the Lown Grades and Late Potentials in Patients after Myocardial Infarction

BACKGROUND AND OBJECTIVES: The aims of this study were to assess the long term overall survival of patients after an acute myocardial infarction (AMI), and to determine the association of survival with the occurrence of ventricular arrhythmia, as recorded by Holter electrocardiography (ECG) and signal-averaged electrocardiography (SAECG). SUBJECTS AND METHODS: One hundred fifty two patients with an AMI were enrolled between January 2000 and August 2006. SAECG and Holter ECG were performed before hospital discharge (at range of 2-10 day). The grading system of Lown was used to evaluate the ventricular premature beats on Holter ECG. Three groups of patients were identified based on the seriousness of the ventricular arrhythmia, as identified by the Holter ECG: Lown grade 0, Lown grades 1, 2 and Lown grades 3, 4, 5. SAECG was performed with a high pass frequency of 25 Hz and 40 Hz. The presence of late potentials (LPs) recorded on SAECG was evaluated. The predictors for survival were assessed using Cox's proportional hazard model and Kaplan-Meier analysis. RESULTS: The mean duration of follow-up was 45.8+/-25.5 months. Twenty four patients (15.8%) died during follow-up. The multivariate predictors of all cause death included age [hazard ratio (HR)=1.25, 95% confidence interval (CI)=1.08-1.47, p=0.003] and Lown grades 3, 4 and 5 (HR=19.17, 95% CI=1.25-290.80, p=0.034). Survival analysis did not show a significant relationship between LPs and overall patient survival. The only predictors for overall mortality were age and the Lown grade. CONCLUSION: SAECG did not predict mortality for the patient with AMI. The ventricular arrhythmias recorded by conventional Holter before hospital discharge may be a useful noninvasive prognostic test after an AMI.

Relationship Between Serum Uric Acid Level and Metabolic Syndrome According to Gender

BACKGROUND AND OBJECTIVES: Hyperuricemia is known to be a risk factor for atherosclerosis, as is gender. The variables related to metabolic syndrome (MS), as well as other cardiovascular risk factors such as serum uric acid (SUA), differ according to gender. The aim of this study was to evaluate the relationship between SUA and the variables of MS according to gender. SUBJECTS AND METHODS: We randomly recruited 675 subjects (373 men and 302 women), who underwent health screening. The subjects were divided into four groups according to SUA quartiles. We compared each quartile of the SUA with the incidence of MS. The variables included body mass index (BMI), hypertension, fasting blood glucose (FBS), high-density lipoprotein (HDL) cholesterol, triglyceride (TG), and the MS score. RESULTS: The incidence of MS in men was significantly increased compared to women, and the incidence of MS was increased according to the SUA values in women. The MS scores tended to increase according to the SUA values in both genders. The incidence of high BMI, high blood pressure, and high TG were correlated with the SUA values in both genders. However, HDL-cholesterol was correlated with MS scores in women, and fasting glucose was not correlated with MS in either gender. CONCLUSION: The variables of the MS might be independently associated with SUA values in both genders. In addition, the incidence of MS in women might be significantly increased according to the SUA values. However, large scale follow-up studies will be required to confirm these possibilities.