Experience with Intracardiac Echocardiography for Guiding Transcatheter Device Closure of Atrial Septal Defects

BACKGROUND AND OBJECTIVES: Phased-array intracardiac echocardiography (ICE) is a novel method for monitoring intracardiac procedures. We report our initial experience with ICE for guiding transcatheter device closure of atrial septal defects (ASD). SUBJECTS AND METHODS: From April 2004 to March 2005, ICE was performed in 27 consecutive patients during percutaneous device closure of ASDs. The procedural feasibility, the procedure time, the fluoroscopic time, and the complication rate were compared with 27 prior cases that had utilized transesophageal echocardiography. RESULTS: The procedure was performed successfully in all patients. The total procedure time (PT), device deployment time (DT), and fluoroscopic time (FT) were 65.7+/-22.3, 30.4+/-23.8, and 12.1+/-6.4 minutes for the study group, and 73.6+/-23.7, 29.8+/-16.1, and 11.9+/-6.0 for the control group, respectively, with no significant difference between the groups. However, PT and DT were significantly shorter in the later 14 cases of the study group compared to the 13 initial cases (52.1+/-10.9 and 13.2+/-4.2 vs. 80.3+/-22.4 and 48.8+/-22.2, p<0.01, respectively). These differences were also significant compared to the control group, suggesting that there was a learning curve for the procedure. CONCLUSION: ICE is a feasible and relatively safe method for monitoring and guiding percutaneous transcatheter closure of ASDs, but a learning period can be expected to achieve better proficiency.

Extragenital Primary Syphilis Acquired by Scratching with the Fingernails / 감염

A 46-year-old woman was admitted with an ulcerative lesion on the posterior neck. Four months before admission, the patient took part in a faith healing ritual, which the pastor performed with his fingernails causing wounds. This abnormal method of healing caused repeated injury to the patient in the posterior neck area. Treatment with cefazolin was begun, but the lesion did not improve. Biopsy of the skin lesion and cervical lymph nodes was performed. Microscopical examination revealed findings highly suggestive of syphilis. Serological tests for syphilis were positive and a computed tomographic (CT) scan of the neck showed enlargement of regional lymph nodes and tonsils. A single dose of penicillin G 2.4 million units was given intramuscularly. Two weeks later, the wound had healed. Eight weeks after treatment, the Venereal Disease Research Laboratory titer had decreased and a CT scan of the neck showed a decrease in the size of the lymph nodes. We reasoned that syphilis was non-sexually transmitted, and that the healing ritual was the cause. Our case suggests that skin trauma by scratching with the fingernails may cause an accidental direct inoculation of Treponema pallidum, resulting in extragenital primary syphilis.

The Effects of Helicobacter Pylori & Cytomegalovirus Infection on the Risk of Restenosis after Percutaneous Transluminal Coronary Angioplasty

BACKGROUND: Previous studies have suggested that chronic infection may play a role in the pathophysiology of restenosis after coronary angioplasty. The purpose of our study was to investigate the relation between Helicobacter pylori(H. pylori) or cytomegalovirus (CMV) infection, and restenosis. METHODS: Fifty nine patients with coronary artery disease underwent percutaneous transluminal coronary angioplasty (PTCA) and follow-up coronary angiography (59+/-13 years, 66% male). H. pylori and CMV IgG antibody titers were measured prospectively. The minimal luminal diameter and reference diameter before and immediately after angioplasty and at follow-up were measured with quantitative analysis. RESULTS: Restenosis occurred in 23 of the 59 (39%) patients. For H. pylori, patients with high antibody titer (upper half, > or =40 U/ml) had a higher restenosis rate than patients with low antibody titer (lower half, < 40 U/ml). Seventeen of the 29 (59%) patients with high antibody titer had restenosis, while 6 of the 30 (20%) patients with low antibody titer had restenosis (p=0.002, RR=2.39, 95% CI 1.35 to 6.37). After adjustment for covariates, including age, sex, body mass index, hypercholestrolemia, hypertension, diabetes mellitus, smoking, diagnosis at admission, modality of intervention, postprocedure minimal luminal diameter, lesion length, and lesion type, H. pylori antibody titer was independently predictive of restenosis (p=0.005). For CMV, patients with high antibody titer did not have a higher restenosis rate than patients with low antibody titer. CONCLUSION: High antibody titer against H. pylori may be an independent risk factor of restenosis after PTCA. However, there was no association between CMV antibody titer and the risk of restenosis.

Long Term Survival Rate and Prognostic Factors of Acute Myocardial Infarction

BACKGROUND AND METHODS: To identify the long term survival rate and prognostic factors of acute myocardial infarction (AMI) in Korea, total 1139 patients who presented between Jan. 1980 and Dec. 1997 at Seoul National University Hospital were followed for an average of 115 months. 321 patients died during follow up periods, 238 patients were lost and 580 patients are alive till the end point of the study. RESULTS: Overall survival rates (+/-standard error) were 88.2+/-1%, 86.8+/-1%, 85.3+/-1.1%, 82.1+/-1.2%, 79.6+/-1.3%, 75.6+/-1.5%, 73.1+/-1.6%, 70.3+/-1.7%, 67.4+/-1.8%, 64.5+/-1.9%, 60.0+/-2.2%, 56.3+/-2.5% at 1,6,12,24,36,48,60,120 months. In univariate analysis, older, history of diabetes, higher degree of Killip class, higher peak creatine kinase level, residual ischemia on treadmill test or MIBI scan, lower ejection fraction on echocardiography or gated blood pool scan, more severe extent of coronary artery disease, lower HDL-cholesterol level at least 3 months after AMI proved as poor long term prognostic factors of AMI with statistical significance (p0.05). In mltivariate analysis, old age and Killip class III versusIproved as independent poor long term prognostic factors of AMI with statistical significance (p<0.05) at combinations of age, sex, Killip class, existence of Q-wave, history of diabetes, ejection fraction on gated blood pool scan. CONCLUSION: The morthality of AMI is composed of two components. At acute phase, within 1 month, the mortality reaches to about 12%, and at chronic phase, after 1 month from AMI, mortality increases by 3% a year for 10 years. The other conclusion is old patients who have poor left ventricular functions show poor prognosis.

Churg-Strauss Syndrome with Acute Renal Failure in a Patient without Asthma / 대한신장학회잡지

Churg-Strauss syndrome(allergic granulomatosis and angiitis) is a distinct entity composed of fever, eosinophilia, systemic vasculitis of multiple organ systems, and pathologically eosinophilic infiltration, granuloma and necrotizing vasculitis. In most cases it develops in patients with asthma, and renal involvement is characteristically mild and acute renal failure is rare in contrast to other systemic vasculitides. We report an unusual case of Churg-Strauss syndrome manifested by acute renal failure as well as fever, rash, eosinophilia, and nonfixed pulmonary infiltrates in a patient without history of asthma but with that of allergic contact dermatitis. Renal biopsy revealed interstitial eosinophil infiltration, glomerular, vascular and perivascular granulomas containing giant cells. Fever, eosinophilia, and acute renal failure improved immediately after prednisolone 1mg/kg/day demonstrating good response to steroid as in previous reports.