N-terminal Pro B-type Natriuretic Peptide and the Evaluation of Cardiac Dysfunction and Severity of Disease in Cirrhotic Patients

PURPOSE: Cardiac dysfunction and hyperdynamic systemic circulation may be present in patients with cirrhosis. The purpose of this study was to identify relations between plasma levels of N-terminal-proBNP (NT-proBNP), reflecting early ventricular dysfunction, and the severity of liver disease and cardiac dysfunction in cirrhotic patients. MATERIALS and METHODS: Sixty-three cirrhotic patients and 15 controls (group 1) were enrolled in this study. Plasma levels of NT-proBNP were determined in echocardiographically examined patients, which were allocated to 1 of 3 groups according to Child-Pugh classification or into 2 groups, i.e., a compensated group without ascites (group 2) and decompensated group with ascites (group 3). RESULTS: Plasma NT-proBNP levels were significantly higher in cirrhotic patients (groups 2 and 3) than in age-matched controls (155.9 and 198.3 vs. 40.3pg/mL, respectively, p < 0.05). NT-proBNP levels were significantly increased in Child class C patients than in classes B and A (250.0 vs. 168.6 and 119.6pg/mL, respectively, p < 0.05). Left atrial dimension, wall thickness of left ventricle, and EF or E/E' were significantly increased, and EDT was prolonged in cirrhotic patients than in controls. Increased LVMI and decreased E/A ratio were noted in the group of patients with ascites as compared with the other groups. CONCLUSION: Plasma NT-proBNP levels were high in cirrhotic patients and are likely to be related to the severity of disease. Advanced cirrhosis is associated with advanced cardiac dysfunction, and NT-proBNP levels has predictive value for concomitant cardiac dysfunction and cirrhosis progression.

A Case of Left Ventricular Outflow Tract Obstruction and Microangiopathic Hemolytic Anemia after Mitral Valve Repair

Many cases have been reported hemolytic anemia and left ventricular outflow obstruction with systolic anterior motion developing after bioprosthetic valve replacement. We report a case of hemolytic anemia and left ventricular outflow tract obstruction occured after mitral valve repair using Duran ring and were resolved by preservative therapy.

Lesion Characteristics of Mitral Valve Prolapse due to Myxomatous Degeneration in Korea: A Prospective Multicenter Study Using Echocardiography

BACKGROUND AND OBJECTIVES: We sought to characterize the lesion characteristics of mitral valve prolapse (MVP), which is being increasingly recognized as a cause of mitral regurgitation (MR) in Koreans SUBJECTS AND METHODS: 497 Patients with MVP that was diagnosed by echocardiography in 13 university-affiliated hospitals from Jan to Dec 2003 were prospectively enrolled in our study. RESULTS: A total of 497 patients (270 males, 54%) were enrolled and their mean age was 52+/-17 years. Grade 4 MR was present in 272 patients (54.7%); grade 3, 2 and 1 MR as present in 30.2%, 10.7% and 4.2%, respectively. MVP of the anterior and posterior mitral leaflet was present in 170 patients (34.2%) and 223 patients (44.9%), respectively; MVP developed in both leaflets in 104 patients (20.9%). In 37 patients (7.4%), MVP developed in all 6 segments of the mitral leaflet and these patients were younger (37+/-14 versus 54+/-16 years, respectively, p<0.05) and had a lower prevalence of chordae rupture and severe MR compared to the other patients. Among the 266 mitral segments showing prolapse in the 132 patients (26.6%) who underwent transesophageal echocardiography, the posterior medial scallop was the most frequently diseased one (26%), and this was followed by the posterior middle scallop (18%), the medial (17%), lateral (14%) and middle (13%) part of the anterior leaflet, and the posterior lateral scallop (12%). Younger patients with a mean age <45 years showed a lower prevalence of single segment prolapse, hypertension, severe MR and chordae rupture compared to the older patients (p<0.001, each). CONCLUSION: The medial part of both mitral leaflets was the predilection site for the development of MVP in Koreans and the lesion characteristics were different according to the patients' age.

The Clinical Feature of Regional Wall Motion Abnormality on Apex of the Left Ventricle with Normal Coronary Angiogram

BACKGROUND AND OBJECTIVES: Stress induced cardiomyopathy has been reported as reversible left ventricular dysfunction with electrocardiographic changes. Although the exact mechanism of this dysfunction has not been clarified, catecholamine "surge" is suspected as a potential cause of this disease. It has not been undergone the studies about the effect of chronic or recurrent psychological stress on the myocardium. We suspect that reversible ischemic change of myocardium could be induced by chronic or recurrent emotional stress. MATERIALS AND METHOD: The clinical, echocardiographic and angiographic data of 189 patients (72 women) who presented with ischemic symptoms and eletrocardiographic changes were participated. BAI (Beck anxiety inventory) and BDI (Beck Depression inventory) were obtained and analyzed for evaluation of degree of psychological stress. RESULTS: 54 patients who had left ventricular apical wall motion abnormalities without significant angiographical stenosis in the coronary artery were younger than the others with left ventricular wall motion abnormalities and angiographic stenosis. And they increased the BAI and BDI as tools of evaluation of psychological stress (p<0.05). CONCLUSION: Data of this study suggested that psychological stress can be associated with myocardial dysfunction. It can be postulated that psychological stress should be considered as one of the cause of non-coronary myocardial injury.

Familial Isolated Noncompaction of the Ventricular Myocardium in Asymptomatic Phase

Isolated noncompaction of the ventricular myocardium (INVM) is a rare cardiomyopathy resulting from a failure of normal endomyocardial embryogenesis and it has been categorized as a form of unclassified cardiomyopathy. The disorder is characterized by an excessively prominent trabecular meshwork with deep intertrabecular recesses. Although the disorder is sporadic, familial incidence may occur. Clinical symptoms and prognosis of INVM may differ markedly, and range from an asymptomatic course to a severe cardiac disability. The diagnostic method of choice for IVNM is echocardiography, which reveals multiple prominent trabeculations with deep intertrabecular spaces communicating with the left ventricular cavity in the middle and apical segments of the left ventricle. The authors report a case of INVM in a family in which three adult members (a brother and two sisters) were found to be affected by this disorder. They were all asymptomatic. The diagnosis of the disorder was made first in the 36-year-old brother by transthoracic echocardiography (TTE) and multidetector CT (MD CT), during the process of preoperative evaluation for surgical treatment of low back intervertebral herniated disc. TTE and MD CT showed similar and peculiar findings of INVM. Echocardiographic screening in all first-degree relatives of this patient, in order to identify asymptomatic patients, demonstrated INVM in two elder sisters.

Predictors of side branch occlusions just after coronary stenting / 대한내과학회지

BACKGROUND: Coronary stenting is one of effective and well-accepted treatments for coronary artery disease. On the other hand, side branch occlusion (SBO) is a known complication of percutaneous transluminal coronary angioplasty (PTCA) and coronary stenting. Accordingly, this study was designed to determine the incidence, predictors and acute clinical outcomes of SBO. METHODS: Coronary angiographic findings of 45 patients who had total 98 side branches originating from the stented segments were analized before and just after coronary stenting. Bifurcation lesions were divided into 3 types : type 1, type 2, type 3 and each type was subdivided into type A with significant ostial narrowing (diameter stenosis >or=50%) and type B without significant ostial narrowing of side branches. Side branch occlusion was defined as development of total occlusion or morphologic changes from type B to type A or reduction of TIMI flow more than grade 1 compared with pre-stenting flow of side branches. RESULTS: After coronary stenting, SBO occurred in 20 of 98 side branches (20.4%). SBO was significantly related with history of previous myocardial infarction (p=0.02), threatened side branch morphology (p=0.016) and poor pre-stenting flow of side branches (p=0.014). There were no serious clinical events such as myocardial infaction and death associated with acute SBO. CONCLUSION: Acute SBO can be developed in a few stented patients. Signifiant clinical and angiographic predictors of SBO just after coronary stenting were the history of previous myocardial infarction, threatened side branch morphology and poor pre-stenting flow of side branches.

Echocardiograpic Findings of Coronary Sinus in Heart Failure

BACKGROUND AND OBJECTIVES: The coronary sinus (CS) is a small tubular structure just below the tricuspid valve. The dilatation of the coronary sinus as well as the inferior vena cava and the hepatic vein may provide echocardiographic signs of systemic congestion. The aim of this study was to evaluate the correlation of size of coronary sinus that had abnormal echocardiographic findings with or without congestive heart failure. SUBJECTS AND METHODS: Echocardiographic examinations of coronary sinus were performed on 58 patients (M : F=20 : 38) who had abnormal echocardiographic findings with current or previous symptoms or signs of congestive heart failure (group 1), and on 63 patients (M:F=27:36) who had abnormal echocardiographic findings but that had never had symptoms or signs of heart failure(group 2) and 94 healthy volunteers (control group, M:F=52:42). The CS was mesured using a two-dimensional echocardiogram in the right ventricular inflow view (5-10 mm below the Thebesian valve at end-systolic phase). RESULTS: In the normal control group, the median size of the CS was 6.2+/-1.2 mm, and showed no difference between gender and age. The sizes of the CS in groups 1 and 2 were 9.0+/-2.3 and 6.4+/-1.3 mm, respectively. There were differences between groups 1 and the normal control group (p<0.001), and between groups 1 and 2 (p<0.001), but a slight change between group 2 and the normal control group. In group 1, the size of the coronary sinus was related with the duration of heart failure (r=0.32, p=0.016), but no correlations to body surface area, left ventricle dimension and TR peak velocity were shown. In the presence of heart failure, as diagnosed according to the size of the CS, the predictive value was high when the size of the CS exceeded 8.0 mm, with an accuracy of 84%. In heart failure, the median size of the IVC was 16.6+/-5.4 mm, the variation rate of the IVC during the respiratory cycle was 0.40+/-0.13, and the variation rate of the CS during cardiac cycle was 0.31+/-0.20. The size of the CS was not related with the size of the IVC, but there was an inverse correlation between the size of the IVC and its variation rate (r=-0.434, p=0.037). The size of the IVC was inversely correlated with the variation rate of the CS (r=-0.490, p=0.024). There was a correlation between the variation rate of the CS and that of the IVC (r=0.411, p=0.021). Comparing the groups with and without systolic flow reversal into the CS in congestive heart failure patients with tricuspid regurgitation, in the former there wrer distensions of the CS, IVC and LA dimensions and reductions in the variation rates of the CS. CONCLUSION: The measurement of the size of the CS and the variation rate of CS may provide valuable information concerning the presence and duration of congestive heart failure.

An Intravenous leiomyoma with cardiac involvement in a patient with uterine leiomyoma / 대한내과학회지

A case of intravenous leiomyomatosis (IVL) invading the vena cava and extending to the right atrium, a rare benign smooth-muscle tumor, is described. Despite their histological benignity, these lesions have a tendency to metastasize and are closely related to the condition called "benign metastasizing leiomyoma" and "intracaval mass and cardiac extension". A 50-year old woman was admitted to the hospital with dyspnea beginning 6 months ago and previous history of hysterectomy due to uterine myoma. Echocardiography revealed severe tricuspid valve insufficiency and a mobile elongated mass which occupied the inferior vena cava and was extending into the right ventricular cavity. Pelvic ultrasonography and pelvic MRI identified suspicious metastasis to both ovaries and peritoneum. She underwent resection of the cardiac tumor, concomitant tricuspid annuloplasty with a closure of the foramen ovale and both salphyngo-oophorectomy with vaginal stump mass biopsy. All of them could be histologically identified as IVL.

Quantitative Evaluation of Right-Ventricular Function in Patients with Tricuspid Regurgitation

BACKGROUND: Tricuspid regurgitation (TR) is a common finding that can be detected with use of Doppler echocardiographic technique in patients with right ventricular dysfunction as well as in normal children, adolescents and adult. It is difficult to evaluate the right ventricular function by conventional method, including echocardiography, especially in case with TR. METHOD: To determine the degree and relationship of right ventricular function and duration of TR, we examined the 41 patients with TR associated with heart disease, group 2 (n=19) with no definitive evidence of right ventricular dysfunction nor significant pulmonary hypertension, and group 3 (n=22) with right ventricular dilatation or wall motion abnormality, or history of longstanding pulmonary hypertension or moderate or severe TR, and compared 59 normal subjects (group 1) with trivial or mild TR without definitive heart disease. Using Doppler echocardiography, duration of TR (TRD) and pulmonary ejection period (ET) is measured, and calculated the TR time interval (RTI) by the difference of TRD and ET divided by ET. RESULT: Pre-ejection period (PEP), ET and systolic time interval (STI, PEP/ET) of right ventricle are significantly prolonged in group 2 and 3 compare to those of group 1 (p<0.001 respectively), TRD is significantly prolonged in group 3 compare to those of group 1 and 2, and isovolumic contraction time (IRT), isovolumic relaxation time (IRT) and RTI are significantly different in each group and prolonged in group 2 and 3. RTI is significantly correlated to STI (r=0.56), ICT (r=0.75) and IRT (r=0.94), but independent to heart rate. CONCLUSION: We conclude that Doppler measurement of RTI (TRD-ET)/ET{=(ICT+IRT)/ET} is a simple and useful new index for the evaluation of RV function including systolic and diastolic function.

Clinical Observation on Congenital Heart Disease in Adult

BACKGROUND: With the advance of the techniques of echocardiography and cardiovascular surgery, early detection and successful cardiovascular surgery of congenital heart disease is possible in infant as well as in child. And with the advance of the social insurance, the new case of adult congenital heart disease with mild cardiovascular symptom or frank symptom of the pulmonary hypertension is decreasing. We statistically analyze the new case of adult congenital heart disease. METHOD: 92 patients who were diagnosed to congenital heart disease by echocardiography from January 1993 to June 1998 were studied. 2.25 MHz probe for two-dimensional and Doppler echocardiography and biplane 5 MHz phased-array probe for transesophageal echocardiography(Ultramark-9) were used. RESULT: Among 92 patients, 45 patients(48.9%) were male and 47 patients(51.1%) were female and 6 patients(male : 2, female : 4) had multiple congenital heart disease. 61 patients(66.3%) had no definitive cardiovascular symptom and right bundle branch block was most common electrocardiographic abnormality. 32 cases(32.8%) were atrial septal defect, 21 cases(21.5%) ventricular septal defect, 12 cases(12.3%) patent ductus arteriosus, 8 cases(8.2%) congenial bicuspid aortic valve and so on. Female predominance was noted in ventricular septal defect and endocardial septal defect, while male predominance in bicuspid aortic valve and discrete subaortic stenosis. Atrial septal defect and patent ductus arteriosus were no sex difference. 23 cases(25.0%) were between 20 29, 17 cases(18.5%) between 15-19, and 2 cases(2.2%) over 70 years old. CONCLUSION: Our analysis shows similarity to previous report. With advance of the technique of echocardiography and cardiovascular surgery, a few new case of adult congenital heart disease can be diagnosed hereafter.

A Study of the Usefulness of Apical Rotation Method of the Transducer for the Visualization of the Left Atrial Appendage / 대한내과학회지

OBJECTIVES: Visualization of the left atrial appendage(LAA) by the transesophageal echocardiography(TEE) is excellent, but it is difficult to visualize the LAA by the modified parasternal short-axis view(MPSA) in transthoracic echocardiography(TTE). We studied to determine the usefulness of the apical horizontal view(AHV) abtained by the apical rotation method of the transducer for the detection of the LAA. METHODS: We studied the MPSA and AHV in 602 patients, The LAA was observed during diastole of the LAA. We obtained an apical horizontal view by 45 degree clockwise rotation of the transducer from the apical 2 chamber view and compared with the visualization of the LAA in AHV and MPSA. RESULTS: Among 602 patients, LAA could not be visualized in 88(14.6%) because of a poor echo-window. LAA was more clearly visualized in 222 patients by the AHV than the MPSA and 56 patients by the MPSA than the AHV. LAA was same degree visualization in patients by the AHV and MPSA. In male and female, more than 55 ages and less than 55 ages, visualization of inner margin of the LAA by the AHV was more clear than by the MPSA. CONCLUSION: The AHV was a useful, noninvasive and reproducible method for the visualization of the LAA.

Usefulness of Echocardiography in the Evaluation of Paracardiac Masses

BACKGROUND: Echocardiography gives a window to mediastinal or paracardiac structures. When mediastinal or paracardiac masses are detected by a routine chest X-ray and thoracic CT, the difference between vascular and nonvascular lesions may be difficult to diagnose. In these situations, echocardiography has been successfully used recently. CT can be easily standardized and allows visualization of the whole chest, but it is less precise in defining highly mobile structures, more expensive and difficult to perform in patients with orthopnea. But echocardiography is easy to perform, gives real time images. We performed this study to evaluate the usefulness of echocardiography in the identification and investigation of the structural and functional effects of paracardiac masses. METHODS: Twenty patients with paracardiac masses detected by chest X-ray and thoracic CT were examined by transthoracic and/or transesophageal echocardiography. We studied the characteristics of masses and compression site by 2-D echocardiographic techniques and also evaluation of functional effects of a paracardiac masses on heart and great vessels by color pulsed waved Doppler echocardiographic techniques. RESULTS: Nine patients(45.0%) had cystic masses, eleven patients(55.0%) had solid masses. All cystic masses revealed benign, and all solid masses revealed malignant. Among metastatic paracardiac tumors, the most frequent primary site were lung. heart chambers were compressed by paracardiac masses in five cases(26.7%) and great vessel compressed in thirteen cases(76.4%). Turbulent flow and peak velocity documented by color and PW dopple suggested that it is hemodynamically significant compression states of the great vessels by masses. CONCLUSIONS: We consider that echocardiography is as useful as other noninvasive radiographic techniques in the evaluation of paracardiac masses and their mechanical effect upon the function of the heart and great vessels.

Doppler Echocardiographic Findings of Mitral Valve Prolapse : Usefulness of the Apical Rotation Method of a Transducer for Assessment of Site of Prolapse

BACKGROUND: Color Doppler echocardiography is sensitive in detecting mitral regurgitation and useful in quantitating its severity. The presence of an eccentric regurgitant jet suggests that regurgitation is caused by prolapsing or flail leaflet of mitral valve. Until recently the direction of regurgitant jet in mitral valve prolapse has been examined in a single(parasternal short axis view) or orthogonal plane using color Doppler echocardiography, and few in the apical rotation method of a transducer. The purpose of this study was to clarify the usefullness of the apical rotation method of a transducer in detection of the direction of mitral regurgitant jet and diagnosis of the sites of mitral valve prolapse. METHODS: Twenty four patients(8 men and 16 women, mean age:47.3+/-18.8 years) with mitral valve prolapse with eccentric regurgitant jet were examined by two-dimensional and color Doppler echocardiograply using conventional parasternal long and short axis views, and four apical longitudinal planes(four chamber, vertical, two chamber and transverse views) obtained by the apical retation method of a transducer. RESULTS: Thirty one regurgitant jets were detected in twenty four patients, eighteen patients had anterior, nine patints posterior, and three patients bi-leaflet(anterior and posterior) prolapse. In eighteen patients with anterior leaflet prolapse, ten had medial, eight had middle, three had lateral, and three had two portions(two, medial and middle; one, middle and lateral) prolapse. In nine patients with posterior leaflet prolapse, five had medial, three had middle, two had lateral, and one had two(medial and middle) scallop prolapse. CONCLUSION: Color Doppler echocardiography by the apical rotation method of transducer is useful in assessment of the site of prolapse in patients with mitral valve prolapse with eccentric regurgitation.

Clinical Study of Healthy Young Men with Mitral Valve Prolapse

BACKGROUND: Mitral valve prolapse(MVP) is now recognized as noe of the most common cardiovascular disorders, particularly in young women with a slender body habitus. However, there is little clinical information about young men with mitral valve prolapse. The purpose of this study was to evaluate the physical and echocardiographic characteristics of young men about 20 years old with mitral valve prolapse. METHOD: Twenty young men with mitral valve prolapse(MVP graoup, mean age ; 19.9±2.4 years) and twenty healthy volunteers(control group, mean age ; 19.9±3.2 years) were examined using physical examination, chest X-ray, computed thoracic tomography and two dimensional and Doppler echocardiography. RESULTS: Compared with control group, MVP group had a smaller chest circumference(p < 0.001), a larger height-arm span difference(p < 0.01), smaller anteroposterior chest diameters(by chest X-ray ; p < 0.001 and computed tomography ; p < 0.01) and smaller anteroposterior/transverse chest diameter ratio(chet X-ray ; p < 0.01 and computed tomography ; p < 0.05). In MVP group, mitral regurgitation was noted 15 men(75%), those had posteriorly directed jets suggesting anterior mitral leaflet anomalies. CONCLUSION: Healthy young men having mitral valve prolapse had narrow chest and slender physical characteristics and anterior mitral leaflet abnormalities.

Transesophageal Echocardiographic Findings of Ischemic Stroke without Obvious Cardiac Disease

To detect the cardiac source of embolism in patient of ischemic stroke of uncertain etiology, biplane transesophageal echocardiography and contrast echocardiography with hand-agitated saline were performed 27 patients(sixteen men and eleven women) of transient ischemic attack and cerebral infarction without definitive cardiac symptom and sign. Transesophageal echocardiography showed potential sources of embolism in nineteen patients (70.4%) including atrial septal aneurysm(n = 9, three of them had patent foramen ovale), spontaneous contrast echo(n = 3), mitral valve prolapse(n= 1), unknown thickening of the tip of the mitral valve(n = 1) and atherosclerotic plaque in descending aorta(n = 7). Thus transesophageal echocardiography and contrast echocardiography identify potential cardiac source of embolism, and provide the rationale of the thrombolytic and anticoagulant therapy in patients with ischemic stroke without obvious cardiac disease.

Two cases atrial septal aneurysm with patent foramen ovale in cerebral infarction

No abstract available.

A case of asymptomatic cor triatriatum

No abstract available.

A Study on Left Ventricular Function in Diabetics by Digitized Echocardiography

Echocardiographic evaluation of left ventricular function permits the demonstration of preclinical diabetic cardiomyopathy. In order to define the relationship between diabetic retinopathy and precence of myocardial dysfunction, M-mode echocardiograms were recorded in three groups of diabetics ; group 1, no retinopathy, group 2, background retinopathy, group 3, proliferative retinopathy, and normal controls without evidence fo coronary heart disease. The resultant traces were digitized, and systolic and diastolic parameters were evaluated. None of parameters fo systolic function was modified. however peak velocity of posterior wall thinning was decreased in group 3(p<0.005), peak velocity of left ventricular demension increase was decreased in all three groups(p<0.005, P<0.001, P<0.001 respectively), duration of rapid thinning of posterior wall increased in group 2 and 3(p<0.001, p<0.001 respectively), and duration of rapid inflow of left ventricle was increased in group 3(p<0.005). These results indicate a diminution of myocardial compliance and relaxation in diabetics with retinopathy. It is concluded that abnormalities of left ventricular diastolic function is present in diabetics when left ventricular systolic function is normal and that more severe abnormalities of left ventricular diastolic function in diabetics with proliferative retinopathy reflect a subclinical diabetic cardiomyopathy due to small vessel disease.