Prognostic Significance of 24-Hour Ambulatory Blood Pressure and Holter Monitoring in Patients without Atrial Fibrillation / 이화의대지

Objectives@#This study investigated the 24-hour ambulatory blood pressure monitoring (ABPM) and Holter parameters for evaluating their prognostic significance of cardiovascular events including stroke in population without atrial fibrillation (AF). @*Methods@#Among 3,199 patients that underwent ABPM, 335 who also underwent Holter recordings were selected in a tertiary hospital. Seventeen patients who had been documented with AF on Holter monitoring or diagnosed with AF were excluded, and finally 318 patients were analyzed. The association between cardiovascular events and ABPM/Holter parameters was analyzed by a logistic regression model, and the risk factors were estimated by a Cox hazard model. Age, sex, and histories of cardiovascular disease were adjusted by a multivariable analysis, and the cut-off values were suggested by a Kaplan-Meyer analysis. @*Results@#During the total follow-up (28.5±1.7 months), 13 (4.1%) stroke, 6 (1.9%) heart failure, and 12 (3.8%) acute coronary syndrome incidences were observed. In the univariate analysis of the ABPM parameters, an increment in the night systolic BP (hazard ratio=1.034, P=0.020) and night diastolic BP (hazard ratio=1.063, P=0.031) significantly elevated the risk of a stroke occurrence. According to the Kaplan-Meyer analysis, there was a significant difference in the stroke incidence between the groups divided by a cut-off value of the night systolic BP of 120 mmHg (P=0.014) and night diastolic BP of 75 mmHg (P=0.023). @*Conclusion@#In a population without AF, the nocturnal BP was a significant predictor of a stroke incidence. At this point, the cut-off value of mean 120/75 mmHg in 24 ABPM was advisable.

Long-Term Clinical Outcomes of Iliac Artery Endovascular Therapy in the Korean Vascular Intervention Society Endovascular Therapy in Lower Limb Artery Diseases (K-VIS ELLA) Registry

Background and Objectives@#Limited data are available regarding long-term clinical outcomes of iliac artery endovascular therapy (EVT) in real-world practice. This study investigated long-term outcomes according to Trans-Atlantic Inter-Society Consensus (TASC) classifications. @*Methods@#We analyzed data from 1,705 limbs of 1,364 patients from the retrospective cohort of the multicenter Korean Vascular Intervention Society Endovascular Therapy in Lower Limb Artery Disease registry. The primary endpoint was target lesion revascularization (TLR)-free survival. @*Results@#TASC A, B, C, and D lesions were present in 19.4%, 26.2%, 28.7%, and 25.7% of the treated limbs, respectively. The technical success rate was 96.2% and did not differ between TASC lesion types. Complications occurred in 6.8% of cases and more occurred in TASC D (11.8%). Iliac artery EVT showed a 5-year TLR-free survival of 89.2%. The TASC D group had the lowest TLR-free rate of 79.3%. TASC D (hazard ratio [HR], 1.75; 95% confidence interval [CI], 1.12–2.73; p=0.014), plain old balloon angioplasty (HR, 4.25; 95% CI, 2.03–8.88; p<0.001), current smoker (HR, 1.89; 95% CI, 1.26–2.83; p=0.002), previous bypass surgery (HR, 3.04;95% CI, 1.28–7.19; p=0.011), combined femoropopliteal treatment (HR, 4.89; 95% CI, 3.19–7.50; p<0.001), combined below the knee treatment (HR, 2.20; 95% CI, 1.25–3.89; p=0.007), and complications (HR, 1.86; 95% CI, 1.07–3.24; p=0.028) were predictors for TLR. @*Conclusions@#Iliac artery EVT achieved excellent technical success and 5-year TLR-free survival. TASC D showed a favorable but lower 5-year TLR-free survival rate and higher complication rate compared with other TASC groups.

Assessment of Image Quality for Selective Intracoronary Contrast-Injected CT Angiography in a Hybrid Angio-CT System: A Feasibility Study in Swine

Purpose@#To compare image quality in selective intracoronary contrast-injected computed tomography angiography (SelectiveCTA) with that in conventional intravenous contrast-injected CTA (IV-CTA). @*Materials and Methods@#Six pigs (35 to 40 kg) underwent both IV-CTA using an intravenous injection (60 mL) and Selective-CTA using an intracoronary injection (20 mL) through a guide-wire during/after percutaneous coronary intervention. Images of the common coronary artery were acquired. Scans were performed using a combined machine comprising an invasive coronary angiography suite and a 320-channel multi-slice CT scanner. Quantitative image quality parameters of CT attenuation, image noise, signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), mean lumen diameter (MLD), and mean lumen area (MLA) were measured and compared. Qualitative analysis was performed using intraclass correlation coefficient (ICC), which was calculated for analysis of interobserver agreement. @*Results@#Quantitative image quality, determined by assessing the uniformity of CT attenuation (399.06 vs. 330.21, p<0.001), image noise (24.93 vs. 18.43, p<0.001), SNR (16.43 vs. 18.52, p=0.005), and CNR (11.56 vs. 13.46, p=0.002), differed significantly between IV-CTA and Selective-CTA. MLD and MLA showed no significant difference overall (2.38 vs. 2.44, p=0.068, 4.72 vs. 4.95, p=0.078).The density of contrast agent was significantly lower for selective-CTA (13.13 mg/mL) than for IV-CTA (400 mg/mL). Agreement between observers was acceptable (ICC=0.79±0.08). @*Conclusion@#Our feasibility study in swine showed that compared to IV-CTA, Selective-CTA provides better image quality and requires less iodine contrast medium.

Spontaneous regression of cardiac sarcoidosis resulting in total occlusion of coronary artery and ventricular aneurysm

No abstract available.

Spontaneous regression of cardiac sarcoidosis resulting in total occlusion of coronary artery and ventricular aneurysm

No abstract available.

The Characteristic Doppler Pattern of the Left Ventricular Outflow Tract in a Patient with Orthostatic Hypotension

No abstract available.

Effect of Triflusal on Primary Vascular Dysregulation Compared with Aspirin: A Double-Blind, Randomized, Crossover Trial

PURPOSE: Primary vascular dysregulation (PVD) is a condition in which the response to cold temperature or external stimuli is abnormal. We investigated whether triflusal use results in amelioration of PVD symptoms and improvement of several related parameters compared with aspirin. MATERIALS AND METHODS: Eighty-eight PVD patients (54% female, 56+/-8 years) were randomly selected to receive either triflusal (300 mg, b.i.d.) or aspirin (150 mg, b.i.d.) for a period of 6 weeks followed by crossover. PVD was defined as both red-blood-cell standstill in video-assisted microscopic capillaroscopy during cold stimulation using carbon dioxide gas and a score of more than 7 points in a validated questionnaire. Efficacy of treatment was assessed by 1) cold intolerance symptom severity (CISS) score, 2) finger Doppler indices, and 3) indocyanine green perfusion imaging. RESULTS: The use of triflusal resulted in a greater improvement in CISS score (44.5+/-18.4 vs. 51.9+/-16.2; p<0.001) and in mean radial peak systolic velocity (69.8+/-17.2 vs. 66.1+/-16.4; p=0.011) compared to aspirin. Furthermore, significant differences were also observed in perfusion rates on indocyanine green perfusion imaging between triflusal and aspirin (45.6+/-25.8 vs. 51.6+/-26.9; p=0.020). CONCLUSION: Triflusal was more effective and demonstrated a more consistent impact on the improvement of symptoms and blood flow in patients with PVD than aspirin.

Late Gadolinium Enhancement in Cardiac MRI in Patients with Severe Aortic Stenosis and Preserved Left Ventricular Systolic Function Is Related to Attenuated Improvement of Left Ventricular Geometry and Filling Pressure after Aortic Valve Replacement

BACKGROUND AND OBJECTIVES: We investigated echocardiographic predictors: left ventricular (LV) geometric changes following aortic valve replacement (AVR) according to the late gadolinium enhancement (LGE) on cardiac magnetic resonance imaging (CMR) in patients with severe aortic stenosis (AS) and preserved LV systolic function. SUBJECTS AND METHODS: We analyzed 41 patients (24 males, 63.1+/-8.7 years) with preserved LV systolic function who were scheduled to undergo AVR for severe AS. All patients were examined with transthoracic echocardiography (TTE), CMR before and after AVR (in the hospital) and serial TTEs (at 6 and 12 months) were repeated. RESULTS: The group with LGE (LGE+) showed greater wall thickness (septum, 14.3+/-2.6 mm vs. 11.5+/-2.0 mm, p=0.001, posterior; 14.3+/-2.5 mm vs. 11.4+/-1.6 mm, p<0.001), lower tissue Doppler image (TDIS', 4.4+/-1.4 cm/s vs. 5.5+/-1.2 cm/s, p=0.021; TDI E', 3.2+/-0.9 cm/s vs. 4.8+/-1.4 cm/s, p=0.002), and greater E/e' (21.8+/-10.3 vs. 15.4+/-6.3, p=0.066) than those without LGE (LGE-). Multivariate analysis show that TDI e' (odds ratio=0.078, 95% confidence interval=0.007-0.888, p=0.040) was an independent determinant of LGE+. In an analysis of the 6- and 12-month follow-up compared with pre-AVR, LGE- showed decreased LV end-diastolic diameter (48.3+/-5.0 mm vs. 45.8+/-3.6 mm, p=0.027; 48.3+/-5.0 mm vs. 46.5+/-3.4 mm, p=0.019). Moreover, E/e' (at 12 months) showed further improved LV filling pressure (16.0+/-6.6 vs. 12.3+/-4.3, p=0.001) compared with pre-AVR. However, LGE+ showed no significant improvement. CONCLUSION: The absence of LGE is associated with favorable improvements in LV geometry and filling pressure. TDI E' is an independent determinant of LGE in patients with severe AS and preserved LV systolic function.

Retrograde Distal Superficial Femoral Artery Approach in the Supine Position for Chronic Superficial Femoral Artery Occlusion

Subintimal angioplasty is an effective method for the treatment of long superficial femoral artery (SFA) occlusions. One of the major limiting factors for the success of this procedure is the failure to re-enter the true lumen. The recently introduced luminal re-entry devices provide a high technical success rate, but failures can occur. In such cases, a retrograde popliteal approach can serve as a potential backup option. However, the need to reposition the patient remains a drawback. Here, we report a case of an 81-year-old male with a long SFA occlusion treated using a retrograde distal SFA approach in the supine position after the initial failure of antegrade angioplasty.

Echocardiographic Investigation of the Mechanism Underlying Abnormal Interventricular Septal Motion after Open Heart Surgery

BACKGROUND: Abnormal interventricular septal motion (ASM) is frequently observed after open heart surgery (OHS). The aim of this study was to investigate the incidence and temporal change of ASM, and its underlying mechanism in patients who underwent OHS using transthoracic echocardiography (TTE). METHODS: In total, 165 patients [60 +/- 13 years, 92 (56%) men] who underwent coronary bypass surgery or heart valve surgery were consecutively enrolled in a prospective manner. TTE was performed preoperatively, at 3-6-month postoperatively, and at the 1-year follow-up visit. Routine TTE images and strain analysis were performed using velocity vector imaging. RESULTS: ASM was documented in 121 of 165 patients (73%) immediately after surgery: 26 patients (17%) presented concomitant expiratory diastolic flow reversal of the hepatic vein, 11 (7%) had inferior vena cava plethora, and 11 (7%) had both. Only 2 patients (1%) showed clinically discernible constriction. ASM persisted 3--6 months after surgery in 38 patients (25%), but only in 23 (15%) after 1 year. There was no difference in preoperative and postoperative peak systolic strain of all segments of the left ventricle (LV) between groups with or without ASM. However, systolic radial velocity (V(Rad)) of the mid anterior-septum and anterior wall of the LV significantly decreased in patients with ASM. CONCLUSION: Although ASM was common (74%) immediately after OHS, it disappeared over time without causing clinically detectable constriction. Furthermore, we consider that ASM might not be caused by myocardial ischemia, but by the decreased systolic V(Rad) of the interventricular septum after pericardium incision.

Aortic Aneurysm Screening in a High-Risk Population: A Non-Contrast Computed Tomography Study in Korean Males with Hypertension

BACKGROUND AND OBJECTIVES: Screening strategies for aortic aneurysm (AA) according to risk factors and ethnicity are controversial. This study explored the prevalence of AA and determined whether screening is necessary in a population of multiple risk factors. SUBJECTS AND METHODS: From June, 2012 to April, 2013, 542 consecutive elderly (> or =65 years) male hypertensive patients without a history of AA were prospectively enrolled. After excluding 15 patients (2.8%) with aortic valve surgery, 30 patients (5.5%) with suboptimal computed tomography (CT) images, the remaining 496 patients (age 73+/-5 years) comprised the study population. Maximal diameters of the thoracic and abdominal aorta were measured using non-contrast CT. RESULTS: The prevalence of thoracic AA (TAA, diameter > or =40 mm) and abdominal AA (AAA, diameter > or =30 mm) was 36.5% (181/496) and 6.0% (30/496), respectively. In the multivariate logistic regression analysis, determinants for TAA were age {odds ratio (OR) 1.059, 95% confidence interval (CI) 1.018-1.101, p=0.005}, dyslipidemia (OR 0.621, 95% CI 0.418-0.923, p=0.018), body surface area (OR 11.92, 95% CI 2.787-50.97, p=0.001), diastolic blood pressure (OR 1.029, 95% CI 1.009-1.049, p=0.004) and AAA (OR 3.070, 95% CI 1.398-6.754, p=0.005). In contrast, AAA was independently associated with dysplipidemia (OR 2.792, 95% CI 1.091-7.143, p=0.032), current/past smokerfs (OR 4.074, 95% CI 1.160-14.31, p=0.028), and TAA (OR 3.367, 95% CI 1.550-7.313, p=0.002). CONCLUSION: The prevalence of AA was significant and TAA was more prevalent than AAA in elderly Korean males with hypertension. Future research should establish distinct screening strategies for TAA and AAA according to risk factors and ethnicity.

Successful Treatment of Severe Aortic Stenosis With Transcatheter Aortic Valve Implantation in a Centenarian Patient

Transcatheter aortic valve implantation (TAVI) is a less invasive procedure to treat severe aortic valve stenosis than conventional surgical aortic valve replacement. Furthermore, TAVI has shown similar clinical outcomes as surgical treatment with less mortality and morbidities in elderly patients at high risk for conventional surgery. In this report, we describe case of successful TAVI using a CoreValve in a 103-year-old patient with symptomatic severe aortic valve stenosis.

Prediction of Hemorrhagic Transformation Following Embolic Stroke in Patients with Prosthetic Valve Endocarditis

BACKGROUND: Hemorrhagic transformation (HT) of stroke is a disastrous complication in patients with infective endocarditis (IE). In patients with mechanical heart valves complicated by IE, physicians struggle with the appropriateness of anticoagulation administration given the risk of thromboembolism and HT of stroke. In this study, we aimed to define predictive parameters of HT of stroke in patients with prosthetic valve endocarditis (PVE). METHODS: This study was a multicenter, retrospective design. We recruited from 7 institutions a total of 111 patients diagnosed with PVE during May, 2011 to April, 2012. RESULTS: Complication of stroke was seen in 26/111 patients (23%), and HT of stroke was seen in 11/111 patients (10%). Most patients with HT (9/11, 82%) had supratherapeutic prothrombin times. However, there were no significant differences in clinical and laboratory values between PVE patients without stroke and those patients who had a stroke and with or without concurrent HT. Furthermore, echocardiographic parameters also did not show significant between-group differences. CONCLUSION: Even though this was a multicenter study, a limited number of patients was identified and may explain the negative results seen here. However, a large number of PVE patients with stroke also developed HT. Therefore, further studies to define predictive parameters of HT should be implemented in a larger population.

Dorsal-Plantar Loop Technique Using Chronic Total Occlusion Devices via Anterior Tibial Artery

The effectiveness of below-the-knee (BTK) percutaneous transluminal angioplasty to obtain successful revascularization in patients with critical limb ischemia has been well established, and many of these patients with chronic lower-extremity disease have been treated by endovascular intervention as the firstline treatment. Dorsal-plantaer loop technique is one of the new BTK interventional techiniques, and includes recanalization of both pedal and plantar arteries and their anatomical anastomoses. This method generally needs two approaches simultaneously, including antegrade and retrograde. In this report, however, we describe a case in which dorsal-plantar loop technique with only one antegrade approach, using chronic total occlusion devices via anterior tibial artery, was used to successfully recanalize BTK arteries. We think that this new technique, which may represent a safe and feasible endovascular option to avoid more invasive, time-consuming, and riskier surgical procedures, especially in end-stage renal disease and diabetes, should be considered whenever the foot is at risk, and results of above-the-ankle percutaneous transluminal angioplasty remain unsatisfactory or insufficient to achieve limb salvage.

Relationship between Angiographic Late Loss and 5-Year Clinical Outcome after Drug-Eluting Stent Implantation

PURPOSE: Currently, insufficient data exist to evaluate the relationship between angiographic late loss (LL) and long-term clinical outcome after drug-eluting stent (DES) implantation. In this study, we hypothesized that angiographic LL between 0.3 and 0.6 mm correlate with favorable long-term clinical outcomes. MATERIALS AND METHODS: Patients were enrolled in the present study if they had undergone both DES implantation in single coronary vessel and a subsequent follow-up angiogram (n=634). These individuals were then subdivided into three groups based on their relative angiographic LL: group I (angiographic LL 0.6 mm, n=134). During a 5-year follow-up period, all subjects were tracked for critical events, defined as any cause of death or myocardial infarction, which were then compared among the three groups. RESULTS: Mean follow-up duration was 63.0+/-10.0 months. Critical events occurred in 25 subjects in group I (6.6%), 5 in group II (4.0%), and 17 in group III (12.7%), (p=0.020; group I vs. group II, p=0.293; group II vs. group III, p=0.013). In a subsequent multivariate logistic regression analysis, chronic renal failure [odds ratio (OR)=3.29, 95% confidence interval (CI): 1.48-7.31, p=0.003] and long lesion length, defined as lesion length >28 mm (OR=1.88, 95% CI: 1.02-3.46, p=0.042) were independent predictors of long-term critical events. CONCLUSION: This retrospective analysis fails to demonstrate that post-DES implantation angiographic LL between 0.3 and 0.6 mm is protective against future critical events.

The First Case of Successful Transcatheter Aortic Valve Implantation Using CoreValve in Korea

Surgical replacement of the aortic valve is the standard therapy for severe aortic valve stenosis. However, it is generally associated with increased mortality and morbidities in older individuals. Transcatheter aortic valve implantation (TAVI) is a less invasive procedure and has shown similar clinical outcomes as surgical treatment in elderly patients at high risk for conventional surgery. In this report, we describe the first case of TAVI using a CoreValve in Korea. An 84-year-old man with symptomatic severe aortic valve stenosis was successfully treated by transfemoral TAVI. The patient was discharged without any significant complications and remained free of adverse clinical event for a follow-up duration of 6 months.

Clinical Characteristics of Acute Aortic Syndrome in Korean Patients: From the Korean Multi-Center Registry of Acute Aortic Syndrome

BACKGROUND AND OBJECTIVES: Acute aortic syndrome (AAS) is a heterogeneous group of disorders that often present with severe chest or back pain. It includes acute aortic dissection (AD), intramural hematoma (IMH), dissecting aneurysm, and penetrating aortic ulcer (PAU). The clinical picture of AAS and its prognosis have not been studied in a large number of Korean patients. Therefore, we organized a multi-center registry to identify the clinical characteristics and treatment patterns, as well as long-term outcomes in Korean patients with AAS. SUBJECTS AND METHODS: Five-hundred twenty-eight patients, who had been diagnosed with AAS, were enrolled into this registry from 10 centers. On a retrospective basis, we collected demographic, laboratory, imaging data, as well as follow-up clinical outcomes by reviewing medical records from individual centers. All the data were collected in core lab and analyzed in detail. RESULTS: The mean patient age was 60.1+/-14.5 years; the male-to-female ratio was M : F=297 : 231. The prevalent risk factors for AAS included hypertension (361, 68.4%) and diabetes (52, 11.1%). The components of AAS that are included in this study are acute AD (446, 84.5%), IMH (57, 10.7%), and PAU (11, 2.1%). By type of AAS, patients diagnosed with Stanford A were 45.6% of enrolled patients, whereas those with Stanford B were 54.4% of enrolled patients. Among nearly half of the patients were treated with medicine (55.7%) alone, whereas 40.0% underwent surgery and 4.3% underwent endovascular treatment. Overall, the in-hospital event rate was 21.2% and the in-hospital death rate was 8.1%. The mean follow-up duration was 42.8 months and there showed 22.9% of total event and 10.1% of death during this period. CONCLUSION: By organizing a multi-center registry of AAS, we could identify the characteristics of AAS in real-world Korean patients. Further, prospective study is warranted with a larger number of patients.

Acute Myocardial Infarction due to Polyarteritis Nodosa in a Young Female Patient

Coronary artery aneurysms are uncommon, are usually associated with atherosclerosis, and rarely involve all three major coronary arteries. The present report describes a rare case of a young female patient presenting with acute myocardial infarction (AMI). Coronary angiography revealed multiple severe aneurysmal and stenotic changes. Based on clinical feature and angiographic findings, it was strongly suspected that the patient had polyarteritis nodosa (PAN) complicated by AMI. The patient was treated with standard cardiac medications and immunosuppressive agents and has remained stable without further complications during a follow-up period of 6 months.

Permanent Pacemaker for Syncope after Heart Transplantation with Bicaval Technique

Sinus node dysfunction occurs occasionally after heart transplantation and may be caused by surgical trauma, ischemia to the sinus node, rejection, drug therapy, and increasing donor age. However, the timing and indication of permanent pacemaker insertion due to sinus node dysfunction following heart transplantation is contentious. Here, we report a case of a permanent pacemaker insertion for syncope due to sinus arrest after heart transplantation, even with a bicaval technique, which has been known to associate with few incidences of sinus node dysfunction.