Clinical efficacy of angiotensin receptor-neprilysin inhibitor in de novo heart failure with reduced ejection fraction

Background/Aims@#We aimed to analyze the efficacy of angiotensin receptor-neprilysin inhibitor (ARNI) by the disease course of heart failure (HF). @*Methods@#We evaluated 227 patients with HF in a multi-center retrospective cohort that included those with left ventricular ejection fraction (LVEF) ≤ 40% undergoing ARNI treatment. The patients were divided into patients with newly diagnosed HF with ARNI treatment initiated within 6 months of diagnosis (de novo HF group) and those who were diagnosed or admitted for HF exacerbation for more than 6 months prior to initiation of ARNI treatment (prior HF group). The primary outcome was a composite of cardiovascular death and worsening HF, including hospitalization or an emergency visit for HF aggravation within 12 months. @*Results@#No significant differences in baseline characteristics were reported between the de novo and prior HF groups. The prior HF group was significantly associated with a higher primary outcome (23.9 vs. 9.4%) than the de novo HF group (adjusted hazard ratio 2.52, 95% confidence interval 1.06–5.96, p = 0.036), although on a higher initial dose. The de novo HF group showed better LVEF improvement after 1 year (12.0% vs 7.4%, p = 0.010). Further, the discontinuation rate of diuretics after 1 year was numerically higher in the de novo group than the prior HF group (34.4 vs 18.5%, p = 0.064). @*Conclusions@#The de novo HF group had a lower risk of the primary composite outcome than the prior HF group in patients with reduced ejection fraction who were treated with ARNI.

Temporal Trend of the Incidence and Characteristics of Renal Infarction:Korean Nationwide Population Study

Background@#Large-scale studies about epidemiologic characteristics of renal infarction (RI) are few. In this study, we aimed to analyze the incidence and prevalence of RI with comorbidities in the South Korean population. @*Methods@#We investigated the medical history of the entire South Korean adult population between 2013 and 2019 using the National Health Insurance Service database (n = 51,849,591 in 2019). Diagnosis of RI comorbidities were confirmed with International Classification of Disease, Tenth Revision, Clinical Modification codes. Epidemiologic characteristics, distribution of comorbidities according to etiologic mechanisms, and trend of antithrombotic agents were estimated. @*Results@#During the 7-years, 10,496 patients were newly diagnosed with RI. The incidence rate increased from 2.68 to 3.06 per 100,000 person-years during the study period.The incidence rate of RI increased with age peaking in the 70s with 1.41 times male predominance. The most common comorbidity was hypertension, followed by dyslipidemia and diabetes mellitus. Regarding etiologic risk factor distribution, high embolic risk group, renovascular disease group, and hypercoagulable state group accounted for 16.6%, 29.1%, and 13.7% on average, respectively. For the antithrombotic treatment of RI, the prescription of antiplatelet agent gradually decreased from 17.0% to 13.0% while that of anticoagulation agent was maintained around 35%. The proportion of non-vitamin K antagonist oral anticoagulants remarkably increased from only 1.4% to 17.6%. @*Conclusion@#Considering the progressively increasing incidence of RI and high prevalence of coexisting risk factors, constant efforts to raise awareness of the disease are necessary. The current epidemiologic investigation of RI would be the stepping-stone to establishing future studies about clinical outcomes and optimal treatment strategies.

Comparison of Clinical Outcomes of Long Stent Implantation with First- and Second-Generation Drug-Eluting Stents Following Rotational Atherectomy

Objective@#Rotational atherectomy (RA) and newly developed second-generation drug-eluting stent (DES) support the strategy of longer stent deployment in comparison to short stent implantations in the past. However, studies analyzing the outcome of patients who received long stent implantation following RA are few in number. The present study compared the clinical outcomes of patients with the coronary arterial disease (CAD) who underwent RA with long stent implantation using first- and second-generation DES. @*Methods@#A retrospective cohort study was performed at the single center from March 2003 to October 2019. Eighty-seven patients with CAD who underwent RA with ≥32 mm long stent implantation were enrolled in the study and divided into two groups according to the type of DES. As a primary endpoint, the cumulative 2-year incidence of major adverse cardiac events (MACE) including death, myocardial infarction (MI), target vessel revascularization, and stent thrombosis (ST) was compared by DES type. Adjusted interaction between the type of stent and clinical variables was estimated to determine the predictor variables of MACE. @*Results@#The second-generation DES group was associated with a shorter procedure duration and more common usage of intravascular ultrasound in procedural characteristics. In the second-generation DES group, a trend toward a lower rate of MI and ST existed. All-cause mortality and cardiovascular mortality were not significantly different. When combined with MACE, we could identify a significant reduction in the second-generation DES group. @*Conclusion@#In comparison to the first-generation DES group, the second-generation DES group was associated with a lower rate of MACE for 2 years in patients who underwent RA with long stent implantation.

Rotational Atherectomy through Inner Guiding Catheter System for 1.25 mm Rotational Burr Non-Crossable Heavily Calcified Coronary Stenosis

Among the various kinds of percutaneous coronary intervention techniques for balloon non-crossable severe calcified coronary stenosis, rotational atherectomy (RA) is known to be a therapy of choice. We describe a case in which a 1.25 mm RA burr non-crossable heavily calcified stenosis was successfully treated by the RA through '6 in 8 child-mother' guiding technique.

A Case of Sheathless Transradial Coronary Intervention for Complex Coronary Lesions with a Standard Guiding Catheter

One of the major limitations of transradial coronary intervention is the inability to use large guiding system, which leads to the development of dedicated sheathless guide catheter system. However, these devices are not available in the Republic of Korea. We present a case in which conventional guiding catheter was used for sheathless transradial coronary intervention in the treatment of complex coronary anatomy.

Infective Endocarditis with Dissection of Sinus of Valsalva Mimicking Type A Aortic Dissection

No abstract available.

The Correlation of Carotid Artery Stiffness with Heart Function in Hypertensive Patients

BACKGROUND: The strength of each heart beat and the stiffness of large arteries contribute to blood pressure (BP). When the large arteries are stiff and their resistance greater, the afterload increases and this may change the function of the heart. However, the relation between common carotid artery stiffness and heart function in hypertensive patients has not been clarified. METHODS: Two hundred and twenty hypertensive patients underwent transthoracic and carotid echocardiography. Measurements of local arterial stiffness were taken at the right common carotid artery level and stiffness parameter (beta), pressure-strain elasticity modulus and intima-media thickness were calculated. Brachial cuff BP was measured just before starting the carotid study. The patients with any cardiovascular disease, diabetes mellitus, stroke, transient ischemic attack, or carotid stenosis were excluded. RESULTS: Carotid artery stiffness parameter (beta) was correlated with age and left ventricular mass index (p < 0.005). Even though beta was not correlated with LV systolic function, it was inversely correlated with diastolic function as measured by early mitral annular velocity. When the artery was stiffer, early mitral annular velocity (e') decreased (p < 0.001) and the index of left atrial (LA) pressure (early diastolic mitral inflow E velocity/e') increased (p = 0.001). In logistic regression, diastolic dysfunction was affected by age (beta -0.385, p = 0.001), LA volume index (beta 0.175, p = 0.013) and beta (beta -0.273, p = 0.019). CONCLUSION: In hypertensive patients, changes in carotid artery stiffness can affect the diastolic function, independent of age and LA volume index. Therefore, measurements and control of carotid stiffness can play an important role in the prevention of diastolic heart failure.

Recanalization of an Accidentally Crushed Coronary Stent by Intravascular Ultrasonography Catheter Entrapment

Intravascular ultrasonography (IVUS) imaging is a user-friendly technique widely used during coronary interventions. An 80-year-old man was admitted with chest pain, and successful percutaneous coronary intervention was performed with stent implantation. One week later, the patient complained of further chest pain. Urgent coronary angiography showed total occlusion of the middle left anterior descending artery and the aspiration of thrombi was high. IVUS imaging showed inadequate stent strut apposition and distal dissection. We attempted another stent implantation but the IVUS catheter was stuck on the 0.014 inch wire. Therefore, we tried to pass the wire across the lateral side. After the wire was successfully passaged, the sprinter balloon was passed through the crushed stent to expand it. After 4 days later, the patient was discharged with no symptoms or electrocardiographic change.

Spontaneous Systemic Tumor Embolism Caused by Tumor Invasion of Pulmonary Vein in a Patient with Advanced Lung Cancer

We describe a 72-year-old man who presented with left hemiparesis due to acute cerebral infarction in the right fronto-temporal lobe. Three months prior to admission, he was hospitalized for right hemiparesis due to the acute cerebral infarction in the left anterior cerebral artery territory. To investigate the cause of his recurrent embolic event, a chest computed tomography scan and echocardiography were performed, which revealed advanced lung cancer invading contiguously through the pulmonary veins to the right main pulmonary artery and left atrium. Tumor embolism is a rare cause of stroke, occurring with primary or metastatic neoplasms of the lung. Echocardiography is a useful tool in patients with cerebral embolic episodes.

Recanalization of a Coronary Chronic Total Occlusion by a Retrograde Approach Using Ipsilateral Double Guiding Catheters

The retrograde approach through a collateral artery is now thought to improve the success rate of percutaneous coronary intervention (PCI) for coronary chronic total occlusion (CTO), and different kinds of strategies for this technique have been developed. However, the basic principles of PCI for CTO, such as firm back-up support with a guiding catheter and fine control of the guide wire, should be adhered to more strictly to succeed with this complex procedure. We present a case in which a CTO of the proximal left anterior descending artery was successfully opened by the retrograde approach through a collateral from the left circumflex artery, during which two guiding catheters were simultaneously used in the same coronary artery for the purpose of strong back up support for the retrograde device and fine control for the antegrade device.

An Unusual Type of Hypertrophic Cardiomyopathy

An unusual type of hypertrophic cardiomyopathy was diagnosed in a 17-year-old girl who presented with dyspnea on exertion. The hypertrophied myocardium was localized to the anterior portion of the left ventricle from the base to the apex without left ventricular outflow tract obstruction. On cardiac magnetic resonance imaging (MRI), patchy and linear delayed hyperenhancement was shown in the anterior and inferior mid-wall, which is not concordant with the coronary artery territory.

A Case Report of Recurrent Subacute Stent Thrombosis After Repetitive Percutaneous Coronary Interventions

Stent thrombosis (ST) is one of the major complications that occur in percutaneous coronary interventions (PCIs) with stents. Various factors have been attributed to the development of ST, and several strategies have been recommended for its management. We report the case of a patient suffering from recurrent subacute STs after recurrent PCIs. The patient was treated by coronary artery bypass graft (CABG).

Successful Recanalization of a Long Superficial Femoral Artery Occlusion by Retrograde Subintimal Angioplasty After a Failed Antegrade Subintimal Approach

The primary success rate of intraluminal angioplasty for long superficial femoral artery (SFA) occlusions is low due to the long occlusion length and the hard component of the occlusion. To overcome this problem, subintimal angioplasty has been previously proposed and this technique is now considered as an effective method for the treatment of SFA occlusions. Subsequently, various devices and strategies have been developed to increase the success rate of subintimal angioplasty for SFA occlusions. Here, we present a case in which a long chronic total occlusion of SFA was successfully recanalized by the retrograde subintimal angioplasty through the popliteal artery after the failed antegrade subintimal approach.

Multi-link Vision and MiniVision stent registry in Asian patients with coronary artery disease: a prospective, multi-center study / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Recent studies have showed that the fine mesh stents are associated with a significant reduction in both clinical and angiographic re-stenosis of the coronary arteries. To maintain a very satisfactory radio-opacity using the stents, Guidant of the USA has designed a new type of bare metal stents (BMS)-Multi-link (ML) Vision/ML MiniVision stents. The clinical outcomes of Asian patients with coronary artery disease (CAD) after implanting the Multi-link Vision or MiniVision stent were investigated in this study.</p><p><b>METHODS</b>An observational, prospective, multi-center, non-randomized post marketing registry was conducted to demonstrate the efficacy of the BMS-ML Vision/ML MiniVision stents. The primary end point of the registry was clinical target lesion revascularization (TLR) at a 6-month follow-up. The major secondary end points included the rate of major adverse cardiac events (MACE) and serious adverse events (SAE) in hospital and at 6 months; and the rate of clinical TLR as a function of the type of angina. A total of 429 Asian people with 449 lesions from 14 centers were selected for this study. The average reference diameter of the lesions was (3.0 +/- 0.5) mm, and the mean length was (15.7 +/- 5.0) mm.</p><p><b>RESULTS</b>The successful rate of the procedure was 99.3%. Twenty-five percent of the lesions were treated by direct stenting without pre-dilation. Eighty-six percent of the lesions were implanted with ML Vision stent. After the 6-month follow-up, the rate of clinical TLR was 1.4%. The MACE, SAE and target vessel revascularization (TVR) were 6.8%, 3.5% and 1.4% respectively.</p><p><b>CONCLUSION</b>The current registry showed the excellent 6-month clinical outcomes of ML Vision/ML MiniVision stents in Asian patients with CAD.</p>

Application of Albumin-adjusted Ischemia Modified Albumin Index as an Early Screening Marker for Acute Coronary Syndrome / 임상검사와정도관리

BACKGROUND: It is often difficult to make a diagnosis of cardiac ischemia in patients attending emergency department (ED) with symptoms of acute coronary syndromes (ACS) because existing cardiac markers are not sensitive for reversible myocardial ischemia. Ischemia modified albumin (IMA) has recently been shown to be an early and sensitive marker of myocardial ischemia. We investigated the usefulness of ischemia modified albumin (IMA) as an early triage marker for ACS and tried to establish a newly standardized albumin-adjusted IMA index which has been expected to be more sensitive and accurate than conventional IMA value. METHODS: We enrolled 209 consecutive patients (men 95, women 114) who presented to the ED with symptoms suggestive of ACS from June to July, 2005. All patients were classified to ACS group (n=42) and others (n=167) based on diagnosis of cardiologists. The ideal cutoff value of IMA was calculated by the receiver operating characteristic (ROC) curve analysis and diagnostic utilities of combination tests (myoglobin, CK-MB, troponin T and EKG) were compared with those of IMA. The albumin-adjusted IMA index was calculated and applicated from the results of correlation assay between serum albumin concentration and IMA value. RESULTS: Mean IMA level (U/mL) of ACS group was significantly higher than that of non-ACS group (P<0.05) and sensitivity and specificity was 92.9% and 35.9% at a cutoff value of 85.1 U/mL, respectably. In combination with conventional cardiac markers, the sensitivity increased to 96.3%. IMA value had a negative lnear relationship with serum albumin concentration (YIMA= -23.1Xalbumin+200, R=0.99) and albumin-adjusted IMA index was calculated as [IMA index = serum albumin conc. (g/dL) x 23 + IMA (U/mL) -100]. The sensitivity and specificity was 97.6% and 34.1% at a cutoff value of 83.3 IMA index, respectively. CONCLUSIONS: IMA is a useful sensitive marker for the identification of ACS in patients with normal cardiac markers and EKG finding and follow-up combination testing may be required to rule out other diseases. The calculated albumin-adjusted IMA index is recommended to make a diagnosis of ACS more sensitively.

Long-term Clinical Follow-up in Patients with Left Main Coronary Disease According to Treatment Strategies

BACKGROUND AND OBJECTIVES: Many studies have shown that coronary artery bypass graft (CABG) surgery prolongs the life of patients with left main coronary artery disease (LMCD). Recently, percutaneous coronary intervention (PCI) has been applied to treat LMCD, with good clinical results. However, a significant portion of patients decline any revascularization therapy, so receive medical treatment only. The aim of this study was to evaluate the long term clinical outcome in these patients with LMCD, according to the treatment strategies. SUBJECTS AND MEHTODS: The clinical outcomes of 281 consecutive patients, with significant LMCD, between January 1997 and December 2000, were evaluated. The patients were divided into three groups, according to their initial treatment strategies;1) CABG, 2) PCI and 3) medical treatment. The mean follow-up duration was 37.4+/-14.9 months. RESULTS: The 1- and 3-year survival rates in the CABG group (97.4+/-1.5% and 95.6+/-1.9%) were significantly higher than those of the medical group (89.8+/-3.9% and 76.1+/-5.9%;p=0.03). The survival rates in the PCI group (one year and 3-year survival rate, 98.1+/-1.3% and 93.8+/-2.5%) were similar to those of the CABG group (p=0.93). The incidence of 3-year MACE in the medical group (40.7%) was higher than those of the CABG (10.5%, p<0.001) and PCI groups (20.4%, p=0.007). There was no significant difference between the CABG and PCI groups (p=0.06). CONCLUSION: In patients with LMCD, a CABG remains the standard therapy for prolonging survival and lowering the incidence of MACE. PCI offers similar survival benefits in selected patients. Medical treatment is associated with a significantly higher mortality and MACE. Active revascularization therapy should be the treatment of choice for the patients with LMCD.

Intravascular Ultrasound Findings of Arterial Remodeling at the Sites of Focal Coronary Spasm in Patients with Vasospatic Angina

BACKGROUND: There is little data about the intravascular ultrasound (IVUS) findings in the patients with vasospastic angina, especially with respect to patterns of vascular remodeling. METHODS: Coronary spasm was documented by angiography and ECG evidence of ischemia in 36 patients after administration of ergonovine (cumulative doses up to 350 microgram). After relief of spasm using 1,000 microgram of intracoronary nitroglycerin, IVUS imaging was performed and analyzed using standard methodology. The 36 focal spasm sites were compared to the proximal and distal reference segments. RESULTS: The angiographic baseline minimum lumen diameter measured 1.78+/-0.66mm, which decreased to 0.66+/-0.38mm with ergonovine provocaton (pproximal reference) was present in 5; intermediate remodeling (proximal reference >spasm site >distal reference arterial area) was present in 7; and negative remodeling (spasm site arterial area

Intravascular Ultrasonic Predictors of Intimal Hyperplasia after Coronary Stenting

BACKGROUND: Several studies using intravascular ultrasound (IVUS) suggested several factors to predict angiographic restenosis or intimal hyperplasia(IH) after stenting. However, independent factors to predict IH have not been reported. Therefore, we evaluated the independent predictors of IH after stenting. METHODS: The serial (pre- and post-intervention, and follow-up) IVUS images were obtained in 77 patients with single stent implantation (GFX in 46 patients and NIR in 31). The matching IVUS image slices at 4 different sites within the same stent (follow-up lesion site, center of the stent and within 2 mm of proximal and distal margin of stent) were selected for serial comparisons. Total 308 matching images were obtained. A number of pre- and post-intervention IVUS variables including remodeling index =(lesion / proximal reference segment) pre-intervention vessel area were entered into multivariate linear regression analysis model to predict percent IH. RESULTS: The independent IVUS predictors of percent IH were pre-intervention plaque burden at follow-up lesion site (r=.252, p=.027) and proximal margin of the stent (r=.245, p=.034), and pre-intervention plaque burden (r=.334, p=.003) and remodeling index (r=0.353, p=.002) at the center of stent, and remodeling index at distal margin of the stent (r=0.230, p=.046). The percent IH positively correlated with pre-intervention plaque burden and inversely with remodeling index. CONCLUSIONS: The independent IVUS predictors of greater percent IH are larger pre-intervention plaque burden and smaller remodeling index.

Recent trends and clinical outcomes of infective endocarditis / 대한내과학회지

BACKGROUND: We sought to analyze the recent trends and clinical outcomes of infective endocarditis in Korea using newly proposed diagnostic criteria, Duke criteria, for this potentially life-threatening disease. METHODS: Retrospective analysis of medical records including echocardiographic data, blood culture and operation records was done for 156 patients (male 103) with clinical diagnosis of infective endocarditis at Asan Medical Center from 1989 to January 1998. RESULTS: One hundred eighteen patients (75%) fulfilled the criteria for definite group (Group I) in Duke criteria, whereas 38 patients (25%) for possible group (Group II). Mean age was 48+/-16 years. Although valvular heart disease was the most common underlying heart disease (49/156, 31%), in more than half (84/156, 54%) infective endocarditis was the first clinical presentation without previous medical history of any cardiac disease. Surgical intervention was required in 69 patients (44%), and the frequency of surgery during hospital course did not show any difference in Group I versus Group II (44% vs. 45%). Overall mortality was 17%, and did not show any difference in Group I versus Group II. Surgical mortality was 12% (8/69), which was not significantly different form mortality with medical treatment (21%, 18/87). Among 98 survivors in Group I, 84 patients (86%) were followed for average 34+/-24 months (0.5-98 months). Five-year survival and event-free survival rate were 85+/-7 % and 57+/-8 % respectively. CONCLUSION: Recently the mean age of patients with infective endocarditis increased dramatically, and infective endocarditis could be an initial clinical presentation without any previous medical history of cardiac disease in many patients. Surgical intervention was needed in considerable numbers of patients and infective endocarditis still shows relatively high mortality. There were no significant different clinical features in Group I and II.

A Case of Murine Typhus Acquired in a Laboratory / 감염

Rickettia typhi is an obligate intracellular organism and usually seen microscopically as gram-negative pleomorphic coccobacilli. Murine typhus is an acute febrile illness caused by R. typhi and transmitted to human by fleas. Fever, skin rash, headache, and myalgia characterize the clinical illness. The risk for laboratory personnel is from exposure to infectious aerosols, accidental inoculation, or exposure to bites by infected ectoparasites. A 27-year old man was admitted to the hospital because of fever and myalgia. He had worked with R. typhi in a laboratory and was exposed to R. typhi 10 days ago. The present illness began seven days before admission, when he developed high fever and conjunctival injection. One day before admission, he developed generalized erythematous skin rash and generalized edema. Immunofluorescence test with rickettsial antigen was positive at 1:4,096 on admission. He received 200 mg of doxycycline for 7 days and became afebrile on the third day after treatment.