Long-Term Clinical Outcomes after Primary Percutaneous Coronary Intervention in Patients with Acute Myocardial Infarction Older than 75 Years

BACKGROUND AND OBJECTIVES: Primary percutaneous coronary intervention (PCI) has been found to be superior, in terms of hospital mortality and long-term follow-up, compared with thrombolytic therapy for acute myocardial infarction (AMI). However, the clinical benefits of primary PCI have not been precisely evaluated in elderly patients. SUBJECTS AND METHODS: Two hundred and twenty three patients (Group I: n=66, age> or =75 years, Group II: n=157, age<75 years), who underwent primary PCI for AMI at Chonnam National University Hospital, between 2000 and 2002, were analyzed according to their clinical, angiographic characteristics, inhospital and one-year survival. RESULTS: Group I had a higher percentage of women (45.5% vs. 19.1%, p=0.00), multi-vessel disease (42% vs. 28%, p=0.031), right coronary artery disease (52% vs. 33%, p=0.021), and more frequent histories of diabetes mellitus (35% vs. 22%, p=0.039) and less smoking (38% vs. 60%, p=0.003) than Group II. Successful reperfusion by PCI was achieved in 97 and 96 %, respectively (p=NS). The rates of in-hospital mortality were similar in both groups (12.1% vs. 8.2%, p=NS). There were no significant differences in the major adverse cardiac events between the two groups during the one-year clinical follow-up (31.4 % vs. 36.9 %, p=NS). CONCLUSION: Primary PCI in AMI patients older than 75 years can be performed with comparable procedural success rates and long-term clinical outcomes to those of younger patients.

The Effects of QRS Duration and Pacing Sites on the Acute Hemodynamic Changes during Right Ventricular Pacing

BACKGROUND: Has been reported that patients exhibiting prolonged paced QRS duration tend to have more serious heart disease, and the paced QRS duration can be an effective indicator of impaired left ventricular function. However, the acute and chronic hemodynamic effects of paced QRS duration and pacing sites during right ventricular (RV) pacing remain unknown. METHODS: A total of 14 patients who underwent electrophysiologic study for paroxysmal supraventricular tachycardia were examined. RV pacing was performed at 10 different sites with cycle lengths of 600 ms and 500 ms utilizing a 6-7F deflectable quadripolar electrode catheter. Systolic, diastolic, and mean blood pressures during pacing were measured once the blood pressure was stabilized. RESULTS: During RV pacing, blood pressures (systolic/diastolic/mean) decreased. The change of post-pacing QRS duration and pre-pacing the systolic blood pressure (SBP) were greater in the group with paced QRS duration. The differences overall were greater than 140 ms. The SBP decrease during pacing was larger in the group exhibiting paced QRS duration of greater than 140 ms. The SBP decrease during pacing showed relation to QRS duration during pacing (r=0.500, p=0.001), the change of QRS duration post-pacing (r=0.426, p=0.001), and SBP during sinus rhythm (r=0.342, p=0.001) on linear correlation analysis. The pacing site, on the other hand, did not affect acute hemodynamic changes during pacing. CONCLUSION: Ventricular pacing of less than 40 ms at the area of paced QRS duration is recommended.

Acute Thrombosis in Coronary and Renal Arteries after Cisplatin and 5-Fluorouracil Administration

A 55-year old male presented with chest and abdominal pain for four hours. One day prior to admission he had received chemotherapeutic agents comprising 130 mg cisplatin and 5,200 mg 5-Fluorouracil for nasopharyngeal carcinoma. EKG showed ST elevations in the leads II, III and aVF. The levels of cardiac enzymes were elevated [creatine kinase (CK) 1129 U/L, CK-MB 180 U/L, troponin T 1.23 ng/mL and troponin I 23.29 ng/mL]. Urokinase was administered at the emergency room, but the patient's chest pain continued with persistent ST segment elevations. Urgent coronary and renal angiograms revealed thrombotic occlusive lesions in the distal right coronary and right renal arteries. Percutaneous transluminal renal angioplasty using 6.0x20 mm balloon was performed for the renal artery. However, filling defects and distal renal flow were not improved and so Abciximab (ReoPro(r)) was administered. Follow-up coronary and renal angiograms on the fifth hospital day showed no filling defects with good distal flow in both right coronary and renal arteries.

Acute Thrombosis in Coronary and Renal Arteries after Cisplatin and 5-Fluorouracil Administration

A 55-year old male presented with chest and abdominal pain for four hours. One day prior to admission he had received chemotherapeutic agents comprising 130 mg cisplatin and 5,200 mg 5-Fluorouracil for nasopharyngeal carcinoma. EKG showed ST elevations in the leads II, III and aVF. The levels of cardiac enzymes were elevated [creatine kinase (CK) 1129 U/L, CK-MB 180 U/L, troponin T 1.23 ng/mL and troponin I 23.29 ng/mL]. Urokinase was administered at the emergency room, but the patient's chest pain continued with persistent ST segment elevations. Urgent coronary and renal angiograms revealed thrombotic occlusive lesions in the distal right coronary and right renal arteries. Percutaneous transluminal renal angioplasty using 6.0x20 mm balloon was performed for the renal artery. However, filling defects and distal renal flow were not improved and so Abciximab (ReoPro(r)) was administered. Follow-up coronary and renal angiograms on the fifth hospital day showed no filling defects with good distal flow in both right coronary and renal arteries.

The effects of QRS duration and pacing sites on the acute hemodynamic change during right ventricular pacing / 대한내과학회지

BACKGROUND: Intraventricular conduction disturbances, as manifested by increased QRS duration, are common in patients with advanced left ventricular (LV) dysfunction and adversely affect LV systolic and diastolic function. It has been reported that the patients with prolonged paced QRS duration have more serious heart disease, and the paced QRS duration can be a useful indicator of impaired LV function. Hemodynamic effects of paced QRS duration and pacing site during right ventricular (RV) pacing are unknown. METHODS: A total of 14 patients who underwent electrophysiologic study for paroxysmal supraventricular tachycardia at Chonnam National University Hospital were examined. All the patients had no structural heart disease. RV pacing was performed at 10 different sites with cycle length of 600 ms and 500 ms using a 6-7F deflectable quadripolar electrode catheter (Livewire, St. Jude Medical, Minneapolis, MN, USA). Systolic, diastolic, and mean blood pressures were measured after stabilization of blood pressure during pacing. RESULTS: Blood pressures (systolic/diastolic/mean) decreased from 146 +/- 31/95 +/- 28/125 +/- 23 mmHg to 128 +/- 33/80 +/- 25/107 +/- 20 mmHg, respectively. The change of QRS duration during pacing and the systolic blood pressure (SBP) before pacing were higher in the group with paced QRS duration greater than 140 msec (59.1 +/- 13.6 msec vs 84.9 +/- 18.7 msec, 141 +/- 30 mmHg vs 152 +/- 38 mmHg, p<0.001, p=0.011, respectively). The decrease of SBP during pacing was higher in the group with paced QRS duration greater than 140 msec (13 +/- 11 mmHg vs 24 +/- 14 mmHg, p=0.009). The decrease of SBP during pacing was related with QRS duration during pacing (r=0.500, p=0.001), the change of QRS duration during pacing (r=0.426, p=0.001), and SBP during sinus rhythm (r=0.342, p=0.001) on linear correlation analysis. Pacing site, however, did not affect acute hemodynamic change during pacing. The independent factors associated with the decrease of SBP during pacing were SBP before pacing and QRS duration during pacing. CONCLUSION: We concluded that acute deleterious hemodynamic effects of RV pacing are related with paced QRS duration but not with pacing site. Ventricuar pacing at the area of paced QRS duration less than 140 msec is recommended particularly in high risk patients.

The role of electrocardiogram in predicting the prognosis of idiopathic dilated cardiomyopathy / 대한내과학회지

BACKGROUND: Although electrocardiographic manifestations of idiopathic dilated cardiomyopathy (DCMP) are usually nonspecific, several studies have suggested that electrocardiogram (ECG) might be used to predict the prognosis. METHODS: The present study was performed to determine the role of standard 12-lead ECG variables as a prognostic factor of patients with idiopathic DCMP. We retrospectively analyzed the ECG findings at the time of the diagnosis in 89 patients with DCMP during a mean follow-up period of 53.2+/-37.1 months. RESULTS: Twenty-eight (31.5%) of the 89 patients died and the cumulative survival rate was 87% at 2 years and 68% at 5 years. By univariate life table analysis, premature ventricular contraction, left bundle branch block, and age were proved as significant predictors. Multivariate analysis using Cox proportional hazards model identified premature ventricular contraction (p=0.014) and left bundle branch block (p=0.02) as an independent predictor for cardiovascular mortality in DCMP. The presence of a premature ventricular contraction increased the mortality 2.8 times and left bundle branch block 2.6 times. CONCLSUION: The present study demonstrates that independent ECG predictors for prognosis of idiopathic DCMP are premature ventricular contraction and left bundle branch block and ECG may be useful in predicting the prognosis of idiopathic dilated cardiomyopathy.

Long-Term Clinical Follow-up after Rotational Atherectomy and Plain Old Balloon Angioplasty for the Treatment of Coronary Stent Restenosis

BACKGROUND AND OBJECTIVES: Since 1987, coronary stents have changed the pattern of practice of interventional cardiology, by reducing the complications and improving the clinical outcomes. However, coronary stent restenosis still remains a significant clinical problem in the field of interventional cardiology. The aim of this trial was to compare the clinical efficacy of a rotational atherectomy (ROTA), with that of a plain old balloon angioplasty (POBA), in patients with coronary stent restenosis. SUBJECTS AND METHODS: One hundred and three patients (men 80, 58.4+/-10.3 years of age), diagnosed with coronary stent restenosis, at Chonnam National University Hospital, between January 1999 and December 2000, were analyzed. The clinical end-points were the occurrence of major adverse cardiac events (MACE): death, myocardial infarction and target lesion revascularization (TLR) during the one-year clinical follow-up. RESULTS: The baseline clinical and angiographic characteristics were similar between the two groups. Before the percutaneous coronary intervention (PCI), the diameter of stenosis of the POBA and ROTA groups were 81.9+/-14.0 and 82.9+/-10.0%, respectively, which decreased to 25.5+/-15 and 22.7+/-12% after treatment. At the one-year clinical follow-up, the TLR rates were 7.0 and 6.3% in the POBA and ROTA groups, respectively. The MACE results were not different between the two groups (7.0 and 9.4% in the POBA and ROTA groups, respectively). CONCLUSION: There was no significant long-term clinical benefit of a rotational atherectomy prior to a POBA, compared with a POBA alone, for the treatment of coronary stent restenosis.

A Successful Management for Acute Thrombotic Myocardial Infarction with Abciximab in a Nephrotic Syndrome

A 28-year old male presented with chest pain of two hours duration. He had histories of 10 years smoking and 2 years of nephrotic syndrome, due to minimal change disease. His EKG showed marked ST segment elevations in the V3-6, I, II, III and aVF leads. The levels of cardiac enzymes were increased (CK: 481 U/l, CK-MB: 96 U/l and Troponin I: 4.8 ng/mL). The prothrombin and activated partial promboplastin times were normal. Accelerated tissue type plasminogen activator (100 mg) was administered at the emergency room, but his chest pain continued, with persistent ST segment elevations. An urgent coronary angiograph revealed huge multiple filling defects, suggestive of thrombi in the proximal left anterior descending artery (LAD), with thrombolysis in the myocardial infarction (TIMI) flow. A rescue percutaneous coronary intervention was performed using repeated angioplasties with a 3.0 mm balloon. However, the filling defects and distal LAD flow did not improve. We administered Abciximab (ReoPro(r)), and the LAD flow improved to a TIMI III flow, with resolution of the thrombus in the LAD. His clinical course was uneventful after discharge, and a left coronary angiogram, at the 6-month follow-up, showed no filling defects, with the TIMI III flow maintained.

Factors for development of left ventricular dysfunction during long-term right ventricular apical pacing / 대한내과학회지

BACKGROUND: It is known that prolonged QRS duration (QRSd) in a 12-lead ECG is associated with decreased left ventricular (LV) systolic function in patients with dilated cardiomyopathy. Development of LV systolic dysfunction and prolongation of paced QRSd are often observed in patients with permanent pacemakers (PPM). However, the significance of prolonged paced QRSd in patients with PPM is not determined. METHODS: We studied sixty-four patients (male:female=27:37, mean age=57.6+/-15.4 years) who had been on PPM (DDD: 15, VDD: 18, VVI: 31) for more than one year (mean: 68.2+/-44.0 months). LV function was normal before implantation of PPM. The 12-lead ECG and echocardiography were recorded prior to implantation, immediately after implantation and at the last follow-up. RESULTS: Paced QRSd did not significantly increase during the follow-up period. LVEF at the last follow-up (LVEF-FU) was significantly lower than that prior to implantation (59.3+/-11.5% vs. 64.9+/-10.1%, por=180 ms than in patients without (44.4+/-12.0% vs. 61.7+/-9.5%, p<0.001). In predicting LV systolic dysfunction with the paced QRSd (cut-off value: 180 ms), sensitivity, specificity, positive and negative predictive values were 60.0%, 88.7%, 50.0% and 99.2%, respectively. The paced QRSd at the last follow-up was significantly correlated with paced QRSd immediately after implantation (r=0.542, p<0.01). CONCLUSION: LV systolic dysfunction after long-term right ventricular apical pacing may develop. Prolongation of paced QRSd 180 ms during follow-up may suggest development of LV systolic dysfunction. New technologies to minimize prolongation of paced QRSd should be investigated to prevent LV systolic dysfunction after permanent ventricular pacing.

The clinical effects of the BiodivYsio Phosphorylcholine-coated Stent in patients with small coronary artery diseases / 대한내과학회지

BACKGROUND: The BiodivYsio stent is a balloon-expandable stent coated with phosphorylcholine designed to reduce the formation of thrombus and the risk of restenosis. METHODS: We prospectively studied 20 patients who underwent implantation of BiodivYsio stent (group I; 60.8+/-9.3 years, male 60.0%) and compared to 20 patients who underwent balloon angioplasty alone (group II; 60.3+/-7.9 years, male 45.0%) for small coronary arterial lesions (target arterial diameter was between 2.0 mm and 2.8 mm) between February 2001 and October 2001. Major adverse cardiac events such as acute myocardial infarction, target vessel revascularization and death were evaluated during hospital admission and at 6-months after percutaneous coronary intervention (PCI). RESULTS: During hospitalization, the incidence of acute myocardial infarction, target vessel revascularization and death was not different between the two groups. At follow-up coronary angiography 6 months after PCI, the incidence of restenosis was lower in group I than in group II (Group I; 3/20, 15.0% vs Group II; 9/20, 45.0%, p=0.032) and the incidence of target vessel revascularization (TLR) was lower in group I than in group II (Group I; 3/20, 15.0% vs Group II; 8/20, 40.0%, p=0.041). CONCLUSION: Coronary BiodivYsio stenting in small coronary artery leads to excellent short- and mid-term clinical outcomes.

The clinical effects of the BiodivYsio Phosphorylcholine-coated Stent in patients with small coronary artery diseases / 대한내과학회지

BACKGROUND: The BiodivYsio stent is a balloon-expandable stent coated with phosphorylcholine designed to reduce the formation of thrombus and the risk of restenosis. METHODS: We prospectively studied 20 patients who underwent implantation of BiodivYsio stent (group I; 60.8+/-9.3 years, male 60.0%) and compared to 20 patients who underwent balloon angioplasty alone (group II; 60.3+/-7.9 years, male 45.0%) for small coronary arterial lesions (target arterial diameter was between 2.0 mm and 2.8 mm) between February 2001 and October 2001. Major adverse cardiac events such as acute myocardial infarction, target vessel revascularization and death were evaluated during hospital admission and at 6-months after percutaneous coronary intervention (PCI). RESULTS: During hospitalization, the incidence of acute myocardial infarction, target vessel revascularization and death was not different between the two groups. At follow-up coronary angiography 6 months after PCI, the incidence of restenosis was lower in group I than in group II (Group I; 3/20, 15.0% vs Group II; 9/20, 45.0%, p=0.032) and the incidence of target vessel revascularization (TLR) was lower in group I than in group II (Group I; 3/20, 15.0% vs Group II; 8/20, 40.0%, p=0.041). CONCLUSION: Coronary BiodivYsio stenting in small coronary artery leads to excellent short- and mid-term clinical outcomes.

A Case of Septic Portal Vein Thrombophlebitis: Presenting with Fever of Unknown Origin / 감염

Pylephlebitis is defined as an inflammation of the portal system, which is a rare but dreaded complication of intra-abdominal inflammatory processes. In the past it was observed as a sequela of neglected or complicated appendicitis. With earlier diagnosis, modern surgical technique and antibiotics, the incidence has declined even further. In addition, thrombosis in portal system (pylethrombosis) can complicate the pylephlebitis, followed by obstruction of the portal system, leading to portal hypertension in the late stage. Proper recognition of early thrombosis and an accompanying intra-abdominal inflammatory process should arouse the suspicion of septic thrombophlebitis and lead to the early institution of adequate therapy to prevent the almost universally fatal outcome. We report the case of woman who had pylephlebitis and presented with fever of unknown origin, probably associated with acute appendicitis.