Safety and Cost-Effectiveness of Bridge Therapies for Invasive Dental Procedures in Patients with Mechanical Heart Valves

PURPOSE: Bridge anticoagulation therapy is mostly utilized in patients with mechanical heart valves (MHV) receiving warfarin therapy during invasive dental procedures because of the risk of excessive bleeding related to highly vascular supporting dental structures. Bridge therapy using low molecular weight heparin may be an attractive option for invasive dental procedures; however, its safety and cost-effectiveness compared with unfractionated heparin (UFH) is uncertain. MATERIALS AND METHODS: This study investigated the safety and cost-effectiveness of enoxaparin in comparison to UFH for bridge therapy in 165 consecutive patients (57+/-11 years, 35% men) with MHV who underwent invasive dental procedures. RESULTS: This study included 75 patients treated with UFH-based bridge therapy (45%) and 90 patients treated with enoxaparin-based bridge therapy (55%). The bleeding risk of dental procedures and the incidence of clinical adverse outcomes were not significantly different between the UFH group and the enoxaparin group. However, total medical costs were significantly lower in the enoxaparin group than in the UFH group (p or =65 years) was significantly associated with an increased risk of total bleeding independent of bridging methods (odds ratio, 2.51; 95% confidence interval, 1.15-5.48; p=0.022). Enoxaparin-based bridge therapy (beta=-0.694, p<0.001) and major bleeding (beta=0.296, p=0.045) were significantly associated with the medical costs within 30 days after dental procedures. CONCLUSION: Considering the benefit of enoxaparin in cost-effectiveness, enoxaparin may be more efficient than UFH for bridge therapy in patients with MHV who required invasive dental procedures.

Died immediately after corrective surgery for right ventricular acute myocardial infarction and ventricular septal rupture / 영남의대학술지

Postinfarction ventricular septal rupture (VSR) is a rare but fatal complication of acute myocardial infarction. In many cases, postinfarction VSR leads to hemodynamic instability and urgent surgical treatment is necessary. Here we describe a case of a patient with right ventricular (RV) dysfunction caused by acute RV infarction and with cardiogenic shock, whose condition improved after development of postinfarction VSR, but the patient died after corrective surgery.

Visceral Obesity of the Heart: Extensive Lipomatous Hypertrophy of Interatrial Septum

No abstract available.

A Case of Esophageal Achalasia Compressing Left Atrium Diagnosed by Echocardiography in Patient with Acute Chest Pain

No abstract available.

Predictors of In-Hospital Mortality and Left Ventricular Functional Recovery in Korean Patients with Stress-Induced Cardiomyopathy: Stress-Induced Cardiomyopathy Registry Data / 대한내과학회지

BACKGROUND/AIMS: The reported frequency of stress-induced cardiomyopathy (SCMP, Takotsubo cardiomyopathy) is increasing; however, there are no data regarding predictors of in-hospital mortality and the recovery of left ventricular (LV) systolic function in patients with SCMP. Therefore, in this study, we sought to identify clinical predictors of in-hospital mortality and of the recovery of LV dysfunction in Korean patients with SCMP. METHODS: From November 2004 to November 2010, 155 patients who fulfilled the clinical diagnostic criteria of the Mayo clinic for SCMP were enrolled retrospectively from eight medical centers in Korea. We checked in-hospital deaths and compared the LV ejection fraction (LVEF) and wall-motion score index (WMSI) upon enrollment for each patient with that after 1 week using echocardiograms. A total of 55 continuous variables and 52 nominal variables were analyzed to find variables associated with in-hospital mortality and the recovery of LV dysfunction. All significant variables were entered into a logistic regression analysis. RESULTS: The mean age of the patients was 64 +/- 15 years; 118 (76.1%) patients were female. The in-hospital mortality rate was 5.2% (n = 8). An elevated initial platelet count was identified as a predictor of in-hospital mortality (odds ratio [95% CI]: 0.99 [0.99-1.00]). There were no predictors of the recovery of LVEF. Predictors of the recovery of WMSI were an absence of arrhythmic events (odds ratio [95% CI]: 22.89 [1.98-265.34]) and an elevated initial LV end-systolic diameter (odds ratio [95% CI]: 0.86 [0.74-1.00]). CONCLUSIONS: An initial absence of arrhythmic events and elevated LV end-diastolic pressure in patients with SCMP may be predictors of the timely recovery of LV dysfunction.

Pseudoaneurysm of Coronary Artery in a Patient with Behcet's Disease

Behcet's disease is multi-systemic vasculitis affecting all sizes of arteries and veins. The prevalence of coronary involvement in Behcet's disease is extremely rare. A 35-year-old woman with one-year history of Behcet's disease was in hospitalized with pseudoaneurysm of left anterior descending coronary artery, which was detected by echocardiography. The patient was successfully treated by implantation of an endovascular graft-stent.

Efficacy and Complications of Angio-Seal(r) Device in Patients Undergoing Coronary Angiography and Angioplasty

BACKGROUND AND OBJECTIVES: The Angio-Seal(r) (a St. Jude Medical Co., USA) hemostatic puncture closure device produces direct femoral arterial hemostasis, by anchoring a collagen plug to the anterior vascular wall, through a sheath delivery system. The rapid and effective hemostasis leads to earlier ambulation, minimized hospital stay, patient discomfort and vascular complications. This study was performed to evaluate the efficacy and complications of an Angio-Seal in patients undergoing coronary angiography and angioplasty. SUBJECTS AND MEHTODS: A total 228 consecutive patients, admitted to our hospital for percutaneous coronary intervention, between October 2001 and May 2002, were enrolled and randomized into 2 groups. 116 patients were treated with an Angio-Seal and the other 112 with manual compression only (control group). The clinical characteristics, procedure related factors, time to ambulation, times to outpatient discharge and complications were analyzed in each patient. All the clinical and procedure-related factors, leading to oozing and delayed bleeding, were also analyzed in the 113 patients who had a successfully completed Angio-Seal deployment. RESULTS: The times to ambulation (7.96+/-5.81 hours vs. 23.32+/-3.35 hours) and times to outpatient discharge (2.00+/-0.94 days vs. 3.47+/-3.61 days) were significantly shorter in the Angio-Seal compared to the control group (p=0.001 & p=0.001, respectively). There was oozing in 20 patients (17.7%) and delayed bleeding in 6 (5.3%) of the successful Angio-Seal deployment group. The occurrence of oozing was significantly higher in the heparin infusion cases (40%. 18.3%, p=0.034), and was correlated with a later hematoma formation rate and the size of the hematoma (30% vs. 9.7%, 0.68+/-1.26 cm vs. 0.17+/-0.70 cm, p=0.015 & p=0.001, respectively). Delayed bleeding was correlated to the hematoma occurrence rate (50% vs. 11.2%, p=0.006). CONCLUSION: The Angio-Seal resulted in earlier ambulation and shorten the patients' hospital stay. Oozing, delayed bleeding, hematomas were noted as complications. Oozing and delayed bleeding were correlated with a high hematoma occurrence rate. Careful inspection of the puncture sites, following an Angio-Seal deployment, should be performed.

Signal Averaged P Wave Dispersion: A New Marker for Predicting the Risk of Paroxysmal Atrial Fibrillation

BACKGROUND AND OBJECTIVES: Prolonged atrial conduction time and inhomogeneous electrical atrial activity have been known to be important electrophysiologic characteristics in patients with paroxysmal atrial fibrillation (PAF). Filtered P wave duration dispersion (Pdisp) is defined as the difference between the maximal and minimal filtered P wave duration of the three X, Y, Z leads of P wave signal averaged ECG (PSAECG). The purpose of this study was to determine and compare conventional PSAECG parameters with this newly developed parameter, Pdisp, for the prediction of PAF risk. SUBJECTS AND METHODS: The study population, consisting of 65 patients with PAF (Group 1) and 56 age and sex matched controls (Group 2), was further subgrouped by the presence (Group A) and absence (Group B)of organic heart disease. The PSAECG was recorded using P wave triggered SAECG and the following parameters were measured: total filtered P wave duration (TFPD), vector magnitude, RMS10, RMS20, RMS30 and Pdisp. These parameter values were compared between groups. RESULTS: TFPD and Pdisp were significantly longer in the PAF group than in the control group (121.2+/-9.7 msec versus 108.5+/-12.7 msec, p=0.005:25.2+/-11.5 msec versus 14.7+/-7.9 msec, p<0.001, respectively). The presence of organic heart disease and the size of the left atrium did not affect the result. The designation of Pdisp greater than 15 msec as the cut-off value for predicting PAF produced a sensitivity of 85% and a specificity of 75%, and was more accurate than TFPD (sensitivity 72%, specificity 66%). CONCLUSION: Pdisp might be a more accurate SAECG parameter for predicting the PAF risk than other conventional parameters.

Types of In-Stent Restenosis and Predictive Factors for Diffuse Type In-Stent Restenosis

BACKGROUND AND OBJECTIVES: oronary stents have been used increasingly in the field of coronary intervention. However, in-stent restenosis (ISR) remains a therapeutic challenge. The subsequent response to repeat intervention in the restenotic lesion may be predicted by the angiographic pattern of ISR. In particular, the restenosis rate following re-intervention in this lesion is higher. This study evaluated the incidence of restenosis types and the predictors for diffuse type ISR. SUBJECTS AND METHODS: he study population included 66 patients with in-stent restenotic lesions after stent implantation. Angiographic restenosis was defined as a diameter stenosis of > or = 50% at follow-up coronary angiography. Patterns of ISR were defined as focal type ( or = 10 mm in length). The patients were divided into two groups according to the angiographic patterns of ISR. Clinical characteristics, pre-stenting angiographic features, and stenting procedure related factors were analyzed. A multivariate logistic regression analysis was performed in order to identify the independent predictors for diffuse-type ISR. RESULTS: ngiographic analysis of 66 restenotic lesions showed diffuse type in 29 lesions (44%) and focal type in 37 (56%). Most of the focal in-stent restenoses occured in the proximal and mid portions of the stents. The reference diameter (3.02+/-0.37 mm vs 3.25+/-0.46 mm, p=0.046) and post-stenting minimal luminal diameter (2.89+/-0.36 vs 3.19+/-0.39 mm, p=0.002) were significantly smaller in the diffuse type as compared to the focal type, whereas other parameters were significantly different. Using multivariate logistic regression analysis, the only predictive factor for diffuse type ISR was post-stenting MLD (OR=4.74, p=0.025). CONCLUSION: mall post-stenting MLD (<3 mm) has a high risk for diffuse type INR. Therefore, new therapeutic strategies are required for these lesions.

Delayed Cardioprotective Effect of Ischemic Preconditioning is mediated by Heat Shock Protein in Cat Heart

BACKGROUND: It is well known that ischemic preconditioning protects the heart against infarction or arrhythmias from a subsequent ischemic injury. Two phases of the effect of preconditioning has been explored, early protection and second window of protection at 24 hours. The late protection was seen in some animal model, but the precise mechanism is controversal. This study was designed to evaluate the late cardioprotective effect and role of HSP70 in ischemic preconditioning of cat heart. METHODS: Two groups of cats were studied. Control animals were subjected to an episode of 40-min coronary artery occlusion followed by 30-min reperfusion. Experimental animals were subjected to ischemic preconditioning before the 40-min ishcemia/reperfusion. The preconditioning protocol was comprised of three 5-min episodes of ischemia interspersed by 10-min episodes of reperfusion. After sustained ischemia and reperfusion, left ventricular risk area and infart area were measured by injection of Evans blue bye and triphenyltetrazolium staining, and myocardial HSP70 mRNA was examined in risk(left ventricular anterior wall) and nonrisk(left ventricular posterior wall) area using northern blot hybridization. HSP70 mRNA expression was quantified as a percent of GAPDH. The late cardioprotective effects of ischemic preconditioning were determined by infarct size (% area at risk). RESULTS: Infarct size was markedly limited by ischemic preconditioning when compared with the control group (18.5+/-6.9% vs 38.5+/-11.1%; p<0.001). HSP70 mRNA expression in risk area was much higher in preconditioning group than control group(78+/-12% vs 41+/-11%; p<0.01). But, there was no significant difference of HSP70 mRNA expression in the posterior wall between control and ischemic preconditioning group. CONCLUSIONS: These data suggest that ischemic preconditioning have delayed myocardial protective effect from ischemia. The increase in myocardial HSP70 mRNA may be one of the contributing factors to the delayed cardioprotective effects of ischemic preconditioning in cats.

P wave dispersion as a predictor of idiopathic paroxysmal atrial fibrillation / 영남의대학술지

BACKGROUND: P wave dispersion(PWD) is defined as the difference between the maximum and minimal P wave duration in any of the 12 leads of the surface ECG. The prolongation of atrial conduction time and the inhomogeneous propagation of sinus impulse are known electrophysiologic features in patients with paroxysmal atrial fibrillation(PAF). The purpose of this study was to determine the role of P wave dispersion for the prediction of PAF and to evaluate the effectiveness of prophylactic antiarrhythmic therapy. MATERIALS AND METHODS: The study population included 20 patients with a history of idiopathic PAF and 20 age and sex matched healthy control subjects. We measured the maximum P wave duration(P maximum) and P wave dispersion from 12 lead ECG. RESULTS: P maximum and P dispersion in idiopathic PAF were significantly higher than normal control group(97.2+/-12, 48.5+/-9msec vs, 76.5+/-11, 21+/-8msec, respectively p<0.001, <0.001). After 12-month follow up period P maximum and P dispersion were significantly reduced than those of initial state(77.2+/-13, 26.4+/-9msec vs. 97.2+/-12, 48.5+/-9msec, respectively p<0.001,<0.001). CONCLUSION: P dispersion and P maximum were significantly different between patients with idiopathic PAF and healthy control group. Those are easily accessible, non-invasive simple electrocadiographic markers that could be used for the prediction and prognostic factors of idiopathic PAF.

The Predictors of Cerebral infarction in Mitral Stenosis / 영남의대학술지

BACKGROUND: Systemic embolism especially, cerebral infarction is one of the most important complications in patients with mitral stenosis. The authors analyse the some that could predict the development of cerebral infarction in cases of mitral stenosis and propose preventive therapeutic measures. METHODS: Retrospective study of 127 patients with rheumatic mitral stenosis was performed by analysis their medical records for transthoracic(TTE) or transesophageal echocardiography(TEE) over a 12months period. The patients were divided into two groups according to the presence (Group I: n=26, age: 55+/-13 years) or absence (Group II: n=101, age: 48.5+/-13 years) of cerebral infarction. No significant difference was observed between the two groups with respect to sex and functional class. RESULTS: Patients of group I were older (55.0+/-13 vs 48.5+/-13;p<0.05), had more dilated left atrial size(5.10+/-0.48 vs 4.81+/-0.70;p<0.05) and smaller mitral surface area(1.01+/-0.39 vs 1.21+/-0.45;p<0.05). In Group I, the incidence of atrial fibrillation(22 out of 26 vs 57 out of 101;p<0.05) and spontaneous left intra-atrial contrast phenomenon(22 out of 26 vs 44 out of 101;p<0.05) was more frequently observed. On multivariate analysis, atrial fibrillation and anticoagulant therapy were the independent predictive factors. CONCLUSION: Age, left atrial dilatation, the severity of mitral stenosis, the presence of spontaneous contrast and especially the presence of atrial fibrillation are the main predictive factors of the development of cerebral infarction in mitral stenosis. Patients presenting one or several of these factors may benefit from prophylactic anticoagulant treatment.

Primary Cardiac Lymphoma: Case Report / 영남의대학술지

Primary cardiac lymphoma defined as involving only the heart and pericardium, is very rare and is diagnosed predominantly late in the course of illness or autopsy. This tumor is commonly fatal and until recently were rarely diagnosed antemortem. Recently, it was reported in patients with acquired immunodeficiency syndrome. We report a case of primary cardiac lymphoma in a 56 year old female who showed progressive exertional dyspnea. On echocardiogram and CT scan, large ill defined mass was demonstrated in right atrial and ventricular wall. It was diagnosed as B-cell type lymphoma on open cardiac biopsy.

Early Outcome and Short Term Restenosis Rate of the Mitral Balloon Valvuloplasty in Mitral Stenosis Patients with Mild Mitral Regurgitation

BACKGROUND: Percutaneous mitral balloon valvuloplasty (PMV) has been proposed as an alternative to surgery for selected patients with symptomatic mitral stenosis. The presence of mild mitral regurgitation (MR) in mitral KERN=5535>stenosis is usually not considered as a contraindication for the procedure. But, the results of PMV in the subgroup KERN=>of patients with concomitant mild MR are unknown. Accordingly, this study evaluates the clinical outcome of a consecutive series of patients with mitral stenosis and mild MR undergoing PMV. METHODS: Between August 1992 and December 1996 we attempted to dilate the mitral valves of 43 consecutive patients with symptomatic mitral stenosis. Mean age of the group was 45.9+/-10.6 years and 37 patients were women. They were divided into two groups according to the presence or absence of mild MR before the procedure. Clinical feature, inital result, complication were compared. RESULTS: 1) Age, gender, symptomatic status, and atrial fibrillation were similar in both groups. 2) Patients with MR had more thickened valve (2.50+/-0.33 vs 1.84+/-0.55, p=0.048) and subvalvular tissue (2.55+/-0.73 vs 1.88+/-0.73, p=0.015), higher echocardiographic score (8.44+/-1.01 vs 7.08+/-1.65, p=0.004). 3) Mitral valve area gain on the first day after PMV was smaller in patients with MR(p=0.008). 4) The success rate of PMV, the incidence of severe MR after PMV, and the restenosis rate on 6 month were similar in both groups. CONCLUSION: Although the PMV in patients with mild MR obtained smaller increments in mitral valve area compared to those without MR, they showed similar immediate and short-term results after PMV.

Difference of QT Dispersion between Patients with Ischemic and Idiopathic Dilated Cardiomyopathy

BACKGROUND AND OBJECTIVES: QT dispersion (QTd) is defined as the difference between the maximum and minimum QT interval in any of the 12 leads of the surface ECG. QTd has been shown to reflect regional variations in ventricular repolarization. Ischemic dilated cardiomyopathy (DCM) may lead to more spatial and temporal dispersion in ventricular repolarization than idiopathic DCM. The purpose of this study was to determine the difference of QTd between patients who had ischemic and idiopathic DCM. MATERIALS AND METHODS: The study population included 30 patients with ischemic DCM and 30 with idiopathic DCM. All standard 12-lead ECGs were examined prospectively by two observers who were unware of the patient's details. RESULTS: QTd in ischemic DCM was significantly higher than that in idiopathic DCM (63+/-32 vs. 44+/-26 msec, p=0.012) and JTd in ischemic DCM was significantly higher than that in idiopathic DCM (48+/-21 vs. 36+/-22 msec, p=0.036). Results did not change when Bazett's QTc and JTc was substituted for QT (QTcd:69+/-33 vs. 52+/-28 p=0.039) and JT (JTcd:56+/-21 vs. 41+/-25 p=0.043). CONCLUSION: Ischemic DCM has increased spatial inhomogeneity of repolarization probably due to more regional myocardial damages compared with idiopathic DCM. The value of QT dispersion as an easily accessible, non-invasive method in predicting the risk of life threatening arrhythmia and overall mortality in patients with dilated cardiomyopathy must be confirmed in prospective trials.

Antihypertensive effect and safety of imidapril on the patient with essential hypertension / 영남의대학술지

Imidapril(Tanatril(R)), a newly developed ACE inhibitor, has been used to treat hypertension and congestive heart failure. This study was designed to assess the antihypertensive effect and safety of Imidapril(Tanatril(R)) in patient with essential hypertension. 5-10mg of imidapril(Tanatril(R)) was administered once day in 30 patients with essential hypertension and followed up to 8 weeks. We tested the drug's effectiveness, safety, and the incidence of imidapril induced dry coughs. After 8 weeks of treatment with Imidapril, 76.2%(16/21) of patient showed lowered blood pressure and 47.6% showed normal blood pressure. The overall incidence of adverse effects was 33.3%(7/21). and among these adverse effects. dry cough was shown in only 9.5%. Thus, concluded that imidapril(Tanatril(R)) is as safe and effective as other ACE inhibitors. especially with imidapril showing very little incidence of dry cough compared to other ACE inhibitors.

Mitral annular velocity by Doppler tissue imaging for evaluation of left ventricular diastolic function / 대한내과학회지

BACKGROUND: Doppler echocardiography is widely used for the noninvasive evaluation of left ventricular diastolic function. However the mitral flow velocity pattern is affected by several physiologic factors. The mitral annular velocity profile by Doppler tissue imaging may provide more additional information about left ventricular diastolic function. Thus, this study designed to assess the relationship between cardiac catheterization, MUGA scan, mitral flow velocity, and mitral annular velocity data and to assess the clinical availavility of mitral annulus velocity in the evaluation of left ventricular diastolic function. METHODS: The study population consisted of 20 patients with dilated cardiomyopathy( 64+/-7years), 20 patients with normal left ventricular function (61+/-7years). Left ventricular catheterization was performed with fluid-filled catheter and left ventricular end diastolic pressure, -dP/dtmax were measured. The mitral flow velocity was recorded at mitral valve tip and the mitral annulus velocity during diastole was measured by Doppler tissue imaging(DTI). Simultaneously EF(ejection fraction), PER(Peak filling rate), PFR(Peak filling rate) were measured by MUGA blood pool scan. RESULTS: Mean peak E velocity, mean peak A velocity, E/A ratio, mean peak E' velocity, mean peak A' velocity, E'/A' ratio and -dP/dtmax significantly difference betweeen two group. -dP/dtmax by cardiac catheterization showed significant correlation with mean peak E' velocity (r=0.552, p=0.003), E'/A' ratio(r=0.507, p=0.003), DT of E'(r=-0.556, p=0.001), TVI of E'(r=0.689, p<0.001) and DT of E wave(r=-0.538, p=0.003). PFR by MUGA scan also showed significant correlation with -dP/dtmax(r=0.537, p=0.01). CONCLUSION: Among mitral annulus velocity index mean peak E' velocity, E'/A' ratio, DT of E',TVI of E' had significant correlation with -dP/dtmax. And DT by mitral flow velocity, PFR by MUGA scan also had significant correlation with -dP/dtmax. Mitral annulus velocity determined by DTI is relatively convenient, safe, and preload-independent variable in evaluating diastole function. Thus mitral annulus velocity by Doppler tissue imaging is may be useful diagnostic modality for evaluating left ventricular diastolic function.

The Characteristics of Clinical Presentation and In-hospital Outcome of Acute Myocardial Infarction Patients Older than 65 Years of Age

BACKGROUND: The aging of the patient population is one of rhe most important factirs influencing health care delivery. Currently 5% of the Korean population is elderly, defined as older than 65years of age, with this group projected to increase to 13.1% by the year 2021. Cardiovascular disease is the leading cause of death and of disability in the elderly age group. mong them, coronary heart disease is the most importane. METHOD: Study population composed of 216 patients who were admittied to the hospital with first acute myocardial infarction and they were divided into two groups according to the age(older than 65 years of age vs younger). Clonical features, risk factors of coronary heart disease, in-hospital outcome and complication were compared in elderly patients and others group. Results : 1) The risk factors of coronary heart disease is similar to younger patients but pattern of chest pain is less typical than younger patients. 2) Clinical presentation of elderly patients is similar to younger patients except Killip class on admission.(1.66vs 1.91,P=0.04) 3) In-hospital mortality of elderly patients in higher than younger patients. In addition to an increased incidence of death, recurrent ischemia, stroke, AV block, ventricular arrythmia, pulmonary edema occured more frequently with advanced age. 4) Especially in the thrombolytic therapy group, in-hospital death, reinfarction and recurrent ischemia is higher than primary PTCA group in elderly patients. CONCLUSIONS: Diagnosis of acute chest pain is difficult in elderly patients and in-hospital mortality and morbidity is higher than in younger patients. Thus more accurate diagnosis and discriminative therapeutic modality is needed.