Multiple Fistula Emptying into the Left Ventricle through the Entire Left Ventricular Wall

Coronary artery fistulae are usually identified during invasive coronary angiographies. However, in this case, we made the early detection of coronary artery fistulae during non-invasive transthoracic echocardiography, by demonstrating diastolic multiple abnormal color Doppler flows on the entire left ventricular walls including left ventricular free wall, interventricular septum and apex, which were mimicking firecracker on the whole left ventricle. Fistulous communication from the coronary artery to the left ventricle is rare. Moreover, a case of multiple coronary fistulae emptying into the left ventricle through the entire left ventricular walls including left ventricular free wall, interventricular septum and apex is uncommon. We report a case of a 31-year-old woman who was diagnosed with multiple fistula communicating with entire left ventricular wall.

Catecholaminergic Polymorphic Ventricular Tachycardia in a Patient With Recurrent Exertional Syncope

A 16-year-old male with a prior history of recurrent syncope was referred to our hospital after being resuscitated from cardiac arrest developed while playing volleyball. His electrocardiogram (ECG) demonstrated ventricular fibrillation at a local emergency department. After referral, an ECG showed bidirectional ventricular tachycardia (VT) and nonsustained Torsade de Pointes. Two days later, his heart rate became regular, and no additional episodes of VT were observed. His ECG showed sinus rhythm with a corrected QT interval of 423 msec, and two-dimensional echocardiography was unremarkable. We made the diagnosis of a catecholaminergic polymorphic VT. However, only premature ventricular complex bigeminy was induced on exercise ECG and epinephrine infusion tests, and the patient showed no episodes of syncope. His father and mother had different missense mutations in the cardiac ryanodine receptor on genetic testing. The proband had both mutations in different alleles and was symptomatic. It was recommended that the patient avoid competitive physical activities, and a beta-blocker was prescribed.

Impact of Multivessel Coronary Disease With Chronic Total Occlusion on One-Year Mortality in Patients With Acute Myocardial Infarction

BACKGROUND AND OBJECTIVES: The impact of multivessel coronary disease (MVD) with chronic total occlusion (CTO) on one-year mortality in patients with acute myocardial infarction (AMI) is not clearly known. We investigated the impact of MVD with concurrent CTO lesion on one-year mortality in patients with AMI. SUBJECTS AND METHODS: We studied 1008 consecutive patients who underwent coronary angiography between November 2005 and December 2008 with a diagnosis of AMI. RESULTS: Among 1008 patients, 432 patients (43%) had MVD, and 88 patients (8.7%) had CTO lesion. The one-year overall mortality was higher in patients with MVD than in patients with single vessel disease (SVD) (10.2% vs. 5.9%, p=0.012). However, the one-year overall mortality was not significantly higher in patients with CTO lesion than in patients without that lesion (12.5% vs. 7.3%, p=0.080). In multivariate analysis, independent predictors of one-year overall mortality were age older than 65 years {hazard ratio (HR) 2.41, 95% confidence interval (CI): 1.43 to 4.08}, Killip class > or =III (HR 3.59, 95% CI: 2.24 to 5.77), ST-elevation myocardial infarction (HR 2.45, 95% CI: 1.49 to 4.05) and MVD (HR 1.76, 95% CI: 1.07 to 2.89). CONCLUSION: Patients with MVD showed higher one-year mortality than patients with SVD. However, the presence of CTO was not an independent predictor of one-year mortality in this study that included patients with successfully revascularized CTO lesion.

A Case of Chronic Periaortitis with Retroperitoneal Fibrosis

A 73-year-old man with a history of hypertension and ascending aortic dissection was hospitalized for aggravated abdominal pain and general ache for 3 months. Follow-up CT showed aggravated abdominal aortic hematoma with aneurysm, atherosclerotic periaortitis and bilateral hydronephrosis. An initial laboratory finding showed elevated levels of inflammatory markers and renal dysfunction. Positron emission tomography-CT showed an increased standardized uptake values level in the aortic arch, descending thoracic aorta, major branch, abdominal aorta, and common iliac artery. For bilateral hydronephrosis, a double J catheter insertion was performed. Tissue specimens obtained from previous surgery on the aorta indicated the infiltration of lympho-plasma cells without granuloma formation in the aortic wall. After a combined therapy of high dose steroid therapy with azathioprine, the patient's initial complaints of abdominal pain, weakness and azotemia improved. This case was diagnosed as chronic periaortitis based on aortic inflammation at biopsy, which was complicated with retroperitoneal fibrosis and ureteric obstruction.

Familial Transthyretin Amyloidosis with Variant Asp38Ala Presenting with Orthostatic Hypotension and Chronic Diarrhea

A 53-year-old man complained of orthostatic, non-rotating dizziness, and chronic watery diarrhea of several years duration. His nerve-conduction velocity test revealed peripheral sensory-motor polyneuropathy and he showed an autonomic function abnormality. Echocardiographic examination showed ventricular and atrial wall thickening with a granular "sparkling" appearance. Left ventricular systolic function was preserved but pseudonormal diastolic dysfunction was present. Coronary angiography showed normal coronary arteries and an endomyocardial biopsy revealed lesions consistent with cardiac amyloidosis. Colonoscopic biopsy also revealed the deposition of amyloid fibrils. Gene analysis found the transthyretin variant Asp38Ala. His son had same mutation, but three daughters did not. In conclusion, we report a case of familial transthyretin amyloidosis with Asp38Ala.

Incidence of Hypertension in Korea: 5-Year Follow-up Study

Limited data are available about the incidence of hypertension over the 5-yr in non-hypertensive subjects. The study subjects were 1,806 subjects enrolled in a rural area of Daegu, Korea for a cohort study from August to November 2003. Of them, 1,287 (71.3%) individuals had another examination 5 yr later. To estimate the incidence of hypertension, 730 non-hypertensive individuals (265 males; mean age = 56.6 +/- 11.1 yr-old) at baseline examination were analyzed in this study. Hypertension was defined as either a new diagnosis of hypertension or self-reports of newly initiated antihypertensive treatment; prehypertension was if the systolic blood pressure was 120-139 mmHg and/or diastolic blood pressure was 80-89 mmHg. During the 5-yr follow-up, 195 (26.7%) non-hypertensive individuals developed incident hypertension. The age-adjusted 5-yr incidence rates of hypertension were 22.9% (95% confidence interval [CI] = 19.9-29.0) in overall subjects, 22.2% (95% CI = 17.2-27.2) in men, and 24.3% (95% CI = 20.4-28.2) in women. The incidence rates of hypertension significantly increased with age. In the multivariate analysis, prehypertension (Odds ratio [OR] 2.25; P < 0.001) and older age (OR 2.26; P = 0.010) were independent predictors for incident hypertension. In this rapidly aging society, population-based preventive approach to decrease blood pressure, particularly in subjects with prehypertension, is needed to reduce hypertension.

Predictors of Weight Reduction and Smoking Cessation in Overweight and Obese Patients with Acute Myocardial infarctions / 영남의대학술지

BACKGROUND: Little is known about predictors of lifestyle modification in overweight or obese patients with acute myocardial infarctions. METHODS: Between October 2005 and May 2007, 311 overweight or obese patients with an AMI visited Kyungpook National University Hospital. Among them, 216 patients (63+/-11 years old, 144 males) with > or =1 year of follow-up were included. RESULTS: Body weight of all patients showed a significant decrease and 20% showed a >3% weight reduction at 1 year of follow-up. Ninety-six (44%) patients were smoking at baseline, and 52% of them had quit by 1 year of follow-up. Only six smokers were successful with both a >3% weight reduction and smoking cessation. In multivariate analysis, age (OR 1.084, 95% CI 1.028-1.144, p=0.003) and smoking cessation (OR 0.167, 95% CI 0.048-0.575, p=0.005) were independent predictors of weight reduction. Abdominal circumference was a negative predictor of smoking cessation (OR 0.903, 95% CI 0.820-0.994, p=0.037). CONCLUSIONS: Mean body weight of all patients showed a significant decrease at follow-up. Smoking cessation and age were independent predictors of weight reduction, and abdominal circumference was a negative predictor of smoking cessation.

The Impact of Circadian Variation on 12-Month Mortality in Patients With Acute Myocardial Infarction

BACKGROUND AND OBJECTIVES: Although circadian variation in the onset of acute myocardial infarction (AMI) has been reported in a number of studies, not much is known about the impact of circadian variation on 12-month mortality. The aim of this study was to investigate the impact of circadian variation on 12-month mortality in patients with AMI. SUBJECTS AND METHODS: Eight hundred ninety two patients (mean age 67+/-12; 66.1% men) with AMI who visited Kyungpook National University Hospital from November 2005 to December 2007 were included in this study. Patients were divided into groups based on four 6-hours intervals: overnight (00:00-05:59); morning (06:00-11:59); afternoon (12:00-17:59) and evening (18:00-23:59). RESULTS: Kaplan-Meier survival curves showed 12-month mortality rates of 9.6%, 9.1%, 12.1%, and 16.7% in the overnight, morning, afternoon, evening-onset groups, respectively (p=0.012). Compared with the morning-onset AMI group, the serum creatinine levels (p=0.002), frequency of Killip class > or =3 (p=0.004), and prescription rate of diuretics (p=0.011) were significantly higher in the evening-onset AMI group, while the left ventricular ejection fraction (p=0.012) was significantly lower. The proportion of patients who arrived in the emergency room during routine duty hours was significantly lower in evening-onset groups irrespective of the presence or absence of ST-segment elevation (p<0.001). According to univariate analysis, the 12-month mortality rate in the evening group was significantly higher compared to the morning group (hazard ratio 1.998, 95% confidence interval 1.196 to 3.338, p=0.008). CONCLUSION: Patients with evening-onset AMI had poorer baseline clinical characteristics, and this might affect the circadian impact on 12-month mortality. Further studies are needed to clarify the role of circadian variation on the long-term outcome of AMI.

Electrocardiography Patterns and the Role of the Electrocardiography Score for Risk Stratification in Acute Pulmonary Embolism

BACKGROUND AND OBJECTIVES: Data on the usefulness of a combination of different electrocardiography (ECG) abnormalities in risk stratification of patients with acute pulmonary embolism (PE) are limited. We thus investigated 12-lead ECG patterns in acute PE to evaluate the role of the ECG score in risk stratification of patients with acute PE. SUBJECTS AND METHODS: One hundred twenty-five consecutive patients (63+/-14 years, 56 men) with acute PE who were admitted to Kyungpook National University Hospital between November 2001 and January 2008 were included. We analyzed ECG patterns and calculated the ECG score in all patients. We evaluated right ventricular systolic pressure (RVSP) (n=75) and RV hypokinesia (n=80) using echocardiography for risk stratification of acute PE patients. RESULTS: Among several ECG findings, sinus tachycardia and inverted T waves in V(1-4) (39%) were observed most frequently. The mean ECG score and RVSP were 7.36+/-6.32 and 49+/-21 mmHg, respectively. The ECG score correlated with RVSP (r=0.277, p=0.016). The patients were divided into two groups {high ECG-score group (n=38): ECG score >12 and low ECG-score group (n=87): ECG score < or =12} based on the ECG score, with the maximum area under the curve. RV hypokinesia was observed more frequently in the high ECG-score group than in the low ECG-score group (p=0.006). Multivariate analysis revealed that a high ECG score was an independent predictor of high RVSP and RV hypokinesia. CONCLUSION: Sinus tachycardia and inverted T waves in V(1-4) were commonly observed in acute PE. Moreover, the ECG score is a useful tool in risk stratification of patients with acute PE.

Examining the Relationship Between Triggering Activities and the Circadian Distribution of Acute Aortic Dissection

BACKGROUND AND OBJECTIVES: There are limited data examining triggering activities and circadian distribution at the onset of acute aortic dissection (AAD) in the context of diagnostic and anatomical classification. The aim of this study was to further investigate this relationship between triggering activities and circadian distribution at the onset of AAD according to diagnostic and anatomic classification. SUBJECTS AND METHODS: A total of 166 patients with AAD admitted to Kyungpook National University Hospital between July 2001 and June 2009 were included. To assess the influence of diagnostic and anatomical classification, we categorized the patients into intramural hematoma (IMH) group (n=67)/non-IMH group (n=99) and Stanford type A (AAD-A, n=94)/type B (AAD-B, n=72). To evaluate circadian distribution, the day was divided into four 6-hour periods: night (00-06 hours), morning (06-12 hours), afternoon (12-18 hours), and evening (18-00 hours). RESULTS: Most (72%) AAD episodes were related to physical (53%) and mental activities (19%), with about one-third occurring during the afternoon, and only 12% occurring at night. No differences in triggering activities or circadian distribution were observed among the groups. Waking hours including morning, afternoon, and evening correlated with triggering activities (p=0.003). These relationships were observed for the non-IMH (p=0.008) and AAD-B (p=0.003) cases. The remaining categories had similar relationships, but did not reach statistical significance. CONCLUSION: Our findings suggest differences in the relationship between triggering activities and the circadian distribution of the onset of AAD according to diagnostic and anatomical classification.

Recurrent Catecholamine-Induced Cardiomyopathy in a Patient With a Pheochromocytoma

Pheochromocytomas presents with variable clinical manifestations. Cardiomyopathy caused by a pheochromocytoma is well known. We report the case of a 62-year-old woman with recurrent left ventricular dysfunction, who was subsequently found to have a pheochromocytoma. The patient had two different patterns of cardiomyopathy. Patients with a cardiomyopathy, of non-specific origin, should have a pheochromocytoma ruled out.

Prognosis and Natural History of Drug-Related Bradycardia

BACKGROUND AND OBJECTIVES: The prognosis and natural history of bradycardia related to drugs such as beta-blockers and non-dihydropyridine calcium channel blockers are not well known. SUBJECTS AND METHODS: We retrospectively analyzed 38 consecutive patients (age 69+/-11, 21 women) with drug-related bradycardia (DRB) between March 2005 and September 2007. A drug-associated etiology for the bradycardia was established based on the medical history and patient response to drug discontinuation. The mean follow-up duration was 18+/-8 months. RESULTS: The initial electrocardiogram (ECG) showed sinus bradycardia (heart rate < or =40/min) in 13 patients, sinus bradycardia with junctional escape beats in 18 patients, and third-degree atrioventricular (AV) block in seven patients. Drug discontinuation was followed by resolution of bradycardia in 60% of patients (n=23). Among them, five (17.8%) patients resumed taking the culprit medication after discharge and none developed bradycardia again. Bradycardia persisted in 10 (26.3%) patients despite drug withdrawal, and a permanent pacemaker was implanted in seven of them. Third-degree AV block, QRS width, and bradycardia requiring temporary transvenous pacing were significantly associated with the bradycardia caused by drugs. CONCLUSION: Beta-blockers were the most common drugs associated with DRB. However, in one quarter of the cases the DRB was not associated with drugs; in these patients permanent pacemaker implantation should be considered.

Gender Differences Among Korean Patients With Coronary Spasm

BACKGROUND AND OBJECTIVES: The gender differences among Korean patients with coronary spasm have not been defined. We thus determined the gender differences among Korean patients with coronary spasm. SUBJECTS AND METHODS: Patients with chest pain and/or syncope who were admitted to Kyungpook National University Hospital between January 2001 and August 2008 were included. Provocation of coronary vasospasm with intracoronary ergonovine maleate was performed when baseline coronary angiography showed no significant stenosis or there was a strong clinical suspicion of coronary spasm. The clinical characteristics were analyzed from 104 consecutive patients (56+/-9 years of age; 21 females) who were diagnosed with coronary spasm. RESULTS: Female patients were younger (52+/-7 vs. 57+/-10 years, p=0.046) with lower rates of smoking and alcohol consumption histories than male patients (19% vs. 65%, p<0.001; and 43% vs. 89%, p<0.001, respectively). The other clinical characteristics were not significantly different, except for the triglyceride levels. CONCLUSION: The majority of patients with coronary spasm were males who were smokers and alcohol consumers. The female patients had lower rates of smoking and alcohol consumption, and they were younger than the male patients. Further studies are needed to investigate the relevance of gender differences in the pathogenesis of coronary spasm.

Blood Pressure Response during the Exercise Treadmill Test and the Risk of Future Hypertension and Cardiovascular Disease

BACKGROUND AND OBJECTIVES: Many studies had established the risk factors for cardiovascular disease. The Duke treadmill score has gained widespread acceptance for making the prognosis and diagnosis for patients with cardiac disease. Recently, the changes in blood pressure during and after exercise have also been studied to predict the prognosis of cardiac disease. We examined the relationship between the incidence of hypertension or cardiovascular disease and the changes of blood pressure during a routine exercise treadmill test. SUBJECTS AND METHODS: 256 men were screened, and they performed exercise treadmill tests from March to May, 2000. Those subjects with histories of hypertension and ischemic heart disease or who were newly diagnosed with ischemic heart disease were excluded. 109 subjects were selected for the final analysis. The follow up period was 78 months. Review of medical records and telephone interviews were used for follow up. We defined clinical events as new onset hypertension, ischemic heart disease, congestive heart failure, cerebrovascular accident, diabetes and atrial fibrillation. The peak systolic blood pressure of 182.5mmHg had the highest specificity and sensitivity on the receiver operating characteristic (ROC) curve of the systolic blood pressure for prediction of clinical events. We defined a hypertensive response as a peak systolic blood pressure over 180 mmHg. RESULTS: 43 (39.4%) of the subjects had a hypertensive response on their exercise treadmill test. The mean exercise capacity was higher in the hypertensive response group. No significant differences were found between the hypertensive and non-hypertensive response groups, in terms of age, gender, body weight, height, body mass index and resting blood pressure. 18 (41.8%) of the hypertensive response subjects had clinical events, while only 11 (16.6%) of the non-hypertensive response subjects had clinical events. The hypertensive response group had more clinical events (p=0.006). 14 (32.5%) of the hypertensive response subjects had hypertension, while only 10 (15.1%) of the non-hypertensive response group had hypertension. The hypertensive response group had more hypertension (p=0.044). On the multivariate analysis, the hypertensive response on the exercise treadmill test was an independent risk factor for hypertension and clinical events (odds ratio=3.990, 95% confidence interval; 1.473-10.808, p=0.006). CONSLUSION: These results indicate that the exercise blood pressure response seems to be a risk factor for hypertension and clinical events. Careful medical care and close follow up may be needed for subjects with a hypertensive blood pressure response on the exercise treadmill test. Further study is needed to understand the significance of an exaggerated blood pressure response on the exercise treadmill test.

Serum gamma-glutamyl transferase activity has no prognostic value in patients with acute myocardial infarction / 대한내과학회지

BACKGROUND: Serum gamma-glutamyl transferase activity (GGT) is able to catalyse low-density lipoprotein oxidation in coronary atherosclerotic plaques and has a role in the pathogenesis of atherosclerosis. GGT has been shown to be an independent risk factor for cardiac mortality in patients with a previous myocardial infarction. The purpose of this study is to determine the prognostic value of GGT within its normal range at an acute stage in patients with acute myocardial infarction. METHODS: In a retrospective study, GGT and other cardiac risk factors were evaluated in 192 patients (M/F=143/49; mean age: 60.8+/-11.8 years) who were diagnosed with an acute myocardial infarction at the emergency room. We compared the serum GGT values for each patient with or without a cardiac event, including cardiac death, non-fetal myocardial infarction and unstable angina, after an acute myocardial infarction for a mean follow-up of 16.5+/-10.8 months. RESULTS: During the follow-up period, 17 patients underwent cardiac death and experienced an acute myocardial infarction and 23 patients had unstable angina. Although the mean GGT values were significantly different from patients with cardiac events (29.5+/-10.0 U/L vs 25.0+/-11.2 U/L, p=0.024), serum GGT was not an independent cardiac risk factor for a cardiac event based on multivariate analysis adjusted for age, sex, alcohol and known cardiovascular risk factors. CONCLUSIONS: Serum GGT within its normal range at an acute stage in patients that experienced an acute myocardial infarction is not an independent prognostic marker.

A Case of Carney Complex: Diagnosed 11 Years after Resection of Recurrent Cardiac Myxomas

Carney complex (CNC) is a rare disease characterized by myxoma, spotty skin pigmentation, and multiple neuroendo crine tumors. Here, we present a case of CNC, diagnosed 11 years after resection of recurrent cardiac myxomas. We had previously reported a 37-year-old woman in 1984 as biatrial myxomas and in 1994 as recurrent left atrial and ventricular myxomas, and at those times, she did not have any other myxomas and skin lesions. On her present admission, she had skin pigmentation and myxomatosis of breast, nostril and forearm. Upon the examination of her relatives, no characteristics of CNC were found on them. She was diagnosed as a sporadic form of CNC. If cardiac myxomas tend to be multiple and recurrent, we should consider the possibility of CNC, even other characteristics of CNC except cardiac myxomas are not present at diagnosis.

Prospective Study to Evaluate the Efficacy and Safety of Pitavastatin in Patients with Risk Factor of Cardiovascular Disease(PEACE Study)

BACKGROUND AND OBJECTIVES: Pitavastatin, a recently approved synthetic 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitor, is known to effectively treat hypercholesterolemia. The goal of this study was to investigate the efficacy and safety of pitavastatin in hyperlipidemic Korean patients with coronary risk factors. SUBJECTS AND METHODS: This was an 8-week, prospective, multicenter, open-label clinical trial. The study subjects were hyperlipidemic Korean patients (triglyceride 130 mg/dL, age; 45-75 years) with at least two coronary risk factors. After a 2-week wash out period, the eligible subjects were given 2 mg of pitavastatin once daily for 8 weeks. In the case of the patients with LDL-cholesterol > or = 100 mg/dL after the first 4 weeks of treatment, the dose of pitavastatin was increased to 4 mg per day for the remaining 4 weeks. RESULTS: Of the 131 patients initially enrolled, 105 completed the study. Among the lipid profiles, the total cholesterol, triglyceride, and LDL-cholesterol levels showed a significant reduction with mean reduction rates of -30.66%, -23.92%, and -41.06%, respectively, after 8 weeks. Interestingly, the HDL-cholesterol level was significantly increased in the subjects with a low HDL-cholesterol level (HDL-cholesterol < 40 mg/dL) after 8 weeks of therapy (35.28+/-4.38 mg/dL to 40.39+/-6.45 mg/dL, 15.9%, p=0.001). The proportions of patients who achieved the LDL-cholesterol goal of the National Cholesterol Education Program Adult Treatment Panel III were 72.5% (37/51), 93.6% (44/47), and 100.0% (7/7) for the patients with goals of 100 mg/dL, 130 mg/dL, and 160 mg/dL, respectively. Five patients had mild adverse drug events, such as fatigue, itching, myalgia, and anorexia. No significant abnormalities were detected in the laboratory tests, including the liver function test and creatinine kinase level. CONCLUSION: The HMG-CoA reductase inhibitor, pitavastatin, was highly effective and generally well tolerated with an acceptable safety profile in hyperlipidemic Korean patients with coronary risk factors.

Complications of 2-D Echocardiography Guided Transfemoral Right Ventricular Endomyocardial Biopsy

Endomyocardial biopsy (EMBx) is a useful tool for diagnosing various cardiac pathologies. However, the routine use of EMBx has not gained widespread acceptance due to the possible complications related to the EMBx. Thus, not much information is available on the complications related to the EMBx. We prospectively evaluated 90 consecutive patients who underwent 2-D echocardiography guided transfemoral right ventricular EMBx at Kyungpook National University Hospital between March 2002 and November 2005 to determine the incidence, nature and subsequent management of complications related to EMBx. The clinical diagnoses before the EMBx were arrhythmogenic right ventricular dysplasia in 54, dilated cardiomyopathy in 19, Brugada syndrome in 9, myocarditis in 6 and miscellaneous in 2 patients. The overall major complication rate was 5.6% and no procedure-related mortality occurred. Myocardial perforation (n=3), which was the most frequent complication, did not progress to cardiac tamponade requiring pericardiocentesis in any patient. Hemodynamically unstable ventricular tachycardia occurred in 1 patient. New and persistent right bundle branch block occurred in another. Our findings suggest that 2-D echocardiography guided transfemoral right ventricular EMBx is a relatively safe procedure.

Complications of 2-D Echocardiography Guided Transfemoral Right Ventricular Endomyocardial Biopsy

Endomyocardial biopsy (EMBx) is a useful tool for diagnosing various cardiac pathologies. However, the routine use of EMBx has not gained widespread acceptance due to the possible complications related to the EMBx. Thus, not much information is available on the complications related to the EMBx. We prospectively evaluated 90 consecutive patients who underwent 2-D echocardiography guided transfemoral right ventricular EMBx at Kyungpook National University Hospital between March 2002 and November 2005 to determine the incidence, nature and subsequent management of complications related to EMBx. The clinical diagnoses before the EMBx were arrhythmogenic right ventricular dysplasia in 54, dilated cardiomyopathy in 19, Brugada syndrome in 9, myocarditis in 6 and miscellaneous in 2 patients. The overall major complication rate was 5.6% and no procedure-related mortality occurred. Myocardial perforation (n=3), which was the most frequent complication, did not progress to cardiac tamponade requiring pericardiocentesis in any patient. Hemodynamically unstable ventricular tachycardia occurred in 1 patient. New and persistent right bundle branch block occurred in another. Our findings suggest that 2-D echocardiography guided transfemoral right ventricular EMBx is a relatively safe procedure.

Influences of Perfusion Defect on the Measurement of Left Ventricular Ejection Fraction and Volumes in Gated Myocardial Perfusion SPECT

BACKGROUND AND OBJECTIVES: The left ventricular ejection fraction (LVEF) and volume (LVV) are important variables in patients with coronary artery disease. Quantitative gated myocardial SPECT (QGS) permits the simultaneous assessment of perfusion, LVEF and LVV. However, the presence of a perfusion defect may influence the LVEF and LVV measured by QGS. SUBJECTS AND METHODS: 67 subjects (M/F=47/20; mean age: 60.2+/-12.4 years) underwent both QGS with Tc-99m MIBI and 2-D echocardiography (Echo) at less than 7 days apart. The LVEF and LVV were measured by Echo, using the modified Simpson's method, and by QGS, using the automatic software, AutoQUANT(TM). The QGS rest images were used to compare with the Echo. RESULTS: The correlations between the QGS and Echo for LVEF, LVEDV and LVESV were good in all 67 subjects (r=0.781, 0.754 and 0.906, respectively, p<0.0001). In patients with no perfusion defect (n=34), the correlations between the QGS and Echo for LVEF, LVEDV and LVESV were good (r=0.689, 0.593 and 0.586, p<0.0001). In patients with a perfusion defect (n=33), the LVEF between the QGS and Echo was well correlated (r=0.777, p<0.0001), but the LVEF was higher by 7.1+/-8.7% from the Echo results. The LVEDV and LVESV by both QGS and Echo were also well correlated (r=0.804 and 0.929, respectively, p<0.0001), but the LVEDV and LVESV were higher from QGS by 17.9+/-34 and 16.9+/-25 mL, respectively. A Bland-Altman analysis showed the agreement between the QGS and Echo in patients without perfusion defect was better than for those with a perfusion defect. CONCLUSION: The perfusion defect from QGS might affect the measurements of the LVEF and LVV; therefore, the QGS and Echo values are not interchangeable.