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Background and Objectives@#The prognostic or safety implication of renin-angiotensinaldosterone system inhibitors (RASi) in hypertrophic cardiomyopathy (HCM) are not well established, mainly due to concerns regarding left ventricular outflow tract (LVOT) obstruction aggravation. We investigated the implications of RASi in a sizable number of HCM patients. @*Methods@#We enrolled 2,104 consecutive patients diagnosed with HCM in 2 tertiary university hospitals and followed up for five years. RASi use was defined as the administration of RASi after diagnostic confirmation of HCM. The primary and secondary outcomes were all-cause mortality and hospitalization for heart failure (HHF). @*Results@#RASi were prescribed to 762 patients (36.2%). During a median follow-up of 48.1months, 112 patients (5.3%) died, and 94 patients (4.5%) experienced HHF. Patients using RASi had less favorable baseline characteristics than those not using RASi, such as older age, more frequent history of comorbidities, and lower ejection fraction. Nonetheless, there was no difference in clinical outcomes between patients with and without RASi use (log-rank p=0.368 for all-cause mortality and log-rank p=0.443 for HHF). In multivariable analysis, patients taking RASi showed a comparable risk of all-cause mortality (hazard ratio [HR], 0.70, 95% confidence interval [CI], 0.43–1.14, p=0.150) and HHF (HR, 1.03, 95% CI, 0.63–1.70, p=0.900). In the subgroup analysis, there was no significant interaction of RASi use between subgroups stratified by LVOT obstruction, left ventricular (LV) ejection fraction, or maximal LV wall thickness. @*Conclusions@#RASi use was not associated with worse clinical outcomes. It might be safely administered in patients with HCM if clinically indicated.
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Background/Aims@#We evaluated changes in the ascending aorta dimension post-transcatheter aortic valve replacement (TAVR) in bicuspid aortic valve (BiAV) and tricuspid aortic valve (TAV) patients. @*Methods@#Patients with severe aortic stenosis undergoing TAVR at Seoul National University Hospital were consecutively recruited. Patients with less than 12 months’ follow-up and/or with an ascending aorta size larger than 50 mm were excluded. The ascending aorta size was measured on a parasternal long axis view using transthoracic echocardiography. @*Results@#Among the 67 patients who were included (age: 76.5 ± 6.5 years; male: 52.2%; AV area: 0.67 ± 0.15 cm2), 19 (28.4%) had BiAV; 48 (71.6%) had TAV. The median (interquartile ranges) follow-up duration was 398 days (361 to 451). BiAV patients were younger (73.2 ± 7.2 vs. 77.8 ± 5.8, p = 0.008), and had lower incidences of chronic renal disease (5.3% vs. 35.4%, p = 0.014) and history of coronary intervention (15.8% vs. 50.0%, p = 0.013), than TAV patients. On pre-procedural echocardiography, the ascending aorta dimensions in BiAV patients were larger than those in TAV patients (40.5 ± 3.8 mm vs. 35.9 ± 4.2 mm, p < 0.005). The ascending aorta dimension changed minimally during follow-up; post-TAVR, the ascending aorta’s growth rate was –0.11 ± 1.9 and 0.26 ± 1.8 mm/yr in patients with BiAV and TAV, respectively (p = 0.50). Progression of the ascending aorta’s dimension postTAVR was not clinically significant in BiAV patients. @*Conclusions@#The concern about the progression of aortopathy in BiAV patients post-TAVR may not be a clinical issue. This should be confirmed in studies with a larger population and with a longer follow-up duration.
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Background@#This study was conducted to evaluate the hemodynamic performance and the incidence of prosthesis-patient mismatch (PPM) after aortic valve replacement (AVR) using bovine pericardial valves (Carpentier-Edwards Perimount Magana and Magna Ease). @*Methods@#In total, 216 patients (mean age, 70.0±10.5 years) who underwent AVR using stented bovine pericardial valves and had follow-up echocardiography between 3 months and 2 years (mean, 12.0±6.6 months) after surgery were enrolled. The implanted valve sizes were 19, 21, 23, and 25 mm in 32, 56, 99, and 29 patients, respectively. @*Results@#On follow-up echocardiography, the mean transvalvular pressure gradients for the 19-mm, 21-mm, 23-mm, and 25-mm valves were 13.3±4.4, 12.6±4.2, 10.5±3.9, and 10.2± 3.7 mm Hg, respectively. The effective orifice area (EOA) was 1.25±0.26, 1.54±0.31, 1.81±0.41, and 1.87±0.33 ㎠ , respectively. These values were smaller than those suggested by the manufacturer for the corresponding sizes. No patients had PPM, when based on the reference EOA. However, moderate (EOA index ≤0.85㎠ /㎡ ) and severe (EOA index ≤0.65 ㎠ /㎡ ) PPM was present in 56 patients (11.8%) and 9 patients (1.9%), respectively, when using the measured values. @*Conclusion@#Carpentier-Edwards Perimount Magna and Magna Ease bovine pericardial valves showed satisfactory hemodynamic performance with low rates of PPM, although the reference EOA could overestimate the true EOA for individual patients.
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Background and Objectives@#Severe aortic stenosis (AS) with left ventricular systolic dysfunction (LVSD) is a class I indication for aortic valve replacement (AVR) but this recommendation is not well established in those at the stage of moderate AS. We investigate the clinical impact of AVR among patients with moderate AS and LVSD. @*Methods@#From 2001 to 2017, we consecutively identified patients with moderate AS and LVSD, defined as aortic valve area 1.0–1.5 cm2 and left ventricular ejection fraction <50%. The primary outcome was all-cause death. The outcomes were compared between those who underwent early surgical AVR (within 2 years of index echocardiography) at the stage of moderate AS versus those who were followed medically without AVR at the outpatient clinic. @*Results@#Among 255 patients (70.1±11.3 years, male 62%), 37 patients received early AVR. The early AVR group was younger than the medical observation group (63.1±7.9 vs. 71.3±11.4) with a lower prevalence of hypertension and chronic kidney disease. During a median 1.8-year follow up, 121 patients (47.5%) died, and the early AVR group showed a significantly lower all-cause death rate than the medical observation group (5.03PY vs. 18.80PY, p<0.001). After multivariable Cox-proportional hazard regression adjusting for age, sex, comorbidities, and laboratory data, early AVR at the stage of moderate AS significantly reduced the risk of death (hazard ratio, 0.43; 95% confidence interval 0.20–0.91; p=0.028). @*Conclusions@#In patients with moderate AS and LVSD, AVR reduces the risk of all-cause death. A prospective randomized trial is warranted to confirm our findings.
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Background@#Longitudinal integrated clerkships (LICs) have been adopted by medical schools to overcome the limitations of traditional block clerkship rotations and to promote continuity of care. In 2018, Seoul National University College of Medicine introduced a patient-centered LIC program as part of a new curriculum in parallel with traditional block rotation clerkships. The purpose of this study was to present the patient-centered LIC program and to investigate its educational effects. @*Methods@#In 2018 and 2019, a total of 298 third-year medical students participated in the LIC program. We divided the students into groups of eight, which were organized into corresponding discussion classes. Throughout the academic year, students followed up patients by interviewing them at the hospital or reviewing their electric medical records.Discussion classes on set topics were held seven times per year with facilitators and clinical faculties. Students completed a course evaluation questionnaire at the end of the academic year. The questionnaire included 22 items measured on a 5-point scale and two open-ended questions asking about the benefits and limitations of the program. The items covered three domains: student experience, satisfaction, and self-assessment. Final reflective essays were collected as both student assessments and data for qualitative analysis. @*Results@#During the study period, the overall experience of the students improved. We increased the number of faculty members and patients and decreased the number of students in each discussion class. We also provided additional feedback through an e-portfolio.Students' satisfaction changed positively. Compared to the rotational clerkship, students answered that the LIC provided additional help in learning the two core competencies.During the first 2 years of the program, the percentage of students who answered that the program was more helpful than the rotational clerkship increased from 23.7% to 46.4% for continuity of care (P < 0.001), and from 20.5% to 50.7% for patient-centered care (P < 0.001). @*Conclusion@#Our patient-centered LIC, in parallel with traditional block rotation clerkships, had a positive effect on students' experience of continuity of care and patient-centered care.
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Background@#Longitudinal integrated clerkships (LICs) have been adopted by medical schools to overcome the limitations of traditional block clerkship rotations and to promote continuity of care. In 2018, Seoul National University College of Medicine introduced a patient-centered LIC program as part of a new curriculum in parallel with traditional block rotation clerkships. The purpose of this study was to present the patient-centered LIC program and to investigate its educational effects. @*Methods@#In 2018 and 2019, a total of 298 third-year medical students participated in the LIC program. We divided the students into groups of eight, which were organized into corresponding discussion classes. Throughout the academic year, students followed up patients by interviewing them at the hospital or reviewing their electric medical records.Discussion classes on set topics were held seven times per year with facilitators and clinical faculties. Students completed a course evaluation questionnaire at the end of the academic year. The questionnaire included 22 items measured on a 5-point scale and two open-ended questions asking about the benefits and limitations of the program. The items covered three domains: student experience, satisfaction, and self-assessment. Final reflective essays were collected as both student assessments and data for qualitative analysis. @*Results@#During the study period, the overall experience of the students improved. We increased the number of faculty members and patients and decreased the number of students in each discussion class. We also provided additional feedback through an e-portfolio.Students' satisfaction changed positively. Compared to the rotational clerkship, students answered that the LIC provided additional help in learning the two core competencies.During the first 2 years of the program, the percentage of students who answered that the program was more helpful than the rotational clerkship increased from 23.7% to 46.4% for continuity of care (P < 0.001), and from 20.5% to 50.7% for patient-centered care (P < 0.001). @*Conclusion@#Our patient-centered LIC, in parallel with traditional block rotation clerkships, had a positive effect on students' experience of continuity of care and patient-centered care.
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BACKGROUND: It is critical to develop remedial education for underperforming medical students, but little is known about how to create an effective remediation program. Deliberate practice (DP) is a structured and reflective activity that is designed to optimize performance. Here we applied the concept of DP to create remedial education to improve the clinical practices of medical students. We also analyzed the effectiveness of the remediation program. METHODS: Based on the expert performance approach of DP, we designed a 4-week remedial program for clinical performance that included feedback and reflection. There were 74 student participants in this program from 2014 to 2017. Their clinical performance was re-evaluated after completion, and changes in their clinical performance scores were analyzed. RESULTS: Students who completed the remediation program showed significant improvements in clinical performance scores (P < 0.001). Most students found the program to be instructive and helpful for improving their clinical performance. They reported that role play with peers was the most helpful for improving their skills. CONCLUSION: The DP-based remediation program improved the clinical performance of failing medical students. This remediation program should continue to be offered to underperforming students to ensure that medical school graduates are competent.
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Humans , Clinical Competence , Education , Education, Medical , Longitudinal Studies , Prospective Studies , Schools, Medical , Students, MedicalABSTRACT
OBJECTIVE: To investigate the diagnostic validity of coronary computed tomography angiography (cCTA) in vasospastic angina (VA) and factors associated with discrepant results between invasive coronary angiography with the ergonovine provocation test (iCAG-EPT) and cCTA. MATERIALS AND METHODS: Of the 1397 patients diagnosed with VA from 2006 to 2016, 33 patients (75 lesions) with available cCTA data from within 6 months before iCAG-EPT were included. The severity of spasm (% diameter stenosis [%DS]) on iCAG-EPT and cCTA was assessed, and the difference in %DS (Δ%DS) was calculated. Δ%DS was compared after classifying the lesions according to pre-cCTA-administered sublingual nitroglycerin (SL-NG) or beta-blockers. The lesions were further categorized with %DS ≥ 50% on iCAG-EPT or cCTA defined as a significant spasm, and the diagnostic performance of cCTA on identifying significant spasm relative to iCAG-EPT was assessed. RESULTS: Compared to lesions without SL-NG treatment, those with SL-NG treatment showed a higher Δ%DS (39.2% vs. 22.1%, p = 0.002). However, there was no difference in Δ%DS with or without beta-blocker treatment (35.1% vs. 32.6%, p = 0.643). The significant difference in Δ%DS associated with SL-NG was more prominent in patients who were aged < 60 years, were male, had body mass index < 25 kg/m2, and had no history of hypertension, diabetes, or dyslipidemia. Based on iCAG-EPT as the reference, the per-lesion-based sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of cCTA for VA diagnosis were 7.5%, 94.0%, 60.0%, 47.1%, and 48.0%, respectively. CONCLUSION: For patients with clinically suspected VA, confirmation with iCAG-EPT needs to be considered without completely excluding the diagnosis of VA simply based on cCTA results, although further prospective studies are required for confirmation.
Subject(s)
Humans , Male , Angina Pectoris, Variant , Angiography , Body Mass Index , Constriction, Pathologic , Coronary Angiography , Diagnosis , Dyslipidemias , Ergonovine , Hypertension , Nitroglycerin , Prospective Studies , Sensitivity and Specificity , SpasmABSTRACT
BACKGROUND AND OBJECTIVES@#Clinical data for Korean patients with bicuspid aortic valve (BAV) that underwent aortic valve (AV) surgery are currently limited.@*METHODS@#Data for 1,160 consecutive adult BAV patients who underwent AV surgery from 2000 to 2014 in 4 tertiary referral centers were retrospectively analyzed. A standard case report form was used for clinical and echocardiographic parameters.@*RESULTS@#Mean age at the time of AV surgery was 59±13 years. The most common cause of AV surgery was aortic stenosis (AS, 892 [77%]), followed by aortic regurgitation (AR, 199 [17%]), and infective endocarditis (69 [6%]). AS showed a skewed peak in the aged population and was the predominant cause of AV surgery (87%) in patients ≥50 years of age, whereas AR (46%) and active infective endocarditis (19%) were more common in younger patients (p < 0.001). Echocardiographic determination of the BAV phenotype revealed that fusion of the right coronary cusp (RCC) and left coronary cusp (LCC) was most common (622 [53%]), followed by fusion of RCC and non-coronary cusp (NCC) (313 [27%]), and fusion of LCC and NCC (42 [4%]); the BAV phenotype could not be determined in the remaining 183 patients (16%). Fusion of RCC and LCC was more commonly observed in patients with AR than in those with AS (74% vs. 49%; p < 0.001).@*CONCLUSION@#BAV patients were characterized by distinct surgical indications according to their age. Possible associations between BAV phenotypes and surgical indications with potential impacts of ethnicity need to be tested in further studies.
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BACKGROUND AND OBJECTIVES: Clinical data for Korean patients with bicuspid aortic valve (BAV) that underwent aortic valve (AV) surgery are currently limited. METHODS: Data for 1,160 consecutive adult BAV patients who underwent AV surgery from 2000 to 2014 in 4 tertiary referral centers were retrospectively analyzed. A standard case report form was used for clinical and echocardiographic parameters. RESULTS: Mean age at the time of AV surgery was 59±13 years. The most common cause of AV surgery was aortic stenosis (AS, 892 [77%]), followed by aortic regurgitation (AR, 199 [17%]), and infective endocarditis (69 [6%]). AS showed a skewed peak in the aged population and was the predominant cause of AV surgery (87%) in patients ≥50 years of age, whereas AR (46%) and active infective endocarditis (19%) were more common in younger patients (p < 0.001). Echocardiographic determination of the BAV phenotype revealed that fusion of the right coronary cusp (RCC) and left coronary cusp (LCC) was most common (622 [53%]), followed by fusion of RCC and non-coronary cusp (NCC) (313 [27%]), and fusion of LCC and NCC (42 [4%]); the BAV phenotype could not be determined in the remaining 183 patients (16%). Fusion of RCC and LCC was more commonly observed in patients with AR than in those with AS (74% vs. 49%; p < 0.001). CONCLUSION: BAV patients were characterized by distinct surgical indications according to their age. Possible associations between BAV phenotypes and surgical indications with potential impacts of ethnicity need to be tested in further studies.
Subject(s)
Adult , Humans , Aortic Valve Insufficiency , Aortic Valve Stenosis , Aortic Valve , Bicuspid , Cardiac Surgical Procedures , Echocardiography , Endocarditis , Heart Valve Diseases , Phenotype , Retrospective Studies , Tertiary Care CentersABSTRACT
The longitudinal integrated clerkship is an innovative approach in medical education that emphasizes continuity as a key principle to provide student-centered experiences and learning. Seoul National University College of Medicine decided to adapt longitudinal integrated clerkships to the new curriculum beginning in 2018, and therefore conducted pilot studies in 2016 and 2017. This study aimed to analyze the program evaluation results of the two pilot programs and discuss issues related to the successful implementation of longitudinal integrated clerkships in Korea. We conducted a focus group interview with nine students who participated in the 2016 pilot program and 13 students who participated in the 2017 pilot program. We also conducted a focus group interview with 11 faculty members who either participated in the pilot program or will participate in the main program. From the 2016 experience, we found that it is not appropriate to assign each patient to a single student and let the students contact their patients personally for feasibility and safety reasons. In the 2017 pilot program, we assigned each patient to a group of students, which made it more feasible for the students to follow-up with their patients. The students were satisfied with their new experience of longitudinal patient follow-up and regular meetings in the pilot program. Faculty emphasized the importance of establishing the course objectives and holding an orientation for the students and the faculty. Further study is planned to evaluate the early outcomes of the main longitudinal integrated clerkship.
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Humans , Curriculum , Education, Medical , Focus Groups , Follow-Up Studies , Korea , Learning , Linear Energy Transfer , Pilot Projects , Program Evaluation , SeoulABSTRACT
PURPOSE: Team-based learning (TBL) is increasingly employed in medical education because of its potential to promote active group learning. In TBL, learners are usually asked to assess the contributions of peers within their group to ensure accountability. The purpose of this study is to assess the validity and reliability of a peer evaluation instrument that was used in TBL classes in a single medical school. METHODS: A total of 141 students were divided into 18 groups in 11 TBL classes. The students were asked to evaluate their peers in the group based on evaluation criteria that were provided to them. We analyzed the comments that were written for the highest and lowest achievers to assess the validity of the peer evaluation instrument. The reliability of the instrument was assessed by examining the agreement among peer ratings within each group of students via intraclass correlation coefficient (ICC) analysis. RESULTS: Most of the students provided reasonable and understandable comments for the high and low achievers within their group, and most of those comments were compatible with the evaluation criteria. The average ICC of each group ranged from 0.390 to 0.863, and the overall average was 0.659. There was no significant difference in inter-rater reliability according to the number of members in the group or the timing of the evaluation within the course. CONCLUSION: The peer evaluation instrument that was used in the TBL classes was valid and reliable. Providing evaluation criteria and rules seemed to improve the validity and reliability of the instrument.
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Humans , Education, Medical , Learning , Methods , Reproducibility of Results , Schools, Medical , Social ResponsibilityABSTRACT
No abstract available.
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Atherosclerosis , Carotid Arteries , Coronary Artery Disease , Coronary Vessels , Risk AssessmentABSTRACT
A permanent pacemaker is a mainstay treatment for symptomatic bradyarrhythmia, including atrioventricular node blocks and sick sinus syndrome. Although this device was introduced to aid electrical recovery, pacemakers can cause mechanical dysfunction of the tricuspid valve, resulting in significant tricuspid regurgitation (TR). Because pacemaker-related TR is a correctable cause of right heart failure, it is of paramount importance to assess the presence or severity of TR and its association with pacemakers. However, acoustic shadowing from the pacemaker wire hampers the accurate visualization of TR jets, and increases the risk of failing to detect severe TR. Accordingly, goal-directed imaging with a high index of clinical suspicion should be performed when patients present with right heart failure after pacemaker implantation. In this issue of the Journal, the authors sought to investigate the frequency of aggravated TR in patients after pacemaker implantation. They also explored the predictors of TR aggravation, which might provide valuable information for identification of patients who require meticulous follow-up to allow timely intervention. These data regarding the predictive variables for pacemaker-related TR can serve as a roadmap for future studies to identify strategies for reducing the risk of significant TR, such as a tailored approach based on heart rhythm (bradyarrhythmia only vs. combined atrial fibrillation), pacemaker mode (VVI vs. DDD), the location of the pacemaker lead (apical vs. base), and the use of state-of-the art techniques (classical lead vs. leadless).
Subject(s)
Humans , Acoustics , Atrioventricular Node , Bradycardia , Follow-Up Studies , Heart , Heart Failure , Shadowing Technique, Histology , Sick Sinus Syndrome , Tricuspid Valve , Tricuspid Valve InsufficiencyABSTRACT
Recently, transcatheter aortic valve replacement (TAVR) has emerged as an alternative for the treatment of severe symptomatic aortic stenosis patients. Although experience with TAVR is increasing exponentially, few cases of post-TAVR endocarditis are reported. We present a case of 76-year-old man with infective endocarditis after TAVR who was definitely diagnosed by echocardiography.
Subject(s)
Aged , Humans , Aortic Valve Stenosis , Aortic Valve , Echocardiography , EndocarditisABSTRACT
BACKGROUND AND OBJECTIVES: The National Cholesterol Education Program-Adult Treatment Panel (NCEP-ATP) III guideline has been widely accepted for the primary prevention of coronary heart disease (CHD). The coronary artery calcium score (CACS) has recently been recognized as an excellent predictor of CHD events, and a primary prevention strategy based on the CACS [the Screening for Heart Attack Prevention and Education (SHAPE) guideline] has been proposed. The purpose of this study was to explore how the guidelines function for asymptomatic South Korean individuals. SUBJECTS AND METHODS: We consecutively enrolled 2,079 asymptomatic subjects (age range for men: 45-75 years, age range for women: 55-75 years) who underwent CACS and coronary CT angiography (CCTA) as a part of a health check-up. We analyzed the differences of the target population for CHD prevention according to the 2 guidelines and we compared them in terms of the presence of occult CHD. RESULTS: Four-hundred eighteen (20%) individuals were recommended for pharmacotherapy according to the NCEP-ATP III and 371 (18%) were recommended for pharmacotherapy according to the SHAPE guideline (Cohen's kappa=0.36). According to the SHAPE guideline, more individuals with significant stenosis noted on the CCTA were categorized into the high or very high risk group (50% vs. 24%, respectively, p<0.001) and recommended for pharmacotherapy (53% vs. 28%%, respectively, p<0.001). However, 57 (43%) individuals with significant stenosis on the CCTA were not suitable for pharmacotherapy according to either the NCEP-ATP III or the SHAPE guideline. CONCLUSION: Comparing the NCEP-ATP III and the SHAPE guidelines, there were considerable differences for primary prevention in the target population. Although SHAPE might provide more accurate stratification in terms of the presence of occult CHD, a more precise risk stratification algorithm needs to be implemented for this population.
Subject(s)
Angiography , Calcium , Cholesterol , Constriction, Pathologic , Coronary Artery Disease , Coronary Disease , Coronary Vessels , Health Services Needs and Demand , Heart , Mass Screening , Primary PreventionABSTRACT
Stress-induced cardiomyopathy is characterized by reversible systolic dysfunction of the ventricles, usually involving the apical segments. It occurs more commonly in women and is frequently precipitated by emotional or physical stressors. Ever since the first report of typical stress-induced cardiomyopathy-usually known as Takotsubo cardiomyopathy or transient left ventricular apical ballooning syndrome-was issued, variant forms of stress-induced cardiomyopathy have been reported. We describe a patient who presented with typical ischemic chest pain, but who was found to have an atypical form of stress-induced cardiomyopathy: midventricular ballooning syndrome involving both the left and right ventricles. Transthoracic echocardiography and computed tomography were used in this patient.
Subject(s)
Female , Humans , Cardiomyopathies , Chest Pain , Echocardiography , Heart Ventricles , Takotsubo CardiomyopathyABSTRACT
Castleman disease (CD) is a rare lymphoproliferative disorder of unknown etiology with different clinical manifestations. A previous healthy 50 year-old man was hospitalized for right upper quadrant (RUQ) abdominal pain. He had jaundice and a 1 cm-sized lymph node in the right supraclavicular area. Pancreas and biliary computed tomography (CT) showed masses at the right renal hilum and peripancreatic areas. Positron emission tomography (PET) showed widespread systemic lymphadenopathy. Excisional biopsy of the right supraclavicular node revealed a hyaline vascular variant of CD. Corticosteroid therapy was started and the extent of disease decreased. We here report a case of multicentric CD, the hyaline vascular variant, presenting with jaundice, diagnosed by excisional biopsy and successfully treated with corticosteroids.