Clinical outcomes of endovascular treatment for ruptured thoracic aortic disease

Background/Aims@#Untreated rupture of the thoracic aorta is associated with a high mortality rate. We aimed to review the clinical results of endovascular treatment for ruptured thoracic aortic disease. @*Methods@#We retrospectively reviewed data on 37 patients (mean age, 67.0 ± 15.18 years) treated for ruptured thoracic aortic disease from January 2005 to May 2016. The median follow-up duration was 308 days (interquartile range, 61 to 1,036.5). The primary end-point of the study was the composite of death, secondary intervention, endoleak, and major stroke/paraplegia after endovascular treatment. @*Results@#The etiologies of ruptured thoracic aortic disease were aortic dissection (n = 11, 29.7%), intramural hematoma (n = 7, 18.9%), thoracic aortic aneurysm (n = 14, 37.8%), and traumatic aortic transection (n = 5, 13.5%). Three patients died within 24 hours of thoracic endovascular aortic repair, and one showed type I endoleak. The technical success rate was 89.2% (33/37). The in-hospital mortality rate was 13.5% (5/37); no deaths occurred during follow-up. The composite outcome rate during follow-up was 37.8% (14/37), comprising death (n = 5, 13.5%), secondary intervention (n = 5, 13.5%), endoleak (n = 5, 13.5%), and major stroke/paraplegia (n = 3, 8.1%). Left subclavian artery revascularization and proximal landing zone were not associated with the composite outcome. Low mean arterial pressure (MAP; ≤ 60 mmHg, [hazard ratio, 13.018; 95% confidence interval, 2.435 to 69.583, p = 0.003]) was the most significant predictor and high transfusion requirement in the first 24 hours was associated with event-free survival (log rank p = 0.018). @*Conclusions@#Endovascular treatment achieves high technical success rates and acceptable clinical outcome. High transfusion volume and low MAP were associated with poor clinical outcomes.

Revisiting Application of Exercise Electrocardiography in Patients with Stable Ischemic Heart Disease

No abstract available.

Erratum: Correction of Figure in the Article: Normal Reference Plots for the Bioelectrical Impedance Vector in Healthy Korean Adults

The present erratum notice corrects one figure of the article.

Normal Reference Plots for the Bioelectrical Impedance Vector in Healthy Korean Adults

BACKGROUND: Accurate volume measurement is important in the management of patients with congestive heart failure or renal insufficiency. A bioimpedance analyser can estimate total body water in litres and has been widely used in clinical practice due to its non-invasiveness and ease of results interpretation. To change impedance data to volumetric data, bioimpedance analysers use equations derived from data from healthy subjects, which may not apply to patients with other conditions. Bioelectrical impedance vector analysis (BIVA) was developed to overcome the dependence on those equations by constructing vector plots using raw impedance data. BIVA requires normal reference plots for the proper interpretation of individual vectors. The aim of this study was to construct normal reference vector plots of bioelectrical impedance for Koreans. METHODS: Bioelectrical impedance measurements were collected from apparently healthy subjects screened according to a comprehensive physical examination and medical history performed by trained physicians. Reference vector contours were plotted on the RXc graph using the probability density function of the bivariate normal distribution. We further compared them with those of other ethnic groups. RESULTS: A total of 242 healthy subjects aged 22 to 83 were recruited (137 men and 105 women) between December 2015 and November 2016. The centers of the tolerance ellipses were 306.3 Ω/m and 34.9 Ω/m for men and 425.6 Ω/m and 39.7 Ω/m for women. The ellipses were wider for women than for men. The confidence ellipses for Koreans were located between those for Americans and Spaniards without overlap for both genders. CONCLUSION: This study presented gender-specific normal reference BIVA plots and corresponding tolerance and confidence ellipses on the RXc graph, which is important for the interpretation of BIA-reported volume status in patients with congestive heart failure or renal insufficiency. There were noticeable differences in reference ellipses with regard to gender and ethnic groups.

The predictive value of echocardiography for chronic thromboembolic pulmonary hypertension after acute pulmonary embolism in Korea

BACKGROUND/AIMS: Chronic thromboembolic pulmonary hypertension (CTEPH) is a life-threatening complication after acute pulmonary embolism (APE) and is associated with substantial morbidity and mortality. This study aimed to investigate the incidence of CTEPH after APE in Korea and to determine echocardiographic predictors of CTEPH. METHODS: Among 381 patients with APE confirmed by chest computed tomography (CT) between January 2007 and July 2013, 246 consecutive patients with available echocardiographic data were enrolled in this study. CTEPH was defined as a persistent right ventricular systolic pressure (RVSP) greater than 35 mmHg on echocardiography during follow-up and persistent pulmonary embolism on the follow-up CT. RESULTS: Fifteen patients (6.1%) had CTEPH. The rate of right ventricular (RV) dilatation (66.7% vs. 28.1%, p = 0.002) and the RVSP (75.5 mmHg vs. 39.0 mmHg, p < 0.001) were significantly higher in the CTEPH group. D-dimers, RV dilatation, RV hypertrophy, RVSP, and intermediate-risk APE were associated with the risk of CTEPH after APE (odds ratio [OR] 0.59, 5.11, 7.82, 1.06, and 4.86, respectively) on univariate analysis. RVSP remained as a significant predictor of CTEPH on multivariate analysis (OR, 1.056; 95% confidence interval, 1.006 to 1.109; p = 0.029). CONCLUSIONS: This study showed that the incidence of CTEPH after APE in Korea was 6.1% and that initial RVSP by echocardiography was a strong prognostic factor for CTEPH.

Safety and Efficacy of an Aortic Arch Stent Graft with Window-Shaped Fenestration for Supra-Aortic Arch Vessels: an Experimental Study in Swine

BACKGROUND AND OBJECTIVES: Thoracic endovascular aortic repair exhibits limitations in cases where the aortic pathology involves the aortic arch. We had already developed a fenestrated aortic stent graft (FASG) with a preloaded catheter for aortic pathology involving the aortic arch. FASG was suitable for elective cases. MATERIALS AND METHODS: An aortic arch stent graft with a window-shaped fenestration (FASG-W) for supra-aortic arch vessels is suitable for emergent cases. This study aims to test a FASG-W for supra-aortic arch vessels and to perform a preclinical study in swine to evaluate the safety and efficacy of this device. Six FASG-Ws with 1 preloaded catheter were advanced through the iliac artery in 6 swine. The presence of endoleak and the patency and deformity of the grafts were examined with computed tomography (CT) at 4 weeks postoperatively. A postmortem examination was performed at 8 weeks. The mean procedure time for FASG-W was 27.15±4.02 minutes. The mean time for the selection of the right carotid artery was 5.72±0.72 minutes. RESULTS: Major adverse events were not observed in any of the 6 pigs who survived for 8 weeks. For the FASG-W, no endoleaks, no disconnection, and no occlusion of the stent grafts were observed in the CT findings or the postmortem gross findings. CONCLUSION: The procedure with the FASG-W was able to be performed safely in a relatively short procedure time and involved an easy technique. The FASG-W was found to be safe and convenient for use in this preclinical study of swine.

Effect of n-3 Polyunsaturated Fatty Acids on Regression of Coronary Atherosclerosis in Statin Treated Patients Undergoing Percutaneous Coronary Intervention

BACKGROUND AND OBJECTIVES: Statins remain the mainstay of secondary coronary artery disease (CAD) prevention, but n-3 polyunsaturated fatty acids (ω-3 PUFA) display biological effects that may also reduce the risk of atherosclerosis and CAD. However, data on the possible antiatherosclerotic benefits of adding ω-3 PUFA to statin therapy are limited. This study aimed to investigate the potential additive effects of ω-3 PUFA on regression of atherosclerosis in CAD patients receiving statin therapy and stent implantation. SUBJECTS AND METHODS: Seventy-four CAD patients undergoing percutaneous coronary intervention (PCI) with stent implantation were enrolled, prescribed statins, and randomly assigned to two groups: n-3 group (ω-3 PUFA 3 g/day, n=38) or placebo group (placebo, n=36). All patients completed the study follow-up consisting of an intravascular ultrasound at baseline and at 12 months. RESULTS: There was no difference in the baseline characteristics and distribution of other medications. No significant differences were observed in primary endpoints, including changes in atheroma volume index (-12.65% vs. -8.51%, p=0.768) and percent atheroma volume (-4.36% vs. -9.98%, p=0.526), and in secondary endpoints including a change in neointimal volume index (7.84 vs. 4.94 mm3/mm, p=0.087). CONCLUSION: ω-3 PUFA had no definite additional effect on the regression of coronary atherosclerosis when added to statin in CAD patients undergoing PCI.

Percutaneous Cardiopulmonary Support Experience of a National University Hospital in Busan / 고신대학교의과대학학술지

OBJECTIVES: Cardiopulmonary support has been used to treat the patients with refractory cardiogenic shock since 1950s. In advent of portable system its use has been widened considerably. In this retrospective study, we report our single center experience concerning possible indications, complications and outcomes of percutanous cardiopulmonary support (PCPS). METHODS: From January 2013 to March 2014, we searched the patients who were supported by PCPS system by reviewing the medical records in cardiology department at our Hospital. Infectious organism was limited to what was identified within 2 weeks after weaning of PCPS. RESULTS: A total of 9 patients were supported by PCPS with CAPIOX CX(R) system (Terumo inc., Tokyo, Japan) initially for ST-segment elevation myocardial infarction/non ST-segment elevation myocardial infarction in 4 patients, myocarditis in 3 patients, valvular heart disease in 1 patient, and acute respiratory distress syndrome in 1 patient. The mean duration of PCPS support was 79.1+/-76.6 hours and 5 of them were recovered and discharged alive. All the patients needed transfusions of various forms of blood products. And there was one major stroke and one hyperbilirubinemia in related to PCPS treatment. CONCLUSIONS: PCPS treatment was a valuable means to treat the patients with cardiovascular collapse, but not without costs. Efforts to reduce its associated complications should be made to improve outcomes.

Effects of Intracoronary Administration of Autologous Adipose Tissue-Derived Stem Cells on Acute Myocardial Infarction in a Porcine Model

PURPOSE: Adipose-derived stem cells (ADSCs) are known to be potentially effective in regeneration of damaged tissue. We aimed to assess the effectiveness of intracoronary administration of ADSCs in reducing the infarction area and improving function after acute transmural myocardial infarction (MI) in a porcine model. MATERIALS AND METHODS: ADSCs were obtained from each pig's abdominal subcutaneous fat tissue by simple liposuction. After 3 passages of 14-days culture, 2 million ADSCs were injected into the coronary artery 30 min after acute transmural MI. At baseline and 4 weeks after the ADSC injection, 99mTc methoxyisobutylisonitrile-single photon emission computed tomography (MIBISPECT) was performed to evaluate the left ventricular volume, left ventricular ejection fraction (LVEF; %), and perfusion defects as well as the myocardial salvage (%) and salvage index. At 4 weeks, each pig was sacrificed, and the heart was extracted and dissected. Gross and microscopic analyses with specific immunohistochemistry staining were then performed. RESULTS: Analysis showed improvement in the perfusion defect, but not in the LVEF in the ADSC group (n=14), compared with the control group (n=14) (perfusion defect, -13.0+/-10.0 vs. -2.6+/-12.0, p=0.019; LVEF, -8.0+/-15.4 vs. -15.9+/-14.8, p=0.181). There was a tendency of reducing left ventricular volume in ADSC group. The ADSCs identified by stromal cell-derived factor-1 (SDF-1) staining were well co-localized by von Willebrand factor and Troponin T staining. CONCLUSION: Intracoronary injection of cultured ADSCs improved myocardial perfusion in this porcine acute transmural MI model.

Cardiogenic Shock in a Patient with Intermediate Coronary Artery Disease due to Preoperative Spasm / 대한구급학회지

The best management strategy for angiographically intermediated coronary artery diseases remains controversial. Lesions, when coupled with spasm, can lead to catastrophic results and cardiogenic shock. We report a case of a 62-year-old man who had an intermediate coronary artery disease presenting with cardiogenic shock due to coronary spasm during a preoperative period.

Percutaneous Retrieval and Redeployment of an Atrial Septal Occluder under Three-Dimensional Transesophageal Echocardiographic Guidance: A Case Report

Percutaneous device closure for secundum atrial septal defects (ASDs) has been performed commonly and safely with high success rates. However, it is still challenging to close ASDs that are surrounded with deficient or hypermobile rims and could be compromised with an unexpected migration of device. We report a case of percutaneous Amplazter Septal Occluder (ASO; St. Jude Medical Inc., St. Paul, Minnesota, USA) device closure for an ASD with a thin and floppy interatrial septum, which immediately migrated into the right atrium and was not pulled back into the delivery sheath. To our knowledge, this is the first report on a successful percutaneous retrieval and redeployment of the device in such a situation, preventing any vascular injury or unplanned emergency open heart surgery.

Full recovery two months after therapeutic hypothermia following cardiopulmonary resuscitation in a patient with out-of-hospital cardiac arrest

Neurologic impairments are very common among patients who get a recovery of spontaneous circulation after suffering from out-of-hospital cardiac arrest. Therapeutic hypothermia is established as a standardized therapeutic strategy for those patients in whom it decreases mortality rate and improves neurologic outcome. Herein, we report a case of patient who experienced out-of-hospital cardiac arrest with ischaemic heart disease and ventricular arrhythmia and got a full recovery without any neurologic impediments 2 months after being managed with therapeutic hypothermia

The Relationship between Microcirculatory Resistance and Fractional Flow Reserve in Patients with Acute Myocardial Infarction

BACKGROUND AND OBJECTIVES: It was demonstrated that the fractional flow reserve (FFR) with partial balloon obstruction may have implications for assessing viable myocardium. In a different way, the index of microcirculatory resistance (IMR) was introduced as a useful indicator for assessing microvascular function. We evaluated the relationship between the FFR0.8 and the IMR. SUBJECTS AND METHODS: We studied 48 consecutive patients who had undergone coronary intervention for acute myocardial infarction (AMI). After revascularization using stent(s), an undersized short balloon was positioned inside the stent and inflated to create a specific normalized pressure drop of FFR (distal coronary/aortic pressure=0.80) at rest. The FFR0.8 was obtained during hyperemia with the fixed state balloon-induced partial obstruction. IMR was measured by three injections of saline. The association between the FFR0.8 and the IMR was investigated. RESULTS: The mean age of the patients was 60+/-12 years and 36 (75%) overall presented with ST-segment elevation myocardial infarction. The mean FFR0.8 was 0.68+/-0.06. A statistically significant correlation between the FFR0.8 and the log-transformed IMR(true) (LnIMR(true)) was found through a multivariable linear regression analysis (beta=0.056, p<0.001). Both the FFR0.8 and the LnIMR(true) had a positive correlation with the log-transformed peak troponin I (TnI) with statistical significance (r2=0.119, p=0.017; r2=0.225, p=0.006, respectively). CONCLUSION: There was a positive correlation between the LnIMR(true) and the FFR0.8. Both of the values were associated with peak TnI. Those values may be used as appropriate surrogate measures of microvascular function after AMI.

Effects of Low Dose Pioglitazone on Restenosis and Coronary Atherosclerosis in Diabetic Patients Undergoing Drug Eluting Stent Implantation

PURPOSE: Thiazolidinediones are insulin-sensitizing agents that reduce neointimal proliferation and the adverse clinical outcomes associated with percutaneous coronary intervention (PCI) in patients with diabetes mellitus (DM). There is little data on whether or not low dose pioglitazone reduces adverse clinical outcomes. MATERIALS AND METHODS: The study population included 121 DM patients with coronary artery disease and they were randomly assigned to 60 patients taking 15 mg of pioglitazone daily in addition to their diabetic medications and 61 patients with placebo after the index procedure with drug-eluting stents (DESs). The primary end points were rate of in-stent restenosis (ISR) and change in atheroma volume and in-stent neointimal volume. The secondary end points were all-cause death, myocardial infarction (MI), stent thrombosis and re-PCI. RESULTS: There were no statistical differences in the clinical outcomes and the rate of ISR between the two groups [all-cause death; n=0 (0%) in the pioglitazone group vs. n=1 (1.6%) in the control group, p=0.504, MI; n=2 (3.3%) vs. n=1 (1.6%), p=0.465, re-PCI; n=6 (10.0%) vs. n=6 (9.8%), p=0.652, ISR; n=4 (9.3%) vs. n=4 (7.5%), p=1.000, respectively]. There were no differences in changes in neointimal volume, percent neointimal volume, total plaque volume and percent plaque volume between the two groups on intravascular ultrasonography (IVUS) study. CONCLUSION: Our study demonstrated that low dose pioglitazone does not reduce rate of ISR, neointimal volume nor atheroma volume in DM patients who have undergone PCI with DESs, despite the limitations of the study.

Hemodynamic Significance of Coronary Cameral Fistula Assessed by Fractional Flow Reserve

Coronary cameral fistula (CCF) is a rare anomaly, where a communication exists between an epicardial coronary artery and a cardiac chamber. Assessing the hemodynamic significance of the fistula is crucial to make a decision concerning the management process. We present two cases of CCF, draining into the left ventricle, in which the hemodynamic significance was assessed by a fractional flow reserve.

Risk factors for reflow disturbance phenomenon during percutaneous coronary intervention in patients with acute myocardial infarction / 대한내과학회지

BACKGROUND/AIMS: The reflow disturbance phenomenon is associated with poor functional and clinical outcomes for patients suffering with acute myocardial infarction (AMI). In the era of primary coronary intervention (PCI), accurately identifying those lesions that are at a high risk of no-reflow is of crucial importance. Therefore, we investigated the risk factors of the reflow disturbance phenomenon in AMI patients who underwent PCI. METHODS: From February 2003 to June 2005, the clinical and angiographic characteristics of 475 patients who had undergone PCI were reviewed retrospectively. RESULTS: 65 patients (13.7%) showed the reflow disturbance phenomenon and the reperfusion times of the reflow disturbance group ranged from 1 hour to 142 hours. On univariate analysis, an older age (p<0.001), low systolic blood pressure (p=0.01), no thrombolysis followed by PCI (p<0.001), primary PCI (p<0.001), less time to PCI (p=0.001), a high peak serum CK-MB level (p=0.013), angiographically visible thrombus (p=0.016), a low pre-TIMI grade (p=0.021) and ST segment elevation on the ECG (p=0.002) were the significant risk factors of the reflow disturbance phenomenon. An older age, a low systolic BP and angiographically visible thrombus were significant risk factors on multivariate analysis. CONCLUSION: An older age, low systolic blood pressure and angiographically visible thrombus were the independent risk factors for the reflow disturbance phenonmenon in AMI patients who undergo PCI.

A Comparison of Tissue Doppler Echocardiography and B-Type Natriuretic Peptide in Estimating Pulmonary Capillary Wedge Pressure

BACKGROUND: There are several echocardiographic parameters, such as early transmitral velocity/tissue Doppler mitral annular early diastolic velocity(E/Ea) or deceleration time, reported to be reliable indices to estimate pulmonary capillary wedge pressure(PCWP). Recently, B-type natriuretic peptide(BNP) level is also reported to increase in accordance with increased left ventricular filling pressure in systolic or diastolic heart failure. This study was performed to compare E/Ea and BNP for the ability to estimate PCWP. METHODS: Several echocardiographic Doppler parameters including especially E/Ea were obtained from transthoracic Doppler echocardiography. Simultaneously, serum BNP level and PCWP estimated by using Swan-Ganz catheter were obtained, respectively. RESULTS: E/Ea revealed a correlation of r=0.88 (p or =11 was the optimal cutoff to predict PCWP > or =15 mmHg (sensitivity, 94%; specificity, 90%), whereas the optimal BNP cutoff was > or =250 pg/mL (sensitivity, 52%; specificity, 74%). CONCLUSION: Mitral E/Ea has a better correlation with PCWP than BNP. Mitral E/Ea appears more sensitive and specific than BNP for PCWP > or =15 mmHg in cardiac patients.

A Case of Common Bile Duct Stone Caused by Foreign Body in Patient with Adenoma of the Ampulla of Vater / 대한소화기내시경학회지

Choledocholithiasis caused by a foreign body is rare. The most common type of foreign body in the common bile duct is a residual object from previous surgery such as a metal clip or suture material. Foreign body may enter the biliary system after choledochointestinal anastomosis or endoscopic sphincterotomy. Rarely, penetrating missile fragment or gunshot shrapnel account for another type of foreign body. We experienced a case of common bile duct (CBD) stone caused by foreign meterial in 75-years-old women who had a plant foreign body in the common bile duct. She had no past history of abdominal surgery or penetrating trauma. The foreign body and stone were successfully extracted with Dormia basket after the endoscopic sphincterotomy.

Causes of elevated cardiac troponin I in patients with normal coronary angiogram / 대한내과학회지

BACKGROUND: Cardiac troponin I (cTnI) is most recently described and has nearly absolute myocardial tissue specificity, as well as high sensitivity. But an increased value for cTnI that indicates myocardial injury is not always synonym of myocardial infarction or ischemia due to coronary artery disease. METHODS: Retrospective follow-up study for whom underwent coronary angiography for suspected coronary artery disease was done if they had an elevated cTnI value and angiographically normal or minimal disease. RESULTS: 33 patients were qualified. Cut-off value for elevated cTnI was 0.06 ng/mL. Increased cTnI values were attributed to severe congestive heart failure in 7 patients, variant angina in 7 patients, myocarditis in 5 patients, pericarditis in 1 patient, severe myocardial bridge in 1 patient, rhabdomyolysis in 1 patient and cerebral infarction in 1 patient. Tachycardia was precipitating cause in 4 patients (sinus tachycardia, paroxysmal supraventricular tachycardia, paroxysmal atrial fibrillation and sustained ventricular tachycardia for each), two of whom had hemodynamic compromise. 2 of 33 patients had no identifiable cause for a rise in cTnI value. There was no acute myocardial infarction at 42+/-34 weeks follow-up. CONCLUSIONS: Although cTnI is a sensitive and specific marker of myocardial injury, an elevation of cTnI value may have a cause other than myocardial infarction or ischemia and may occur without significant angiographic coronary artery disease.

A Case of Kikuchi's disease accompanied by Hemophagocytic Lymphohistiocytosis

Kikuchi's disease usually occurs in young women and is characterized by localized lymphadenitis (mostly cervical) usually associated with fever. It is considered a self-limited disease and most patients recover spontaneously within a few weeks to 6 months without any serious sequelae. However, patients with Kikuchi's disease require a systemic survey and regular follow-up for several years because it may be associated with other diseases such as systemic lupus erythematosus. To our knowledge, there are very few reports of Kikuchi's disease accompanied by hemophagocytic lymphohistiocytosis. Biopsy of a right cervical lymph node in a 35-year-old female who presented with fever and masses in the right cervical region showed necrotizing lymphadenitis and a diagnosis of Kikuchi's disease was reached. She was started on methylprednisolone pulse therapy (500 mg for 3 days) but developed generalized rash and fever. Laboratory data showed pancytopenia, elevation of serum transaminase and ferritin levels. Bone marrow and liver biopsy showed proliferation of histiocytes and Kupffer's cells engulfing lymphocytes, platelets and red blood cells, respectively. We report a case of Kikuchi's disease accompanied by hemophagocytic lymphohistiocytosis.