Transradial versus transfemoral intervention in ST-segment elevation myocardial infarction patients in Korean population

BACKGROUND/AIMS: Transradial intervention (TRI) is becoming the preferred method over transfemoral intervention (TFI) because TRI is associated with lower incidence of major bleeding and vascular complications. However, there has been limited published data regarding the clinical outcomes of TRI versus TFI in Korean patients with ST-elevation myocardial infarction (STEMI). METHODS: A total of 689 consecutive STEMI patients who underwent primary percutaneous coronary intervention (PCI) with drug-eluting stents (DESs) from January to December of 2009 at nine university hospitals were enrolled in this study. Mid-term angiographic and 12-month cumulative clinical outcomes of the TRI group (n = 220, 31.9%) were compared to those of the TFI group (n = 469, 28.1%). RESULTS: After propensity score matching, in-hospital complications and the 12-month major clinical outcomes during follow-up in the two groups were similar to each other. However, the incidence rates of repeat revascularization (6.4% vs. 0.5%, p = 0.003), target vessel revascularization (6.4% vs. 0.5%, p = 0.003), and major adverse cardiac events (MACE; 11.6% vs. 4.6%, p = 0.018) in the TFI group were higher than those in the TRI group during the 12-month of follow-up. CONCLUSIONS: In our study, TRI in STEMI patients undergoing primary PCI with DESs was associated with lower incidence of access site hematoma, 12-month repeat revascularization, and MACE compared to TFI. Therefore, TRI might play an important role in reducing bleeding complications while improving major clinical outcomes in STEMI patients undergoing primary PCI with DESs.

Usefulness of B-type Natriuretic Peptide in Congestive Heart Failure

BACKGROUND AND OBJECTIVES: B-type natriuretic peptide (BNP) is released from the cardiac ventricles in response to increased wall tension. Early diagnosis of congestive heart failure (CHF) and assessment of the left ventricular end diastolic pressure (LVEDP) are thought to be important in the diagnosis, treatment and follow up of patients with CHF. SUBJECTS AND METHODS: Between March, 2002 and November, 2002, 50 patients, who were admitted for treatment and hemodynamic monitoring, were studied. For the BNP measurement, 3 to 5ml blood samples were collected into tubes containing EDTA. The BNP was measured with a fluorescence immunoassay kit (Triage, Biosite, San Diego, U.S.A.). Cardiac Catheterization was performed for the assessment of the LVEDP. RESULTS: Of the 50 subjects, 34 with CHF had a mean BNP level of 483.1+/-77.8 pg/mL, whereas those without CHF had a level of 79.2+/-24.0 pg/mL. The difference between the groups was statistically significant (p=0.005). A significant positive correlation was seen between the BNP and the LVEDP (r=0.53, p=0.001). The correlation between the BNP and the left ventricular ejection fraction (LVEF) was not statistically significant (r=-0.226, p=0.198). CONCLUSION: The plasma BNP was significantly increased in CHF, and might reflect the LVEDP. Further study will be required to see whether the BNP is a useful parameter for the staging and treatment of CHF.

Echocardiographic Indices Associated with Left Ventricular End-Diastolic Pressure

BACKGROUND AND OBJECTIVES: It has been suggested that the indices based on tissue doppler and color M-mode echocardiography reflect the left ventricular end-diastolic pressure. These include the early diastolic transmitral velocity (E) to early myocardial velocity ratio measured by tissue doppler (E') and the E to the wave propagation velocity (Vp) ratio measured from color M-mode images. However, these indices have not been well validated in congestive heart failure patients. SUBJECTS AND METHODS:Thirty one congestive heart failure patients who underwent simultaneous cardiac catheterization and echocardiography, and had normal sinus rhythm were enrolled in this study. The left ventricular end-diastolic pressure obtained from the left heart catheterization was compared with the diastolic indices using pulsed doppler, tissue doppler and color M-mode echocardiography. RESULTS: The left ventricular end-diastolic pressure (LVEDP) ranged from 3.3 to 23 mmHg. Some parameters showed a significant correlation with the LVEDP. The propagation velocity showed a significant correlation with the LVEDP (r=0.382, p=0.034), and the E to propagation velocity ratio (E/Vp) showed a good correlation with the LVEDP(r=0.408, p=0.023). In addition, the E to early diastolic velocity of the mitral annulus (E') ratio had an insignificant correlation with the LVEDP(r=0.322, p=0.078). Among the patients with ischemic congestive heart failure, the E to the propagation velocity ratio (E/Vp) showed a marginal correlation with the LVEDP (r=0.461, p=0.047). CONCLUSION: In patients with congestive heart failure, the Vp and E/Vp showed a good correlation with the LVEDP. In the subgroup of patients with ischemic congestive heart failure, only the E/Vp showed a significant correlation with the LVEDP.

Apolipoprotein E Polymorphism in Patients with Myocardial Infarction

BACKGROUND AND OBJECTIVES: In this study we investigated the association between the polymorphism of apolipoprotein E and the development of myocardial infarction, and assessed whether this polymorphism produces any changes of plasma lipid level. SUBJECTS AND METHODS: A total of 182 patients participated in this study and were divided into two groups; 91 patients with myocardial infarction (MI group) and 91 patients with no known heart disease (control group). For both groups we analyzed the clinical parameters, the changes of plasma lipid level and the degree of polymorphism of apolipoprotein E. RESULTS: Total cholesterol, triglyceride and LDL cholesterol levels were significantly higher in the MI group, while the HDL cholesterol level was significantly lower. Compared with the control group, the frequency of epsilon2 allele was significantly lower while that of epsilon3 allele was significantly higher in the MI group. As for the control group, the triglyceride level was significantly higher in the patients with epsilon 2 allele than in those without epsilon 2 allele, and the total cholesterol level was significantly higher in the patients with epsilon 4 allele than in those without epsilon 4 allele. In the MI group, the plasma lipid levels were not significantly different from those in the control group. CONCLUSION: We suggested that apolipoprotein E polymorphism could affect the lipid metabolism as well as the development of myocardial infarction. However further study is needed in patients with myocardial infarction.

Incidence of coronary anomaly in coronary angiography / 대한내과학회지

BACKGROUND: Coronary anomalies are found incidentally, in which anatomy is altered but physiology is normal; that is, coronary blood flow is normal. However, certain anomalies are associated with myocardial ischemia or infarction, heart failure, and sudden death. METHODS: From February 1988 to February 2000, 3534 cases have been catheterized, among them we experienced 28 cases of coronary anomalies. The incidence of coronary anonalies and clinical characteristic were evaluated. RESULTS: The incidence of coronary anomalies was 0.79% and in 28 cases of coronary anomalies, 5 cases of anomalous origin from the aorta (0.14%), 2 cases of coronary artery aneurysm (0.16%) and 21 cases of coronary arteriovenous fistula (CAVF,0.59%) were found. In 5 cases of anomalous origin from the aorta, 4 cases showed that right coronary artery originated from left coronary sinus of Valsalva, 1 case showed that left circumflex coronary artery originated from right coronary sinus of Valsalva. All of coronary artery aneurysm were found in right coronary artery. In 21 cases of CAVF, 28 sites of fistula were found and 14 sites originated from right coronary artery (50%), 6 sites from left circumflex coronary altery (21.5%), 6 sites from left anterior-descending coronary artery, 2 sites from left main coronary artery (7%). 13 sites of CAVF drained into pulmonary artery (46%), 10 sites into right atrium (36%), 5 sites into right ventricle (18%). In 7 cases which had double CAVF, 4 cases were originated from bilateral coronary artery, 3 cases were originated from single coronary artery. In 10 cases CAVF without other cardiac lesion, 4 cases confirmed ischemic heart disease. CONCLUSION: In our study, CAVF is most common coronary anomaly and without other cardiac disease CAVF may develope ischemic cardiac disease.

Incidence of coronary anomaly in coronary angiography / 대한내과학회지

BACKGROUND: Coronary anomalies are found incidentally, in which anatomy is altered but physiology is normal; that is, coronary blood flow is normal. However, certain anomalies are associated with myocardial ischemia or infarction, heart failure, and sudden death. METHODS: From February 1988 to February 2000, 3534 cases have been catheterized, among them we experienced 28 cases of coronary anomalies. The incidence of coronary anonalies and clinical characteristic were evaluated. RESULTS: The incidence of coronary anomalies was 0.79% and in 28 cases of coronary anomalies, 5 cases of anomalous origin from the aorta (0.14%), 2 cases of coronary artery aneurysm (0.16%) and 21 cases of coronary arteriovenous fistula (CAVF,0.59%) were found. In 5 cases of anomalous origin from the aorta, 4 cases showed that right coronary artery originated from left coronary sinus of Valsalva, 1 case showed that left circumflex coronary artery originated from right coronary sinus of Valsalva. All of coronary artery aneurysm were found in right coronary artery. In 21 cases of CAVF, 28 sites of fistula were found and 14 sites originated from right coronary artery (50%), 6 sites from left circumflex coronary altery (21.5%), 6 sites from left anterior-descending coronary artery, 2 sites from left main coronary artery (7%). 13 sites of CAVF drained into pulmonary artery (46%), 10 sites into right atrium (36%), 5 sites into right ventricle (18%). In 7 cases which had double CAVF, 4 cases were originated from bilateral coronary artery, 3 cases were originated from single coronary artery. In 10 cases CAVF without other cardiac lesion, 4 cases confirmed ischemic heart disease. CONCLUSION: In our study, CAVF is most common coronary anomaly and without other cardiac disease CAVF may develope ischemic cardiac disease.

A Clinical Study of Adult Aortic Stenosis Treated with Aortic Valve Replacement

BACKGROUND: Significant aortic stenosis of various underlying etiologies presents with similar clinical characteristics and is usually treated with aortic valve replacement. We performed a clinical study to evaluate the clinical characteristics, changes of echocardiographic parameters before and after aortic valve replacement in adult aortic stenosis patients. METHODS: From January 1991 through December 1995, 159 patients underwent aortic valve replacement at Sejong General Hospital. Sixty-two cases(39%) of those patients were pure or predominant aortic stenosis. We observed the clinical characteristics, etiology, operative procedure, perioperative complication and mortality, And we observed the changes of echocardiographic parameters such as mean and peak pressure gradients at aortic valve, ejection fraction, systolic and diastolic left ventricular internal dimensions, left ventricular wall thickness, left ventricular mass index retospectively at preoperative and postoperative periods regularly within 1 month, 1 yr, 3 yrs after operation(mean follow up period : 16 months, 1-36 months). RESULTS: 1) The age of patients ranged from 31 to 71 years(mean 55+/-11), and 60%(37 cases) of them were men. 2) Regarding underlying heart disease, the most common etiology of aortic stenosis was rheumatic valvular heart disease(32 cases, 52%), followed by congenital bicuspid aortic valve(16 cases, 25%) and degenerative change(14 cases,23%). 3) 44 cases(77%) of the patients had dyspnea,12 cases(19%) had chest pain, and 5 cases(8%) had history of syncope at the time of operation. Asymptomatic patient was only 1 case. 4) Seven patients(11%) had associated coronary artery disease, and only 1 case(about 2%) underwent concomitant coronary bypass surgery. 5) Post-operative complications which developed within 1 month were bleedings(8 cases, 13%), arrhythmias(7 cases, 11%) and infections(4 cases, 6%). After 1 month, bleedings related with anticoagulation were most common(7 cases, 11%). Other complications were hemolytic anemia(1 case), and aortic dissection(1 case). There was one surgery related mortality(2%) which happened during operatin due to myocardial ischemia. 6) The size of implanted prosthetic valves ranged from 19 to 25mm(mean 22+/-2mm). Larger valves(23-25mm) showed lower peak(p=0.839) and mean pressure gradients(p=0.019) than smaller valves(19-21mm). 7) We observed that peak and mean pressure gradient, left ventricular internal dimension, and left ventricular mass index had decreased significantly after aortic valve replacement. 8) The average preoperative functional class(2.3) had improved significantly at 1 month after surgery(1.2), and 1 year after surgery(1.0). CONCLUSIONS: In our series, the most common etiology of aortic stenosis was rheumatic valvular disease(52%). The incidence of combined coronary artery disease was 11%, lower than other reports. And only 1 case(2%) underwent concomitant coronary artey bypass graft surgery. The average size of implanted valves was 22mm, and the larger size had lower transaortic peak and mean pressure gradients after operation. The most common perioperative complication was bleeding and mortality rate was about 2%. Echocardiography was useful for evaluation of postoperative changes, such as transaortic peak and mean pressure gradient, left ventricular internal dimension and left ventricular mass index.

A Case of Congenital Coronary Arteriovenous Fistula Presented as Congestive Heart Failure and Aortic Valve Infective Endocarditis

A 43-year-old female patient with a congenital right coronary artery to right atrial fistula presented as congestive heart failure and aortic valve infective endocarditis. The diagnosis was made on the basis of echocardiography, especially TEE and confirmed by tight heart catheterization & aortography. She underwent aortic valve replacement due to severe aortic valve regurgitation with vegetations, fistulectomy and coronary aneurysmorrhaphy. The postoperative course was uneventful. She was treated with antibiotics because of infective endocarditis for 6 weeks. At present she remains well and visits out patient clinic regularly for oral anticoagulation without problem.