Clinical and Echocardiographic Changes after Short-Term Denopamine (Cardopamin(R)) Therapy in Patients with Chronic Congestive Heart Failure

BACKGROUND: Inotropic agents have been shown to improve cardiac function in patients with congestive heart failure. The purpose of the present study is to evaluate the short-term efficacy and safety of denopamine(Cardopamin(R)), and orally available beta-stimulant, in patients with chronic congestive heart failure. SUBJECTS AND METHODS: Twenty-four patients(54.1+/-10.9 years, male:female=1.4:1) with chronic congestive heart failure whose functional classes were equal or greater than New York Heart Association(NYHA) Class II were enrolled in this study after informed consents were obtained. Upon completion of baseline evaluation, denopamine(Cardopamin(R)) was administered orally, startion with 15 mg per day and increased to 30 mg per day according to the clinical response of each patient. Blood pressure, heart rate, electrocardiographic(EKG) findings, AST, BUN, and creatinine were also followed up at 4 weeks' interval. The clinical effects and side effects at 4 weeks' interbal and echocardiographic examination at baseline and 8 weeks after trentment were evaluated. RESULTS: Mean dosage of denopamine(Cardopamin(R)) was 22.9+/-5.3mg per day. The clinical symptoms of 18(75%) of 24 patients were improved. The echocardiographic follow-up revealed a significant decrease in left vetricular(LV) end-Systolic dimemsion(fron 4.8+/-0.2mm to 4.5+/-0.1mm. p<0.005) and LV end-systolic volume(from 92.0+/-8.5ml to 80.3+/-4.5ml, p<0.005). However, there was no significant interval change in LV end-diastolic dimension, LV end-diastolic volume, ejection fraction, and fractional shortening. Blood pressure, heart rate, EKG findings, AST, BUN, and creatinine were not changed significantly during treatment. CONCLUSION: Above results suggest that short-term therapy of denopamine(Cardopamin(R)) may improve clinical symptom with no side effect in patients with chronic congestive heart failure, but the long-term efficacy remains to be determined with a randomized long-term follow up study.

Clinical Experiences of Long-Balloon Percutaneous Transluminal Coronary Angioplasty

BACKGROUND: The lesion length of coronary artery stenosis has been regarded as a risk factor for acute complication and long segment stenosis of the coronary artery is associated with a less chance of successful percutaneous transluminal coronary angioplasty(PTCA). Many new interventional techniques auch as excimer laser angioplasty, directional atherectomy, and long-balloon angioplasty catheter have been developed and used for long lesion of coronary artery stenosis. Only a little data is, however, available on long-balloon PTCA. This study was carried out to see the clinical results of PTCA using long-balloon angioplasty catheters. SUBJECTS AND METHODS: Fifty-four coronary arterial stenotic lesions in 49 patients(M:F=32:17, 54.48.9 years)were attempted to dilate with long-balloon PTCA. Clinical diagnoses in 49 patients were acute myocardial infarction in 13, old myocardial infarction in 9, unstable angina in 18, andd stable angina in 9. Lesion length and TIMI(Thrombolysis in Myocardial Infarction) flow of target lesions were measured before PTCA. PTCA was performed in standard fashion using long-balloon angioplasty catheters. Immediate success rate, complications, and retenosis rate were evaluated. RESULTS: The associated risk factors of atherosclerosis were hypertension in 16, hypercholesterolemia in 10, smoking in 27, and diabetes mellitus in 9 patients. The target vessels were 34 left anterior descending arteries, 6 left circumflex arteries, and 14 right coronary arteries. PTCA using long-balloon catheters was performed as an adjunct to suboptimal PTCA using standard balloon catheters in 6 patients. In the remaining 44 patients, long-balloon PTCA was primarily performed due to lesion length greater than 2.0 cm. The overall success rate of long-balloon PTCA was 85.2%, and the procedure-related complications were occurred in 12(22.2%) lesions. Restenosis was revealed in 9(50%) of 18 lesions which were evaluated with follow-up coronary angiography. CONCLUSION: Above results suggest that PTCA using a long-balloon angioplasty catheter is efficacious in dilation long segment stenosis of coronary artery with a low complication rate.

A Study of Plasma Apolipoprotein A-1 and Apolipoprotein B Levels in Patients with Coronary Artery Disease

BACKGROUND: It is known that dyslipidemia plays and important role in atherogenesis and progression for the disease. Recently it was reported that apolipoprotein levels are important in athcrogenesis. In Korean patients the study of the apolipoprotein levels as for the risk factor for atherogenesis is still needed. Subjects and METHODS: The 107 patients who underwent coronary angiography to differentiate chest pain syndrome were subjected to this study. Thirty-two patients who had no significant coronary artery disease served as a control group and 75 patients who had one or more coronary stenoses more than 50% narrowing by luminal diameter served as the coronary artery disease(CAD) group. Plasma levels of total cholesterol, triglycerides, high density lipoprotein cholestero(HDL-C), apolipoprotein A-1(Apo- A1) and apolipoprotein B(Apo B) were measured from venous blood after overnight fastion, and the results were compared between the groups. RESULTS: The male gender and smoking habits were more prevalent in the CAD group. Total cholesterol levels were significantly higher in the CAD group but the HDL-C level was not significantly different in two groups though the mean level of the HDL-C was some lower in the CAD group. The Apo A-1 level was lowere in the CAD group while the Apo B level was higher in teh CAD group compared to those of the control, Apo B / Apo A-1 ratio much more distinctly discriminated the two groups. CONCLUSION: Theses results suggest that the plasma Apo-A-1, Apo B levels and the ratio of Apo B / Apo A-1 can be used for risk statification of CAD.

2 Cases of Apical Hypertrophic Cardiomyopathy with Left Ventricular Endomyocardial Calcification

Calcification of myocardium is most common in the site of an old infarction or in an aneurysmal wall. In addition, Myocardial calcification may occur in association with endomyocardial fibrosis and hyperparathyroidism, as a result of focal toxic or inflammatory myocardial necrosis, as well as in patients undergoing hemodialysis. Calcium deposits due to parasites and due to neoplastic disease may also be seen, But, left ventricular endomyocardial calcification associated with apical hypertrophic cardiomyopathy is very rare. This report describes 2 cases of apical hypertrophic cardiomyopathy with left ventricular endomyocardial calcification, diagnosed by the echocardiographic, angiographic and histologic findings.

Antioxidant Action of Transthyretin in Human Cerebrospinal Fluid

Protective effect of human cerebrospinal fluid antioxidants against enzyme inactivation caused by metal-catalyzed oxidation systems were investigated. When purified glutamine synthetase(GS) was incubated with human cerebrospinal fluid(CSF), the enzyme was progressively inactivated. Catalase and EDTA could inhibit the enzyme inactivation by 50-80%. Small-molecular(Mr-10,000) fraction did not. The GS inactivation by the small-molecular fraction was also markedly inhibited by catalase and EDTA. These results suggested that metal-catalyzed oxidation is involved in the GS inactivation by the small-molecular fraction of CSF. Dithiothreitol(DTT)was shown to inhibit almost completely the oxidative inactivation of GS by CSF. However, DTT inhibited only partially the oxidative inactivation of GS caused by small-molecular fraction of CSF. When large-molecular fraction of CSF was separated by anion-exchange HPLC chromatography, there was a peak of antioxidant activity inhibiting the small-molecular fraction-induced GS inactivation in the presence of DTT. The antioxidant activity was neutralized by monoclonal antibodies to transthyretin. Purified transthyretin was found to efficiently inhibit ascorbate/Cu2+-induced GS inactivation in the presence of DTT. Uric acid and glucose did not shoe any protective effect on the GS inactivation in the same condition. The above results suggest that metal-catalyzed oxidation occurs normally in human CSF, and the transthyretin may play an important role as a CSF antioxidant in protecting proteins from metal-catalyzed oxidation.

Clinical Study for Coronary Artery Stenting

BACKGROUND: Coronary artery stent has been introduced recently to overcome major problems of percutaneous trausluminal coronary angioplasty(PTCA). To evaluate the success rate, complications and predictive factors associated with restenosis in coronary artery stenting, clinical analysis after coronary srtery stent was performed. METHODS: Sixteen patients who underwent coronary artery stent in Chonnam University Hospital beteen Apr. 1992 and Dec. 1993 were observed. The authors analyzed the stent dilivery success, rate complications and restenosis after follow-up coronary angiogram. RESULTS: 1) The palmaz-Schatz stents were implanted in 16 patients(12 male, 4 female, mean age : 53.3 years) and clinical diagnosis of patients were 7 myocardial infarction, 8 unstable angina and one stable angina. Stents were implanted in 10 cases of left anterior descending arteries and 6 cases of right coronary arteries. Three stents were implanted in a patient with long spiral dissection after middle right coronary artery PTCA, single stent was implanted in the other patients. 2) Stent delivery was successful in all cases, but acute stent thrombosis developed just after bail-out procedure for PTCA-induced intimal dissection in myocardial infarction patient who had multivessel lesion and intracoronary thrombus. Subacute stent thrombosis and major bleeding requiring transfusion were not documented. 3) On follow-up coronary angiogram in 10 patients, no restenosis observed in 5 right coronary arterial stents, but restenosis developed in 3 of 5 left anterior descending artery stents. Restenosis was observed in none of 4.0mm stents, two of six 3.5mm stents and one of two 3.0mm stents. 4) Stent restenosis was observed in 3 cases of positive201TI dipyridamole scan which was performed one month after coronary artery stenting. CONCLUSION: Coronary artery stent is a safe and effective in elective procedure. The restenosis rate after intracoronary stent is lower in right coronary artery than left anterior descending artery and larger stent.

Radiofrequency Catheter Ablation of Atrioventricular Accessory Pathways : Factors Influencing the Outcome of Catheter Ablation of Accessory Pathways

BACKGROUND: Catheter ablation of accessory pathways using radiofrequency(RF) energy was recently introduced to cure accessory pathway related tachyarrhythmias. The purpose of the present study was to evaluate the efficacy and safety of radiofrequency catheter ablation of accessory pathways and to determine factors influencing the outcome of catheter ablation. METHODS: Electrophysiology study was performed with standard technique and catheter ablation of accessory pathways using RF and conventional ablation technique. The outcome of RF catheter ablation were evaluated according to the location and the overtness of accessory pathways. Eighty patients(Mean +/-SD age, 36+/-15 years ; 50 male, 30 female)comprising 49(61%) with Wolff-Parkinson-White(WPW) syndrome and 31(39%) with atrioventricular reentry tachycardia(AVRT) using concealed bypass tract underwent RF catheter ablation for total of 85 accessory pathways in the Chonnam University Hospital. Five(6.3%) patients had multiple accessory pathways. RESULTS: Seventy-nine(92.9%) out of 85 pathways and all the pathways in 75(93.8%) out of 80 patients were ablated successfully. The success rate showed no significant difference between patients with overt accessory pathways and patients with concealed accessory pathways(92.0% vs. 93.9%). However, the success rate in right free wall location(72.7% of 11) was significantly lower than that in the other sites (95.9% of 74, p<0.05). More attempts were tried to ablate right-sided accessory pathway than left-sided pathways(6.4+/-24.1 vs. 3.8+/-6.8, p<0.05). Three(3.8%) pathways recurred within 30 minutes after the initial successful ablation. Four(5.1%) pathways recurred from 16 hours to 7 months after completion of the initial successful ablation session during the mean follow-up period of 43+/-24 weeks(range, 2-84 weeks). This late recurrence was more frequent, although statistically insignificant, in right-sided accessory pathways(11.1% vs. 3.3%, p=0.22). All 4 recurrent pathways(1 at the same session, 3 at the repeated sessions) reattempted for ablation were successfully ablated. As procedure-related complications, second degree AV block developed in a patients with mid septal and posteroseptal pahways and hemopericardium in a patients with a left anterolateral pathway. CONCLUSION: RF catheter ablation of atrioventricular accessory pathways is very effective and safe, with a success rate of 93.8% and a complication rate of 2.5%. Right-sided accessory pathways are more difficult to ablate than left-sided accessory pathways, requiring the development of a better technique for right free wall pathways.

Left Ventricular Function in Patients with Angina and Normal Coronary Angiogram

BACKGROUND: Angina with normal coronary angiogram has been called syndrome X or microvascular angina, but pathophysiologic mechanisms for chest patin in this group of patients are not known exactly. To observe the changes of left ventricular function in patients with angina and normal coronary angiogram, the authors analyzed the left ventricular systolic and diastolic function with echocardiogram and cardiac catheterization. METHODS: The authors performed resting and treadmill exercise electrocardiogram, 201TI dipyridamole scan, M-mode and Doppler echocardiogram, cardiac catheterization and coronary angiogram in patients with angina and normal coronary angiogram. The systolic and diastolic left ventricular function indices from M-mode and Doppler echocardiogram, left ventricular catheterization and coronary angiogram were analyzed in 12 patients excluding diabetes, hypertension, cardiomyopathy and esophageal motility disorders among 1626 patients who underwent coronary angiogram between Jan. 1991 and Aug. 1992 in Chonnam University Hospital. RESULTS: 1) Studied subjects were 12 patients, 5 male and 7 female, mean age was 51+/-9.4 year-old. Resting electrocardiograms were normal in 8 cases and ST-T changes in 4 cases. Ischemic ST-T changes were observed in all cases during treadmill exericise test and perfusion defects in 3 cases out of 8 cases during 201TI dipyridamole scan. 2) On echocardiogram, ejection fraction(EF) was 68.9+/-4.5%, fractional shortening(FS) 37.4+/-4.4%, ratio of left atrial to aortic root dimension(LAD/AOD) 1.2+/-0.1, OR slope 3.8+/-0.8c,/sec, mitral valve Doppler E/A velocity ratio[E/A(V)] 0.9+/-0.2, mitral valve Doppler E/A area ratio[E/A(a)]1.3+/-0.3, early diastolic deceleration rate(EDDR) 4.3+/-1.3m/sec2, isovolumic relaxation time(IVRT) 96.2+/-15.7msec, isovolumic contraction time(IVCT) 38.1+/-9.1 msec and aortic valve Doppler peak flow velocity[Ao(V)] 0.8+/-0.2m/sec. EF, FS, IVCT and A(V) were normal. LAD/AOD and IVRT were increased, but E/A(V), E/A(a), OR slope and EDDR were decreased compared to normal subjects. 3) On cardiac catheterization and angiogram, mean left ventricular end-diastolic pressure was 15.3+/-5.1mmHg and ejection fraction by left ventriculogram 78.2+/-7.4%. There was no regional wall motion abnormality. CONCLUSION: Above results suggest that angina with normal coronary angiogram may be associated with impaired left ventricular diastolic function.

Predictive Factors of Restenosis after Percutaneous Transluminal Coronary Angioplasty

BACKGROUND: One of major limitations of percutaneous transluminal coronary angioplasty(PTCA) is restenosis. The reliable factors predicting restenosis after successful PTCA might be important in the prevention and treatment of coronary restenosis after PTCA. METHODS: To see whether any of the clinical, angiographic. or procedural factors is likely coronary angiography due to recurrent ischemic symptoms and positive stress tests among 529 patients recived PTCA between Jul '90 and Sep '93 at the Chonnam University Hospital were analysed. RESULTS: 1) Follow-up coronary angiogram demonstrated restenosis in 67 patient(group A, 55.1+/-10.3 year, 58 male, 9 female) and no restenosis in 27 patients(group B, 55.4+/-10.3 year, 24 male, 3 female) demonstrating restenosis rate of 60.6% in this clinically suspicious group. 2) Age, sex, class and duration of angina, and clinical diagnosis were not different from each other between two groups. But the time interval from PTCA to follow-up angiogram was shorter in group A (5.3 +/-5.2 months) than in group B(9.1+/-5.6 months) and hypertension was more prevalent in group A (83.3%) than in group B(16.7%). 3) Angiographic findings such as AHA lesion types, lesion sites, TIMI flow, angulation, lesion length, branching lesion, dissection and residual stenosis were similar in two groups. But all of the eleven lesions with coronary artery calcification were found to develop restenosis. 4) As procedural factors, total ballon inflation time, the numbers of repeated inflations and maximal inflation pressure were not significantly different between two groups. CONCLUSION: Above results show that any single or combined clinical and angiographic findings except symptoms or signs suggesting myocardial ischemia, hypertension and coronary calcification could not predict the development of coronary restenosis ie the patients with shorter duration from PTCA to the clinical evidence suggestive of myocardial ischemia, hypertension and coronary calcification demonstrated by cineangiography were more likely to develop subsequent restenosis.

Predictive Factors of Restenosis after Percutaneous Transluminal Coronary Angioplasty

BACKGROUND: One of major limitations of percutaneous transluminal coronary angioplasty(PTCA) is restenosis. The reliable factors predicting restenosis after successful PTCA might be important in the prevention and treatment of coronary restenosis after PTCA. METHODS: To see whether any of the clinical, angiographic. or procedural factors is likely coronary angiography due to recurrent ischemic symptoms and positive stress tests among 529 patients recived PTCA between Jul '90 and Sep '93 at the Chonnam University Hospital were analysed. RESULTS: 1) Follow-up coronary angiogram demonstrated restenosis in 67 patient(group A, 55.1+/-10.3 year, 58 male, 9 female) and no restenosis in 27 patients(group B, 55.4+/-10.3 year, 24 male, 3 female) demonstrating restenosis rate of 60.6% in this clinically suspicious group. 2) Age, sex, class and duration of angina, and clinical diagnosis were not different from each other between two groups. But the time interval from PTCA to follow-up angiogram was shorter in group A (5.3 +/-5.2 months) than in group B(9.1+/-5.6 months) and hypertension was more prevalent in group A (83.3%) than in group B(16.7%). 3) Angiographic findings such as AHA lesion types, lesion sites, TIMI flow, angulation, lesion length, branching lesion, dissection and residual stenosis were similar in two groups. But all of the eleven lesions with coronary artery calcification were found to develop restenosis. 4) As procedural factors, total ballon inflation time, the numbers of repeated inflations and maximal inflation pressure were not significantly different between two groups. CONCLUSION: Above results show that any single or combined clinical and angiographic findings except symptoms or signs suggesting myocardial ischemia, hypertension and coronary calcification could not predict the development of coronary restenosis ie the patients with shorter duration from PTCA to the clinical evidence suggestive of myocardial ischemia, hypertension and coronary calcification demonstrated by cineangiography were more likely to develop subsequent restenosis.