Alteration of Nitric Oxide/cyclic-GMP pathway in patients with exaggerated systolic blood pressure response during exercise test / 대한내과학회지

BACKGROUND: The diagnostic and prognostic implication of exaggerated blood pressure response to exercise has not been well characterized. Endothelial dysfunction has been demonstrated in patients with atherosclerosis or with risk factors for coronary artery disease. However, whether the cause of exercise induced hypertension might be due to endothelial dysfunction has not been well elucidated. Therefore, we designed this study to evaluate the endothelial function in patients with exaggerated blood pressure response during exercise. METHODS: Exercise hypertension is defined as a systolic blood pressure >or= 210 mmHg in men and >or= 190 mmHg in female, during treadmill exercise test. The endothelial function of the brachial artery, in 35 patients with exercise hypertension and 35 control subjects (mean age of 45.5+/-8.1) were measured by a high resolution ultrasound technique. The concentrations of nitrite and cyclic-GMP were measured from exercise hypertension group and control subjects during, before and after treadmill exercise. RESULTS: There were no significant differences in the clinical variables between the control and exercise hypertension group. The LVH on ECG was detected more frequently in exercise hypertension group (14 % vs. 40 %, p0.05), a significant difference of cyclic GMP level during the maximal exercise was noted between the groups (10+/-1.8 vs. 8.3+/-2.5 pmol/mL, p<0.05). CONCLSUION: Patients with exercise induced hypertension have impaired endothelium-dependent vasodilation. This study supports the concept that endothelial dysfunction may play a significant role in exercise induced hypertension.

Radiofrequency Catheter Ablation of Atrioventricular Nodal Re-entrant Tachycardia in a Patient with Dextrocardia Associated with Atrial Septal Defect

It is known that tachyarrhythmias in patients with congenital heart defects have a potentially high impact on quality of life, morbidity and mortality. Conventional treatment with antiarrhythmic drugs may have untoward results including recurrence of tachyarrhythmia and its adverse effects. Therefore, radiofrequency catheter ablation is increasingly used for the treatment of supraventricular tachycardias in patients with congenital heart diseases, although abnormal anatomy and atypical conduction systems have the potential to complicate catheter ablation procedures. This report describes our experience with the successful radiofrequency catheter ablation of atrio-ventricular nodal reentrant tachycardia (AVNRT) in a patient with dextrocardia with situs solitus (isolated dextrocardia).

Echocardiographic and Clinical Factors Affecting Normalization of LV Systolic Function in Patients with Cardiomyopathy

BACKGROUND: During clinical practice we found that left ventricular systolic function(LVSF) has been normalized in some patients with cardiomyopathy. We investigated the echocardiographic and clinical factors affecting normalization of LVSF in these patients. METHOD: The patients with LV systolic dysfunction(EF or =55%) in FUE were defined to Group 1(mean age 57+/-16, male 21, female 29, mean follow-up 18+/-6 month) and another consecutive 50 patients with sustained decreased LVSF(EF<40%) and no increment of EF over 10% in FUE were defined to Group 2(mean age 56+/-14, male 32, female 18, mean follow-up 20+/-6 month). RESULTS: By univariate analysis, significant factors affecting normalization of LVSF were female sex, non-smoker, first experience of dyspnea, absence of bundle branch block in ECG, end-diastolic dimension of LV(LVEDD), end-diastolic volume of LV(LVEDV), LA size, less sphericity, presence of pericardial effusion, peak and end systolic wall stress. By multivariate analysis, LVEDD(Group 1: 61+/-7, Group 2: 71+/-7mm, p<0.001), LVEDV(Group 1: 139+/-59, Group 2: 190+/-51ml, p<0.01), absence of bundle branch block in ECG and 1st attack of symptom were significant. By Receiver operating characteristics curve analysis, area under curve of LVEDD and LVEDV were 0.859(95%CI: 0.775-0.920) and 0.805(95%CI: 0.681-0.896), respectively. LVEDD< or =64mm predicted normalization of LVSF with a sensitivity 76% and a specificity 86%. CONCLUSION: Determination of cardiac dimension and volume by echocardiography is very important to predicting normalization of LV systolic function in primary myocardial disease. And this results suggest that myocardial structural integrity may be important for recovery of LV function in clinical setting.

Usefulness and Limitation of 24 Hour Reinjection Images to Assess Myocardial Viability in Patients with Acute Myocardial Infarction

OBJECTIVE: The study was performed to evaluate whether thallium reinjection (RI) distinguishes viable from nonviable myocardium among myocardial segments which showed persistent perfusion defect (PD) in patients with acute myocardial infarction (AMI). MATERIALS AND METHODS: We studied 22 patients underwent PTCA after AMI. SPECT was performed in all patients using dipyridamole stress- 4 hour redistribution (RD) followed by 24 hour RI protocols. Dysfunctional segs were classified into 5 groups: 1) normal, 2) reversible, 3) mild to moderate PD, 4) severe PD and 5) reverse redistribution (RR). All patients underwent follow up echocardiography after 4 months to assess regional wall motion (WM) improvement such as a criteria of viable myocardium. RESULTS: A total of 127 segs with abnormal WM was analyzed. Of 74 segs with PD, 17 (23%) showed enhanced uptake after 24 hour RI. Five of 17 segs (29%) with PD that responded to RI with enhanced thallium uptake showed WM improvement. WM improvement were seen in the 24 of 57 segs (42%) not responding to RI. All four segs (100%) with RR that responded to RI showed improvement. WM improvement were not seen in the 5 of 8 segs (71%) with RR not responding to thallium RI. Eleven (73%) of 15 segs with mild-moderate PD after RI showed improvement, but 33% of segs with severe PD after RI did not showed improvement. Segs with mild-moderate PD after RI and fill in after RI showed improvement in comparison to segs with severe PD after RI(p<0.05). CONCLUSIONS: These data indicate that because only small proportion of PD showed further perfusion improvement after RI and predictive value by the uptake after RI was low, there was limited role of RI after myocardial infarction. Usefulness of RI could be found in segs showing RR responding to RI in AMI reflects viable myocardium.

Intracoronary thrombosis treated with stent and abciximab in patient with membranous glomerulonephritis

The association of nephrotic syndrome with a hypercoagulable state and vascular thrombosis is well recognized. In all adult series of nephrotics, venous thrombosis are much more common than arterial thrombosis, which has been mainly reported in children. Intracoronary thrombus is among the rarest arterial thromboses. We present a case of acute myocardial infarction in a 39-year-old women with nephrotic syndrome secondary to membranous glomeluronephritis, in which subsequent coronary angiography showed no evidence of atherosclerotic change and thrombotic occlusion in the left main coronary artery which was successfully treated with intracoronary stent and intravenous abciximab.

Role of Redistribution and 24 Hour Reinjection Images to assess Myocardial Viability in Patients with Acute Myocardial Infarction / 대한핵의학회잡지

PURPOSE: We evaluated the importance of redistribution and 24 hour reinjection images in Tl-201 SPECT assessment of myocardial viability after acute myocardial infarction (AMI). MATERIALS AND METHODS: We performed dipyridamole stress-4 hour redistribution-24 hour reinjection Tl-201 SPECT in 43 patients with recent AMI (4-16 days). The myocardium was divided into 16 segments and perfusion grade was measured visually with 4 point score from 0 to 3 (absent uptake to normal uptake). A perfusion defect with stress score 2 was considered moderate. A defect was considered severe if the stress score was 0 or l (absent uptake or severe perfusion decrease). Moderate defect on stress image were considered viable and segments with severe defect were considered viable if they showed improvement of 1 score or more on redistribution or reinjection images. We compared the results of viability assess-ment in stress-redistribution and stress-reinjection images. RESULTS: On visual analysis, 344 of 688 segments (50%) had abnormal perfusion. Fifty two (15%) had moderate perfusion defects and 292 (85%) had severe perfusion defects on stress image. Of 292 severe stress defects, 53 were irreversible on redistribution and reversible on reinjection images, and 15 were reversible on redistribution and irreversible on reinjection images. Two hundred twenty four of 292 segments (76.7%) showed concordant results on stress-redistribution and stress-reinjection images. Therefore 24 hour reinjection image changed viability status from necrotic to viable in 53 segments of 292 severe stress defect (18%). However, myocardial viability was underestimated in only 5% (15/292) of severe defects by 24 hour reinjection. CONCLUSION: The 24 hour reinjection imaging is useful in the assessment of rnyocardial viability. It is more sensitive than 4 hour redistribution imaging. However, both redistribution and reinjection images are needed since they complement each other.

A Case of non-islet Cell Tumor Hypoglycemia Due to Gepatoma-increased serum subfraction of big insulin-like growth factor II / 대한내분비학회지

Hypoglycemia due to non-islet cell tumor is usually associated with hypersecretion of big insulin-like growth factor II (IGF-II). This big IGF-II cannot form ternary IGF complex, and is biologically more active in peripheral tissue, inducing increased glucose utilization and hypoglycemia. A 57-year-old man developed severe hypoglycemia due to hepatocellular carcinoma. To control hypoglycemia, the patient required continuous glucose infusion. The circulating levels of cortisol and free T4 were in the normal range. The plasma levels of insulin, C-peptide, IGF-I, IGF binding protein-3 (IGFBP-3), and total IGF-II levels were decreased. Radioimmunoassay of IGF-II revealed that big IGF-II immunoreactivity markedly increased compared to that of normal control. In this patient, it was strongly suggested that big IGF-II might be a cause of severe intractable hypoglycemia.

Left Atrial Dissection after Mitral Valve Replacement Demonstrated by Transesophageal Echocardiography

Left atrial dissection is one of extremely rare complications associated with mitral valve surgery. We reported a case of left atrial dissection, which was developed after mechanical mitral valve replacement and was demonstrated by transesophargeal echocardiography. The cause of dissection was due to excessive traction of left atrial endocardial layer during surgery.

A Case of Adrenal Cortical Carcinoma with Invasion of Inferior Vena Cava / 대한내과학회지

The adrenal cortical carcinoma is a rare cancer with an estimated incidence of about 1 case per 1,700,000 population. Further development of the tumor thrombi invasion of the inferior vena cava is very rare. The adrenal cortical carcinoma has poor prognosis due to delayed onset of symptoms and signs with regional and metastatic diseases are about 70M at the time of diagnosis. The diagnosis is made by hormonal and imaging studies. Adrenal cortical carcinoma is slightly more frequent in female and hormonally non-functioning tumor is more frequent. Traditionally, surgery and mitotane chemotherapy are known as a valuable therapeutic modality. But recently usefullness of mitotane is questioned due to low response rate and complication such as gastrointestinal trouble and there is not established optimal dosage and duration of treatment. Recently, in metastatic adrenal cortical carcinoma, some literature with combined chemotherapy had tried and reported good response. But, in general, combined chemotherapy has known as ineffective. We experienced and report adrenal cortical carcinoma with inferior vena caval invasion which is diagnosed by computed tomography and magnetic resonance imaging, and we treated surgery and postoperative chemotherapy.

Two Cases of Emphysematous Cholecystitis / 대한내과학회지

Emphysematous cholecystitis is an uncommon form of acute cholecystitis characterized by the presence of gas within the wall, lumen of the gall bladder or biliary ducts. Clinically it is very similar to ordinary farm. But since the risk of perforation is five times that expected from ordinary cholecystitis, early diagnosis and appropriate surgical treatment are important. We could diagnose these cases by the simple abdomen, abdominal ultrasound and abdominal CT by the presence of air in the lumen and the wall of the gall bladder. Percutaneous trans hepatic gall bladder drainage (PTGBD) for decompression was used because poor general condition of patients and later, we could successfully perform the cholecystectomy without any complication. We presented two cases of emphysematous cholecystitis with review of the relevant literature on the subject.

One Case of Mucinous Ductal Ectasia Diagnosed with Ultrathin Pancreatoscopy / 대한소화기내시경학회지

Mucinous ductal ectasia(MDE) is a newly described entity of mucinous neoplasm of pancreas with characteristic endoscopic and pancreatographic findings. It is charaeterized by a patulous duodenal papilla extruding mucus and a pancreatogram showing dilatation with amorphous filling defects, communication of the mass with the pancreatic duct. MDE is intraductal lesion consisting of dilated "cystified" ducts lined by mucin-producing columnar cells. The lesion is usually located in the head or uncinate process. When the radiographic appearance of the ERCP cannot provide sufficient information for definite diagnosis, additional endoscopic visualization is desirable. With the advent of pancreatoscopy, an endoscopic procedure is now available that has proven to enhance diagnostic accuracy. The 0.8-mm ultrathin pancreatoscope allows macroscopic diagnosis under direct vision. Endoscopic sphincterotomy is not required, and insertion into the pancreatic duct is feasible in most cases with the aid of guidewires. Major indications are unclear filling defects on ERCP, strictures of uncertain origin, and duct cut-offs. A limitation of this procedure are the lack of angulation, insufficient illumination, fragility of endoscopic equipment, and nonspecific findings. In addition, biopsy while directly viewing the lesion is impossible at present. We experienced one case of MDE who presented with the symptom of weight loss. Ultrathin pancreatoscopy was useful for the direct visualization af pancreatic duct in the differential diagnosis of filling defects of main pancreatic duct.