Two cases of isolated pulmonary valve infective endocarditis complicating ventricular septal defect / 대한내과학회지

Isolated infective endocarditis in the native pulmonary valve is an unusual clinical entity in non-intravenous drug users. Intravenous drug abuse, alcoholism, sepsis, catheter related infections and congenital heart diseases account for the majority of predisposing factors. We report two cases of isolated pulmonary valve infective endocarditis complicating ventricular septal defect (VSD). A 43 year-old male was admitted because of mild fever, pansystolic murmur on the left lower sternal border. Transthoracic and transesophageal echocardiography revealed a large perimembranous ventricular septal defect and vegetations at the pulmonary valve. After the intravenous use of penicillin and gentamicin, patch closure of VSD with resection of vegetations, resection of anomalous muscle bundles on the right ventricle outlet tract and pulmonary valvuloplasty was performed. A 43 year-old female was admitted with spiking fever, dyspnea. Transthoracic and transesophageal echocardiography showed a small perimenbranous ventricular septal defect with pulmonary valve vegetations. Intravenous penicillin and gentamicin were continued for 4 weeks and she is doing well.

A Case of Parachute Mitral Valve in an Adult

Parachute mitral valve is a rare congenital cardiac anomaly in which the chordae tendineae of both leaflets of the mitral valve insert into a single papillary muscle. We diagnosed a 54-year-old adult with dyspnea after upper respiratory infection, who was proven to have the parachute mitral valve. To the best of our knowledge, this is the oldest patient reported with this congenital anomaly. The clinical, echocardiographic and MRI findings are described. We recommended surgery for anomalous lesion, but the patient refused. After medical treatment, the patient recovered uneventfully and remained asymptomatic during a follow-up of 13 months.

Genetic Polymorphism of Epoxide Hydrolase and GSTM1 in Chronic Obstructive Pulmonary Disease / 결핵

BACKGROUND: Although smoking is a major cause of chronic obstructive pulmonary disease (COPD), only 10-20% of cigarette smokers develop symptomatic COPD, which suggests the presence of genetic susceptibility. This genetic susceptibility to COPD might depend on variations in the activities of the enzyme that detoxify hazardous chemical products, such as microsomal epoxide hydrolase (mEPHX) and glutathione-S transferase M1 subunit (GSTM1) genes. METHODS: The genotypes of 58 patients with COPD, and 79 age matched control subjects, were determined by a polymerase chain reaction, followed by restriction fragment length polymorphism (PCR-RFLP) for the mEPHX, and multiplex PCR for the GSTM1. RESULTS: GSTM1 was deleted in 53.3% of the subjects. There was no difference in GSTM1 deletion rates between the COPD patients (32/58, 55.2%) and the control subjects (41/79, 51.9%). The combination patterns of two polymorphisms of mEPHX showed slow enzyme activity in 29(21.2%), normal in 73(53.3%) and fast in 32(23.4%). The COPD group (7/57, 12.3%) showed a significantly lower incidence of slow enzyme activity compared to the control subjects (22/77, 28.6%, p<0.05). However, when the COPD and control groups were compared with smokers only, there were no significant differences in the genotypes of GSTM1 and mEPHX. CONCLUSION: The genotypes of GSTM1 and mEPHX were not significant risk factors of COPD in this cohort of study.

Immediate and long-Term Results of Percutaneous Mitral Valvuloplasty Using the Inoue Balloon

BACKGROUND AND OBJECTIVES: The objective of this study was to assess the short- and long-term clinical outcomes and valvular changes after percutaneous mitral valvuloplasty (PMV) in Sejong Hospital. SUBJECTS AND METHOD: Four hundred sixty-seven patients received PMV (Ed-already defined above) using the Inoue Balloon at Sejong hospital from 1990 to 2002. Short and long-term results, restenosis-free survival rate and prognostic factors for each result were analyzed by Chi-square, Cox regression analysis, Life table method and Cox proportional hazard model. RESULTS: After PMV, mitral valve area increased from 0.94+/-0.21 cm2 to 1.76+/-0.37 cm2 and the success rate (MVA>1.5 cm2 or increased by at least 50% without the development of moderate to severe mitral regurgitation) was 78.9%. Age ( or =1.1 cm2, p=0.001) were independent favorable prognostic factors for short-term result. As for the development of moderate to severe mitral regurgitation, pre-procedural MVA (9, p=0.043) were independent predictive factors. Median restenosis-free survival was 82.98 months and the restenosis-free survival rate was 70.9% at 3 years post-PMV, 48.1% at 6 years and 29.6% at 10 years. The independent prognostic factor for restenosis-free survival rate was left atrial dimension (LAD or =1.0 cm2, p=0.24) and ejection fraction (EF> or =55%, p=0.146) had an effect on the good long-term results of PMV from multivariate analysis. CONCLUSION: PMV was a very successful treatment method for mitral stenosis. Pre-procedural MVA was a representative predictive factor for short and long-term outcomes and the development of mitral regurgitation.

Redo Konno Procedure / 대한흉부외과학회지

A 28 year-old male who had received Konno procedure twelve years ago with 23mm mechanical aortic valve and bovine pericardium with which his small aortic annulus, ventricular septum and right ventricular outflow tract had been enlarged was transferred due to sudden congestive heart failure. There were perforations on aortic and interventricular portion of bovine pericardial patch above and below the aortic valve, respectively, which was calcified and denaturated severely. The perforations seemed to be attributed to the cracks, resulting from mobility of mechanical aortic valve itself and stiffness of calcified and denaturated bovine patch. We performed a redo Konno procedure applying PTFE patch.

A Case of Hyperplastic Gastric Polyposis with Morphological Changes during Short Follow-up Period / 대한소화기내시경학회지

Hyperplastic polyps are often multiple and by far the most frequent lesions among gastric polyps, contributing for about 90% of the polypoid lesions observed in the stomach. However, hyperplastic gastric polyposis is rare and was not exactly evaluated for natural course. These lesions are considered reactive and not genetically determined conditions. So it has been claimed that the hyperplastic polyps and hyperplastic polyposis are non-neoplastic lesions that result from regenerative hyperplastic reaction to inflammation and erosion. Recently we experienced a hyperplastic gastric polyposis with morphological changes during short follow-up period and reported herein.

Noninvasive calculation of left heart compliance by echocardiography and its clinical significance in mitral stenosis

BACKGROUND: Although the net atrioventricular compliance can be obtained by invasive catheterization (Ccath) in mitral stenosis (MS), feasibility of noninvasive echocardiographic calculation of the compliance (Cecho) and its hemodynamic significance were not tested. METHODS: Using valve area by 2D planimetry (A2D) and deceleration slope (dv/dt) of transmitral velocity decay in continuous wave Doppler echocardiographic tracing, Cecho was defined as -A2D/(gamma dv/dt), which was compared with Ccath obtained directly during the catheterization in 30 MS patients with sinus rhythm. Exercise Doppler echocardiography with symptom-limited treadmill was performed in 66 patients with moderate to tight MS: mean mitral gradient (MG) and peak pressure gradient of tricuspid regurgitation (PGTR) at baseline and immediately after exercise were obtained using continuous wave Doppler echocardiographic tracing. Hemodynamic variables including Cecho, MG, PGTR and mitral valve area were analyzed to determine the association with patients' exercise tolerance. RESULTS: Cecho in 30 patients with tight MS (valve area 0.9+/-0.2 cm 2) was 4+/-1 ml/mmHg (2-7 mmHg), which showed a significant correlation with Ccath (r=0.48, p=0.01). Exercise time in 66 patients with moderate to tight MS showed significant negative correlation with resting MG, resting and postexercise PGTR, and positive correlation with Cecho: exercise time in those patients did not show any significant correlation with resting valve area. In multivariate analysis, Cecho and postexercise PGTR were independent factors determining exercise time in MS. CONCLUSIONS: The net atrioventricular compliance in MS can be calculated by noninvasive echocardiography, and it is an important hemodynamic factor determining exercise tolerance in MS.

The Relationship between the Excursion of Mitral Valve Leaflets Recorded by M-Mode Echocardiography and the Transmitral Inflow Measured by Doppler Echocanliography

BACKGROUND AND OBJECTIVES: Movement of mitral valve during diastole and blood flow velocity through the valve can be accurately measured using M-mode and pulsed wave Doppler technique, respectively. However, the relationship between mechanical excursion and flow phenomenon at the same cardiac cycle has not been seriously investigated. METHOD: The subjects of this study included twenty cases with normal mitral flow pattern in Doppler echocardiography (Group I, mean age:44+/-20.8years, mean ejection fraction (EF):52+/-20.9%), twenty three cases with relaxation abnormality (Group II, mean age:59+/-11.4years, mean EF:43+/-18.2%) and seventeen cases with restrictive physiology (Group III, mean age: 47+/-15.9years, mean EF: 24+/-11.0%). We measured excursion of mitral leaflets at early (DE) and late (DA) diastole, area of mitral valvular opening using two dimensional calibration on M mode images, and transmitral inflow velocity (E (early ventricular filling)-, A (atrial contraction)-velocity), TVI (time velocity integral) on Doppler echocardiography. RESULTS: DE-excursions (mm) in group I, II, III were 16.8+/-4.7, 14.2+/-3.5, 15.3+/-4.1, DA-excursions (mm) were 9.8+/-3.2, 10.7+/-3.0, 8.3+/-2.7, E-areas (cm2) were 2.8+/-1.3, 2.6+/-0.8, 2.5+/-1.0, A-areas (cm2) were 1.7+/-0.8, 1.7+/-0.7, 2.0+/-0.6, respectively. In E-, A-velocity, deceleration time, E-TVI and A-TVI, there were significant differences among three groups. However, in DE-, DA-excursion, E-, A-area, there were no significant differences among three groups. Between DE excursion and E velocity, DA excursion and A velocity, and total opening area and total TVI in total subjects, significant correlations were absent. CONCLUSION: The mitral excursions and mitral opening areas on M mode images did not show any significant correlations with the mitral inflow velocities and TVI by pulsed Doppler, which suggests that the excursion of mitral leaflets is independent of transmitral inflow.

Two cases of sudden cardiac death syndrome associated with right bundle branch block and ST segment elevation

In 1992, Brugada described clinical features of patients with aborted sudden cardiac death who showed no demonstrable heart disease and a peculiar ECG pattern consisting of right bundle branch block and ST-segment elevation in right precordial leads. Recently, We experienced two cases with aborted sudden cardiac death and similar ECG pattern. Physical examination, routine laboratory tests including serum electrolytes, echocardiography, myocardial thallium SPECT, MRI and MIBG scans were within normal limit. Arrhythmias were not induced in treadmill exercise test, and signal averaged ECGs revealed positive late potentials. Coronary angiography showed normal coronary artery with no evidence of induced vasospasm. Polymorphic ventricular tachycardia and ventricular fibrillation were induced by ventricular stimulation. Intravenous administration of flecainide, procainamide augmented ST segment elevation in one patient, and isoproterenol reduced ST segment elevation in the other patient. For prevention of sudden death, ICDs were implanted in the two patients. Ventricular fibrillations occurred in one patient 12 and 13 months after the implantation and were successfully terminated by ICD.

Decreased QTc dispersion after coronary revascularization: relationships with the quantitative degree of improvement in myocardial ischemia

OBJECT & METHOD: Thirty-four patients (mean age: 58.1+/-8.3 years, M:F=1:13) with angina in the absence of previous myocardial infarction, who underwent percutaneous coronary intervention (stenting and/or balloon PTCA, n=5) or coronary arterial bypass grafting (CABG, n=) were evaluated to assess the relationships between the degree of improvement in myocardial dipyridamole Tl-201 SPECT and the degree of decrease in QTc dispersion after coronary revascularization. QTc dispersions were measured manually using digitizer by a single observer from ECGs printed at 25mm/sec, 1 day before, immediately, 1 day, and 1 month after the revascularization procedure. Myocardial Tl-201 SPECTs were performed before and 1 month after the revascularization and ischemic indices were measured in all cases. RESULTS: Mean QTc dispersion was 51.4+/-17.0msec before revascularization, 42.6+/-15.1msec immediately after, 45.6+/-19.3msec 1 day after and 37.4+/-11.6msec 1 month after revascularization. The decrease of QTc dispersion immediate (p=.001) and 1 month (p<0.001) after revascularization, were statistically significant. Mean Tl-201 SPECT ischemic index measured before the revascularization (7.8+/-5.9) was significantly higher (p<0.001) than the one measured 1 month after the revascularization (1.5+/-2.8). But, in deltaischemic index (ischemic index before revascularization-ischemic index 1 month afer revascularization), there was no significant difference between the patients with decrease in QTc dispersion after revascularization(6.2+/-6.3, n=7) and the patients without decrease in QTc dispersion (6.6+/-5.2, n=). There was no statistically significant correlation between deltaQTc (QTc dispersion before revascularization-QTc dispersion 1 month afer revascularization) and delta ischemic index in total subjects. CONCLUSION: QTc dispersions decrease after successful coronary revascularizations in patients with angina, but considering the relationships between the changes of QTc dispersions and ischemic indices in myocardial dipyridamole Tl-201 SPECT, the degree of decrease in QTc dispersion after coronary revascularization does not have the relationships with the quantitative degree of improvement in myocardial ischemia.

Decreased QTc dispersion after coronary revascularization: relationships with the quantitative degree of improvement in myocardial ischemia

OBJECT & METHOD: Thirty-four patients (mean age: 58.1+/-8.3 years, M:F=1:13) with angina in the absence of previous myocardial infarction, who underwent percutaneous coronary intervention (stenting and/or balloon PTCA, n=5) or coronary arterial bypass grafting (CABG, n=) were evaluated to assess the relationships between the degree of improvement in myocardial dipyridamole Tl-201 SPECT and the degree of decrease in QTc dispersion after coronary revascularization. QTc dispersions were measured manually using digitizer by a single observer from ECGs printed at 25mm/sec, 1 day before, immediately, 1 day, and 1 month after the revascularization procedure. Myocardial Tl-201 SPECTs were performed before and 1 month after the revascularization and ischemic indices were measured in all cases. RESULTS: Mean QTc dispersion was 51.4+/-17.0msec before revascularization, 42.6+/-15.1msec immediately after, 45.6+/-19.3msec 1 day after and 37.4+/-11.6msec 1 month after revascularization. The decrease of QTc dispersion immediate (p=.001) and 1 month (p<0.001) after revascularization, were statistically significant. Mean Tl-201 SPECT ischemic index measured before the revascularization (7.8+/-5.9) was significantly higher (p<0.001) than the one measured 1 month after the revascularization (1.5+/-2.8). But, in deltaischemic index (ischemic index before revascularization-ischemic index 1 month afer revascularization), there was no significant difference between the patients with decrease in QTc dispersion after revascularization(6.2+/-6.3, n=7) and the patients without decrease in QTc dispersion (6.6+/-5.2, n=). There was no statistically significant correlation between deltaQTc (QTc dispersion before revascularization-QTc dispersion 1 month afer revascularization) and delta ischemic index in total subjects. CONCLUSION: QTc dispersions decrease after successful coronary revascularizations in patients with angina, but considering the relationships between the changes of QTc dispersions and ischemic indices in myocardial dipyridamole Tl-201 SPECT, the degree of decrease in QTc dispersion after coronary revascularization does not have the relationships with the quantitative degree of improvement in myocardial ischemia.

Changes in Insulin Sensitivity and Insulin Secretory Function in Hyperthyroid Patients / 대한내분비학회지

The impairement of glucose metabolism is frequently associated in hyperthyroidism. The present study was performed to determine the effect of the thyroid hormone excess on insulin sensitivity and on insulin secretory function in vivo. Ten newly diagnosed hyperthyroid patients and fifteen healthy control subjects were subjected to frequently sampled intravenous glucose tolerance tests(FSIGT) after an overnight fast. Insulin sensitivity, represented by the insulin sensitivity index(S_1), was assessed by minimal model analysis of FSIGT data. Insulin secretion was measured by the total area under the insulin curve after glucose load.The results were as follows.1) The K_G values, which represent glucose tolerance, were not different between the hyperthyroid patients and the normals(2.2+-0.3 vs. 2.5+-0.3%/min, p>0.05).2) S_1 was significantly decreased in the hyperthyroid patients in comparison to the normals(7.5+-1.4 vs. 2.6+-0.3X10