A case of sinus node dysfunction and atrial tachycardia after the excision of a left atrial myxoma / 대한내과학회지

Atrial myxoma is the most common primary cardiac tumor, and surgical removal is the treatment of choice. Atrial flutter-fibrillation is common after the surgical excision of such tumors, whereas sinus node dysfunction is a rare complication. We detected postoperative sinus node dysfunction and atrial tachycardia after the excision of a left atrial myxoma in a 63-year-old woman. The patient underwent the implantation of a permanent pacemaker two weeks after the operation. The patient underwent successful catheter ablation of macroreentrant right atrial tachycardia 16 months after the operation with no recurrence of atrial tachycardia over the next four months.

A Case of Late Recurrent Vasospasm After Sirolimus-Eluting Stent Implantation

A 67-year-old male with stable angina was admitted to our cardiovascular center. He had neither any history of smoking, diabetes mellitus, hypertension, cerebrovascular accident nor family history of coronary artery disease. Coronary angiography showed a 90% tubular eccentric luminal narrowing at the mid left anterior descending artery (m-LAD). A sirolimus-eluting stent (SES) was implanted in the m-LAD. Coronary angiography performed after 9 months did not reveal restenosis or recurrent coronary artery disease. However, the patient returned to the emergency room with severe chest pain after 17 months. Coronary angiography showed severe diffuse vasospasm distal to the m-LAD stent site. After 20 days, vasospastic myocardial infarction developed. A zotarolimus-eluting stent with a phosphorylcholine polymer was implanted distal to the m-LAD stent. The zotarolimus-eluting stent was used because the polymer in the SES or sirolimus was considered a possible cause for the recurrent vasospasm. The patient had no further chest pain during the 9 months after zotarolimus-eluting stent implantation. We suspect that the polymer in the SES or sirolimus might have caused endothelial dysfunction and provoked the late vasospasm. Here, we describe this case of late recurrent vasospasm after SES implantation.

Angioplasty for Difficult Complex Lesions With Using the Venture(TM) Catheter for Wire Placement

We report here on the use of the Venture(TM) catheter to facilitate successful advancement of a guidewire across difficult, complex lesions after the prior attempts at guide wire passage were unsuccessful with using standard wires. This Venture(TM) catheter may increase the success rate and reduce the procedural time for such a challenging interventional procedure.

The Effect of Intra-coronary Nicorandil Prior to Reperfusion in Acute ST Segment Elevation Myocardial Infarction

BACKGROUND AND OBJECTIVES: Intravenous nicorandil infusion with percutaneous coronary intervention (PCI) has been reported to reduce reperfusion injury events and to improve cardiac function in patients with an acute myocardial infarction. However, there is limited information on the use of intra-coronary nicorandil. A prospective randomized single center study was designed to evaluate the efficacy of the use of intra-coronary nicorandil. SUBJECTS AND METHODS: Seventy-three patients with an acute ST segment elevation myocardial infarction were randomly assigned to the nicorandil group (n=37) or a control group (n=36); all patients received a PCI. In the nicorandil group of patients, 4 mg of intra-coronary nicorandil was infused directly into the infarct area prior to reperfusion (2 mg before ballooning, 2 mg before stenting). The composite endpoint was the incidence of ventricular arrhythmia, no-reflow and slow flow. We estimated the post thrombolysis in myocardial infarction (TIMI) grade, the myocardial perfusion grade after PCI and the short-term clinical outcome. RESULTS: The baseline characteristics were similar in both groups of patients. A significant difference was observed in the composite endpoint in the nicorandil group of patients as compared to the control group of patients (p=0.037). The achievement rate of post TIMI grade 3 was significantly higher in the nicorandil group of patients (p=0.019). The myocardial perfusion grade 1 was not observed in the nicorandil group of patients; however, it was observed in five patients in the control group (p=0.019). Major adverse cardiac events in hospital and in 30 days were similar between the two groups. CONCLUSION: Intra-coronary nicorandil infusion reduced the occurrence of no-reflow, slow reflow, reperfusion arrhythmia and improved the myocardial perfusion grade and TIMI flow during PCI. The results of this study showed that the use of intracoronary nicorandil improved the clinical outcome in patients with an acute myocardial infarction.

Severe Stenosis of the Left Main Coronary Artery Detected on Electrophysiologic Study

A cardiac electrophysiologic study (EPS) is a safe procedure with a low complication rate. We report here a case of severe stenosis of the left main coronary artery (LMCA) that was incidentally detected during an EPS; this was successfully managed by stenting the LMCA. The patient was a 75-year-old man with recurrent chest fluttering and no previous angina underwent EPS and he developed acute ischemic chest pain due to induced atrial fibrillation. The coronary angiography showed a critical stenosis in the distal LMCA. The patient underwent percutaneous coronary intervention with a sirolimus-eluting stent in the LMCA. The patient has remained asymptomatic during a 1-year follow-up period. To prevent potentially catastrophic complications, performing a stress myocardial imaging test should be strongly considered before conducting EPS in elderly patients.

Two Cases of an Implantation of a Permanent Pacemaker Using a Transaxillary Incision

In surgeries that require the implantation of a pacemaker, the endocardial pacemaker leads are introduced into the cardiac chambers through subclavian or axillary venous catheterization or cephalic vein cutdown. The drawback of this type of surgery is scarring of the pectoral area, which can be a serious cosmetic problem especially for young women. In this study, we report on 2 cases where a permanent pacemaker in two young women with symptomatic bradycardia was implanted using a transaxillary incision. Both patients successfully recovered with no complications and were asymptomatic for more than 17 months after the procedure. Therefore, we found that implantation of a pacemaker via transaxillary incision provided excellent cosmetic results and should be considered in young women that require this type of surgery.

Comparison of the Clinical and Angiographic Outcomes of Compromised Side Branches (Stent Jail) after Percutaneous Coronary Intervention between Sirolimus-Eluting Stents and Paclitaxel-Eluting Stents

BACKGROUND AND OBJECTIVES: Drug-eluting stents (DES) have been used worldwide for conducting safe and effective percutaneous coronary intervention (PCI) for treating coronary artery disease. However, the DES might cause a higher frequency of an acute side branch occlusion or stent jails near the target lesion after PCI than that with using bare metal stents (BMS). This may be due to the eluted drug or the thick stent struts. We evaluated the clinical and angiographic outcomes of compromised side branches (stent jail) after PCI and the frequency of side branch occlusion or stent jails between sirolimus-eluting stents (SES) and paclitaxel-eluting stents (PES). SUBJECTS AND METHODS: We analyzed the clinical results and angiographic findings of 47 patients who were treated with a SES and 45 patients who were treated with a PES. We only analyzed the left anterior descending artery (LAD) and its side branches that were more than one millimeter in diameter. Side branch occlusion was defined as the development of total occlusion or a reduction of the thrombolysis in myocardial infarction (TIMI) flow more than grade 1 after stenting. The peak cardiac enzyme levels were measured. We evaluated the clinical outcomes in the hospital and at the 6 month follow up. RESULTS: There were no significant differences of the baseline clinical demographics between the SES and the PES groups. The total length and diameter of the implanted stents were 42.85+/-15.3 mm vs. 41.68+/-13.3 mm (p=0.93) and 3.09+/-0.3 mm vs. 3.1+/-0.2 mm (p=0.69) in the SES group and PES group, respectively. On average, the number of side branches of the LAD were 2.00+/-0.9 vs. 2.13+/-0.8 and on angiography after stenting, side branch occlusion and reduction of the TIMI developed in 8.51% vs. 13.33% (p=0.46) and 17% vs. 15% (p=0.88) of the SES group and PES group, respectively. The laboratory data showed that the peak creatine kinase-MB (CK-MB) and troponin-I levels were 13.5+/-31 U/L vs. 15.6+/-33 U/L (p=0.77) and 6.3+/-15 ng/mL vs. 5.42+/-9 ng/mL (p=0.77), respectively. There were no clinical in-hospital events for either group. There were no statistically significant differences in major adverse cardiac events (MACEs) at the 6-month follow up (4.3% vs. 8.9%, respectively). CONCLUSION: The clinical and angiographic outcomes of compromised side branches (stent jail) after PCI and the frequency of side branch occlusion or stent jails between SES and PES were similar.

Biochemical Analysis of Serum and Pericardial Fluid in Patients with Hemorrhagic Pericardial Effusion

BACKGROUND AND OBJECTIVES: Since echocardiography became a routine diagnostic tool, pericardial effusion has become a common clinical finding. The major causes of hemorrhagic pericardial effusion are malignancy and tuberculosis. However, it was unknown to the use of biochemical analysis of pericardial fluid and serum, for differentiation of malignancy from tuberculosis. To evaluate this, we investigated the biochemical analysis of pericardial fluid and serum in relation to the causes of pericardial tamponade. SUBJECTS AND METHODS: 46 patients who were admitted to Pusan National University Hospital from January 1, 1995, to April 30, 2002, and underwent both a pericardiocentesis and a pericardiostomy for the relif of cardiac tamponade, were included in this study. the pericardial fluid was routinely analyzed for the following: gross appearance, cell count, glucose, total protein(P), lactate dehydrogenase(LDH), cytology, gram stain, cultures for bacteria and mycobacterium, pericardial fluid to serum ratios of total protein and lactate dehydrogenase,(p/s TP, p/s LDH, respectively). RESULTS: f the 46 patients who underwent both pericardiocentesis and pericardiostomy, for the relief of cardiac tamponade, 33 patients(71.7%) had hemorrhagic pericardial effusion. The common causes of hemorrhagic pericardial effusion were malignancy(51.5%) and tuberculosis(33.3%) but, those of nonhemorrhagic pericardial effusion were idiopathic (38.5%). Cell counts were higher in hemorrhagic than nonhemorrhagic group(p=.029). Serum LDH(sLDH) was higher in malignant than tuberculous group(p=.001) but, serum total protein(sTP) was higher in tuberculous group(p=.004). Compared malignant group with tuberculosis group in patients with hemorrhagic pericardial effusion, p/s ratio of LDH and sTP were higher in tuberculous group (p=.029, p=.017), but sLDH was higher in malignant group(p=0.002). CONCLUSION: It is difficult to differentiate tuberculosis from malignancy only on the basis of the biochemical analysis of pericardial fluid in hemorrhagic pericardial effusion. However, the analysis of both pericardial fluid and serum may make it possible to evaluate the cause of pericardial effusion.

Analysis of deaths of the patients with terminal cancer / 대한내과학회지

BACKGROUND: Although most patients with cancer have a fatal outcome, it seems that the concern and study may be not enough. This study was aimed to perform the analysis of the cause of death, main symptom and treatment of the patients with terminal cancer and to provide the basic information about their adequate management. METHODS: We reviewed the medical records of 73 terminal cancer patients who had been managed with palliative therapy and died at Pusan National University Hospital from January 1999 to December 2001. The underlying malignant disease, ante-mortem symptoms, therapy and immediate cause of deaths were studied. RESULTS: A total 73 terminal cancer patients was included. The mean age was 53 years. Underlying malignant diseases were solid tumor (62%), acute myeloid leukemia (12%), non-Hodgkin's lymphoma (11%), chronic myeloid leukemia (10%), multiple myeloma (5%). The solid tumor was composed of gastrointestinal tract cancer (38%), head and neck cancer (13%), cancer of unknown primary site (9%), lung cancer (11%), hepatobiliary tract cancer (7%), cervical cancer (7%), ovarian cancer (4%), malignant melanoma (4%), soft tissue sarcoma and osteosarcoma (4%) and brain tumor (2%). The frequencies of the clinical complaints evaluated were the pain necessitating opiates, dyspnea (WHO grade >or=2), CNS disturbances, fever, hemorrhage, jaundice and intractable vomiting. Opiates, transfusions and antibiotics were the main therapy and pneumonia were the most important immediate causes of death. CONCLSUION: This results could be used as the basic information for the patients with terminal cancer and suggests a need for multi-center cooperation study.

A Case of Takayasu's Arteritis with Bilateral Involvement of Ostial Coronary Arteries / 대한류마티스학회지

Takayasu's arteritis is a chronic large-vessel vasculitis affecting young women more frequently than young men. The patients frequently have signs and symptoms of peripheral vascular insufficiency caused by arterial luminal obliteration or narrowing. Coronary artery involvement occurs in only 9~27% of patients. Most of the coronary artery lesions are predominantly involved unilaterally. We describe a presentation of Takayasu's arteritis in a young woman with involvement of the bilateral ostial coronary arteries.

Aberrant Promoter Methylation of Death-Associated Protein Kinase in Serum DNA from Lung Cancer Patients / 결핵

BACKGROUND: Promoter methylation of tumor suppressor genes is one of the key epigenetic changes in many human cancers. The aim of this study was to evaluate the promoter methylation status of the Death-associated protein(DAP) kinase gene, which played an important role in lung cancer, in the serum DNA of primary lung cancer patients. METHODS: This study investigated the aberrant methylation of DAP kinase in the serum of 65 primary lung cancer patients by methylation-specific PCR (MSP). RESULTS: Methylation in the serum was detected in 29 of 65(44.6%) for DAP kinase. There was no statistical association between methylation of DAP kinase and age, smoking history, histologic type, or stage. Methylation of DAP kinase was found more frequently in men (p=0.044). CONCLUSIONS: This study suggests that the aberrant methylation of the DAP kinase promoter is readily detectable in the serum DNA of lung cancer patients using MSP analysis.

A Case of Cerebral Aspergillosis in a Patients with Rheumatoid Arthritis / 대한류마티스학회지

We report a case of aspergillosis of the central nervous system in patient with rheumatoid arthritis (RA). A 46-year-old woman with 20-year history of RA and on treatment with corticosteroid, hydroxychloroquine and methotrexate, was admitted because of drowsiness, dizziness and dysarthria. On admission, physical examination and laboratory data showed, among other findings, disappearance of pupil reflex, positive Babinski and Chaddock reflex. Magnetic resonance imaging (MRI) of brain showed multiple high signal intensity lesion on medulla, pons, midbrain, basal ganglia, internal capsule, thalamus and hypothalmus. Stereotactic brain biopsy was performed and biopsy specimen revealed an invasive Aspergillus.

A Case of Pheochromocytoma with Ganglioneuronal Differentiation Producing Vasoactive Intestinal Peptide / 대한내분비학회지

Vasoactive intestinal peptide(VIP) is a 28-amino acid peptide, which may cause secretory diarrhea by stimulating the production of adenylate cyclase. Neuroendocrine tumors, secreting vasoactive intestinal peptide (VIP), are almost always of a pancreatic in origin. However, a pheochromocytoma may produce several neuropeptides, containing VIP, as they are considered to be neuroendocrine tumors. A 57-year-old woman, who presented with chronic watery diarrhea, hypokalemia, weight loss and a left adrenal mass, is described. Histologically, the tumor was diagnosed as a pheoch-romocytoma, with ganglioneuronal differentiation, and was histochemically confirmed to produce a vasoactive intestinal polypeptide. A left adrenal VIP-producing pheochromocytoma was successfully resected. After surgery, her diarrhea subsided and the electrolytes, affected neuroendocrine hormone levels, blood pressure and blood sugar level were normalized.