Tachyarrhythmia Cycle Length in Appropriate versus Inappropriate Defibrillator Shocks in Brugada Syndrome, Early Repolarization Syndrome, or Idiopathic Ventricular Fibrillation

BACKGROUND AND OBJECTIVES: Implantable cardioverter–defibrillators (ICDs) are indicated in patients with Brugada syndrome (BS), early repolarization syndrome (ERS), or idiopathic ventricular fibrillation (IVF) who are at high risk for sudden cardiac death. The optimal ICD programming for reducing inappropriate shocks in these patients remains to be determined. We investigated the difference in the mean cycle length of tachyarrhythmias that activated either appropriate or inappropriate ICD shocks in these three patient groups to determine the optimal ventricular fibrillation (VF) zone for minimizing inappropriate ICD shocks. SUBJECTS AND METHODS: We selected 41 patients (35 men) (mean age±standard deviation=42.6±13.0 year) who received ICD shocks between April 1996 and April 2014 to treat BS (n=24), ERS (n=9), or IVF (n=8). Clinical and ICD interrogation data were retrospectively collected and analyzed for all events with ICD shocks. RESULTS: Of the 244 episodes, 180 (73.8%) shocks were appropriate and 64 (26.2%) were inappropriate. The mean cycle lengths of the tachyarrhythmias that activated appropriate and inappropriate shocks were 178.9±28.7 ms and 284.8±24.4 ms, respectively (p<0.001). The cutoff value with the highest sensitivity and specificity for discriminating between appropriate and inappropriate shocks was 235 ms (sensitivity, 98.4%; specificity, 95.6%). When we programmed a single VF zone of ≤270 ms, inappropriate ICD shocks were reduced by 70.5% and appropriate shocks were missed in 1.7% of these patients. CONCLUSION: Programming of a single VF zone of ≤270 ms in patients with BS, ERS, or IVF could reduce inappropriate ICD shocks, with a low risk of missing appropriate shocks.

Transvenous Lead Extraction via the Inferior Approach Using a Gooseneck Snare versus Simple Manual Traction

BACKGROUND AND OBJECTIVES: The number of patients with cardiac implantable electronic devices needing lead extraction is increasing for various reasons, including infections, vascular obstruction, and lead failure. We report our experience with transvenous extraction of pacemaker and defibrillator leads via the inferior approach of using a gooseneck snare as a first-line therapy and compare extraction using a gooseneck snare with extraction using simple manual traction. SUBJECTS AND METHODS: The study included 23 consecutive patients (43 leads) who underwent transvenous lead extraction using a gooseneck snare (group A) and 10 consecutive patients (17 leads) who underwent lead extraction using simple manual traction (group B). Patient characteristics, indications, and outcomes were analyzed and compared between the groups. RESULTS: The dwelling time of the leads was longer in group A (median, 121) than in group B (median, 56; p=0.000). No differences were noted in the overall procedural success rate (69.6% vs. 70%), clinical procedural success rate (82.6% vs. 90%), and lead clinical success rate (86% vs. 94.1%) between the groups. The procedural success rates according to lead type were 89.2% and 100% for pacing leads and 66.7% and 83.3% for defibrillator leads in groups A and B, respectively. Major complications were noted in 3 (mortality in 1) patients in group A and 2 patients in group B. CONCLUSION: Transvenous extraction of pacemaker leads via an inferior approach using a gooseneck snare was both safe and effective. However, stand-alone transvenous extraction of defibrillator leads using the inferior approach was suboptimal.

Complications of Cardiac Perforation and Lead Dislodgement with an MRI-Conditional Pacing Lead: a Korean Multi-Center Experience

Medtronic CapSureFix MRI 5086 pacing lead (5086; Medtronic, Inc., Minneapolis, MN, USA) has been reported to be associated with increased cardiac perforation and lead dislodgement. This study aimed to compare the incidence of cardiac perforation and lead dislodgement within 30 days after pacemaker implantation between 5086 MRI lead and previous Medtronic CapSureFix Novus 5076 non-MRI pacing lead. This was a nationwide, multicenter retrospective study in which we compared the incidence of adverse events between 277 patients implanted with 5086 lead and 205 patients implanted with 5076 lead between March 2009 and September 2014. Cardiac perforation within 30 days of pacemaker implantation occurred in 4 patients (1.4%) with the 5086 lead and in no patient with the 5076 lead (P = 0.084). Lead dislodgement occurred in 8 patients (2.9%) with the 5086 lead and in 5 patients (2.4%) with the 5076 lead (P = 0.764). On multivariate logistic regression analysis, age was significantly associated with cardiac perforation. Congestive heart failure and implantation of right atrial (RA) lead at RA free wall or septum were significant factors for the incidence of lead dislodgement and lead revision. The incidence of cardiac perforation and lead dislodgement were not statistically different between the patients with 5086 lead and the patients with 5076 lead. However, careful attention for cardiac perforation may be needed when using the 5086 MRI lead, especially in elderly patients.

Impact of Impaired Renal Function on the Incidence of Atrial Fibrillation following Radiofrequency Ablation of Cavotricuspid Isthmus-Dependent Atrial Flutter

BACKGROUND AND OBJECTIVES: Atrial fibrillation (AF) occurs frequently after successful radiofrequency ablation (RFA) of cavotricuspid isthmus-dependent atrial flutter (CTI-AFL). Renal impairment has been implicated in the development of AF. The purpose of this study is to clarify the impact of impaired renal function on the incidence of AF after RFA of CTI-AFL. SUBJECTS AND METHODS: Between January 2001 and December 2013, 240 non-dialysis patients with no prior history of AF {mean age 55.9+/-15.2 years old; male, 192 (80.0%)} who had undergone successful CTI-AFL ablation were included in the present study. The baseline estimated glomerular filtration rate was calculated, and patients were divided into those with impaired renal function ( or = 60 mL/min/1.73 m2). The incidence of AF was retrospectively analyzed. RESULTS: 69 (28.8%) patients experienced new onset AF during a median follow-up duration of 26 months (inter-quartile, 7-53). The incidence of AF was significantly higher in patients with impaired renal function than in those with preserved renal function {13/25 (52.0%) versus 56/215 (26.0%), log rank p=0.019}. Age, CHADS2 score, impaired renal function, and left atrial diameter were significantly associated with the incidence of AF in univariate Cox regression analysis. Multivariate analysis showed that age was the only significant predictor of AF incidence (hazard ratio, 1.024; 95% confidence interval, 1.004-1.044, p=0.020). CONCLUSION: Patients with impaired renal function may require careful attention for the incidence of new onset AF following successful RFA of CTI-AFL.

APACHE II Score, Rather Than Cardiac Function, May Predict Poor Prognosis in Patients With Stress-Induced Cardiomyopathy

While the disease course of stress-induced cardiomyopathy (SIC) is usually benign, it can be fatal. The prognostic factors to predict poorer outcome are not well established, however. We analyzed the Acute Physiology And Chronic Health Evaluation (APACHE) II score to assess its value for predicting poor prognosis in patients with SIC. Thirty-seven consecutive patients with SIC were followed prospectively during their hospitalization. Clinical factors, including APACHE II score, coronary angiogram, echocardiography and cardiac enzymes at presentation were analyzed. Of the 37 patients, 27 patients (73%) were women. The mean age was 66.1 +/- 15.6 yr, and the most common presentation was chest pain (38%). Initial echocardiographic left ventricular ejection fraction (EF) was 42.5% +/- 9.3%, and the wall motion score index (WMSI) was 1.9 +/- 0.3. Six patients (16%) expired during the follow-up period of hospitalization. Based on the analysis of characteristics and clinical factors, the only predictable variable in prognosis was APACHE II score. The patients with APACHE II score greater than 20 had tendency to expire than the others (P = 0.001). Based on present study, APACHE II score more than 20, rather than cardiac function, is associated with mortality in patients with SIC.

Early Adenocarcinoma Arising from Traditional Serrated Adenoma in the Colon / 대한소화기내시경학회지

A serrated adenoma is a precursor lesion for some cases of microsatellite unstable colorectal carcinoma (CRC). The serrated neoplasia pathway has been associated with carcinogenesis of serrated adenoma, which is different from the traditional adenoma-carcinoma sequence. The serrated neoplasia pathway accounts for 10~15% of CRCs, and these tumors typically demonstrate microsatellite instability. Cases of a CRC arising from a serrated adenoma have been rarely identified with the recent recognition of the serrated neoplasia pathway. However, these cases are not frequently reported in Korea, because this concept has only been recently emphasized. We report a case of an early adenocarcinoma arising from a traditional serrated adenoma of the colon, which was diagnosed and treated by a colonoscopic polypectomy.

A Case of Chronic Neuropathic Pseudo-obstruction of the Colon / 대한소화기내시경학회지

Colonic pseudo-obstruction, which is characterized by repetitive episodes or continuous symptoms and signs of a bowel obstruction, is a rare disease that results in colorectal dilatation without any obstructing lesions. Cases with neuropathic chronic colonic pseudo-obstruction have rarely been reported in Korea. We report a case of neuropathic colonic pseudo-obstruction, which results in decreased number of interstitial cells of Cajal and hypoganglionosis, in a 50-year-old man with chronic constipation accompanied by megacolon.

A Case of Colonic Obstruction Due to Phytobezoars / 대한소화기내시경학회지

Colonic phytobezoars are defined as conglomerate masses of fruit or vegetable matter in the colon, and these have rarely reported as a cause of colon obstruction. Because it is extremely rare, its correct diagnosis might be delayed even with the aid of abdominal computed tomography. We report here on a case of diagnosed colonic obstruction due to colonic phytobezoars in a 67-year-old female with diabetic end stage renal disease and chronic constipation. Although abdomino-pelvic computed tomography did not demonstrate the presence of phytobezoars, multiple phytobezoars impacted in the colon were found and these were removed by colonoscopy. This is a rare case in that colonic obstruction due to phytobezoar was diagnosed early and it was treated by colonoscopy.

Two Cases of Nontuberculous Mycobacterial Lung Disease in Heart Transplant Recipients / 결핵및호흡기질환

Nontuberculous mycobacterial (NTM) diseases are increasing worldwide. However NTM lung disease in organ transplant recipients has been rarely reported. Here, we report 2 cases of NTM lung disease in heart transplant recipients. A 37-year-old man, who had undergone a heart transplant one year previous, was admitted to hospital due to a cough. Chest CT scan showed multiple centrilobular nodules in both lower lungs. In his sputum, M. abscessus was repeatedly identified by rpoB gene analysis. The patient improved after treatment with clarithromycin, imipenem, and amikacin. An additional patient, a 53-year-old woman who had undergone a heart transplant 4 years prior and who suffered from bronchiectasis, was admitted because of purulent sputum. The patient's chest CT scan revealed aggravated bronchiectasis; M. intracellulare was isolated repeatedly in her sputum. Treatment was successfully completed with clarithromycin, ethambutol, and ciprofloxacin. NTM lung disease should be considered as a potential opportunistic infection in organ transplant recipients.

Two Cases of Nontuberculous Mycobacterial Lung Disease in Heart Transplant Recipients / 결핵및호흡기질환

Nontuberculous mycobacterial (NTM) diseases are increasing worldwide. However NTM lung disease in organ transplant recipients has been rarely reported. Here, we report 2 cases of NTM lung disease in heart transplant recipients. A 37-year-old man, who had undergone a heart transplant one year previous, was admitted to hospital due to a cough. Chest CT scan showed multiple centrilobular nodules in both lower lungs. In his sputum, M. abscessus was repeatedly identified by rpoB gene analysis. The patient improved after treatment with clarithromycin, imipenem, and amikacin. An additional patient, a 53-year-old woman who had undergone a heart transplant 4 years prior and who suffered from bronchiectasis, was admitted because of purulent sputum. The patient's chest CT scan revealed aggravated bronchiectasis; M. intracellulare was isolated repeatedly in her sputum. Treatment was successfully completed with clarithromycin, ethambutol, and ciprofloxacin. NTM lung disease should be considered as a potential opportunistic infection in organ transplant recipients.

A Case of Successful Conservative Treatment of Esophageal Perforation from Penetration of Esophageal Wall by a Fish Bone

A 71-year-old man with a history of percutaneous transluminal coronary angioplasty(PTCA) was referred to our clinic with a one-day history of a continuous substernal chest pain radiating to his left shoulder. In retrospect, he experien- ced chest discomfort after eating fish one day before but did not seek medical attention then. An upper gastrointestinal endoscopy was performed. The cause was not visible during the advancement of the endoscope through the eso- phagus, but a small segment of a fish bone protruding from an ulcerative lesion in the lower esophagus was iden- tified while withdrawing the endoscope. The fishbone was immediately removed. A follow-up CT scan revealed pneumo- mediastinum. Now hemodynamically stable, the patient underwent conservative medical treatment including total parenteral nutrition(TPN) and intravenous antibiotic drugs. The patient made complete recovery. We report a case of a 71- year-old male found to have an esophageal perforation from an ingested fish bone, which was managed successfully with conservative treatment. A pertinent literature review is also included.

Long-term Outcome of Treatment of Mycobacterium Abscessus Pulmonary Disease / 결핵및호흡기질환

BACKGROUND: Although there is an increasing incidence of Mycobacterium abscessus pulmonary disease in Korea, the optimal therapeutic regimen has not yet been established and there are no reports of the long-term treatment outcomes. This study examined the long-term treatment outcomes of M. abscessus pulmonary disease. METHODS: Twenty-nine patients diagnosed with M. abscessus pulmonary according to the American Thoracic Society criteria and treated from January 1996 to December 2003 were enrolled in ghis study. The clinical characteristics, radiological findings, treatment outcome, and follow up data were analyzed retrospectively. RESULTS: The mean age of the 29 patients was 56.1 (+/- 13.6) years and there was a female (22/29) dominance. The chest radiography revealed the nodular bronchiectatic type to be dominant (69%, 20/29). Twenty-seven (93.1%) were prescribed clarithromycin-containing regimens, and injectable drugs, mainly aminoglycosides, were included in the regimen of nineteen patients. The most predominant regimen (48.3%) consisted of clarithromycin and amikacin. The treatment success, failure, and default were achieved in 19(65.5%), 9(31.0%), and 1(3.4%), respectively. The median duration to culture conversion was 42 days (range 15-362) and the median duration of treatment in the success group was 543 days (range 176-1,160). An adjunctive surgical resection was performed in five patients, which resulted in treatment success in two patients. After the completion of treatment, nineteen patients were followed up for a median duration of 931 days (range 230-2,294). Only one (5.3%) patient relapsed 45 days after completing treatment. CONCLUSION: Treatment with clarithromycin-containing regimens resulted in a successful treatment in approximately two thirds of patients with M. abscessus pulmonary disease. The long-term relapse rate was also quite low.

Endoscopic Removal of a Severed, Impacted Lithotomy Basket in the Pancreatic Duct in a Patient with Pancreas Divisum: Endoscopic Removal of Severed, Impacted Basket / 대한소화기내시경학회지

Therapeutic endoscopy in patients with pancreas divisum has continued to evolve with the availability of minor papilla endoscopic sphincterotomy, stenting, or sphinteroplasty. A combination of a sphincterotomy followed by balloon/basket deployment and emergency mechanical lithotripsy had facilitated the removal of impacted or large stones in the pancreatic and biliary ducts. The impaction of the basket with captured stones or rupture of the basket traction-wire during mechanical lithotripsy are rare complications. We report the successful retrieval of a center-severed and impacted lithotomy basket in the duct of Santorini in a 47-year-old patient with pancreas divisum. Endobiliary biopsy forceps were introduced into minor papilla, the basket was drawn and the stone was removed successfully after 2 months. To the best of our knowledge, this is a first report of the removal of a center-severed and impacted lithotomy basket in the pancreatic duct.

Detection of Mycobacterium tuberculosis DNA by PCR in Peripheral Blood of Patients with Pulmonary Tuberculosis / 결핵및호흡기질환

BACKGROUND: Although pulmonary tuberculosis (TB) is a respiratory disease, the presence of Mycobacterium tuberculosis (Mtb) DNA or Mtb itself has been reported in the peripheral blood (PB) of several patients with pulmonary TB. Additionally, it was recently announced that active pulmonary TB patients donated PB, and that this blood was then transfused to other individuals in Korea. METHODS: Sixty-nine patients with bacteriologically-confirmed pulmonary TB (35), non-tuberculous mycobacterial (NTM) lung disease (6), and other lung diseases (28) were enrolled in this study, which was conducted to determine if Mtb DNA could be detected in the PB by PCR. In addition, 10 pulmonary TB patients with high-burden bacilli were also enrolled in this study for the culture of Mtb in PB. RESULTS: PCR detected the presence of Mtb in 22.8% (8/35) of the pulmonary TB patients, in 16.7% (1/6) of the patients with NTM lung disease, and in none of the patients with other diseases (0%). In addition, no Mtb was cultured from the PB of the 10 pulmonary TB patients. CONCLUSION: Although Mtb DNA was detected in the PB of some patients with pulmonary TB, viable Mtb was not isolated from the PB of those patients, which indicates that patients that viable Mth may not be transmitted via trasfusion of blood of pulmonary TB patients.