The Relevance of the Primary Prevention Criteria for Implantable Cardioverter Defibrillator Implantation in Korean Symptomatic Severe Heart Failure Patients

BACKGROUND AND OBJECTIVES: Implantable cardioverter defibrillator (ICD) therapy is recommended as the primary tool for prevention of sudden cardiac death (SCD) in symptomatic patients with severe left ventricular dysfunction. There is a paucity of information on whether this recommendation is appropriate for the Korean population with severe heart failure. SUBJECTS AND METHODS: The study group consisted of 275 consecutive patients (mean age 65 years, 71% male) who met the ICD implantation criteria for primary prevention (left ventricular ejection fraction 0.05). All-cause mortality and the incidence of SCD in the NICMP group were comparable to those of the DEFINITE standard therapy group (13% vs. 17%, 6% vs. 6%, respectively, all p>0.05). CONCLUSION: Korean patients with severe heart failure in both the ICMP and NICMP groups had all-caused mortality and risk of SCD comparable to patients in the MADIT-II and DEFINITE standard therapy groups. Therefore, the primary prevention criteria for ICD implantation would be appropriate in both Korean ICMP and NICMP patients.

Long-term Prognosis of Left Ventricular Lead

Transvenous left ventricular (LV) lead implantation is on the increase due to cardiac resynchronization therapy (CRT). However, there has been paucity of data on the prognosis of LV lead. Consecutive 32 patients with LV lead for CRT (n=22) or pacemaker (n=10) were subjected. Serial changes in pacing threshold and impedance along with lead-related complications were evaluated. Over 2 yr follow-up, there was no significant change in relative threshold voltage to the initial value (100%, 110%, 89.6%, and 79.6% at baseline, 1, 6, and 24 months respectively, P=0.62) as well as lead impedance (816+/-272, 650+/-178, 647+/-191, and 590+/-185 ohm at baseline, 1, 6, and 24 months respectively, P=0.80). The threshold change was not affected by lead position, lead polarity, and indication of lead implantation. The cumulative rates of lead revision were 6.3% (n=2) and 9.4% (n=3) in 6 month and 2 yr follow-up, respectively. One case of phrenic nerve capture at left lateral decubitus position was detected 1 month after the implantation. However, there were no serious complications over 2 yr period. In conclusion, transvenous LV lead implantation showed favorable long-term prognosis. Pacing parameters remained stable without significant changes over 2 yr follow-up.

Short-Term Autonomic Denervation of the Atria Using Botulinum Toxin

BACKGROUND AND OBJECTIVES: Major epicardial fat pads contain cardiac ganglionated plexi (GP) of the autonomic nervous system. Autonomic denervation may improve the success rate of atrial fibrillation (AF) ablation. This study was designed to elucidate the acute effects of blocking the right atrium-pulmonary vein (RA-PV) and left atrium-inferior vena cava (LA-IVC) fat pads on the electrophysiologic characteristics of the atrium and AF inducibility with a botulinum toxin injection. Materials and Methods: Eight mongrel dogs were studied. The RA-PV and LA-IVC fat pads were exposed through a median thoracotomy. Botulinum toxin (BT, 50 U to each fat pad, n=6) or normal saline (NS, n=2) was injected in the entire area of two fat pads. The study protocol was applied before injection and repeated at 1, 2, 3, 4, and 5 hours thereafter. The sinus rate, ventricular rate during rapid atrial pacing with a cycle length of 50 ms, and AF inducibility were measured with and without vagal stimulation (VS). Bilateral cervical VS was applied (20 Hz, 0.2 ms, 5.6+/-2.0 V). AF inducibility was evaluated with burst pacing with 200 impulses at a 50-ms cycle length. RESULTS: VS effects on the sinus node and AF inducibility were eliminated a few hours after injection of BT; these changes were not observed after injection of NS. CONCLUSION: Short-term autonomic denervation of the atria was achieved by blocking the major epicardial GP with BT.

Characteristics of P wave in Patients with Sinus Rhythm after Maze Operation

Maze operation could alter P wave morphology in electrocardiogram (ECG), which might prevent exact diagnosis of the cardiac rhythm of patients. However, characteristics of P wave in patients with sinus rhythm after the operation have not been elucidated systematically. Consecutive patients who underwent the modified Cox Maze operation from January to December 2007 were enrolled. The standard 12-lead ECG and echocardiography were evaluated in patients who had sinus rhythm at 6 months after the operation. The average axis of P wave was 65+/-30 degrees. The average amplitude of P wave was less than 0.1 mV in all 12-leads, with highest amplitude in V1. The most common morphology of P wave was monophasic with positive polarity (49%), except aVR lead, which was different from those in patients with enlarged left atrium, characterized by large P-terminal force in the lead V1. There were no significant differences in P-wave characteristics and echocardiographic parameters between patients with LA activity (30.6%) versus without LA activity (69.4%) at 6 months after the operation. In conclusion, the morphology of P wave in patients after Maze operation shows loss of typical ECG pattern of P mitrale: P wave morphology is small in amplitude, monophasic and with positive polarity.

Remodeling of Ion Channel Expression in Patients with Chronic Atrial Fibrillation and Mitral Valvular Heart Disease

BACKGROUND/AIMS: Underlying cardiac pathology and atrial fibrillation (AF) affect the molecular remodeling of ion channels in the atria. Changes in the expression of these molecules have not been demonstrated in Korean patients with mitral valvular heart disease. Thus, the purpose of this study was to analyze ion channel expression in patients with chronic AF and mitral valvular heart disease. METHODS: A total of 17 patients (eight males and nine females; mean age, 57 +/- 14 years [range, 19 to 77]) undergoing open-heart surgery were included in the study. Twelve patients (seven with coronary artery disease and five with aortic valvular disease) had sinus rhythm, and five patients (all with mitral valvular disease) had chronic, permanent AF. A piece of right atrial appendage tissue (0.5 g) was obtained during surgery. RT-PCR was used to evaluate the expression of L-type Ca2+ channels, ryanodine receptor (RyR2), sarcoplasmic reticular Ca2+-ATPase (SERCA2), gene encoding the rapid component of the delayed rectifier Ikr (HERG), gene encoding calcium-independent transient outward current I(to1) (Kv4.3), gene encoding the ultrarapid component of the delayed rectifier Iku (Kv1.5), K+ channel-interacting protein 2 (KChIP2), hyperpolarization-activated cation channel 2 associated with the pacemaker current If (HCN2), and gene encoding Na+ channel (SCN5A). RESULTS: Reduced L-type Ca2+ channel, RyR2, SERCA2, Kv1.5, and KChIP2 expression and borderline increased HCN2 expression were observed in the patients with AF and mitral valvular heart disease. Left atrial diameter was negatively correlated with RyR2 and KChIP2 expression. Fractional area shortening of the left atrium was positively correlated with RyR2 and KChIP2 expression. CONCLUSIONS: Alterations in ion channel expression and the anatomical substrate may favor the initiation and maintenance of AF in patients with mitral valvular heart disease.

Successful Pacemaker Revision Through Sustained Right Superior Vena Cava in a Patient With Situs Inversus Totalis

In patients with situs inversus totalis, the superior vena cava is normally positioned on the left side and drains into a left-sided right atrium (RA). If right-side superior vena cava (RSVC) is also present, it should be thought of as a combined congenital anomaly. Here, we report a case of successful pacemaker lead insertion through the RSVC in a patient with situs inversus totalis. The left-side superior vena cava (LSVC) had been already used as a route for the first pacemaker lead insertion 15 years earlier. During the pacemaker lead revision, we found that the LSVC was obliterated, and used the RSVC as a route for a new pacemaker lead insertion.

The Association between CD14 Polymorphism and Response to Infectious Agents or Heat Shock Protein in Patients with Stable Coronary Artery Disease in Koreans

BACKGROUND: CD14 is the receptor for lipopolysaccharides and heat shock protein (HSP), which has been suggested being associated with increased risk of coronary artery disease (CAD). We investigated whether the response to infectious agents or HSP is different according to CD14 polymorphism in Koreans. MATERIALS AND METHODS: Antibody titers to Helicobacter pylori, Chlamydia pneumoniae, and human HSP60 (hHSP60) were measured in 48 patients with stable CAD and in 41 healthy controls by ELISA. CD14 genotype was determined by PCR and high-sensitivity C-reactive protein (hs-CRP) was measured. RESULTS: Seropositivity to C. pneumoniae and H. pylori, and antibody titer to hHSP60 were not significantly associated with the presence of CAD. CD14 genotype distribution was 31 TT (35%), 43 CT (48%), and 15 CC (17%). To compare the response to the infectious organism and hHSP60, we divided study population into 3 groups; CAD patients with non-TT genotype (group I, n=30), CAD patients with TT genotype (group II, n=18), and normal controls (group III, n=41). Seropositivity to C. pneumoniae and H. pylori, and antibody titer to hHSP60 were not significantly different among 3 groups. Though hs-CRP level was significantly different among 3 groups, post-Hoc analysis showed that hs-CRP level was not significantly different between group I and group II (group I: 1.6[1.1-3.5] mg/L and group II: 0.35[0.1-2.0] mg/L). Conclusions:This study suggests that the inflammatory responses to infectious organisms and HSP do not differ according to the CD14 genotype in Koreans.

The Association between CD14 Polymorphism and Response to Infectious Agents or Heat Shock Protein in Patients with Stable Coronary Artery Disease in Koreans

BACKGROUND: CD14 is the receptor for lipopolysaccharides and heat shock protein (HSP), which has been suggested being associated with increased risk of coronary artery disease (CAD). We investigated whether the response to infectious agents or HSP is different according to CD14 polymorphism in Koreans. MATERIALS AND METHODS: Antibody titers to Helicobacter pylori, Chlamydia pneumoniae, and human HSP60 (hHSP60) were measured in 48 patients with stable CAD and in 41 healthy controls by ELISA. CD14 genotype was determined by PCR and high-sensitivity C-reactive protein (hs-CRP) was measured. RESULTS: Seropositivity to C. pneumoniae and H. pylori, and antibody titer to hHSP60 were not significantly associated with the presence of CAD. CD14 genotype distribution was 31 TT (35%), 43 CT (48%), and 15 CC (17%). To compare the response to the infectious organism and hHSP60, we divided study population into 3 groups; CAD patients with non-TT genotype (group I, n=30), CAD patients with TT genotype (group II, n=18), and normal controls (group III, n=41). Seropositivity to C. pneumoniae and H. pylori, and antibody titer to hHSP60 were not significantly different among 3 groups. Though hs-CRP level was significantly different among 3 groups, post-Hoc analysis showed that hs-CRP level was not significantly different between group I and group II (group I: 1.6[1.1-3.5] mg/L and group II: 0.35[0.1-2.0] mg/L). Conclusions:This study suggests that the inflammatory responses to infectious organisms and HSP do not differ according to the CD14 genotype in Koreans.

Differences of the Exercise Capacity According to Left Ventricular Geometrical Changes and Its Associated Factors in Hypertensive Patients with Isolated Diastolic Dysfunction

BACKGROUND: Left ventricular(LV) adaptation to high blood pressure produces unique geometrical change, which is closely associated with the prognosis and quality of life in hypertensive patients irrespective of the presence of LV hypertrophy. Exercise capacity assessed by treadmill test(TMT) can provide prognostic information in these patients. We evaluated relationship between LV geometry and exercise capacity in hypertensive patients with isolated diastolic dysfunction. METHODS: According to the echocardiographic results, 109 patients with essential hypertension, who performed TMT for estimating exercise capacity, were classified as having normal LV geometry (NG, n=40) or concentric LV geometry (CG, n=69). Patients with concentric LV geometry were categorized into moderate (n=55) or marked (n=14) CG on the basis of the criteria previously reported. Conventional echocardiographic and tissue Doppler imaging indices were obtained with standard techniques. RESULTS: There were no differences in age, gender and resting heart rate between NG and CG. Maximal exercise time was longer in NG than in CG (617.3+/-131.5 vs. 566.0+/-155.0 seconds, p<0.05). Late diastolic mitral annular velocity (AO) exhibited a significant correlation with maximal exercise time in moderate and marked CG (r=0.30 and 0.56, both p<0.05), which remained significant after multivariate linear regression analysis with variables such as age, LV mass, early to late mitral inflow ratio, AO velocity, LV ejection fraction and left atrial size, whereas such a correlation could not be found in NG. CONCLUSION: Since exercise performance decreases when there is LV concentric remodeling, LV geometry needs to be considered in the assessment of exercise capacity in patients with essential hypertension and isolated diastolic dysfunction. Atrial systolic function plays a crucial role in maintaining exercise capacity in these patients, especially in those with increased LV concentricity.

Late Late Stent Thrombosis after Intracoronary Brachytherapy: Learning from Brachytherapy Experiences in the Drug-Eluting Stent Era

Stent thrombosis is generally a fatal complication after percutaneous coronary intervention. Combined antiplatelet therapy is recommended to prevent stent thrombosis in those patients who have undergone stenting. However, there are conflicting opinions on the appropriate duration of instituting antiplatelet treatment, especially after intracoronary radiation therapy or drug-eluting stent implantation, which are two situations closely associated with an increased risk of stent thrombosis. We report here on 2 cases of late stent thrombosis that occurred despite giving combined antiplatelet therapy, and these maladies developed more than 4 years after intracoronary brachytherapy.

Echocardiographic Parameters for Predicting the Outcome of Patients Undergoing Surgery for Severe Tricuspid Regurgitation

BACKGROUND AND OBJECTIVES: This study was performed to identify echocardiographic parameters related to postoperative clinical outcome (PCO) in patients undergoing surgery for severe tricuspid regurgitation (TR) following mitral valve surgery. The indications for surgery due to severe TR following mitral valve surgery are not well defined largely because of a lack of knowledge of the prognostic factors of PCO in these patients. SUBJECTS AND METHODS: Eighteen patients (male/female; 2/16, mean age 58 years) with severe TR associated with prior mitral valve surgery were prospectively enrolled. Comprehensive echocardiographic examinations were performed before and 15+/-7 months after surgery. Favorable PCO was defined as an improvement of > or =1 in New York Heart Association (NYHA) functional class or a >25% increase in respiratory variation of IVC diameter. Non-survivors and survivors without a favorable PCO were defined as having an unfavorable PCO. RESULTS: The operative mortality was 11% (2/18). Of the 16 survivors, nine (9/16, 56%) achieved a favorable PCO. NYHA functional class, age, left ventricular ejection fraction, right ventricular fractional area change, severity of TR and pulmonary artery pressure were not related to PCO. Only systolic tricuspid annulus velocity (ST') was found to be associated with PCO (favorable vs unfavorable PCO; 12.9+/-2.1cm/s vs 9.7+/-1.7cm/s, p<0.05). For ST' value (9.5 cm/s, the sensitivity, specificity, positive and negative predictive values for predicting an unfavorable PCO were 67%, 100%, 100% and 75%, respectively. CONCLUSION: This study shows that ST' can predict PCO in patients undergoing surgery for severe TR following mitral valve surgery.

Association of the Invasively Measured Aortic Stiffness and Coronary Artery Disease

BACKGROUND AND OBJECTIVES: Aortic stiffness is believed to be an important risk factor of coronary artery atherosclerosis (CAA), as it directly affects coronary perfusion. The following aspects of the invasively measured aortic pulse wave velocity (PWV) were assessed in relation to CAA: The effect of cardiovascular risk factors on PWV, the effect of PWV on the severity of CAA and on the development of the restenosis after drug-eluting stent (DES) implantation. SUBJECTS AND METHODS: 371 subjects who had undergone coronary angiography were enrolled, with all undergoing an invasive aortic PWV measurement also. 112 patients, who had undergone a DES implantation, were prospectively investigated for the effect of PWV in relation to the subsequent risk of major adverse cardiac events (MACE). RESULTS: Among the conventional cardiovascular risk factors, an age >60 (10.79+/-4.92 vs. 8.35+/-4.02, p=0.0006), diabetes (10.97+/-4.66 vs. 9.26+/-4.70 m/sec, p=0.0118) and dyslipidemia (10.38+/-4.97 vs. 9.47+/-4.55m/sec, p=0.0421) were significantly associated with an increased PWV, but sex, smoking and hypertension were not associated with an increased PWV. The PWV was shown to be significantly associated with the severity of CAD. The odds ratio (OR) of 1m/sec increment in the PWV for an increased vessel score was 1.08 (95% confidence interval (CI): 1.03-1.13, p=0.0017). There were no differences in the incidence of MACE and the changes in the angiographic parameters between the high (>10 m/sec) and low PWV groups. CONCLUSION: The invasively measured aortic PWV was affected by age (>60), diabetes and dyslipidemia, and also showed a strong association with the severity of CAD. The aortic PWV was not a significant risk factor for restenosis following a DES implantation.

Long-Term Effect of Repeated Brachytherapy in Intracoronary Brachytherapy Failed Lesions

BACKGROUND AND OBJECTIVES: An intracoronary brachytherapy is the only approved treatment for in-stent restenosis. However, a considerable rate of restenosis occurs after a brachytherapy. Up to now, there was no long term outcome for repeated brachytherapy for these lesions. SUBJECTS AND METHODS: Eleven patients were admitted due to angina, with significant ischemic evidence in the stress test after the intracoronary brachytherapy. These patients were re-treated with a beta-emitting 188 rhenium-DTPA (diethylene triamine penta-acetic acid) filled balloon catheter system, using an identical method and radiation dose (17.6 Gy) to the initial radiation treatment. The long term angiographic and clinical outcomes of repeated brachytherapy in these patients were evaluated. RESULTS: The angiographic and clinical data of ten patients were evaluated, as 1 was lost. The follow-up period was 37.4+/-16.2 months (range, 8 to 53 months). There was no angiographic restenosis or target lesion revascularization (TLR) during the short term follow-up period (mean 6 months). but 2 restenosis (25%) occurred in the 2 year follow-up period and one other was added during the long term clinical follow-up period. All these restenosis lesions needed revascularization. These three TLRs occurred at 15, 24 and 43 months after the repeated brachytherapy. There was no death or nonfatal MI. No vascular perforation, aneurysm or late thrombosis was observed. CONCLUSION: A repeated brachytherapy for the treatment of a failed intracoronary brachytherapy lesion is safe and acceptably effective during the long term follow-up period. This modality might be considered as a therapeutic option for failed intracoronary brachytherapy lesions.

Long-term clinical outcomes of newly implanted stents during intracoronary radiation / 대한내과학회지

BACKGROUND: New stent implantation during intracoronary brachytherapy is discouraged due to the high risk of late thrombosis. However, new stent implantation is inevitable in some cases due to the inadequate ballooning or major dissections. Long-term follow-up results of newly implanted stents during brachytherapy are not well-known. We performed this study to evaluate the long-term clinical outcomes of newly implanted stents during intracoronary brachytherapy. METHODS: In the Seoul national university Post-Angioplasty RhEnium irradiation (SPARE) trial, patients were treated with conventional catheter-based technique and then randomized to either beta- radiation (RG) or control group (CG). Radiation was performed with 188 -rhenium-filled conventional balloon catheter system. From 1999 to 2001, new stent implantation was performed in 58 and 56 patients in RG and CG, respectively. Clinical and angiographic follow up data were analyzed. RESULTS: In RG, short-term angiographic restenosis rate was lower than CG (28.6% vs 53%, p=0.03). In RG, late thrombosis was found in 3 patients. However, there was no late thrombosis in CG. Two year major cardiac event rates were not different between the 2 groups (RG: 25.9% vs CG: 28.3%). Independent predictors for major cardiac event in RG were major dissections (>or=type C) after stent implantation (beta=70, p=0.01) and longer administration of dual antiplatelets (aspirin+clopidogrel/ ticlopidine, >6 months, beta=0.07, p=0.04). CONCLUSION: Stenting during intracoronary brachytherapy seems to be ineffective in reducing long-term event rates. When new stent implantation is inevitable during brachytherapy, extreme attention is required not to make a dissection and long-term dual antiplatelet treatment should be followed after stent implantation.

A Case of Idiopathic Acute Myocarditis with Isolated Right Ventricular Failure

A 68 year-old woman was admitted due to chest pain with dyspnea. Transthoracic echocardiography showed isolated right ventricular dysfunction. Coronary angiogram was normal. Cardiac enzyme was elevated persistently. Under the supposed diagnosis of acute idiopathic myocarditis, she was treated with supportive care but symptom and cardiac enzyme was not improved. After steroid pulse therapy, symptom was improved and cardiac enzyme was normalized. She was discharged with improvement of symptoms.

Changes in Coronary Flow Reserve Assessed by Transthoracic Echocardiography after Lipid-Lowering Therapy in Patients with Hypercholesterolemia

BACKGROUND: The coronary flow reserve is known to be reduced in patients with hypercholesterolemia, and has also been reported to improve after lipid-lowering therapy. Using transthoracic Doppler echocardiography, the changes in the coronary flow reserve were evaluated after lipid-lowering therapy in hypercholesterolemic patients. METHODS: The coronary flow reserve was determined by pulsed-wave Doppler examination at the distal left anterior descending coronary artery before and after five months of lipid-lowering therapy in 14 hypercholesterolemic patients (total cholesterol > or =230 mg/dL) with no other modifiable risk factors of coronary heart disease. RESULTS: In all patients, the total cholesterol and low-density lipoprotein (LDL) cholesterol were significantly decreased after therapy (from 273+/-27 mg/dL to 199+/-22 mg/dL, p=0.001, from 182+/-25 mg/dL to 110+/-27 mg/dL, p=0.001, respectively). However, there was no significant change in the coronary flow reserve after lipid-lowering therapy (from 2.4+/-0.5 to 2.5+/-0.5, p=0.875). The Baseline LDL-cholesterol showed an inverse correlation with the baseline coronary flow reserve (r =-0.649, p=0.012). CONCLUSIONS: In the present study, no significant change in the coronary flow reserve was noted after lipid-lowering therapy in hypercholesterolemic patients with no other risk factors of coronary heart disease, although the baseline LDL-cholesterol levels were found to correlate well with the baseline coronary flow reserve. Transthoracic Doppler echocardiography can be used to easily and non-invasively evaluate the changes in the coronary flow velocity, coronary flow reserve and other related parameters. Therefore, a controlled trial using transthoracic Doppler echocardiography relating to the effect of lipid-lowering therapy on patients showing a wider range of baseline risk factors and LDL-cholesterol level is required.

A Patient with Prior History of Open Heart Surgery, who Survived from a Traumatic Ventricular Free Wall and Coronary Artery Rupture, without Surgical Repair

A case of a 23 year-old man who, thanks to his parietal pericardium, scarred by previous open heart surgery, survived traumatic ventricular free wall and coronary artery rupture, without surgical repair, is reported. He was injured in a traffic accident and transferred to our hospital immediately. On arrival, he was hypotensive, with blood pressure of 53/25 mmHg. Because hemoperitoneum was suspected, an emergency exploratory laparotomy was performed. After surgery, his blood pressure stabilized, but electrocardiography showed abnormal findings that had not existed before the traffic accident. To find the probable cause of the electrocardiographic changes, echocardiography was performed, which showed a right ventricular free wall and right coronary artery ruptures. Nevertheless, he survived, without surgery, due to the thickened and adhered pericardium around the rupture site, which presumably resulted from the prior open heart surgery. Since discharged, he has remained well for nine months, with no further events.

Risk Factors of No-Reflow Phenomenon after Primary Percutaneous Coronary Intervention with Stent Implantation

BACKGROUND AND OBJECTIVES: No-reflow is an important phenomenon for limiting the prognosis of patients following primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI). Coronary stenting is the current standard procedure for primary PCI in AMI. However, stenting is suspected to cause more microembolization, and no-reflow phenomenon. This study was performed to elucidate the risk factors for the no-reflow phenomenon following primary PCI with stenting, in patients with AMI. SUBJCETS AND METHODS: The clinical, angiographic and procedure related parameters were reviewed in patients with AMI that had undergone primary PCI, with stent implantation, within 12 h of the onset of chest pain, at Seoul National University Hospital, Yonsei University Hospital Cardiovascular Center and Chungbuk National University Hospital (n=183). RESULTS: 29 patients (16%) showed no-reflow phenomenon (final TIMI flow grade less than 3). Conventional risk factors for coronary artery disease were not significant risk factors for the no-reflow phenomenon. In a univariate analysis, a high initial CK-MB level (>50 IU) (8.45% vs. 21.9%, p=0.04), low left ventricular ejection fraction (LV EF) (30 sec) (31% vs. 15%, p=0.04) were significant risk factors of the no-reflow phenomenon. A low LV EF and long pre-dilatation balloon inflation time were significant risk factors in a multivariate analysis. CONCLUSION: LV dysfunction at presentation and a long pre-dilatation balloon inflation time were independent risk factors for the no-reflow phenomenon following primary PCI with stenting for AMI. Preventive measures against the no-reflow phenomenon should be considered in patients with these risk factors.

Risk Factors of No-Reflow Phenomenon after Primary Percutaneous Coronary Intervention with Stent Implantation

BACKGROUND AND OBJECTIVES: No-reflow is an important phenomenon for limiting the prognosis of patients following primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI). Coronary stenting is the current standard procedure for primary PCI in AMI. However, stenting is suspected to cause more microembolization, and no-reflow phenomenon. This study was performed to elucidate the risk factors for the no-reflow phenomenon following primary PCI with stenting, in patients with AMI. SUBJCETS AND METHODS: The clinical, angiographic and procedure related parameters were reviewed in patients with AMI that had undergone primary PCI, with stent implantation, within 12 h of the onset of chest pain, at Seoul National University Hospital, Yonsei University Hospital Cardiovascular Center and Chungbuk National University Hospital (n=183). RESULTS: 29 patients (16%) showed no-reflow phenomenon (final TIMI flow grade less than 3). Conventional risk factors for coronary artery disease were not significant risk factors for the no-reflow phenomenon. In a univariate analysis, a high initial CK-MB level (>50 IU) (8.45% vs. 21.9%, p=0.04), low left ventricular ejection fraction (LV EF) (30 sec) (31% vs. 15%, p=0.04) were significant risk factors of the no-reflow phenomenon. A low LV EF and long pre-dilatation balloon inflation time were significant risk factors in a multivariate analysis. CONCLUSION: LV dysfunction at presentation and a long pre-dilatation balloon inflation time were independent risk factors for the no-reflow phenomenon following primary PCI with stenting for AMI. Preventive measures against the no-reflow phenomenon should be considered in patients with these risk factors.

A Case of Successful Implantation of a DDD Type Permanent Pacemaker in a Patient with Persistent Left Superior and Absent Right Superior Vena Cava

Persistent left superior vena cava is a rare congenital anomaly resulting from the failure of the left cardinal vein to degenerate in utero. This anomaly was discovered in 0.3% of large autopsy examinations. Its most relevant clinical implication is the association with cardiac impulse formation and conduction problems. In the case of DDD pacemaker implantation for this anomaly, skillful manual stylet shaping is required or an active fixation device, for example a screw device for stable positioning of pacemaker leads, is needed. We experienced a case of sick sinus syndrome in a patient with persistent left superior and absent right superior vena cava in 72-year-old man. We successfully implanted a DDD type pacemaker through the left superior vena cava via coronary sinus. This is the first Korean report of a successfully implanted permanent pacemaker in a patient with persistent left superior and absent right superior vena cava.