Sequential bilateral rectus sheath hematoma after anticoagulation

Bilateral rectus sheath hematoma [RSH] is extremely rare. Its causes are similar to those of unilateral RSH. However, its clinical manifestation is more serious, usually requiring surgical or endovascular intervention. We report a case of sequential bilateral RSH that was treated successfully. Reinitiating anticoagulation after RSH should be done cautiously, with consideration for the risks and benefits

Spontaneous Coronary Artery Dissection in a female patient with fragile X syndrome / 고신대학교의과대학학술지

We report a case of Spontaneous coronary artery dissection associated with fragile X syndrome. The relationship between fragile X syndrome and Spontaneous coronary artery dissection is unclear. However, More research will need about the causes and treatment of Spontaneous coronary artery dissection.

Paraplegia due to Acute Aortic Coarctation and Occlusion

Coarctation and occlusion of the aorta is a rare condition that typically presents with hypertension or cardiac failure. However, neuropathy or myelopathy may be the presenting features of the condition when an intraspinal subarachnoid hemorrhage has compressed the spinal cord causing ischemia. We report two cases of middle-aged males who developed acute non-traumatic paraplegia. Undiagnosed congenital abnormalities, such as aortic coarctation and occlusion, should be considered for patients presenting with nontraumatic paraplegia in the absence of other identifiable causes. Our cases suggest that spinal cord ischemia resulting from acute spinal subarachnoid hemorrhage and can cause paraplegia, and that clinicians must carefully examine patients presenting with nontraumatic paraplegia because misdiagnosis can delay initiation of the appropriate treatment.

The Value of Assessing Myocardial Deformation at Recovery after Dobutamine Stress Echocardiography

BACKGROUND: The purpose of this study was to evaluate whether performing an assessment of myocardial deformation using speckle tracking imaging during the recovery period after dobutamine stress echocardiography (DSE) allows detection of significant coronary artery disease (CAD) in patients with chest discomfort. METHODS: DSE and coronary angiography were performed in 44 patients with chest discomfort. The mean global longitudinal peak systolic strain (GLS) was measured at rest, at low stress (dobutamine infusion rate of 10 microg/kg/min) and at recovery (5 min after cessation of dobutamine infusion) of DSE using automated function imaging with apical views. Fractional flow reserve (FFR) was also performed in patients with intermediate coronary stenosis. CAD was defined as having a > or = 70% diameter stenosis on coronary angiography or as having a FFR < 0.8. Patients were divided two groups based on the absence or presence of CAD [CAD (-) group vs. CAD (+) group]. RESULTS: There were no significant differences in the clinical characteristics and results of conventional echocardiography between the two groups. GLS at recovery was lower in the CAD (+) group than in the CAD (-) group (-18.0 +/- 3.4% vs. -21.0 +/- 1.9%, p = 0.003). The optimal cutoff of GLS at recovery for detection of CAD was -19% (sensitivity of 70.6%, specificity of 83.3%). CONCLUSION: Assessment of GLS at recovery of DSE is a reliable and objective method for detection of CAD. This finding may suggest that systolic myocardial stunning remains even after recovery of wall motion abnormalities in patients with CAD.

Endovascular repair of bilateral iliac artery aneurysm with branched iliac stents: case report and review of the current literature / 대한외과학회지

Common iliac artery aneurysm (CIA) often occurs in conjunction with an abdominal aortic aneurysm (AAA), which extends into one or both CIAs in 20% to 30% of patients. Conventional endovascular treatment includes coil embolization of the internal iliac artery (IIA), followed by extension of the main bifurcated AAA stent-graft into the external iliac artery. However, complications from intentional occlusion of unilateral or bilateral IIAs are frequent and sometimes serious. Several methods try to preserve the unilateral or bilateral IIA. Here we report a case of concomitant bilateral CIA and AAA successfully treated with bilateral branched iliac stent-grafts.

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 Cardiac Valvular Changes in Ankylosing Spondylitis: A Transesophageal Echocardiography Study

BACKGROUND: This study was conducted to determine the early cardiac valvular changes in young male ankylosing spondylitis (AS) patients. METHODS: A total of 70 AS patients on treatment without clinical cardiac symptoms were divided into group I ( or = 10 years, n = 20) depending on their disease duration after first diagnosis. Twenty-five healthy volunteers were selected as control subjects. All the subjects underwent transthoracic and transesophageal echocardiography, electrocardiography, and rheumatologic evaluation for AS patients. RESULTS: The thickness of both the aortic and mitral valve was more increased in AS patients than in controls. Aortic valve thickness over 1.3 mm could predict AS with a sensitivity of 73% and specificity of 76%. The prevalence of aortic valve thickening was higher in the AS group compared to the controls. The prevalence of aortic and mitral regurgitation was very low and there was no difference between the controls and the patients. The aortic valve thickening was related to longer disease duration, high blood pressure, disease activity and inflammatory markers. CONCLUSION: Thickening of the aortic and mitral valve was observed without regurgitation in male AS patients early in the course of their disease without clinical cardiac manifestations. This subclinical change of aorto-mitral valve in early AS should be considered and followed up to determine its prognostic implication and evolution.

Early Cardiac Valvular Changes in Ankylosing Spondylitis: A Transesophageal Echocardiography Study

BACKGROUND: This study was conducted to determine the early cardiac valvular changes in young male ankylosing spondylitis (AS) patients. METHODS: A total of 70 AS patients on treatment without clinical cardiac symptoms were divided into group I ( or = 10 years, n = 20) depending on their disease duration after first diagnosis. Twenty-five healthy volunteers were selected as control subjects. All the subjects underwent transthoracic and transesophageal echocardiography, electrocardiography, and rheumatologic evaluation for AS patients. RESULTS: The thickness of both the aortic and mitral valve was more increased in AS patients than in controls. Aortic valve thickness over 1.3 mm could predict AS with a sensitivity of 73% and specificity of 76%. The prevalence of aortic valve thickening was higher in the AS group compared to the controls. The prevalence of aortic and mitral regurgitation was very low and there was no difference between the controls and the patients. The aortic valve thickening was related to longer disease duration, high blood pressure, disease activity and inflammatory markers. CONCLUSION: Thickening of the aortic and mitral valve was observed without regurgitation in male AS patients early in the course of their disease without clinical cardiac manifestations. This subclinical change of aorto-mitral valve in early AS should be considered and followed up to determine its prognostic implication and evolution.

Pharmacokinetic and Pharmacodynamic Study Determines Factors Affecting Blood Pressure Response to Valsartan

BACKGROUND: Valsartan is an angiotensin II receptor blocker and is used for patient with hypertension. Although response to valsartan varies each individual, there is no study about factors affecting the variability of valsartan response. METHODS: To investigate the effects of valsartan on the baseline characteristics of blood pressure, single group, open label, pre- and post-comparison clinical study was conducted. Total 21 male Korean volunteers were enrolled. Each subject was administered no drugs in first period and valsartan 80 mg (Diovan HCT) in second period. For pharmacodynamic analysis, 24 hours blood pressure changes were monitored by ambulatory blood pressure monitoring. Twenty-four hour blood pressure changes were matched to valsartan concentration and analyzed by correlation analysis. Changes in blood pressure pattern were also analyzed. Subjects were divided into responder, non-responder, and reverse responder according to pre- and post- 24 hours blood monitoring results. For determination of pharmacokinetic parameters, plasma concentration of valsartan was measured by a validated ultra-performance liquid chromatography-tandem mass spectrometry method. Pharmacokinetic parameters including area under the plasma concentration versus time curve from 0 hour to the last measurable concentration (AUCt), area under the plasma concentration versus time curve extrapolated to infinity, maximum plasma concentration (Cmax), and time required to reach maximum plasma concentration (Tmax) were calculated by noncompartmental models in the BA-CALC 2008 program ver. 1.0.0. RESULTS: There were no significant associations between blood pressure changes and pharmacokinetic parameters of valsartan. Blood pressure pattern change analysis showed significant results. For AUCt, total amount of absorbed valsartan was 25,808 +/- 6,863.0 ng.hr/mL, 20,683 +/- 8,782.7 ng.hr/mL, and 12,502 +/- 5,566.6 ng.hr/mL in responder, non-responder, and reverse responder, respectively (p = 0.041). In C max, maximum concentration of valsartan was 4,314 +/- 1,522.6 ng/mL, 2,588 +/- 1,273.9 ng/mL, and 2,056 +/- 1,075.5 ng/mL, respectively. CONCLUSIONS: These results showed that response to valsartan was not associated with blood concentration in healthy volunteers and changes in blood pressure patterns to valsartan might be associated with the amount of drugs which are absorbed to subjects.

Treadmill Exercise Stress Echocardiography in Patients With No History of Coronary Artery Disease: A Single-Center Experience in Korean Population

BACKGROUND AND OBJECTIVES: Treadmill exercise stress echocardiography (TSE) has superior diagnostic accuracy than exercise electrocardiography (ECG). The objectives of the study are 1) to define the diagnostic accuracy and safety of TSE in patients without a history of coronary artery disease (CAD), 2) to identify the clinical characteristics that predict positive TSE results and 3) to assess the differential predictive value between TSE and concomitant exercise ECG in a Korean population. SUBJECTS AND METHODS: A total of 1,287 patients among 1,500 consecutive patients with no prior history of CAD and who were referred for TSE during a 4-year 3-month period were enrolled. RESULTS: Of the 1,287 patients, 95 (7.4%) showed positive TSE results (newly developed regional wall motion abnormality). Among the 154 patients with coronary angiography, 94 patients (61%) showed significant CAD (30 of 77 patients with negative TSE results and 64 of 77 patients with positive TSE results). The TSE positive population had more cardiovascular risk factors and showed a higher Duke treadmill score and wall motion score index than the TSE negative group. TSE showed relatively good sensitivity (68%), specificity (78%) and positive and negative predictive values (83% and 61%, respectively), and TSE also had higher diagnostic accuracy than concomitant exercise ECG (72% vs. 64%, respectively). CONCLUSION: TSE is safe and offers greater diagnostic power for CAD than exercise ECG in Korean population without a history of CAD. Its prognostic value in this population needs to be confirmed in a larger prospective study.

Sudden Hearing Loss Subsequent to the Percutaneous Coronary Intervention / 대한이비인후과학회지

Sudden sensorineural hearing loss is otologic emergency, accompanying tinnitus and vertigo occasionally within several hours or a few days. Many etiologic theories such as viral infection, vascular occlusion, cochlear membrane break, bacterial infection, autoimmune disorder and neurologic diseases and so forth have been suggested. The risk of cerebrovascular accident in cardiac catheterization and percutaneous coronary intervention is less than 0.5%. The main mechanism of injury results from microembolism and hypoperfusion. A 66-years-old male with long-standing history of ischemic heart disease was presented complaining profound hearing loss, ear fullness, and tinnitus in his right ear and mild vertigo subsequent to the percutaneous coronary intervention in the right side. There was sensory deficit on the right facial side and impairment of eyeball movement on the same side. The T1, T2-weighted and diffusion-weighted magnetic resonance imaging showed acute infarction of the right pons. Heparin was infused intravenously for 5 days. On the 8th day of treatment, the hearing threshold level was completely recovered to the level of the opposite ear. We report a case of hearing loss subsequent to coronary intervention with a review of literature.

Infective Endocarditis with Isolated Double Chambers of the Right Ventricle during Adulthood

Isolated double chambers of the right ventricle (DCRV) are a rare variant of congenital heart disease. We report here on a case of right-sided infective endocarditis with isolated DCRV that presented in adulthood.

Clinical Characteristics of Nosocomial Infective Endocarditis in a Tertiary Referral Hospital

BACKGROUND AND OBJECTIVES: Despite case reports of nosocomial infective endocarditis (NIE), the clinical characteristics of the hospital acquired infective endocarditis have not been investigated in Korea. SUBJECTS AND METHODS: The clinical records of patients with infective endocarditis, treated at Asan Medical Center between January 1989 and December 2003, were retrospectively analyzed. RESULTS: Of the 309 case of native-valve endocarditis, 17 (5.5%) cases were found to be NIE. The mean age of these 17 patients was 51+/-17 years, which included 9 women and 8 men. Staphylococcus aureus was the most frequent causative organism of NIE in 11 cases (65%), of which nine (82%) had methicillin-resistant strains. The prevalence of right-sided vegetation in NIE was higher than that of community acquired infective endocarditis (CIE)(29 vs. 10%, p<0.05); however, left-sided vegetation was observed in more than 70% of patients with NIE (12/17). Surgeries, with or without wound infection (59%) and insertion of a central venous catheter (29%), were the two most common possible sources of NIE. In hospital mortality was significantly higher in patients with NIE than in those with CIE (47 vs. 11%, p<0.001). CONCLUSION: Patients with NIE, which comprises a minor portion of those with infective endocarditis, show unique clinical characteristics in terms of causative organisms, risk factors, sites of vegetation and in-hospital mortality.

Right-Sided Infective Endocarditis in Korea

BACKGROUND AND OBJECTIVES: Right-sided infective endocarditis (RtIE) occurs in about 5-10% of total infective endocarditis cases. In western countries, many cases of RtIE are related to drug addiction. However, there been only scant reports of right-sided infective endocarditis in Korea. The aim of the study was to identify the clinical characteristics of RtIE, such as frequency, predisposing risk factors, causative organisms and in-hospital mortality in Korea. SUBJECTS AND METHODS: All episodes diagnosed as infective endocarditis, between 1989 and 2003, at the Asan Medical Center were retrospectively reviewed using Duke's criteria. A total of 308 patients were diagnosed as infective endocarditis. RESULTS: RtIE was found in 34 patients (11.0%), with a mean age of 44.1+/-15.0 years. Fifteen patients had congenital heart diseases. However, several in-hospital invasive procedures and skin injuries were the most common predisposing risk factors in patients with uncorrected congenital heart disease (group A), whereas unknown causes were most common in patients without uncorrected congenital heart disease (group B). The most common causative organisms in groups A and B were Streptococcus viridans (6/15, 40%) and Staphylococcus aureus (13/19, 68.4%), respectively. In group A, the location of vegetations was variable according to the turbulent flow, but was exclusively at the tricuspid valve in group B. There were 6.7% (1/15) and 26.3% (5/19) inhospital mortalities in groups A and B, respectively (p=0.196). CONCLUSION: No drug addict with RtIE was seen. The most important predisposing risk factor in patients with RtIE was the presence of uncorrected congenital heart disease. The predisposing risk factors, causative organisms and the locations of vegetation in patients with RtIE differed according to the patient's uncorrected congenital heart disease.

Early and late clinical outcomes after primary stenting of the unprotected left main coronary artery stenosis in the setting of acute myocardial infarction / 대한내과학회지

BACKGROUND: Acute left main coronary artery occlusion is a dramatic condition with very high mortality. The study was aimed to evaluate the effect of primary stenting in patients with left main coronary artery disease in the setting of acute myocardial infarction. METHODS: Between June 1997 and April 2002, primary stenting for left main coronary artery disease was performed in eighteen patients with acute myocardial infarction. We evaluated clinical outcomes and prognostic determinants in this clinical setting. RESULTS: Mean ages of patients were 59 +/- 12 years. Fourteen patients had cardiogenic shock on admission. Angiographic success (TIMI flow >or= 2 and diameter stenosis or= 2) was identified as a good prognostic determinant of in-hospital survival. During mean follow-up of 39 +/- 22 months, there was no late death and 1 patient received bypass surgery. Probability of freedom from death at 3-year was 56 +/- 12%. CONCLUSION: Primary stenting is a valuable therapeutic strategy for left main coronary disease in the setting of acute myocardial infarction, and it might save the life especially in patients with good pre-intervention TIMI flow (grade >or= 2). Long-term clinical outcome of patients surviving to hospital discharge is favorable.

Acute pericarditis caused by penetrated polymethylmethacrylate of the right ventricle after percutaneous vertebroplasty / 대한내과학회지

Percutaneous vertebroplasty (PVP) has been known as minimally invasive procedure to treat aggressive vertebral hemangioma, painful osteolytic vertebral tumors, and osteoporotic compression fractures. Some cases were reported to be associated with infrequent but serious complications of this procedure, such as severe arterial hypotension, pulmonary embolism, cerebral embolism, paraplegia, and bronchospasm. We report a case of acute pericarditis after PVP, which was treated successfully with open heart surgery.

Chronobiological Patterns of Acute Aortic Syndrome : Comparison with Those of Acute Myocardial Infarction

BACKGROUND AND OBJECTIVES: Chronobiological rhythms have been shown to influence the occurrence of a variety of cardiovascular disorders, including acute myocardial infarction (AMI). The present study investigated whether the onset of acute aortic syndrome (AAS) has unique chronobiological rhythms in Korean populations. SUBJECTS AND METHODS: The clinical data of 371 consecutive AAS patients, admitted between 1993 and 2003, were retrospectively analyzed; 310 AMI patients, who underwent primary percutaneous angioplasty in the hyperacute phase between 1998 and 2001, were also selected. RESULTS: In the AAS group, the final diagnoses were aortic dissection (AD) and aortic intramural hematoma (AIH) in 212 and 159 patients, respectively Similar to AMI, AAS showed a significantly higher occurrence from 6 AM to noon compared with other time periods (p=0.0013). AAS showed a second peak occurrence from 6 PM to midnight, which was not observed in the AMI group. A subgroup analysis revealed that younger patients (age < 60 years) and those with a past medical history of hypertension had the highest occurrence from 6 PM to midnight, which was quite different compared to the AAS patients. No significant variation was found for the day of the week in either group. Although no significant seasonal variation was observed in the frequency of AMI, the frequency of AAS was significantly higher during winter (p<0.001). The circadian and seasonal variations in the frequency of AIH were similar to those of AD. CONCLUSION: AAS shows unique circadian and seasonal variations in Korean populations. Our findings may have implications for the prevention of AAS by tailoring treatment strategies to ensure maximal benefits during the vulnerable periods.