The Comparative Clinical Effects of Valsartan and Ramipril in Patients With Heart Failure

BACKGROUND AND OBJECTIVES: Angiotensin II receptor blocker (ARB) has emerged as an alternative to angiotensin converting enzyme inhibitor (ACEI) for the treatment of heart failure. This study aimed at comparing the effectiveness and safety of valsartan with ramipril in patients with heart failure, and these patients were hospitalized at Chonnam National University Hospital, Wonkwang University Hospital, Gunsan Medical Center, Presbyterian Medical Center, Seonam University Hospital and Gwangju Christian Hospital. SUBJECTS AND METHODS: Between March 2005 and March 2007, 82 patients (60.5+/-12.4 years, 59 males) who complained of class II to IV dyspnea, according to the New York Heart Association (NYHA) classification, and who had low left ventricular ejection fraction (LVEF) less than 50% were randomly allocated to valsartan or ramipril. After 6 months, the clinical symptoms, vital signs, biochemical tests and echocardiography were compared between the two groups. RESULTS: The NYHA class was improved in both groups (the valsartan group: 2.31+/-0.51 vs. 1.46+/-0.58, p<0.001; the ramipril group: 2.21+/-0.55 vs. 1.61+/-0.50, p<0.001). The incidence of cough, as measured by the cough index, was significantly lower in the valsartan group than in the ramipril group (p=0.045). The LVEF was improved in both groups (the valsartan group: 36.4+/-8.5% vs. 46.9+/-12.9%, p<0.001; the ramipril group: 35.1+/-8.5% vs. 45.3+/-11.2%, p<0.001). The improvements of the left ventricular end-systolic dimension (p=0.754) and end-diastolic dimension (p=0.998) were not different between the two groups. N-terminal Pro-B-type natriuretic peptide level was improved in both groups (the valsartan group: 2619.6+/-4213.5 vs. 995.4+/-2186.0 pg/mL, p=0.012; the ramipril group: 3267.9+/-4320.0 vs. 828.1+/-1232.8 pg/mL, p=0.009), and there was no difference between the groups (p=0.877). CONCLUSION: Both valsartan and ramipril were effective treatments, with relatively low adverse events, in patients with heart failure.

The effects of TIMI flow before mechanical reperfusion therapy on the long term clinical outcomes in patients with acute ST-segment elevation myocardial infarction / 대한내과학회지

BACKGROUND: Epicardial infarct-related artery patency is reliably assessed by the Thrombolysis In Myocardial Infarction flow grade (TFG), and this index is associated with clinical outcomes after fibrinolytics or primary angioplasty in patients with acute myocardial infarction (AMI). The aim of this study was to examine long-term clinical outcomes according to the pre-procedural TFG in AMI after percutaneous coronary intervention (PCI). METHODS: A total of 132 patients with AMI who underwent PCI between July 2001 and December 2001 at Chonnam National University Hospital were divided into two groups according to the pre-procedural TFG: Group I (n=60, 62.7+/-9.2 years, male 66.7%) with TFG 0-1 and Group II (n=72, 61.6+/-11.1 years, male 68.1%) with TFG 2-3. RESULTS: Hypertension was more prevalent in Group I than that in Group II (56.7% vs. 27.8%, p=0.001) and cardiogenic shock on admission was more frequently observed in Group I than that in Group II (20.0% vs. 5.6%, p=0.011). The left ventricular ejection fraction was lower in Group I than that in Group II (42.6+/-10.5% vs. 50.5+/-12.1%, p=0.022). The levels of inflammatory markers such as C-reactive protein (CRP), erythrocyte sedimentation rate, fibrinogen, white blood cell and monocyte counts were higher in Group I than in Group II. On diagnostic coronary angiogram, complex lesion was more frequently observed in Group I than that in Group II (53.4% vs. 36.2%, por=0.5 mg/dL, age >or=70 years, triple vessel disease, low pre-interventional TFG (0-1) and post-interventional TFG (0-2). CONCLUSION: Low pre-procedural TFG is associated with hypertension, cardiogenic shock, left ventricular dysfunction, and high mortality, and low event-free survival during one-year clinical follow-up after PCI in AMI.

The Clinical Effects of Nicorandil during Percutaneous Coronary Intervention in Patients with Unstable Angina

BACKGROUND AND OBJECTIVES: The purpose of the study was to evaluate the clinical effect of Nicorandil during percutaneous coronary intervention (PCI) in patients with unstable angina (UA). SUBJECTS AND METHODS: Two hundred patients (61+/-10 years, male 143) with UA were randomly assigned to two groups: intravenous Isosorbide dinitrate (Group I, n=100) and intravenous Nicorandil (Group II, n=100). PCI was performed 12-48 hours after infusion of the agents. The post-procedural cardiac enzymes, 6-month MACE (major adverse cardiac event) and left ventricular ejection fraction (LVEF) were compared between the two groups. RESULTS: Successful PCI was performed in 96 patients (Group I=54, Group II=42). Patients requiring either emergent coronary angiography, temporary pacemaker or platelet glycoprotein IIb/IIIa receptor blocker were excluded. No significant differences were observed between the two groups in terms of the clinical and coronary angiographic characteristics. The level of creatine kinase-MB was elevated in 9 (17%) and 6 patients (14%), troponin T in 16 (30%) and 6 (14%) and troponin I in 25 (46%) and 9 (21%) patients of Groups I and II, respectively, after the PCI. The elevation of all troponins was lower in Group II (28 vs. 10 patients, p=0.01). MACE developed in 9 (17%) and 5 (12%) patients of Groups I and II (p=NS), respectively, during the 6-month clinical follow-up. The LVEF was higher in Group II than in Group I on follow-up echocardiography (65.4+/-7.2% vs. 71.0+/-6.7%, p=0.003). CONCLUSION: Nicorandil may have a myocardial protective effect during PCI in patients with UA.

The Effects of QRS Duration and Pacing Sites on the Acute Hemodynamic Changes during Right Ventricular Pacing

BACKGROUND: Has been reported that patients exhibiting prolonged paced QRS duration tend to have more serious heart disease, and the paced QRS duration can be an effective indicator of impaired left ventricular function. However, the acute and chronic hemodynamic effects of paced QRS duration and pacing sites during right ventricular (RV) pacing remain unknown. METHODS: A total of 14 patients who underwent electrophysiologic study for paroxysmal supraventricular tachycardia were examined. RV pacing was performed at 10 different sites with cycle lengths of 600 ms and 500 ms utilizing a 6-7F deflectable quadripolar electrode catheter. Systolic, diastolic, and mean blood pressures during pacing were measured once the blood pressure was stabilized. RESULTS: During RV pacing, blood pressures (systolic/diastolic/mean) decreased. The change of post-pacing QRS duration and pre-pacing the systolic blood pressure (SBP) were greater in the group with paced QRS duration. The differences overall were greater than 140 ms. The SBP decrease during pacing was larger in the group exhibiting paced QRS duration of greater than 140 ms. The SBP decrease during pacing showed relation to QRS duration during pacing (r=0.500, p=0.001), the change of QRS duration post-pacing (r=0.426, p=0.001), and SBP during sinus rhythm (r=0.342, p=0.001) on linear correlation analysis. The pacing site, on the other hand, did not affect acute hemodynamic changes during pacing. CONCLUSION: Ventricular pacing of less than 40 ms at the area of paced QRS duration is recommended.

Stent Graft for a Coronary Arteriovenous Fistula in Acute Myocardial Infarction

The stent graft has recently been used for the treatment of coronary artery aneurysms, perforations, dissection and arteriovenous fistula. An 81-year-old male presented with chest pain of 2-day duration. A 12-lead electrocardiogram showed atrial fibrillation and ST-T changes over the precordial leads. A diagnostic left coronary angiogram (CAG) revealed critical stenosis in the proximal left anterior descending coronary artery (LAD) and prestenotic dilatation with large coronary arteriovenous fistula draining into the main pulmonary artery. After predilation, a polytetrafluoroethylene (PTFE) covered stent graft (3.0x16 mm JoStent Graft Master(r), JoMed, Germany) for fistula and an additional conventional stent for just below the graft stented site of proximal LAD stenosis were implanted successfully. After stenting, no visible large fistula or remaining stenosis was demonstrated on CAG. The stent graft was deployed with a high success rate. The restenosis rate was not higher than expected for bare stents. However, as subacute occlusion may occur more frequently, long-term ticlopidine or clopidogrel treatment should be required.

Pacemaker Lead Endocarditis Caused by Achromobacter xylosoxidans

We report the case of a 35-yr-old patient who presented with high fever and chills. He had undergone a patch closure of the ventricular septal defect 18 yr before. One year later, a VVI pacemaker was implanted via the right subclavian vein because of complete heart block. Nine years after that, a new VVI pacemaker with another right ventricular electrode was inserted controlaterally and the old pacing lead was abandoned. Trans-thoracic and trans-esophageal echocardiogram identified the pacemaker lead in the right ventricle (RV) attaching hyperechoic materials and also a fluttering round hyperechoic mass with a stalk in the RV outflow tract. Cultures in blood and pus from pacemaker lead grew Achromobacter xylosoxidans. A diagnosis of pacemaker lead endocarditis due to Achromobacter xylosoxidans was made. In this regards, the best treatment is an immediate removal of the entire pacing system and antimicrobial therapy.

The Clinical Effect of Intracoronary Adenosine and Nicorandil on No-reflow in Acute Myocardial Infarction during Percutaneous Coronary Intervention

BACKGROUND AND OBJECTIVES: This study aimed to clarify the role of combined intracoronary administration of adenosine and nicorandil in the no-reflow phenomenon. SUBJECTS AND METHODS: Thirty four patients (66+/-10 years, 19 male) who developed no-reflow phenomenon during percutaneous coronary intervention (PCI) between January 2000 and December 2002 were examined as the subjects of the study. We classified the subjects into two groups:group I (20 patients, 67+/-10 years, 10 male, nitrate alone) and group II [14 patients, 69+/-11 years, 9 male, combined intra-coronary administration of adenosine (24 microgram/mL), nicorandil (2 mg/mL), and nitrate]. In-hospital and 6-month major adverse cardiac events (MACE) after PCI were compared between the two groups. RESULTS: Mean age, sex, and risk factors were similar in both groups. Left ventricular ejection fraction was 49+/-7.4% in group I and 49+/-13.6% in group II (p=NS). The number of involved vessels, lesion type according to ACC/AHA classification, and TIMI flow rate were similar in both groups (p=NS). Incidence of dissection after balloon angioplasty, diameter and length of stent, and use of Reopro(r) did not differ during PCI. TIMI 3 flow was obtained in 10 (50%) out of 20 patients in group I and in 11 (78.6%) out of 14 patients in group II (p=0.033);blush score 3 was obtained in 8 (40%) patients in group I and in 10 (71.4%) patients in group II (p=0.01). In-hospital death did not occur in group II, but occurred in 4 patients in group I (p=0.041). MACE developed in an additional two patients in group I, and heart failure occurred in 6 (30%) and 3 (21.4%) patients in groups I and II, respectively, during a 6-month follow-up period (p=NS). CONCLUSION: Intracoronary administration of ade-nosine with nicorandil improves no-reflow in patients with AMI during PCI and enhances the short-term clinical outcome.

Acute Myocardial Infarction due to Coronary Arteriovenous Fistula in the Left Main and Anterior Descending Coronary Artery

A coronary arteriovenous fistula (CAVF) is an unusual anomaly in adults, and a CAVF arising from the left main and anterior descending arteries, presenting with acute myocardial infarction and cardiogenic shock, has not been reported. A 62 year-old male suffered from chest discomfort of 3-hour duration. His blood pressure at the emergency room was 70/40 mmHg, and an electrocardiogram showed marked ST segment depression in leads II, III and aVF, and from V3 to V6. The levels of creatinine kinase-MB and troponin I were 65 U/L and 4.36 ng/mL, respectively. A diagnostic coronary angiogram revealed no significant coronary stenosis, but large coronary arteriovenous fistulae originating from the left main and anterior descending coronary arteries to the main pulmonary artery. Surgical ligation for a CAVF was successfully performed, and a one-month follow-up coronary angiogram showed completely ligated fistulae.

Long-term predictive factors of major adverse cardiac events in patients with acute myocardial infarction complicated by cardiogenic shock / 대한내과학회지

BACKGROUND: Cardiogenic shock (CS) after acute myocardial infarction (AMI) is developed in 5~10% of patients and associated with high mortality. The aim of this study is to assess the predictive factors of major adverse cardiac events (MACE) in patients with AMI and CS. METHODS: Two hundred fifty five AMI patients with CS (66.0 +/- 11.0 years, M:F=156:99) out of 1,268 AMI patients, who admitted at Chonnam National University Hospital between July 2000 and June 2002, were analyzed according to clinical characteristics, coronary angiographic findings and MACE during admission and 1-year clinical follow-up. RESULTS: Among the enrolled patients, 129 patients survived without MACE (Group I, 64.2 +/- 10.6 years, M:F=76:53) and 126 patients had MACE (Group II, 68.1 +/- 10.0 years, M:F=80:46) during admission and 1-year follow-up period. There were significant differences in age (64.2 +/- 10.6 vs. 68.1 +/- 11.0 years, p=0.004) and previous MI history (0 vs. 17.4%, p<0.001). Left ventricular ejection fraction (EF) was lower in Group II (Group I vs. II: 49.1 +/- 13.0 vs. 39.1 +/- 12.9%, p<0.001). The levels of troponin (Tn) I and C-reactive protein (CRP) were higher in Group II (Group I vs. II: 29.2 +/- 7.72 vs. 50.8 +/- 5.17 ng/dL, p=0.017, 3.8 +/- 0.48 vs. 9.9 +/- 1.21 mg/dL, p<0.001 respectively). Left main stem lesion (LMSL) was more common in Group II than in Group I (0.7% vs. 22.0%, p=0.004). In-hospital death was associated with low Thrombolysis In Myocardial Infarction (TIMI) flow after coronary revascularization. CONCLUSION: Old age, previous MI history, high Tn and CRP, low EF and LMSL are associated with higher MACE in patients with AMI and CS. Coronary revascularization with TIMI 3 flow lowers in-hospital mortality.

Acute Thrombosis in Coronary and Renal Arteries after Cisplatin and 5-Fluorouracil Administration

A 55-year old male presented with chest and abdominal pain for four hours. One day prior to admission he had received chemotherapeutic agents comprising 130 mg cisplatin and 5,200 mg 5-Fluorouracil for nasopharyngeal carcinoma. EKG showed ST elevations in the leads II, III and aVF. The levels of cardiac enzymes were elevated [creatine kinase (CK) 1129 U/L, CK-MB 180 U/L, troponin T 1.23 ng/mL and troponin I 23.29 ng/mL]. Urokinase was administered at the emergency room, but the patient's chest pain continued with persistent ST segment elevations. Urgent coronary and renal angiograms revealed thrombotic occlusive lesions in the distal right coronary and right renal arteries. Percutaneous transluminal renal angioplasty using 6.0x20 mm balloon was performed for the renal artery. However, filling defects and distal renal flow were not improved and so Abciximab (ReoPro(r)) was administered. Follow-up coronary and renal angiograms on the fifth hospital day showed no filling defects with good distal flow in both right coronary and renal arteries.

Acute Thrombosis in Coronary and Renal Arteries after Cisplatin and 5-Fluorouracil Administration

A 55-year old male presented with chest and abdominal pain for four hours. One day prior to admission he had received chemotherapeutic agents comprising 130 mg cisplatin and 5,200 mg 5-Fluorouracil for nasopharyngeal carcinoma. EKG showed ST elevations in the leads II, III and aVF. The levels of cardiac enzymes were elevated [creatine kinase (CK) 1129 U/L, CK-MB 180 U/L, troponin T 1.23 ng/mL and troponin I 23.29 ng/mL]. Urokinase was administered at the emergency room, but the patient's chest pain continued with persistent ST segment elevations. Urgent coronary and renal angiograms revealed thrombotic occlusive lesions in the distal right coronary and right renal arteries. Percutaneous transluminal renal angioplasty using 6.0x20 mm balloon was performed for the renal artery. However, filling defects and distal renal flow were not improved and so Abciximab (ReoPro(r)) was administered. Follow-up coronary and renal angiograms on the fifth hospital day showed no filling defects with good distal flow in both right coronary and renal arteries.

A Successful Stenting of the Coarctation of the Distal Thoracic Aorta (Middle Aortic Syndrome) in an Adult

An isolated coarctation of the lower descending thoracic aorta in adults is a very rare vascular disorder. To the best of our knowledge, the treatment of a coarctation of the descending aorta (middle aortic syndrome) in an adult, using stenting, has never been reported in Korea. A 44 year-old male, suffering from claudication of the both legs for 25 years, was admitted to our hospital. An aortogram revealed a coarctation of the distal thoracic aorta at the T11 level, with a 60 mmHg peak systolic pressure gradient across the lesion. A balloon angioplasty, followed by an 18x40 mm stent implantation, was performed successfully. The peak systolic pressure gradient decreased from 60 mmHg to 15 mmHg. The patient's symptom was relieved after stenting, with no significant adverse events observed during a three-month clinical follow-up.

A Successful Stenting of the Coarctation of the Distal Thoracic Aorta (Middle Aortic Syndrome) in an Adult

An isolated coarctation of the lower descending thoracic aorta in adults is a very rare vascular disorder. To the best of our knowledge, the treatment of a coarctation of the descending aorta (middle aortic syndrome) in an adult, using stenting, has never been reported in Korea. A 44 year-old male, suffering from claudication of the both legs for 25 years, was admitted to our hospital. An aortogram revealed a coarctation of the distal thoracic aorta at the T11 level, with a 60 mmHg peak systolic pressure gradient across the lesion. A balloon angioplasty, followed by an 18x40 mm stent implantation, was performed successfully. The peak systolic pressure gradient decreased from 60 mmHg to 15 mmHg. The patient's symptom was relieved after stenting, with no significant adverse events observed during a three-month clinical follow-up.

The effects of QRS duration and pacing sites on the acute hemodynamic change during right ventricular pacing / 대한내과학회지

BACKGROUND: Intraventricular conduction disturbances, as manifested by increased QRS duration, are common in patients with advanced left ventricular (LV) dysfunction and adversely affect LV systolic and diastolic function. It has been reported that the patients with prolonged paced QRS duration have more serious heart disease, and the paced QRS duration can be a useful indicator of impaired LV function. Hemodynamic effects of paced QRS duration and pacing site during right ventricular (RV) pacing are unknown. METHODS: A total of 14 patients who underwent electrophysiologic study for paroxysmal supraventricular tachycardia at Chonnam National University Hospital were examined. All the patients had no structural heart disease. RV pacing was performed at 10 different sites with cycle length of 600 ms and 500 ms using a 6-7F deflectable quadripolar electrode catheter (Livewire, St. Jude Medical, Minneapolis, MN, USA). Systolic, diastolic, and mean blood pressures were measured after stabilization of blood pressure during pacing. RESULTS: Blood pressures (systolic/diastolic/mean) decreased from 146 +/- 31/95 +/- 28/125 +/- 23 mmHg to 128 +/- 33/80 +/- 25/107 +/- 20 mmHg, respectively. The change of QRS duration during pacing and the systolic blood pressure (SBP) before pacing were higher in the group with paced QRS duration greater than 140 msec (59.1 +/- 13.6 msec vs 84.9 +/- 18.7 msec, 141 +/- 30 mmHg vs 152 +/- 38 mmHg, p<0.001, p=0.011, respectively). The decrease of SBP during pacing was higher in the group with paced QRS duration greater than 140 msec (13 +/- 11 mmHg vs 24 +/- 14 mmHg, p=0.009). The decrease of SBP during pacing was related with QRS duration during pacing (r=0.500, p=0.001), the change of QRS duration during pacing (r=0.426, p=0.001), and SBP during sinus rhythm (r=0.342, p=0.001) on linear correlation analysis. Pacing site, however, did not affect acute hemodynamic change during pacing. The independent factors associated with the decrease of SBP during pacing were SBP before pacing and QRS duration during pacing. CONCLUSION: We concluded that acute deleterious hemodynamic effects of RV pacing are related with paced QRS duration but not with pacing site. Ventricuar pacing at the area of paced QRS duration less than 140 msec is recommended particularly in high risk patients.

The effect of the carvedilol-loaded BiodivYsioTM DD stent on the inhibition of neointimal proliferation in a porcine coronary stent restenosis model / 대한내과학회지

BACKGROUND: Carvedilol is a beta- and alpha-receptor blocker, a direct inhibitor of smooth muscle cell proliferation and migration, and produces a significant suppression of neointimal hyperplasia in rat carotid injury model. We tested whether carvedilol stent coating is effective in preventing neointimal formation in a porcine model of stent restenosis. METHODS: BiodivYsio phosphorylcholine-coated stents were dip-coated with carvedilol at the concentrations of 0, 7, 96 and 154 micrometer/stent by the immersion in a methanolic carvedilol followed by the evaporation of the solvent. Thirty-two stents, 8 stents per each concentration, were deployed in the porcine coronary arteries. The treatment effect was assessed at 28 days after stent implantation. RESULTS: Angiographic minimal lumen diameter and late loss index were similar among the four groups. On histomorphometry, neointimal area decreased by 58% and lumen area increased by 20%, resulting in a 58% reduction of percent in-stent stenosis in 7 micrometer carvedilol/stent (p=0.002, 0.008 and 0.004, respectively, 7 micrometer vs. 0 micrometer carvedilol/stent). Modest change in neointimal and lumen area was observed in 96 and 154 micrometer carvedilol/stent. A proliferating nuclear cell antigen-positive cells was noted 7.78 +/- 2.97% in 7 micrometer carvedilol/stent vs. 17.82 +/- 1.45% in 0 micrometer carvedilol/stent (p=0.0001). CONCLUSION: A Low dose carvedilol stent coating produces a significant inhibition of neointimal hyperplasia in a porcine model of stent restenosis. This study provides a potential therapeutic benefit of carvedilol coating in the prevention of human stent restenosis.

The prognostic significance of statin therapy in acute myocardial infarction patients with left ventricular dysfunction / 대한내과학회지

BACKGROUND: Statins reduce mortality of patients with coronary artery disease. However, many trials have excluded patients with ischemic heart failure. Statins may have other beneficial effects besides cholesterol lowering, such as anti-inflammatory properties and improvement of endothelial function. The aim of this study was to determine the effects of statin therapy in acute myocardial infarction (AMI) patients with left ventricular (LV) dysfunction. METHODS: We studied 202 patients with AMI with LV dysfunction [ejection fraction (EF) below 40%] between January 2001 and June 2002. The patients were divided into two groups: Group I (n=106, 60.8 +/- 10.3 years, male 71.7%) who were treated with simvastatin and Group II (n=96, 60.9 +/- 10.4 years, male 78.1%) who were not treated with simvastatin. RESULTS: At six-month after percutaneous coronary intervention (PCI), LVEF was more improved in Group I than in Group II (30.8 +/- 10.0% to 42.4 +/- 10.7% vs 31.9% to 38.9%, p=0.042). The levels of total cholesterol, triglyceride and low density lipoprotein-cholesterol were more decreased and the level of high density lipoprotein-cholesterol was more increased in Group I than in Group II. The levels of C-reactive protein, fibrinogen, white blood cell and monocyte count were more decreased in Group I than in Group II. During one-year clinical follow-up, statin therapy was associated with a significant reduction in mortality (1.9% vs 7.5%, p=0.048), restenosis rate (25.7% vs 43.1%, p=0.033) and repeat PCI rate (25.7% vs 43.1%, p=0.033). The event-free survival rate was higher in Group I than in Group II (79.8% vs 57.0%, p=0.001). CONCLUSION: Statin therapy improves LV systolic function and decreases mortality, restenosis and repeat PCI in the AMI with LV dysfunction.

A New Porcine Model of Ischemic Heart Failure and Pathologic Findings by Intra-Coronary Injection of Ethanol

BACKGROUND AND OBJECTIVE: A new porcine model of acute myocardial infarction (AMI), ischemic heart failure and pathologic findings of coronary artery by a transcatheter intracoronary ethyl alcohol injection has been developed. MATERIALS AND METHODS: Twelve female pigs underwent a transcatheter injection in the left anterior descending artery (LAD), using alcohol, to produce an apicoanteriorseptal AMI. Low pressure ballooning using a 2.5 mm over-the-wire balloon, just above the second and first diagonal branches, followed by a 1 mL injection of 99.9% ethyl alcohol was administered to 8 and 4 pigs, respectively. Follow-up coronary and left ventricular (LV) angiograms and echocardiography were performed 4 weeks after the alcohol injection. Myocardial SPECT using 201Tl (and 99mTc-MIBI) and triphenyl tetrazolium chloride (TTC) stain were performed after sacrifice. The quantity of TTC stain and amount of 201Thallium uptake were compared using the Vision Workstation. The histopathological findings of the infarcted myocardium and coronary artery were demonstrated after 28 days. RESULTS: Procedure-related mortality was observed in two-pigs of the proximal LAD injection group. Four pigs suffered from ventricular tachycardia, which was converted into sinus rhythm by dc cardioversion. The four-week follow-up coronary angiography revealed persistently occluded LAD in all pigs. The LV angiogram showed akinetic movement in the apicoanteriorseptal wall with an ejection fraction of 46.5+/-3.3%. Myocardial SPECT revealed a perfusion defect in the apicoanterior wall of all pigs. The percentage area of perfusion defect was 22.2+/-3.06%. The TTC did not stain the myocardium in the apicoanterior wall. The percentage of non-stained myocardium was 23.5+/-2.70%. A histological examination revealed severe fibrosis in the infarcted myocardium and massive thrombus, with organization and calcification. CONCLUSION: The porcine model of acute myocardial infarction using an intracoronary ethanol injection into the distal LAD is safe, reliable and reproducible, and can be used for future research into myocardial regeneration and ischemic LV failure.

Predictive Factors for Heart Failure in Patients with Unstable Angina and Acute Non-ST Elevation Myocardial Infarction

BACKGROUND AND OBJECTIVES: Besides the acute coronary syndrome (ACS), the left ventricular failure (LVF) is the next important determinant of morbidity and mortality after acute coronary syndrome (ACS). The prediction of high risk groups for LVF may be in the initial management of patients with unstable angina (UA) or acute non-ST elevation myocardial infarction (NSTEMI). SUBJECTS AND METHODS: 179 patients (60.4+/-11.6 years, 121 male) who underwent diagnostic coronary angiography under the diagnosis of UA/NSTEMI between January and December, 2000, in the Chonnam National University Hospital Heart Center were enrolled for evaluation of relationship between the development LVF and various parameters, including clinical features, initial electrocardiogram, laboratory findings and coronary angiographic findings. RESULTS: Unstable angina was clinically diagnosed in 124 patients, and NSTEMI in 55 patients. During a 12-month follow-up period, less than 40% of the left ventricular ejection fraction (EF), a low amount, was observed in 28 patients (15.7%). In diabetic patients, the incidence of LVF was significantly higher than in non-diabetics (p<0.05). Patients with elevated C-reactive protein (CRP) or positive troponin I had LVF more frequently (p<0.05). On the initial electrocardiogram, the total summation of ST segment change inversely correlated with EF (p<0.05). Patients whose QT dispersion was longer than 80 ms had a higher incidence of LVF (p<0.05). Coronary angiographic findings of total occlusion correlated with the development of LVF (p<0.05), but not with other characteristics. On multiple logistic regression analysis, high CRP level (p=0.024), summation of ST change (p=0.021), total occlusion of the coronary artery (p=0.008) were independent prognostic factors of LVF. CONCLUSION: Elevated CRP, summation of ST change and total coronary artery occlusion are important predictive factors for LVF in UA/NSTEMI.

Successful Stent Grafting for a Coronary Aneurysm

The stent graft can be used for the treatment of coronary artery aneurysms, perforations, dissection and arteriovenous fistula. A 54-year-old man presented with progressively worsening chest pain for several months. A diagnostic coronary angiogram revealed critical stenosis with a huge aneurysmal sac (6.0x8.2 mm in size) in the proximal right coronary artery. We implanted two membrane covered stent grafts (3.0x16 mm, JoStent GraftMaster(r), JoMed, Germany) without complication. No visible coronary aneurysm or residual stenosis was demonstrated after stent grafting. A two-month follow-up coronary angiogram showed patent stent grafted right coronary artery.

A Novel Method of Brachytherapy Using Local Delivery of (99m) Tc-HMPAO for Coronary Stent Restenosis

BACKGROUND: Restenosis after percutaneous coronary intervention (PCI) is a matter that still remains to be resolved. Herein, the inhibitory effect of locally delivered (99m) Tc-HMPAO (hexamethyl propylene amine oxime) on neointimal hyperplasia after coronary stenting was examined in a pocine model, and its safety and efficacy observed in patients with coronary stent restenosis. METHODS: After a stent overdilation injury, local radioisotope delivery using (99m) Tc-HMPAO was applied to one coronary artery (Group I) and control therapy to another (Group II) in each of 10 pigs. Follow-up coronary angiogram (CAG) and histopathologic assessment were performed 4 weeks after stenting. Eleven patients (10 males and one female, 62.4 +/- 5.7 years of age) underwent local administration of 30 mCi/ 2 mL (99m) Tc-HMPAO shortly after PCI, via a Dispatch CatheterTM, followed by a whole body scan to evaluate the distribution of the (99m) Tc-HMPAO, as well as a thallium-201 (Tl-201) myocardial scan to evaluate myocardial perfusion. The major adverse cardiac events (MACE) were assessed during a one-year clinical follow-up. RESULTS: On histopathological analysis, the neointimal areas were 1.2 +/- 0.6 and 2.7 +/- 0.4 mm2 (p=0.002), and the histopathological areas of stenosis were 27.16.3 and 53.4 +/- 5.2% in Groups I and II (p=0.001), respectively. In the clinical study, there was no in-hospital MACE. On a quantitative coronary angiographic analysis, the minimal luminal diameter was increased from 0.4 +/- 0.3 to 2.9 +/- 0.2 mm, and diameter stenosis decreased from 84.2 +/- 9.5 to 16.3 +/- 11.0% following PCI. Follow-up CAG was performed in 9 cases (81.8%) and restenosis occurred in 2 (22.2%). On a follow-up CAG, the minimal luminal diameter, diameter stenosis rate, lumen loss and loss index were 2.0 +/- 0.8 mm, 27.7 +/- 2.9%, 0.7 +/- 0.7 mm and 0.2 +/- 0.3, respectively. During the one-year clinical follow-up there were no cases of death or acute MI, but two cases of target vessel revascularization (18.2%). CONCLUSION: Local delivery of (99m) Tc-HMPAO, a novel radiotherapy, can be used safely and effectively for coronary stent restenosis.