Five-year Clinical follow-up after Revascularization for Chronic Total Coronary Artery Occlusion / 대한구급학회지

BACKGROUND: Chronic total occlusion (CTO) has been considered as an unsuitable lesion for percutaneous coronary intervention (PCI) because of technical difficulty and low success rate. Owing to technical advances and increased operator's experience, PCI has been attempted in a large number of patients with CTO in recent years, but there are few long-term follow-up reports for PCI to CTO. METHODS: We analyzed 83 patients (59.7+/-9.2 years, 28 female) with CTO on diagnostic coronary angiogram at the Heart Center and Coronary Care Unit of Chonnam National Hospital from January 1996 to July 1997. The patients were divided into two groups according to revascularization by PCI or CABG (coronary artery bypass graft): the revascularized group (received PCI or CABG, Group I) and non-revascularized group (Group II). RESULTS: PCI was tried in 46 patients and successful in 33 patients (71.7% of the success rate). Eleven patients (13.3%) were treated with the coronary artery bypass graft (CABG) and 31 (37.3%) patients were medically treated. During 5-year clinical follow-up 11 patients died [13.1%; cardiac death 6 (7.1%), non-cardiac death 5 (6.0%)] and the major adverse cardiac events occurred to 24 (28.6%) patients. Cardiac death occurred to one patient of the Group I and 5 patients of Group II (p=0.06). The mean survival time was significantly different (57.8+/-9.2 months in Group I and 50.9+/-19.5 months in Group II, p=0.038). CONCLUSIONS: Revascularization for CTO prolonged the mean survival time of the patients on long- term clinical follow-up.

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.

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 Long-term Clinical Results of a Platelet Glycoprotein IIb/IIIa Receptor Blocker (Abciximab: ReoPro (R) ) Coated Stent in Patients with Coronary Artery Disease

BACKGROUND: Previously, the inhibition of coronary restenosis with Abciximab (ReoPro (R) ) -coated stent in a porcine model was reported. ReoPro (R) inhibits platelet aggregation, the proliferation of vascular smooth muscle cells and the inflammatory reaction. METHODS: A prospective randomized trial was performed to compare two types of stent for revascularization in the native coronary artery. The primary effective end points were major adverse coronary events (MACE) : cardiac death, acute myocardial infarction, target vessel revascularization (TVR) and restenosis at the 6-month clinical and angiographic follow-ups. RESULTS: One hundred and fifty-five patients were enrolled between August 2001 and June 2003. The mean ages (56.0 +/- 10.0 vs. 56.9 +/- 10.8 years), baseline diameter of stenosis and minimal luminal diameter were no different between the two groups. There was one myocardial infarction and revascularization during the hospital stay in control stent group. During the clinical follow-up there were two myocardial infarctions in control group. Follow-up coronary angiograms were performed in 62.3% (48/77) and 65.4% (51/78) of the coated and control groups, respectively. The diameter of stenosis and late loss were significantly less in the ReoPro (R) -coated stent group compared with the controls (16.4 +/- 5.8% vs. 34.3 +/- 6.1%, p=0.009; and 0.33 +/- 0.28 mm vs. 0.88 +/- 0.41 mm; p=0.002). The restenosis and TVR rates of the ReoPro (R) -coated stent were relatively lower compared with the control stent [14.6% (7/48) vs. 29.4% (15/51), p=0.062; and 9.2% (7/76) vs. 14.7% (11/75) ; p=0.327]. CONCLUSION: A ReoPro (R) -coated stent is safe, and may be effective in the prevention of coronary restenosis.

A Case of Huge Right Atrial Thrombi Treated with Thrombolytic Agent

Thrombi in the right atrium (RA) are infrequent, and are rarely diagnosed before death. In addition, right heart thrombi are frequently associated with major pulmonary thromboembolism, and carry a very high risk of mortality, and therefore, require accurate diagnosis and prompt treatment. RA thrombi are generally associated with dilatation of the atrium, a low cardiac output state, intracardiac catheters, such as endocardial pacemakers and central venous hyperalimentation catheters, recent cardiac surgery, involving the atrium, and peripheral deep vein thrombosis. In addition, some systemic diseases, such as malignant tumors, amyloidosis and nephrotic syndrome, have been shown to contribute to the formation of an intracardiac thrombus. Echocardiography is valuable in the diagnosis of RA thrombi. There are some options in the treatment of RA thrombi, such as anticoagulant therapy using heparin, thrombolytic therapy and surgical removal. However, there is still adverse criticism as to the selection of the correct treatment method. A patient with RA thrombi, who presented with sudden cardiogenic shock, was diagnosed by two-dimensional echocardiography. He had been in a prolonged bed-ridden state because of quadriparesis caused by an injury to the cervical spine. The RA thrombi were successfully treated with anticoagulant and thrombolytic agents.

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.

Effects of Oxygen Free Radicals on KATP Channel Activity in Mouse Cardiac Myocytes

BACKGROUND AND OBJECTIVE: Oxygen-derived free radicals (OFRs), produced as myocardium is reperfused after ischemic injury, contribute to reversible and irreversible cellular injury. KATP channels, activated by ischemia, have been reported to participate in the arrhythmogenic response to acute myocardial ischemia. Therefore, we examined the effects of OFRs on the regulation of KATP channel activity. MATERIALS AND METHODS: Isolated mice (ICR) hearts were perfused with Tyrode's solution on a Langendorff apparatus. Single ventricular myocytes were isolated using enzymatic digestion with collagenase and protease. Single channel currents in the inside-out patch mode were recorded. OFRs were applied by mixing hypoxanthine and xanthine oxidase. The currents were recorded in the patch membrane at a holding potential of -60 mV. RESULTS: OFRs generated by 0.1 U/mL xanthine oxidase and 0.5 mM hypoxanthine had no effects on the activities of KATP channels before and after treatment with 200 micrometer ATP. OFRs generated with 0.2 U/mL xanthine oxidase and 1.0 mM hypoxanthine reactivated the channel activities which had been attenuated by 100 micrometer ATP. In the presence of 100 U/mL superoxide dismutase and 122 U/mL catalase, which are OFRs scavengers, OFRs did not affect the KATP channels activities. CONCLUSION: OFRs generated by the reaction of hypoxanthine and xanthine oxidase increased the KATP channel activities in the inside-out patch.

The Long-Term Clinical Outcomes of Low Molecular Weight Heparin Combined with Platelet Glycoprotein IIb/IIIa Inhibitor in Patients with Acute Coronary Syndrome

BACKGROUND AND OBJECTIVES: Platelet activation and aggregation, with resultant arterial thrombus formation, play pivotal roles in the pathophysiology of acute coronary syndrome (ACS). The efficacy of tirofiban, a specific inhibitor of the platelet glycoprotein IIb/IIIa receptor, combined with heparin, or low molecular heparin (LMWH), in the management of ACS were evaluated. SUBJECTS AND MEHTODS: One hundred seventeen patients (60.8+/-10.9 years, 76 male), with unstable angina or non-ST elevation myocardial infarction, who had ST-T changes and elevated troponin, were divided into 4 groups : Group I (n=30 : heparin alone), Group II (n=28 : LMWH, dalteparin alone), Group III (n=29 : tirofiban combined with heparin) and Group IV (n=30 : tirofiban with LMWH). The major adverse cardiac events (MACE) among the 4 groups, during 6-month clinical follow-ups, were compared. RESULTS: Percutaneous coronary intervention, or a coronary artery bypass graft, was performed in 23, 19, 19 and 22 patients from Groups I, II, III and IV, respectively (p=0.87). A minor bleeding complication developed in 2 (6.7%), 1 (3.6%), 1 (3.4%) and 2 patients (6.7%) in groups I, II, III and IV, respectively (p=0.79). During the six-month follow-up MACE occurred in 7 (30.4%), 6 (31.6%), 3 (15.8%) and 4 patients (18.2%) in groups I, II, III and IV, respectively (p=0.02 : Group I and II vs. Group III and IV). CONCLUSION: Tirofiban combined with LMWH is safe and may improve the long-term prognosis of patients with ACS.

The long-term clinical results of a platelet glycoprotein IIb/IIIa receptor blocker (Abciximab: ReoPro(R)) coated stent in patients with coronary artery disease / 대한내과학회지

BACKGROUND: Previously we reported the inhibition of coronary restenosis with Abciximab (ReoPro(R))-coated stent in a porcine model. ReoPro(R) inhibits platelet aggregation, the proliferation of vascular smooth muscle cells and inflammatory reaction. METHODS: We performed a prospective randomized trial to compare two types of stents for the revascularization in native coronary artery. The primary effective end points were major adverse coronary events (MACE): cardiac death, acute myocardial infarction, target vessel revascularization (TVR), restenosis at 6-month clinical and angiographic follow-up. RESULTS: One hundred fifty-five patients were enrolled between Aug, 2001 and Jun, 2003. Mean ages (56.0 +/- 10.0 vs. 56.9 +/- 10.8 years), baseline diameter stenosis and minimal luminal diameter were not different between the two groups. There was one myocardial infarction and revascularization during hospital stay in control stent group. During clinical follow-up, there were two myocardial infarctions in control group. Follow-up coronary angiogram was done 62.3% (48/77) in coated and 65.4% (51/78) in control groups. Diameter stenosis and late loss were significantly less in the ReoPro(R)-coated stent group compared with controls (16.4 +/- 5.8% vs. 34.3 +/- 6.1%, p=0.009; and 0.33 +/- 0.28 mm vs. 0.88 +/- 0.41 mm; p=0.002). The restenosis and TVR rates of ReoPro-coated stent were relatively lower compared with control stent [14.6% (7/48) vs. 29.4% (15/51), p=0.062; and 9.2% (7/76) vs. 14.7% (11/75); p=0.327]. CONCLUSION: A ReoPro(R)-coated stent is safe and may be effective in the prevention of coronary restenosis.

Predictive factors of restenosis after stenting in proximal left anterior descending coronary artery / 대한내과학회지

BACKGROUND: A proximal Left anterior descending coronary artery (LAD) is one of the most important arterial segment due to its wide area of myocardial blood supply and high incidence of restenosis after percutaneous coronary intervention. This study was aimed to predict the risk factor after stenting in proximal LAD. METHODS: A total of 412 patients with proximal LAD stent implantation, who underwent follow-up coronary angiogram except for the LAD ostial lesion between 1996 and 2001 at Chonnam National University Hospital, were divided into two groups: Restenosis group (n=144 : 57.5 +/- 10.2 years, 78.8% male) and no restenosis group (n=268 : 57.4 +/- 10.0 years, 76.8% male). Restenosis rate, complications and predictive factors after proximal LAD stenting were analyzed. RESULTS: There were no differences in baseline clinical characteristics of sex, age, risk factors of atherosclerosis, lipid profile, clinical diagnosis, type and number of lesion coronary artery, Thrombolysis In Myocardial Infarction flow between the two groups. The restenosis rate after proximal LAD stenting was 35.0%. The complications during the follow up period after stenting were one transient ischemic attack in restesnosis group and one non-hemorrhagic stroke in both groups. There were no differences in major advanced cardiac event until the 12th month clinical follow up. There were no differences in lesion length, reference diameter, minimal luminal diameter, diameter stenosis and stent diameter, but the stent length were longer (20.7 +/- 6.92 mm) in restenosis group compared with no restenosis group (18.8 +/- 6.18 mm, p=0.006). CONCLUSION: The restenosis rate after proximal LAD stenting is relatively high and the only predictive factor for restenosis is stent length.

The long-term clinical effect of cutting ballon angioplasty for coronary in-stent restenosis / 대한내과학회지

BACKGROUND: Coronary stent implantation reduced the restenosis rate after percutaneous coronary intervention (PCI) but, still coronary in-stent restenosis (ISR) remains the major problem after PCI. Cutting balloon angioplasty is one of the method for ISR treatment. The purpose of this study is prospectively comparing the effect of cutting balloon angioplasty (CBA) with plain old balloon angioplasty (POBA) for the ISR. METHODS: A total of 50 patients with ISR, who underwent PCI (randomized CBA or POBA for ISR) from January to December 2001 at Chonnam National University Hospital, were divided into two groups: Group I (n=25: 58.4+/-7.9 years, male 88%) with CBA and Group II (n=25: 58.1+/-8.7 years, male 92%) with POBA. The early luminal gain, late luminal loss, major adverse cardiac event and angiographic restenosis rate were compared. RESULTS: There were no differences in baseline clinical characteristics of sex, age, ejection fraction, cardiac enzyme, risk factors of atherosclerosis, number of coronary artery lesions, and type of ISR between the groups. The minimal luminal diameters of before and after PCI were 0.83+/-0.34 mm, 2.10+/-0.55 mm in group I and 0.93+/-0.58 mm, 2.08+/-0.79 mm in group II. There were no differences in early luminal gain. All patients underwent follow-up coronary angiogram and the restenosis rate was 32% (8/25) in group I and 28% (7/25) in group II, and late luminal loss were 0.60+/-0.40 mm in group I and 0.65+/-0.61 in group II (p=NS). The major adverse cardiac events during 6-month follow-up developed in 3 cases of group I and 4 cases of group II (p=NS). CONCLUSION: There were no differences in early and long-term clinical effects after CBA and POBA for the treatment of ISR.

The Clinical Outcome of Acute Myocardial Infarction with Normal Coronary Angiogram

BACKGROUND AND OBJECTIVES: Little data exist concerning the clinical outcome of patients with acute myocardial infarction (AMI) and angiographically normal coronary arteries (NCA). The purpose of this study was to evaluate the clinical outcome, the etiological factors and prognosis of these patients. SUBJECTS AND METHODS: The subjects were divided into two groups according to findings from coronary angiograms performed between January 1999 and December 2001, Group 1 : comprised of 46 patients, 34 males and 12 females, with a mean age of 50.4+/-11.9 years, had AMI with NCA ; Group II : 181 patients, 143 males and 38 females, with a mean age of 59.0+/-10.3 years, with AMI and total occlusion of the coronary arteries. RESULTS: The percentages of smoking and hypertension were similar between the two groups ; a higher prevalence rates of hyperlipidemia and diabetes were observed in group II compared to group I (p=0.03, 0.01). In group I, coronary spasm, combined inflammatory diseases and embolization were demonstrated in 32.6, 6.5 and 4.3% of subjects, respectively. The left ventricular ejection fraction was higher in group I than group II (51.5+/-11.3% vs. 46.2+/-10.5%, p=0.006). In-hospital outcomes, with the combined end-point defined as death, re-infarction and stroke was 0% in group I vs. 7.7% in group II (p=0.07). The mean long-term survival rate during the 26.5-month clinical follow-up were 100 and 92.2% in groups I and II (p=0.04), respectively. CONCLUSION: A coronary spasm is the most common cause of AMI with NCA, but these patients had the higher long-term clinical event-free survival.

The Changes of Fractional Flow Reserve after Intracoronary Nitrate and Nicorandil Injection in Coronary Artery Ectasia

BACKGROUND AND OBJECTIVES: Little data exist relating to the mechanism of myocardial ischemia in patients with coronary artery ectasia (CAE). The purpose of this study was to evaluate the fractional flow reserve (FFR), as an index of myocardial ischemia, in patients with CAE. SUBJECTS AND METHODS: Ten patients (7 males, 54.0+/-12.6 years) who diagnosed as CAE, by coronary angiographies, between March 2002 and July 2002, were analyzed. The clinical diagnosis of all the patients was unstable angina. FFR were performed using a pressure wire on the patients diagnosed with slow flow CAE from their coronary angiograms. After measurement of the baseline FFR using adenosine 20 microgram for the right coronary artery, and 24 microgram for the left anterior descending artery, the changes in the FFR with 500 microgram of intracoronary nitrate and 2 mg of Nicorandil were observed. RESULTS: Smoking was the most frequently associated risk factor. Type I CAE, according to Markis' classification, was the most prevalent at 60.0%. The values of the baseline FFR in the left anterior descending artery and right coronary artery, following the intracoronary injection of adenosine were both normal, and there were no significant changes in the FFR following the intracoronary injections of nitrate and Nicoronadil. CONCLUSION: The value of the FFR with CAE was normal, and an intracoronary injection of vasodilators did not change the FFR in patients with CAE. Therefore, vasodilator therapy might be beneficial for patients with symptomatic CAE.

A Case of Recurrent In-Stent Restenosis with Abundant Proteoglycan Component

A percutaneous coronary intervention (PCI) is known to be one of effective methods in the treatment of coronary artery disease. However, restenosis remains a major limitation to a PCI. Although neointimal cell proliferation is suspected to be the major cause of coronary stent restenosis, few histological characterizations of recurrent instent restenosis exist. We report a case of a 61-year-old man suffering from unstable angina due to secondary coronary in-stent restenosis in the proximal left anterior descending artery (LAD). An atherectomized tissue, obtained by a directional coronary atherectomy, showed myxoid tissue, characterized by a few stellate smooth muscle cells in the abundant extracellular matrix, which was blue-colored proteoglycan on modified Movat staining.

Long-Term Clinical Outcomes of Percutaneous Coronary Intervention According to the Lesion Location in Proximal Left Anterior Descending Artery

BACKGROUND AND OBJECTIVES: The proximal left anterior descending artery (LAD) is one of the most important arterial segments due to its wide area of myocardial blood supply and the high incidence of restenosis after revascularization (RV) with percutaneous coronary intervention (PCI), especially in patients with LAD ostial and/or main involvement. SUBJECTS AND METHODS: One hundred and ninety four patients (58.9+/-10.9 year-old, 154 male) that had undergone PCI at proximal LAD lesions were divided into four lesion types; Type I (n=56): the stenosis beginning from the left main, Type II (n=58): the stenosis beginning within 3 mm of the origin of the LAD, Type III (n=44): the stenosis beginning more than 3 mm from the origin of the LAD and Type IV (n=36): the stenosis beyond the first septal perorator or the first diagonal artery. The primary success rates of the PCI and the major adverse cardiac events (MACE), during a 12-month clinical follow-up, were compared between the 4 types. RESULTS: The primary success rate was lower in the Type I than in Types II, III and IV (87.5% vs. 98.3, 97.7 and 97.2%, p=0.02). MACE, after a successful PCI, occurred in 19 [40.4%; 3 death, 2 myocardial infarction (MI) and 14 RV] of the Type I, 22 (40.0%; 1 MI, 21 RV) of the Type II, 12 (28.6%; 12 RV) of the Type III and 7 (21.2%; 1 MI, 6 RV) of the Type IV patients during the 12-month clinical follow-up (Type I and II vs. III and IV, p=0.03). CONCLUSION: LAD ostial lesions are associated with a relatively high PCI primary success rate, but with a related high MACE equivalent to left main involvement on long-term clinical follow-up.

The prognostic significance of elevated troponin I on admission in acute myocardial infarction patients who underwent multivessel percutaneous coronary intervention / 대한내과학회지

BACKGROUND: Cardiac troponin I (cTnI) is a sensitive and specific biomarker for myocardial injury. The aim of this study was to determine the significance of clinical and angiographic outcomes, success rate of the percutaneous coronary intervention (PCI), major adverse cardiac events and event-free survival rate after PCI according to the value of cTnI on admission in acute myocardial infarction (AMI) patients with multivessel lesions. METHODS: A total of 154 patients with AMI who underwent multivessel PCI between June 2000 and December 2001 at Chonnam National University Hospital were divided into two groups: Group I (n=70, 61.5+/-10.5 years, male 81.4%) with cTnI less than 10 ng/mL (6.9+/-4.7 ng/mL) and Group II (n=84, 60.8+/-10.0 years, male 75.0%) with cTnI higher than 10 ng/mL (57.4+/-40.0 ng/mL) on admission. RESULTS: Baseline ejection fraction of the left ventricle (LV) was lower in Group II than in Group I (Group I; 58.8+/-13.6% vs. Group II; 51.6+/-7.9%, p=0.002). Thrombolysis in Myocardial Infarction (TIMI) flow was higher in Group I than in Group II (2.86+/-1.24 vs. 2.42+/-1.37, p=0.024) and the diameter stenosis was less severe in Group I than in Group II (92.2+/-7.2% vs. 96.4+/-5.4%, p=0.020). The number of stents placed was lower in Group I than in Group II (1.45+/-0.50 vs. 1.63+/-0.70, p=0.023). The event-free survival rate was higher in Group I than in Group II during hospitalization and 12-month clinical follow-up after PCI (87.1% vs. 69.0%, 72.9% vs. 50.0%, p=0.008, 0.004, respectively). The independent predictors for target lesion revascularization were lesion length, CRP level on admission, stent use, diabetes mellitus, cTnI on admission (p=0.001, 0.009, 0.012, 0.019, 0.035, respectively) and the independent predictors for 1-year mortality were cardiogenic shock on admission, CRP level on admission, cTnI on admission (p<0.001, =0.005, 0.021, respectively). CONCLSUION: The high level of cTnI on admission is associated with LV dysfunction, low grade of TIMI flow and lower long-term event-free survival rate during hospitalization and at 12-month after PCI in patients with AMI.

A Case of Acute Myocardial Infarction after Blunt Chest Trauma in a Young Man

Coronary artery injury rarely occurs after blunt chest trauma, but it can lead to extensive myocardial infarction and be frequently overlooked. A 16-yr-old man was presented with comatose mental state and rapid respiration rate. He ran into guard rail while riding a motorcycle. In routine examination, his electrocardiogram showed Q wave and 2 mm ST segment elevation in all precordial leads, I and aVL. The cardiac enzymes were also elevated: creatine kinase (CK)-MB was 300 U/L, and cardiac specific troponin I was 5.7 ng/mL. Two-dimensional echocardiography showed anteroseptal akinesia with severely depressed left ventricular function, ejection fraction of 28%. He could not receive any anticoagulation or thrombolytic therapy because of his brain lesion. Three weeks later, his mental state improved. A diagnostic coronary angiogram revealed total occlusion in the proximal left anterior descending artery (LAD) with collaterals from the right coronary artery and left circumflex artery. We successfully performed a percutaneous coronary intervention for the LAD lesion, and the final angiogram showed a good coronary flow without residual stenosis.