A Case of Acute Myocardial Infarction with Resolution of ST-Segment Elevation Immediately after Ventricular Defibrillation / 대한내과학회지

A 38-year-old man presented with typical squeezing-type anterior chest pain. An initial electrocardiogram (ECG) showed prominent ST-segment elevation (V1-V4 lead, 3 mm). Suddenly, the patient fell unconscious and had no pulse. At that time, the ECG showed polymorphic ventricular fibrillation (VT). After direct current (DC) cardioversion, the patient regained vital signs and defibrillation converted the VT into an accelerated idioventricular rhythm with resolution of the ST-segment elevation. The patient was referred to our hospital for close observation and further evaluation. At our hospital, an ECG showed normal sinus rhythms and cardiac enzymes were within normal limits. We diagnosed the patient with variant angina rather than ST elevation myocardial infarction (STEMI), because his clinical manifestations were quite distinct; ST-segment elevations disappeared slowly at the reperfusion stage. However, the patient's final diagnosis was STEMI because coronary angiography showed severe eccentric tubular stenosis (85%) with remnant thrombus in the middle left anterior descending artery. Defibrillation likely removed the thrombus, which led to STEMI.

Effect of Aspiration Thrombectomy on Microvascular Dysfunction in ST-Segment Elevation Myocardial Infarction With an Elevated Neutrophil Count

BACKGROUND AND OBJECTIVES: Aspiration thrombectomy (AT) during primary percutaneous coronary intervention (PCI) is an effective adjunctive therapy for ST-segment elevation myocardial infarction (STEMI). An elevated neutrophil count in STEMI is associated with microvascular dysfunction and adverse outcomes. We evaluated whether AT can improve microvascular dysfunction in patients with STEMI and an elevated neutrophil count. SUBJECTS AND METHODS: Seventy patients with STEMI undergoing primary PCI from August 2007 to February 2009 in our institution were classified by tertiles of neutrophil count on admission (7,600/mm3). The angiographic outcome was post-procedural thrombolysis in myocardial infarction (TIMI) flow grade. Microvascular dysfunction was assessed by TIMI myocardial perfusion (TMP) grade and ST-segment resolution on electrocardiography 90 minutes after PCI. The clinical outcome was major adverse cardiac event (MACE), defined as cardiac death, re-infarction, and target lesion revascularization at 9 months. RESULTS: There were no significant differences in the clinical characteristics and pre- and post-procedural TIMI flow grades between the neutrophil tertiles. As the neutrophil count increased, a lower tendency toward TMP grade 3 (83% vs. 52% vs. 54%, p=0.06) and more persistent residual ST-segment elevation (>4 mm: 13% vs. 26% vs. 58%, p=0.005) was observed. The 9-month MACE rate was similar between the groups. On subgroup analysis of AT patients (n=52) classified by neutrophil tertiles, the same tendency toward less frequent TMP grade 3 (77% vs. 56% vs. 47%, p=0.06) and persistent residual ST-segment elevation (>4 mm: 12% vs. 28% vs. 53%, p=0.05) was observed as neutrophil count increased. CONCLUSION: A higher neutrophil count at presentation in STEMI is associated with more severe microvascular dysfunction after primary PCI, which is not improved with AT.

Effect of Aspiration Thrombectomy on Microvascular Dysfunction in ST-Segment Elevation Myocardial Infarction With an Elevated Neutrophil Count

BACKGROUND AND OBJECTIVES: Aspiration thrombectomy (AT) during primary percutaneous coronary intervention (PCI) is an effective adjunctive therapy for ST-segment elevation myocardial infarction (STEMI). An elevated neutrophil count in STEMI is associated with microvascular dysfunction and adverse outcomes. We evaluated whether AT can improve microvascular dysfunction in patients with STEMI and an elevated neutrophil count. SUBJECTS AND METHODS: Seventy patients with STEMI undergoing primary PCI from August 2007 to February 2009 in our institution were classified by tertiles of neutrophil count on admission (7,600/mm3). The angiographic outcome was post-procedural thrombolysis in myocardial infarction (TIMI) flow grade. Microvascular dysfunction was assessed by TIMI myocardial perfusion (TMP) grade and ST-segment resolution on electrocardiography 90 minutes after PCI. The clinical outcome was major adverse cardiac event (MACE), defined as cardiac death, re-infarction, and target lesion revascularization at 9 months. RESULTS: There were no significant differences in the clinical characteristics and pre- and post-procedural TIMI flow grades between the neutrophil tertiles. As the neutrophil count increased, a lower tendency toward TMP grade 3 (83% vs. 52% vs. 54%, p=0.06) and more persistent residual ST-segment elevation (>4 mm: 13% vs. 26% vs. 58%, p=0.005) was observed. The 9-month MACE rate was similar between the groups. On subgroup analysis of AT patients (n=52) classified by neutrophil tertiles, the same tendency toward less frequent TMP grade 3 (77% vs. 56% vs. 47%, p=0.06) and persistent residual ST-segment elevation (>4 mm: 12% vs. 28% vs. 53%, p=0.05) was observed as neutrophil count increased. CONCLUSION: A higher neutrophil count at presentation in STEMI is associated with more severe microvascular dysfunction after primary PCI, which is not improved with AT.

Pylephlebitis: Report of a Case Secondary to Appendicitis and Review of Cases Reported in Korea / 감염과화학요법

Pylephlebitis occurs secondary to infection in the region drained by the portal venous system. We described a case of pylephlebitis which developed as a complication of appendicitis and reviewed 22 cases of pylephlebitis, including the current case, reported in Korea. Appendicitis, followed by diverticulitis, was the most common infection associated with pylephlebitis. Fever and abdominal pain were the most common presenting symptoms. Bacteremia was present in 60% of cases. Streptococci, enteric gram-negative bacilli, and Bacteroides fragilis were common organisms isolated from the blood. Liver abscess was identified in 3 cases. All patients survived regardless of anticoagulation therapy. Although pylephlebitis is a rare disease, it should be included in the differential diagnosis in patients with fever of unknown origin who present with nonspecific abdominal symptoms or abnormal liver function test.

Primary Cardiac Lymphoma Presenting With Atrioventricular Block

Primary cardiac lymphomas (PCL) are extremely rare. Clinical manifestations may be variable and are attributed to location. Here, we report on a case of PCL presenting with atrioventricular (AV) block. A 55 year-old male had experienced chest discomfort with unexplained dyspnea and night sweating. His initial electrocardiogram (ECG) revealed a first degree AV block. Along with worsening chest discomfort and dyspnea, his ECG changed to show second degree AV block (Mobitz type I). Computed tomography (CT) scan showed a cardiac mass (about 7 cm) and biopsy was performed. Pathologic finding confirmed diffuse large B-cell lymphoma. The patient was treated with multi-drug combination chemotherapy (R-CHOP: Rituximab, cyclophoshamide, anthracycline, vincristine, and prednisone). After treatment, ECG changed to show normal sinus rhythm with complete remission on follow-up CT scan.

A Case of Systemic Thrombolysis in the Membranous Glomerulonephritis Presenting as Acute Inferior Vena Cava and Renal Vein Thrombosis / 대한신장학회지

Thromboembolism is one of the common complications in nephrotic syndrome. The incidence of renal vein thrombosis in the setting of nephrotic syndrome varies from 5% to 62%. Membranous glomerulonephritis (MGN) has been rarely manifested as inferior vena cava (IVC) and/or renal vein thrombosis. We report a case of acute IVC and left renal vein thrombosis as initial manifestation of MGN. The renal vein thrombosis was successfully treated with systemic thrombolysis with temporary IVC filter insertion. After 4 months, MGN was diagnosed by renal biopsy.

Intraoperative diagnosis of right atrial thrombi with pulmonary embolism using transthoracic echocardiography / 대한내과학회지

Right atrial (RA) thrombi are rarer than left atrial thrombi; they are frequently associated with major pulmonary embolism and carry a very high risk of mortality, requiring prompt diagnosis and treatment. In particular, multiple, mobile right atrial thrombi have a very poor prognosis because of the high incidence of massive pulmonary embolism. Echocardiography is useful in the diagnosis of RA thrombi. The treatment options for RA thrombi are anticoagulation, thrombolysis, and thrombectomy. Here, we report a case of multiple, mobile right atrial thrombi and pulmonary embolism that presented as cardiogenic shock during arthroscopic lavage of a septic knee. It was diagnosed using transthoracic echocardiography and treated successfully with thrombolytics and anticoagulants.