Predictors of Acute Thrombotic Occlusion after Coronary Intervention in Acute Myocardial Infarction

BACKGROUND: The most important acute complication of percutaneous transluminal coronary angioplasty (PTCA) is abrupt closure by dissection and thrombus, which account for the majority of deaths and emergency coronary artery bypass procedures associated with PTCA. We sought to determine the relationship between clinical, angiographic characteristics and abrupt thrombotic closure related to coronary intervention. METHODS: One hundred thirty two patients (61.6+/-8.0 year, 98 male) underwent PTCA or stenting under the diagnosis of acute myocardial infarction were analyzed at Chonnam University Hospital between Jan '97 and Jun '98. Patients were divided into two groups, one, 14 patients (Group A, 61.7+/-8.0 year, 9 male), who developed thrombotic occlusion, and the other, 118 patients (Group B, 61.5+/-8.0 year, 89 male) who did not develop abrupt closure related to the coronary intervention. RESULT: There were no significant differences in age, sex, risk factors, activated partial thromboplastin time, fibrinogen, erythrocyte sedimentation rate, C-reactive protein, location of lesion, branch involvement, lesion severity, AHA/ACC morphology between two groups. The incidence of intra-coronary thrombus was greater in Group A than in Group B (44% vs. 2%, p=0.025). Acute thrombotic occlusion related to the coronary interventions developed more frequently in the lesions within two days after the symptomatic onset (55% vs. 19%, p=0.035) and in the right coronary artery (RCA) lesions (55% vs. 24%, p=0.041). CONCLUSION: Predictors of abrupt thrombotic occlusion during coronary intervention in patients with acute myocardial infarction are intracoronary thrombus, earlier intervenion within 2 days after onset of aucte myocardial infarction and RCA lesion.

The Effects of Anti-Platelet Agents in Preventing Coronary Stent Restenosis

BACKGROUND: Restenosis is still remained as the most important limitation in clinical practice with coronary stent. Experimental study in a porcine model and clinical study in patients with coronary artery disease were performed to test the efficacy and safety of various anti-platelet agents (Aspirin, Ticlopidine, Cilostazol) to prevent restenosis of coronary stent. METHODS: In animal study, Cilostazol 200 mg/day (Group I, n=7) or Ticlopidine 500 mg/day (Group II, n=4) in addition to Aspirin (300 mg/day) was administered to pigs from 3 days before stenting to 4 weeks after stenting. Angiographic and pathologic findings were compared at 4 weeks after stenting. In clinical study, 134 patients underwent coronary stent as Group A (46 patients with 49 lesions:39 M, 7 F:60.8+/-10.1 year) receiving 300 mg Aspirin and 200 mg Cilostazol, and Group B (88 patients with 92 lesions:63 M, 25 F:60.6+/-8.8 year) receiving 300 mg Aspirin and 500 mg Ticlopidine between Sep '97 and May '98 at Chonnam University Hospital. RESULTS: Angiographic degree of stenosis at baseline, immediately after and at 4 weeks after stent was not different between Group I and II. With the histopathologic examination of the stented artery segments 4 weeks after stenting, diameter stenosis was 44.8+/-25.5% in Group I and 64.2+/-6.7% in Group II, which was not different (p=0.054). In clinical study, clinical diagnosis and indications for stent were not different between two Groups. Acute stent thrombosis developed in one (1.1%) of Group B and subacute stent thrombosis in three (6.5%) of Group A. Restenosis of the stented coronary artery was observed in 3 (18.8%) in Group A and 10 (37.0%) in Group B (p=NS). Minimal luminal diameter was 2.17+/-1.49 mm in Group A and 2.05+/-1.15 mm in Group B (p=NS). No patient in Group A developed side effect, while 4 (4.5%) patients developed side effects including toxic hepatitis in one, gastritis in one patient and thrombocytopenia in two patients. CONCLUSION: Combination antiplatelet therapy with Cilostazol and Aspirin is equally effective and more safe in the prevention of coronary stent restenosis, compared with the conventional therapy using Ticlopidine and Aspirin.

Risk Factors for the Second Restenosis after Coronary Interventions

BACKGROUND AND OBJECTIVES: One of the major limitations in coronary intervention is restenosis. This study was aimed to identify clinical, angiographic and procedural factors, which may be related to the second restenosis (SR). MATERIALS AND METHOD: We studied 101 patients who underwent more than two follow-up coronary angiograms after two coronary interventions between Jan 1996 and Dec 1998 in Chonnam University Hospital (out of 4092 total coronary interventions in 3030 patients during the same period). The patients were divided into two groups according to the evidence of second restenosis (SR). Fifty two patients (Group A: 56.6+/-9.9 year, M: F=44:8) who had SR, and the other 49 patients (Group B: 53.8+/-8.5 year, M: F=44: 5) were analyzed. Clinical features, angiographic characteristics, coronary interventional procedures, and other risk factors were compared between two groups by univariate analysis and multivariate stepwise logistic regression analysis for the predictive factors of second restenosis. RESULTS: 1) The clinical variables of age, sex, clinical diagnosis, and risk factors were not different between two groups. 2) The lesion types severer than B2 by AHA/ACC classification were associated with SR (p<0.05). 3) Recurrent angina as an indication for follow up angiography was associated with SR (p<0.01). CONCLUSION: The predictive factors associated with SR were patient's subjective symptom and lesion severer than type B2 according to AHA/ACC classification.

A case of prominent epicardial fat mimicking a tumor on echocardiography

Epicardial fat may anteriorly produce an echo-free space that can be mistaken for pericardial fluid. We recently experienced a 67-year-old woman with prominent epicardial fat which was presented as an echogenic tumor-like mass. She underwent open pericardiostomy to relieve large amount of pericardial effusion. Operative findings revealed only prominent epicardial fat. Biopsy of the pericardial and fat tissues revealed an inflammation and normal fat cells without any malignant cell infiltration.

The Effects of the Heparin-Coated Maximum Arterial Re-Creation (MAC) Stent on Porcine Coronary Stent Restenosis

BACKGROUND: Stent thrombosis and late restenosis are still major limitations in the clinical use of coronary stenting. Heparin-coated stent may reduce the incidences of stent thrombosis and restenosis. Heparin-coated stents were compared with control stents in a porcine coronary stent restenosis model in order to evaluate the effects of heparin-coated stent on stent restenosis. METHODS: Heparin was coated on a stent by deposition of an ultra-thin polymeric film containing amine groups by means of plasma polymerization. And then stent was immersed in heparin solution. Stent overdilation injury (stent:artery=1.3:1.0) was performed with bare (Group I, n=4) and heparin-coated (Group II, n=5) MAC stents in porcine coronary arteries. Follow-up quantitative coronary angiography (QCA) was performed at 4 weeks after stenting. The histopathologic assessments (KERN=*)of stented porcine coronary arteries were compared in between 2 groups. RESULTS: 1)Luminal area of stented artery was 7.05+/-1.25 mm2 in Group I and 7.67+/-2.85 mm2 in Group II, which were not different between two Groups. 2)Histopathologic stenosis of Group I was 35.7+/-13.2%, which was higher than 28.6+/-14.7% of Group II (p<0.05). Ratio of neointima/media was 1.16+/-0.52 in Group I and 0.87+/-0.31 in Group II and neointimal area was higher in Group I than in Group II (3.81+/-1.78 mm2 vs. 2.82+/-1.11 mm2, p<0.05 respectively). 3)PCNA (Proliferating cell nuclear antigen) index of GroupI was 10.0+/-2.2%, which was higher than in Group II (6.8+/-4.0%). CONCLUSIONS: Heparin-coated MAC stent may be effective in the inhibition of neointimal proliferation in a porcine stent restenosis model.

Clinical Characteristics of Korea Women with Ischemic Heart Disease

BACKGROUND: The prevalence of ischemic heart diseases (IHD) has increased remarkably during the past 10 years in Korea. Because only few reports on risk factors of IHD in Korean women exist, the aim of this study was to determine the clinical characteristics (including risk factors) of IHD in Korean women. METHODS: Fifty-six female patients and 122 (out of 655) of male patients with significant coronary artery stenosis were included in this study. There were 12 cases of angina pectoris and 35 cases of myocardial infarction in the 56 female patients. There were 54 cases of angina pectoris and 68 cases of myocardial infarction in the 122 male patients. Age and sexdistributions, risk factors of atherosclerosis, and coronary angiographic findings were compared between the female and male patients. RESULTS: The female patients were older than the male patients (63+/-8 years vs. 58+/-4 years, p or = 2) was greater in men than in women (43% vs. 25%, p<0.05). Hypertension was more prevalent (66% vs. 11%, p<0.001) and smoking was less (65% vs. 11%, p<0.001) in women than men. After age adjustment, hypertension was more frequent in women, and smoking was more in men (p=0.001). On coronary angiograms there were no difference in the morphology of coronary artery stenosis, the distribution of culprit vessels, and the number of vessels involved between women and men, In terms of therapeutic modalities, there were no differences between women and men in our study. CONCLUSIONS: In Koean women with IHD, hypertension is more common and smoking is less common. However, coronary artery lesion morphology and distribution are comparable between women and men.

Two Cases of Sliding Hiatal and Morgagni Hernia Mimicking Pericardial Lipomas

The differential diagnosis between pericardial and non-cardiac masses may be sometimes difficult in the evaluation of chest mass adjacent to the heart. One misdiagnosed case of non-cardiac mass as a pericardial mass turned out to be a hernia. When the contents of hernia originate from the gastrointestinal tract, the diagnosis is made easily by air-fluid shadow on plain chest roentgenogram. Morgagni hernia is usually detected on plain chest roentgenograms as a smooth, supradiaphragmatic shadow at the right pericardiophrenic angle. In the case of Morgagni hernia, in which the contents are only the omentum, it is necessary to differentiate the hernia from mediastinal fatty tumors. We report two cases of hiatal and Morgagni hernia containing omentum which were misdiagnosed as pericardial masses.

Hemolytic Anemia after mitral Valve Repair with a Duran Ring

No abstract available.

Clinical Experiences of Coronary MAC (Maximum Arterial Re-Creation) Stent

BACKGROUND AND OBJECTIVES: We previously reported the effects of MAC (Maximum Arterial Re-Creation) stent on stent restenosis in a porcine model. The clinical trial was performed in patients with ischemic heart disease after MAC stent implantation. MATERIALS AND METHOD: We analyzed the clinical and angiographic results in 20 patients in 22 lesions (15 M, 5 F, 59+/-11 year), who underwent MAC stent at Chonnam University Hospital between Nov '97 and Aug '98. Clinical diagnosis was 13 unstable angina (65%), 6 acute myocardial infarction (30%) and 1 old myocardial infarction (5%). RESULTS: Indications for stent were 3 de novo lesion (13.6%), 7 restenosis (31.8%), 8 suboptimal angioplasty result (36.4%) and 4 bail-out procedure (18.2%). Target stented coronary arteries were 15 left anterior descending coronary arteries (67.3%), 2 left circumflex coronary arteries (9.1%) and 5 right coronary arteries (22.7%). Morphologic types were 13 type B1 (59.1%), 5 B2 (22.7%) and 4 C (18.2%). Minimal luminal diameter (MLD) before stent was 0.75+/-0.35 mm and percent diameter stenosis (DS) was 75+/-11.5%, which were improved 2.97+/-0.28 mm in MLD and 2.79+/-5.4% in DS after stent. MAC stent was placed successfully in all patients and one case of acute stent thrombosis was improved after ReoPro infusion. Mean follow-up period was 5.2+/-3.2 months and 100 % event-free survival was observed in all patients. Follow-up coronary angiography was performed in 5 patients and showed no stent restenosis. CONCLUSION: The MAC stent is one of effective and safe devices in the treatment of coronary artery diseases without significant complications and target vessel revascularization.

The Clinical Effects of Losartan (Cozaar) on Hypertensive Patients

BACKGROUND: Losartan potassium, one of an orally active, selective type 1 angiotensin II receptor blocker, has been introduced recently as an antihypertensive agent. METHOD: Losartan, angiotensin II receptor blocker, was administrated as an initial antihypertensive agent over 12 weeks in 30 patients (11 male, 19 female, 60.1+/-7.2 years) with stage 1 to 3 hypertension in order to observe the clinical effects. Changes in quality of life, side effects, electrocardiogram and left ventricular function were also evaluated before and after losartan therapy. RESULTS: 1) After 12 weeks treatment with 50 to 100 mg of losartan, blood pressure was lowered markedly in 18 (60%), moderately in 9 (30%) and mildly in 1 (3%) out of 30 patients studied. The average of blood pressures of the 30 subjects were systolic 159.0+/-13.2 mmHg and diastolic 100.7+/-9.4 mmHg before treatment, which were lowered to 130.7+/-15.6 and 85.9+/-9.1 mmHg respectively after 12 weeks (p<0.005). 2) Heart rates were not changed with losartan. 3) Quality of life including general well-being, physical symptom, sleep and sexual dysfunction improved markedly in 2 (7%) and slightly in 17 (57%) out of 30 subjects. 4) Laboratory findings revealed no significant changes. 5) In electrocardiographic and echocardiographic follow-up 1 patient with ST-T abnormality and 2 patients with mild LV systolic dysfunction improved to normal. 6) Undesirable side effects were observed in 2 cases with dizziness, 1 dry cough, 1 skin rash, 1 leg edema and 1 epigastric discomfort, among whom one with dizziness stopped losartan. 7) In the final clinical assessment according to the scores of hypotensive effect, quality of life, LV function and side effect, losartan was very useful in 3 (10%), useful in 18 (60%) and slightly useful in 3 (10%) out of 30 hypertensive patients. CONCLUSION: Losartan can be used as an effective initial agent for the treatment of hypertension of various severities with the improvement of quality of life and low side effects.

Successful Coronary Interventions with the Aid of Abciximab (ReoPro (R)) in High-Risk Patients: Report of Two Cases / 대한구급학회지

Abrupt closure of coronary artery during coronary intervention is one of major limitations especially in high-risk patients. Platelets are responsible for composing acute thrombotic occlusion at the site of therapeutic arterial injury. Abciximab (platelet glycoprotein IIb/IIIa receptor blocker) might be helpful in preventing the acute thrombotic occlusion. We experienced an excellent effects of the drug in two cases of high-risk patients, unsuccessful thrombolytics and PTCA with acute occlusion. With additional use of abciximab we overcame the complications and succeeded in getting normal coronary flow and resultant successful angioplasties.

Effective Approaches to Successful Target Sites in Catheter Ablation of the Right-side Accessory Pathways / 대한내과학회지

BACKGROUND: Although radiofrequency catheter ablation (CA) of the accessory pathway (AP) is very effective and safe, it has been reported that CA is more difficult in the right-side AP than the left-side AP, requiring the refinement of the conventional CA technique for the right-side AP. This study was, therefore, aimed to develop an effective technique for CA of the right-side AP. METHODS: Fifty right-side APs in 45 patients which underwent CA were included in this study. The locations of APs were divided into 8 regions (anteroseptal, mid septal, posteroseptal, posterior, posterolateral, lateral, anterolateral, and anterior). After localizing APs, CA of the APs was attempted via the inferior vena cava (IVC) in all patients. If CA attempt via the IVC for more than 1 hour was failed, then CA was tried via the superior vena cava (SVC). Successful CA was defined as permanent loss of AP conduction even during infusion of isoproterenol (1-4microg/min). The ways of approaching the ablation catheter to the successful target sites were classified into over-the-tricuspid valve approach (OV) via the IVC (IVC-OV), OV via the SVC (SVC-OV), under-the-tricuspid valve (UV) approach via the IVC (IVC-UV), and UV via the SVC (SVC-UV) and evaluated according to the AP locations. RESULTS: The locations of the APs were anteroseptal in 5 APs, mid septal in 6, posteroseptal in 12, posterior in 3, posterolateral in 5, right lateral in 11, anterolateral in 4, and anterior in 4. Forty-eight (96.0%) of 50 APs were successfully ablated; 35 (70.0%) with primary IVC approaches and 13 (26.0%) with secondary SVC approaches. As a successful approach, IVC-OV was 26 (54.2%); IVC-UV, 9 (18.8%); SVC-OV, 4 (8.3%), and SVC-UV, 9 (18.8%). Secondary SVC approaches were required 7 (70.0%) in the lateral APs, 2 (50.0%) in the anterolateral APs, 1 (25.0%) of the posterolateral APs, 1 (25.0%) in the anterior APs, 1 (20.0%) of the anteroseptal APs, and 1 (8.3%) in the posteroseptal APs but none in the midseptal and posterior APs. SVC-UV approach was used in 9 (69.2%) in 13 APs which were ablated with SVC approach. CONCLUSIONS: The ways of approach to successful target site in CA of the right-side APs are different according to the location and SVC approaches are frequently required in ablation of the lateral or anterolateral APs. Therefore, SVC approaches should be considered in these locations if the initial IVC approaches are not successful.

Changes of Intracoronary Electrocardiogram by Repeated Occlusion: Repefusion During Percutaneous Transluminal Coronary Angioplasty / 대한내과학회지

OBJECTIVE: Brief epidodes of ischemia have been shown to make the heart more resistant to subsequent ischemia in animal studies(known as ischemic preconditioning, IP). This phenomenon was tested in patients undergoing percutaneous transluminal coronary angioplasty(PTCA). METHODS: Thirteen patients who had significant epicardial coronary stenosis without myocardial infarction, ventricular hypertrophy or conduction defect, received two to four 2-min balloon inflations separated by 5 min of reperfusion. Surface electrocardiogram(S-ECG) and intracoronary electrocardiogram (IC-ECG) from an angioplasty guide wire were recorded before and after balloon inflation. RESULTS: The changes of ST segment were observed in 13 out of 15 lesions on IC-ECG and 7 on S-ECG. The maximal ST changes on IC-ECG and S-ECG were 20.2+/-13.7mm and 1.21.5mm respectively(p<0.01). The time to beginning of ST segment change after balloon inflation were 10.1+/-12.6 seconds and 63.3+/-14.2 seconds on IC-ECG and S-ECG, respectively(p<0.01). The maximal changes of ST segment on IC-ECG during the second inflation were significantly lower than that during the first(20.2+/-13.7 vs 16.312.3mm, p<0.05). However, changes of R wave, T wave and QT interval were not significantly different between two inflations. The recovery time to baseling ECG after initiation of reperfusion were 50.2+/-41.7 seconds and 38.5+/-29.6 seconds for the first inflation and the second, respectively(P<0.05). CONCLUSION: These results suggest that IC-ECG is more sensitive and reliable than S-ECG in detection of myocardial ischemia and that IP may occur during PTCA since ST segment shift is decreased and is normalized earlier at the second balloon inflation compared with the first.