Doppler Tissue Image for Diagnosis of Myocardial Dyssynchronicity in Congestive Heart Failure: Comparison with EKG

BACKGROUND AND OBJECTIVES: Electrical dyssynchronicity (Dsyn) appears to be prognostic of survival in congestive heart failure (CHF). Recent study has shown some discrepancy between the electrical Dsyn and the Doppler tissue image (DTI) assessed mechanical Dsyn. The aim of our study was to evaluate the relationship between the QRS duration and DTI assessed Dsyn. SUBJCETS AND METHODS: One hundred and forty patients, with CHF and left ventricular ejection fractions 130 msec, standard deviation (SD) of the RS time >40 msec, or a difference in the maximal and minimal RS times (RS time-diff) >100 msec were indicators of'Dsyn'. RESULTS: The prevalence of myocardial Dsyn, by QRS duration, SD of the RS time and the RS time-diff were 19, 43 and 47%, respectively. The SD of the RS time (49.8+/-23.6 vs. 36.6+/-20.7, p130 msec) compared with the narrow QRS group. There was also a weak positive correlation between the QRS duration and the SD of the RS time (R=0.34, p<0.001) and the RS time-diff (R=0.38, p<0.001). However, from a cross-tabulation analysis, more than one third of patients had a discrepancy between QRS duration and DTI assessed mechanical Dsyn. From a multivariate analysis, a major determinant of the SD of the RS time was the QRS duration. CONCLUSION: Although a major determinant of the DTI assessed Dsyn was the QRS duration, more than one-third of patients had a discrepancy between electrical and mechanical Dsyn. Therefore, not only the QRS duration, but the DTI assessed Dsyn, should be measured when considering cardiac resynchronization therapy.

Doppler Tissue Image for Diagnosis of Myocardial Dyssynchronicity in Congestive Heart Failure: Comparison with EKG

BACKGROUND AND OBJECTIVES: Electrical dyssynchronicity (Dsyn) appears to be prognostic of survival in congestive heart failure (CHF). Recent study has shown some discrepancy between the electrical Dsyn and the Doppler tissue image (DTI) assessed mechanical Dsyn. The aim of our study was to evaluate the relationship between the QRS duration and DTI assessed Dsyn. SUBJCETS AND METHODS: One hundred and forty patients, with CHF and left ventricular ejection fractions 130 msec, standard deviation (SD) of the RS time >40 msec, or a difference in the maximal and minimal RS times (RS time-diff) >100 msec were indicators of'Dsyn'. RESULTS: The prevalence of myocardial Dsyn, by QRS duration, SD of the RS time and the RS time-diff were 19, 43 and 47%, respectively. The SD of the RS time (49.8+/-23.6 vs. 36.6+/-20.7, p130 msec) compared with the narrow QRS group. There was also a weak positive correlation between the QRS duration and the SD of the RS time (R=0.34, p<0.001) and the RS time-diff (R=0.38, p<0.001). However, from a cross-tabulation analysis, more than one third of patients had a discrepancy between QRS duration and DTI assessed mechanical Dsyn. From a multivariate analysis, a major determinant of the SD of the RS time was the QRS duration. CONCLUSION: Although a major determinant of the DTI assessed Dsyn was the QRS duration, more than one-third of patients had a discrepancy between electrical and mechanical Dsyn. Therefore, not only the QRS duration, but the DTI assessed Dsyn, should be measured when considering cardiac resynchronization therapy.

Depressed Inflammatory Response to Repeated Angioplasty in Unstable Angina Patients with an In-Stent Restenosis

BACKGROUND: Inflammation plays a key role in the pathogenesis of an in-stent restenosis because it promotes neointimal proliferation. This study was performed to determine responses of the C-reactive protein (CRP) in unstable angina patients with an in-stent restenosis undergoing repeated percutaneous transluminal coronary angioplasty (re-PTCA). METHODS: The study subjects (unstable angina) were classified into 2 groups:Group A (n=30, 15 men, mean age 62 years) had a re-PTCA for an in-stent restenosis lesion and Group B (n=60, 33 men, mean age 63 years) underwent a stent implantation for a de novo lesion. RESULTS: The baseline CRP levels in group A were significantly lower than in group B, as well as 6 and 24 hours after intervention. Twenty four hours after intervention, the CRP levels increased (>4 mg/L) in 3 out of 30 patients (10%) of group A but increased in 32 out of 60 patients (53%) in group B (p<0.001). The differences in the CRP levels between the baseline and 24 hours after intervention were significantly lower in group A than in group B (0.8 and 2.15 mg/L, respectively, p<0.001). In group B, the serum CRP levels 24 hours after intervention were significantly higher than the baseline levels (p<0.05), but not in group A. CONCLUSION: The CRP expression level is significantly lower in unstable angina patients undergoing a re-PTCA for an in-stent restenosis than those undergoing a stent implantation for a de novo lesion.

The Change of Pulmonary Artery Pressure in Graves'Disease Before and After Treatment / 대한내분비학회지

BACKGROUND: Exertional symptoms, dyspnea and impaired effort tolerance are common in patients with Graves' disease. Proposed explanations include: high-output left heart failure, ineffective oxygen utilization and respiratory muscle weakness. In addition, pulmonary hypertension has also been reported in patients with Graves' disease. A high prevalence of hypothyroidism and positive thyroid autoantibody were also observed in patients with pulmonary arterial hypertension. Therefore, the pulmonary artery pressure in patients with Graves' disease was evaluated. METHODS: Two-dimensional and Doppler echocardiographic examinations (Hewlett Packard Sonos 2500) were performed to determine the pulmonary artery (PA) pressure in 26 Graves' disease patients, both before and after treatment (23 patients with propylthiouracil and 3 with RAI), and in 10 euthyroid controls. The changes in the PA pressure after treatment were evaluated in 13 patients with Graves' disease, who became euthyroid after treatment. RESULTS: The pulmonary artery pressure was increased in the untreated Graves' disease patients compared to the normal controls (23.5+/-2.32 vs. 29.6+/-10.3 mmHg). 38.5% of the Graves' disease patients (10/26) showed pulmonary arterial hypertension (PA>30 mmHg) and the serum TBII levelwas higher in the Graves' disease patients with pulmonary arterial hypertension than in those with normal PA pressure (P<0.05). In the Graves' patients who became euthyroid after treatment, the PA pressure was significantly decreased. CONCLUSION: 38.5% of the untreated Graves' disease patients showed pulmonary arterial hypertension, and the pulmonary artery pressure was significantly decreased in those who became euthyroid after treatment. The pathogenesis and clinical importance of pulmonary arterial hypertension in Graves' disease requires further studies.

Myocardial Synchronicity: As a Predictor of Left Ventricle Function Recovery in Severe Congestive Heart Failure

BACKGROUND AND OBJECTIVES: The recovery of the left ventricular ejection fraction (LVEF) appeared to be prognostic of survival in congestive heart failure (CHF). The aim of our study was to evaluate the parameters that appear to predict the LVEF recovery in CHF. SUBJECTS AND METHODS: Forty-nine patients, with CHF and a LVEF or =5%, n=20). RESULTS: The baseline clinical and echocardiographic parameters were similar in both groups. In group II, the LV end-systolic and end-diastolic volumes were decreased, but the LVEF was increased by up to 44% at the follow-up. The right ventricular annulus velocity (group I: 6.7+/-2.1 vs. group II: 8.0+/-2.0 cm/sec, p< 0.05), the use of beta-blocker (69 vs. 100%, p< 0.05) and the SD of the RS time (46+/-21 vs. 21+/-12, p< 0.01) were significantly different between the two groups. However, the systolic duration and the SD of the RE time were similar in the two groups. From a multivariate analysis, only the SD of the RS time was an independent predictor of the LVEF recovery. CONCLUSION: Myocardial systolic synchronicity is an important predictor of the LVEF recovery.

Quantification of Regional Wall Motion Abnormality Using Myocardial Strain in Acute Myocardial Infarction

BACKGROUND AND OBJECTIVES: Several echocardiographic methods, such as ejection fraction, fractional shortening, and Doppler tissue imaging (DTI), have been developed to quantify systolic function but all had several important limitations. The purpose of this study was to quantify the regional wall motion abnormality, using strain, in an acute myocardial infarction, compared with a visual estimation. SUBJECTS AND MEHTODS: Forty-five patients, with acute anterior (n=28) and inferior myocardial (n=17) infarctions, who underwent color DTI, were examined using longitudinal strain and standard echocardiography, and the results were compared with 54 normal controls. A total of 594 segments [3 segments (apical, mid and basal portion) of septum and inferior wallx99 patients] were evaluated. RESULTS: In the normal control group, the strain was uniformly distributed in all segments (-20%~-23%). In the infarction groups, the strain was negatively related with the wall motion score. The strain of the apical segments and mid-septum was decreased in the anterior wall infarctions, and the strain of basal septum and mid to basal inferior wall was decreased in the inferior wall infarctions. The dyskinetic segments showed positive strain. CONCLUSION: This study validates strain as a superior method for the quantification of the regional wall motion abnormality in an acute myocardial infarction than visual estimation.

Clinical Outcome and ECG Change in Patients with Acute Myocardial Infarction and Prodromal Angina

BACKGROUND AND OBJECTIVES: Ischemic preconditioning reduces the size of myocardial infarct in animal models, however its role in humans remains unclear. Clinical data suggests that episodes of angina immediately before acute myocardial infarction may be associated with a protective effect on the human myocardium. We performed an analysis on the effect of prodromal angina on infarct size, in-hospital outcome and newly developed Q-wave in patients with acute myocardial infarction. SUBJECTS AND METHODS: 65 patients who had received thrombolytic therapy were enrolled in the study. Eleven patients (17%) had experienced previous angina within 24 hours prior to acute myocardial infarction (group I), and the remaining 54 patients (83%) did not have a history of previous angina (group II). Killip class, cardiac enzyme, ECG findings, echocardiographic data and in-hospital outcomes were compared between the two groups. RESULTS: Group I tended to have lower peak creatine kinase (CK) and CK-MB levels, although the difference between the two groups in regards to the level of cardiac enzyme was statistically insignificant. Despite similar patient characteristics, Group I showed a lower incidence of heart failure during hospitalization than group II. 6/11 patients (55%) in group I and 47/54 (87%) in group II had a Q-wave at discharge ECG. Group I showed better left ventricular systolic function during admission. None of the DM patients (14 patients) had prodromal angina and 13 of 14 patients (93%) demonstrated Q-wave infarction. CONCLUSION: Prodromal angina prior to acute myocardial infarction as a marker of ischemic preconditioning may also confer beneficial effects in terms of in-hospital outcomes. Further studies concerning the long term outcomes of such cases are needed.

Predictive Value of C-Reactive Protein for Cardiac Events after Coronary Stenting

BACKGROUND AND OBJECTIVES: Recent studies have implicated inflammation in the pathogenesis of coronary artery disease. The aim of this study was to determine whether C-reactive protein (CRP) levels are predictive of major adverse cardiac events (MACE) following stenting. SUBJECTS AND METHODS: The study comprised 193 patients (90 men, 152 unstable angina, mean age 63 years) between October 1999 and March 2001. The patients were classified into 2 groups according to their MACE, [group A; MACE (+), n=46 and group B; MACE (-), n=147]. RESULTS: During clinical follow-up at a mean duration of 15 months, there was 1death, 7 myocardial infarctions, 25 cases of revascularization therapy, and 13 recurrent anginas. At 24 hours after stenting, the CRP levels were significantly higher in group A compared to group B (5.4, 0.6-15.2 vs. 3.1, 0.1-9.8 mg/L, respectively, p8.0 mg/L) occurring more commonly in group A than group B (24% vs. 9%, p<0.05). The differences in the CRP levels between the baseline and 24 hours following stenting (CRP 24h-base ) were also significantly higher in group A than in group B. After adjustment for age, sex, and cardiovascular risk factor, multi-variate analysis using logistic regression revealed the CRP levels 24 hours after stenting were predictive of MACE, with an odd ratio of 1.6 (95% CI 1.1-2.2, p=0.01). CONCLUSION: CRP levels, 24 hours following intervention, are powerful predictor of cardiac events in patients with stable or unstable angina undergoing coronary stenting. These results suggest that the inflammatory responsiveness to coronary intervention can plays an important role in predicting cardiac events.

"Recovery Only" ST-Segment Depressions in an Exercise Treadmill Test and the Prediction of Coronary Artery Disease

BACKGROUND AND OBJECTIVES: "Recovery only" ST-segment depressions are sometimes detected during an exercise treadmill test. We undertook this study in order to clarify the predictive value of exercise-induced ST-segment depression occurring in recovery only. SUBJECTS AND METHODS: The study included 931 patients who had both a sign or symptom -limited treadmill test. Of the 66 patients who demonstrated abnormal ST-segment responses, 43 experienced ST-segment depressions during exercise (Group A) and 23 displayed such responses only during recovery (Group B). RESULTS: The positive predictive value of an exercise treadmill test for significant angiographic disease in group A (81.3%) was statistically different from the predictive value in group B (30.4%). Horizontal ST-segment depression in recovery periods and female sex were statistically significant factors favoring negative coronary angiographic results. CONCLUSION: The occurrence of horizontal mild ST-segment depression during only the recovery periodgenerally represents a "false positive" response, particularly in female patients.

The Optimal Timing to Measure C-Reactive Protein to Predict Cardiac Events in Patients with Unstable Angina

BACKGROUNDS AND OBJECTIVES: C-Reactive protein (CRP) levels are powerful predictors of cardiac complications and death in patients with unstable angina unrelated with myocardial cell damage or myocardial ischemia. This study was performed to determine the optimal timing to measure CRP to predict cardiac events in patients with unstable angina. MATERIALS AND METHOD: The study was comprised 50 patients with unstable angina (Braunwald Class IIIb). We randomized the study subjects by the time of CRP elevation (> 8mg/L): Group A (on admission, 15 patients), Group B (during hospitalization, 19 patients), and Group C (at discharge, 19 patients). RESULTS: 1) CRP levels (median and range) of Group A, B, and C were 10.6 (8.2-24.2), 12.8 (8.1-33.7), and 10.3 (8.1-18.7) mg/L, respectively (p=S). 2) During clinical follow-up at a mean duration of 12 months, there were 1 death, 1 myocardial infarction, 6 revascularization therapy (PTCA or CABG) and 11 recurrent angina. 3) In Group A, 10 cardiac events (1 myocardial infarction, 4 revascularization therapy, and 5 recurrent angina) occurred. The elevated levels of CRP predicted cardiac events during clinical follow-up with sensitivity of 53%(10/19), positive predictive value of 67%(10/15), and negative predictive value of 74%(26/35). In Group C, 13 cardiac events were occurred. Sensitivity, positive and negative predictive value to predict cardiac events of elevated levels of CRP were 68%(13/19), 68%(13/19) and 81%(25/31), respectively. 4) Elevated levels of CRP (>8mg/L) were predictors for cardiac events in patients with unstable angina (Group A; p 8mg/L at discharge were only predictive of cardiac events with odd ratio of 6.01 (95% CI 1.50-44.3, p 8mg/L) was elevated in 38% of patients at discharge and elevated levels of CRP at discharge were only predictive of cardiac events in patients with unstable angina.

Emergent Use of Intraaortic Balloon Pump in Patients with Ischemic Heart

BACKGROUND AND OBJECTIVES: The purpose of this study is to examine clinical characteristics and outcome in patients with cardiogenic shock or ongoing cardiogenic shock by acute coronary syndrome who underwent intraaortic balloon pump(IABP) support, and to identify factors predictive of in-hospital mortality. MATERIALS AND METHODS: Thirty-two consecutive patients with IABP support from 1994 to 1997 were analyzed retrospectively. RESULTS: The causes for insertion of IABP are cardiogenic shock(31%), unstable hemodynamics during angiography or angioplasty(31%), ventricular tachycardia(15%), mechanical complications(15%), and ongoing chest pain(6%). The overall survival rate was 47%. Revascularization procedures were done in 23 cases(72%) in whom inhospital survival rate was 52%. The mortality rate was significantly higher in patients with cardiogenic shock(80%) and mechanical complications(100%) including ventricular septal defect and acute mitral regurgitation, but lower with intractable ventricular tachycardia. Differences between survivors and nonsurvivors were not significant in regard to clinical characteristics, extent of coronary artery disease, time to IABP, time to coronary artery bypass graft, and clamping time, but only duration of IABP is longer in nonsurvivors. CONCLUSIONS: Emergent uses of IABP in patients with intractable ventricular tachycardia may be effective in maintaining hemodynamics before revascularization procedures, but patients with pump failure by cardiogenic shock or mechanical complications have higher mortality rates.

Transcatheter Coil Embolization of Coronary Arteriovenous Fistula in Patient with Turner Phenotype with 46,XX

The coronary arteriovenous fistula (CAVF) is a rare congenital anomaly but constitutes the most common hemodynamically significant coronary artery anomaly. Transcatheter embolization is as an effective alternative to surgery even though procedure may be complicated by migration of the coil into peripheral vessels or pulmonary arteries. To our knowledge, the association of CAVF with Turner syndrome was not reported. We report a case of successful coil embolization of CAVF using a complex, helical-fibered platinum coil in patient with Turner phenotype with 46,XX.

The Prognostic Significance of Troponin-T in Patients with Acute Myocardial Infarction: Can Late Peak Concentration of Troponin-T after Myocardial Infarction Predict Cardiovascular Events?

BACKGROUND AND OBJECTIVES: It has been demonstrated that the estimated infarct size is a prognostic variable which significantly influences the short-term and long-term prognosis after an acute myocardial infarction (AMI). Recently, the late peak level of troponin-T has been determined as a reliable and simple non-invasive method for estimation of infarct size. This study was performed to determine whether the late peak level of troponin-T can be used to predict cardiovascular events during in-hospital stay and out-patient follow-up in patients with AMI. MATERIALS AND METHOD: The study was comprised 100 patients (male 91, mean age 57+/-1 years) with AMI and thrombolysis which was initiated within 6 hours after the onset of symptoms. The late peak concentration of troponin-T was defined as a more larger level between 48 and 72 hours after thrombolysis. We investigated the factors influencing on the late peak level of troponin-T and assessed the relation of the late peak level and cardiovascular events. RESULTS: 1) The late peak level of troponin-T was significantly correlated with the peak creatine kinase (CK) level, (r=0.69, p=0.0001) but not ejection fraction of left ventricle (LVEF) at 7 days after AMI. The late peak level of troponin-T was significantly higher in patients with LVEF of <40% at 7 days after AMI (13.49+/-3.62 vs. 6.44+/-0.72, p=0.035) but not different by location of AMI and reperfusion status. 2) During clinical follow-up at a mean duration of 27 months, 1 cardiac death, 10 congestive heart failure, 8 recurrent infarction, and 20 post-myocardial infarction angina were occurred. 3) In patients who occurred cardiac events during in-hospital stay, the peak level of CK (4377+/-938 vs. 2661+/-234, p=0.001) and TIMI forward flow grade < 3 (5/13 vs. 6/55, p=0.022) were significantly higher, but the late peak level of troponin-T (8.69+/-1.22 vs. 6.91+/-0.79, p=0.021) and the peak level of troponin-T (21.09+/-2.29 vs. 13.28+/-1.37, p=0.021) were significantly higher in patients who occurred cardiac events during out-patient follow-up. On multi-variate analysis by logistic regression, the late peak level of troponin-T was predicted the cardiac events during clinical follow-up (CI 1.022-1.196, p=0.022). CONCLUSIONS: The late peak level of troponin-T is significantly correlated with peak CK level and higher in patients with LVEF of

Buerger's Disease in Female Habitual Smoker with Involvement of the Right Hand

No abstract available.

A Case of Eisenmenger Syndrome with Brain Abscess

The Eisenmenger syndrome is characterized by severe irreversible pulmonary hypertension and right-to-left shunting of blood through the pulmonary-systemic communication. The resultant right-to-left shunt leads to clinical cyanosis and secondary manifestations of chronic hypoxemia. Clinical features include dyspnea on exertion, fatigue, palpitation, hemoptysis, syncope, chest pain and predisposition to brain abscess and cerebrovascular accident. Brain abscess is a serious complication of cyanotic congenital heart disease and major cause of death. We report a patient with Eisenmenger syndrome in whom the presence of right-to-left shunt and paradoxical embolism appears to be critical for the development of brain abscess.

Transient Left Ventricle Systolic Dysfunction in Amniotic Fluid Embolism

Amniotic fluid embolism (AFE) is a rare peripartum complication with a mortality rate of 61 to 86%. The main clinical manifestations include shock, acute pulmonary edema, neurologic signs, and coagulopathies. Most diagnosis of AFE is made on the postmortem examination of the maternal pulmonary vasculature, but antemortem confirmation of amniotic fluid material by aspiration of pulmonary blood is rare. We report the first case in Korea who survived from amniotic fluid embolism confirmed by the identification of amniotic fluid debris in pulmonary artery blood. Serial echocardiographic changes of left ventricle systolic dysfunction are also described with a brief review of literatures.

Infective Endocarditis with Systemic Septic Emboli

Infective endocarditis is still one of the important fatal diseases, especially with systemic embolic manifestations. Infective endocarditis is often misdiagnosed because of variability of systemic embolic manifestations. We have experienced 3 cases of infective endocarditis with systemic embolic manifestations who were initially misdiagnosed as other infectious diseases. Case 1 is a 66 year-old man, who was admitted to our hospital with dyspnea , fever and petechia. His chest X-ray showed rapid decrease of cardiomegaly and pulmonary congestion in two days. At 1 week after discharge he was readmitted for recurrent fever. On the follow-up echocardiography, mitral regurgitation was newly detected. Case 2 is a 75 year-old man, who was admitted to neurology department with sudden left hemiplegia and headache, in whom it was initially difficult to differentiate from ischemic brain infarction. Case 3 is a 29 year-old man, who was admitted to neurosurgery department with fever and back pain, in whom it was initially difficult to diffrentiate from tuberculous spondylitis in early radiologic study. All 3 cases were treated effectively with appropriate antibiotic therapy and discharged with improvement of symptoms. We report 3 cases of systemic embolic manifestations complicated by infective endocarditis with a brief review of literatures.

Clinical and Angiographic Characteristics and Long-term Follow-up in Patients with Variant Angina Who Presented as Acute Myocardial Infarction

BACKGROUNG AND OBJECTIVES: There were numerous reports for clinical characteristics and prognosis of patients with variant angina (VA) but little information is available for patients with VA who presented as acute myocardial infarction (AMI). The purpose of this study is to determine the clinical and angiographic predictors for initial development of AMI in patients with VA and prognosis of patients with VA who presented as AMI. MATERIALS AND METHODS: The study group comprised 166 patients with VA:forty one (25%) of whom presented as AMI (Group A;Male 32, mean age 50 years) and 125 presented as typical VA or unstable angina (Group B;Male 73, mean age 54 years). The diagnosis of VA was made by spontaneous spasm and ergonovine or acetylcholine (only Group B) provocation. RESULTS: 1)Male gender (78% vs. 58%, p<0.05), smoking (74% vs. 53%, p<0.05), and disease duration (18+/-5 vs. 7+/-1 month, p<0.0001), and ST-segment elevation during chest pain (71% vs. 23%, p<0.05) were significantly higher in group A than in Group B. 2)Prevalence of fixed stenosis of 50% or greater was higher in Group A than in group B (12% vs. 2%, p<0.05) and the percent stenosis after nitroglycerin injection was also greater in group A than in group B (43+/-5% vs. 28+/-2, p<0.01), but the disease activity such as frequency of resting angina, spontaneous spasm, and multivessel spasm were not different between two groups. 3)During clinical follow-up at a mean duration of 2.7 years, three patient (2%) in group B died of a cardiac cause. Non-fatal MI occurred 1 (2%) and 3 patients (2%) in group A and B, respectively. CONCLUSIONS: Our data show that male gender, smoking, duration of disease, ST-segment elevation during chest pain, and a fixed stenosis of 50% or greater are predictors for initial development of AMI in patients with VA. The prognosis in group A is excellent and this may be associated with less severe atherosclerotic disease and a high rate of medication with calcium channel blocker or nitrate compared with those in previous studies.

Valvular Regurgitation in Patients with Graves' Disease

The high cardiac output state and an increased incidence of atrial fibrillation are well-known cardiovascular complications of Graves' disease, whereas the valvular complications are less well recognized. With 2D color Doppler echocardiography, the cardiac and valvular function of 39 patients with Graves' disease were evaluated and our data were compared with previous Kage's study. The incidences of mitral regurgitation (MR) and tricuspid regurgitation (TR) in patients with Graves' disease were 54% and 51%, respectively. There was no correlation between the incidence of MR and ventricular dilatation. In patients with congestive heart failure (CHF), the incidences of severe TR and atrial fibrillation were significantly higher than in patients without CHF. The incidences of TR and MR in patients with Graves' disease were not different by thyroid function status (hyperthyroid vs. euthyroid). We suggest that the examination for TR and MR in patients with Graves' disease is important not only their high prevalence but also their clinical significance as a risk factor for CHF.

Four Cases of Pericardial Tamponade Following Percutaneous Transluminal Coronary Angioplasty

Percutaneous transluminal coronary angioplasty (PTCA) is a relatively safe and effective procedure in the treatment of coronary artery disease, but complications related to dilating catheters and guide wires such as coronary artery dissection, spasm, rupture, and perforation can be. Pericardial tamponade is a rare complication of cardiac catheterization, and prompt diagnosis and proper management are important in lifesaving. We report 4 patients who developed pericardial tamponade following PTCA, presumably from coronary artery or right ventricular perforation. All 4 patients received heparin during PTCA and temporary pacemaker was placed in the right ventricle. Pericardial tamponade was recognized in the catheterization laboratory in 1 patient, within 3 hours after leaving the laboratory in 3 patients. Emergent pericardiocentesis was performed in all patients. Three patients recovered and one patient died.