An Open-label, Single-arm, Multicenter Feasibility Study Evaluating the Safety of Catheter-based Renal Denervation with DENEX™ in Patients with Uncontrolled Hypertension on Standard Medical Therapy

Background and Objectives@#DENEX™ is a novel renal sympathetic denervation (RDN) system that is equipped with 3 electrodes that deliver radiofrequency energy to the renal nerves along renal arteries. The purpose of this study was to evaluate the safety and efficacy of RDN with DENEX™ in resistant hypertension. @*Methods@#This was an open-label, single-arm, multicenter, first-in-man pilot study. Between November 2016 and May 2018, a total of 16 patients were enrolled at 4 centers in South Korea. The inclusion criteria were systolic blood pressure (SBP) ≥150 mmHg and use of 3 or more antihypertensive medications, including diuretics. The primary objective was the safety outcome of RDN with the DENEX™ system. The secondary objective was efficacy outcome based on changes of office, and 24-hour ambulatory SBP from baseline to 3 months. The patients underwent abdominal computed tomography (CT) or duplex ultrasonogram before and 6 months after RDN. @*Results@#No major adverse events occurred after RDN for 6 month of follow-up period. There was no vascular complication either by CT or duplex ultrasonogram. The office SBP was significantly reduced from 164.6±11.6 mmHg at baseline to 142.0±20.4 mmHg (−24.4±24.4 mmHg, p=0.003) at 3 months. The ambulatory SBP was reduced from 151.44±12.85 mmHg at baseline to 140.0±16.5 mmHg (−13.1±18.9 mmHg, p=0.056) at 3 months. @*Conclusion@#RDN with the DENEX™ system showed a favorable safety profile in resistant hypertension. A significant reduction in office SBP and a borderline reduction in ambulatory SBP were observed.

Effects of Smoking on Long-Term Clinical Outcomes and Lung Cancer in Patients with Acute Myocardial Infarction

Background and Objectives@#Smoking is well-established as a risk factor for coronary artery disease. However, recent studies demonstrated favorable results, including reduced mortality, among smokers, which are referred to as the “smoker's paradox”. This study examined the impact of smoking on clinical outcomes in patients with acute myocardial infarction (AMI) undergoing percutaneous coronary intervention (PCI). @*Methods@#Patients with AMI undergoing PCI between 2004 and 2014 were enrolled and classified according to smoking status. The primary endpoint was a composite of major adverse cardiovascular events (MACE) including cardiac death, myocardial infarction, stroke, and revascularization. @*Results@#Among the 10,683 patients, 4,352 (40.7%) were current smokers. Smokers were 10.7 years younger and less likely to have comorbidities such as hypertension, diabetes mellitus, chronic kidney disease, stroke, and prior PCI. Smokers had less MACE (hazard ratio [HR], 0.644; 95% confidence interval [CI], 0.594–0.698; p<0.001) and cardiac death (HR, 0.494; 95% CI, 0.443–0.551; p<0.001) compared to nonsmokers during the 5 years in an unadjusted model. However, after propensity-score matching, smokers showed higher risk of MACE (HR, 1.125; 95% CI, 1.009–1.254; p=0.034) and cardiac death (HR, 1.190; 95% CI, 1.026–1.381; p=0.022). Smoking was a strong independent predictor of lung cancer (propensityscore matched HR, 2.749; 95% CI, 1.416–5.338; p=0.003). @*Conclusions@#In contrast to the unadjusted model, smoking is associated with worse cardiovascular outcome and higher incidence of lung cancer after adjustment of various confounding factors. This result can be explained by the characteristics of smokers, which were young and had fewer comorbidities.

An Open-label, Single-arm, Multicenter Feasibility Study Evaluating the Safety of Catheter-based Renal Denervation with DENEX™ in Patients with Uncontrolled Hypertension on Standard Medical Therapy

Background and Objectives@#DENEX™ is a novel renal sympathetic denervation (RDN) system that is equipped with 3 electrodes that deliver radiofrequency energy to the renal nerves along renal arteries. The purpose of this study was to evaluate the safety and efficacy of RDN with DENEX™ in resistant hypertension. @*Methods@#This was an open-label, single-arm, multicenter, first-in-man pilot study. Between November 2016 and May 2018, a total of 16 patients were enrolled at 4 centers in South Korea. The inclusion criteria were systolic blood pressure (SBP) ≥150 mmHg and use of 3 or more antihypertensive medications, including diuretics. The primary objective was the safety outcome of RDN with the DENEX™ system. The secondary objective was efficacy outcome based on changes of office, and 24-hour ambulatory SBP from baseline to 3 months. The patients underwent abdominal computed tomography (CT) or duplex ultrasonogram before and 6 months after RDN. @*Results@#No major adverse events occurred after RDN for 6 month of follow-up period. There was no vascular complication either by CT or duplex ultrasonogram. The office SBP was significantly reduced from 164.6±11.6 mmHg at baseline to 142.0±20.4 mmHg (−24.4±24.4 mmHg, p=0.003) at 3 months. The ambulatory SBP was reduced from 151.44±12.85 mmHg at baseline to 140.0±16.5 mmHg (−13.1±18.9 mmHg, p=0.056) at 3 months. @*Conclusion@#RDN with the DENEX™ system showed a favorable safety profile in resistant hypertension. A significant reduction in office SBP and a borderline reduction in ambulatory SBP were observed.

Effects of Smoking on Long-Term Clinical Outcomes and Lung Cancer in Patients with Acute Myocardial Infarction

Background and Objectives@#Smoking is well-established as a risk factor for coronary artery disease. However, recent studies demonstrated favorable results, including reduced mortality, among smokers, which are referred to as the “smoker's paradox”. This study examined the impact of smoking on clinical outcomes in patients with acute myocardial infarction (AMI) undergoing percutaneous coronary intervention (PCI). @*Methods@#Patients with AMI undergoing PCI between 2004 and 2014 were enrolled and classified according to smoking status. The primary endpoint was a composite of major adverse cardiovascular events (MACE) including cardiac death, myocardial infarction, stroke, and revascularization. @*Results@#Among the 10,683 patients, 4,352 (40.7%) were current smokers. Smokers were 10.7 years younger and less likely to have comorbidities such as hypertension, diabetes mellitus, chronic kidney disease, stroke, and prior PCI. Smokers had less MACE (hazard ratio [HR], 0.644; 95% confidence interval [CI], 0.594–0.698; p<0.001) and cardiac death (HR, 0.494; 95% CI, 0.443–0.551; p<0.001) compared to nonsmokers during the 5 years in an unadjusted model. However, after propensity-score matching, smokers showed higher risk of MACE (HR, 1.125; 95% CI, 1.009–1.254; p=0.034) and cardiac death (HR, 1.190; 95% CI, 1.026–1.381; p=0.022). Smoking was a strong independent predictor of lung cancer (propensityscore matched HR, 2.749; 95% CI, 1.416–5.338; p=0.003). @*Conclusions@#In contrast to the unadjusted model, smoking is associated with worse cardiovascular outcome and higher incidence of lung cancer after adjustment of various confounding factors. This result can be explained by the characteristics of smokers, which were young and had fewer comorbidities.

Effect of Pioglitazone in Combination with Moderate Dose Statin on Atherosclerotic Inflammation: Randomized Controlled Clinical Trial Using Serial FDG-PET/CT

BACKGROUND AND OBJECTIVES: Non-statin therapy plus lower intensity statin might be an alternative in patients with coronary artery disease (CAD). A recent data suggested an anti-inflammatory therapy can reduce recurrent cardiovascular events and pioglitazone is also an intriguing inflammatory-modulating agent. However, limited data exist on whether pioglitazone on top of statins further attenuates plaque inflammation. METHODS: Statin-naïve patients with stable CAD and carotid plaques of ≥3 mm were randomly prescribed moderate dose atorvastatin (20 mg/day), or moderate dose atorvastatin plus pioglitazone (30 mg/day) for 3 months. The primary endpoint was the change in the arterial inflammation of the carotid artery measured by 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG-PET/CT) during 3 months. RESULTS: Of the 41 randomized patients, 33 underwent an evaluation by fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT; 17 atorvastatin plus pioglitazone and 16 atorvastatin patients). The addition of pioglitazone significantly improved the insulin sensitivity and increased the high-density lipoprotein cholesterol after 3 months. Although a reduction in the (FDG) uptake by pioglitazone on top of atorvastatin in carotid arteries with plaque showed marginally statistical significance in the entire patient group (atorvastatin plus pioglitazone; −0.10±0.07 and atorvastatin −0.06±0.04, p=0.058), pioglitazone showed a further reduction of the fluorodeoxyglucose (FDG) uptake among patients who had a baseline FDG uptake above the median (atorvastatin plus pioglitazone; −0.14±0.04 and atorvastatin −0.03±0.03, p < 0.001). CONCLUSIONS: Pioglitazone demonstrated marginally significant anti-inflammatory effects in addition to moderate dose atorvastatin. This may have been due to the lack of power of the study. However, pioglitazone may have an anti-inflammatory effect in those patients with high plaque inflammation (Trial registry at ClinicalTrials.gov, NCT01341730).

Effect of Pioglitazone in Combination with Moderate Dose Statin on Atherosclerotic Inflammation: Randomized Controlled Clinical Trial Using Serial FDG-PET/CT

BACKGROUND AND OBJECTIVES@#Non-statin therapy plus lower intensity statin might be an alternative in patients with coronary artery disease (CAD). A recent data suggested an anti-inflammatory therapy can reduce recurrent cardiovascular events and pioglitazone is also an intriguing inflammatory-modulating agent. However, limited data exist on whether pioglitazone on top of statins further attenuates plaque inflammation.@*METHODS@#Statin-naïve patients with stable CAD and carotid plaques of ≥3 mm were randomly prescribed moderate dose atorvastatin (20 mg/day), or moderate dose atorvastatin plus pioglitazone (30 mg/day) for 3 months. The primary endpoint was the change in the arterial inflammation of the carotid artery measured by 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG-PET/CT) during 3 months.@*RESULTS@#Of the 41 randomized patients, 33 underwent an evaluation by fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT; 17 atorvastatin plus pioglitazone and 16 atorvastatin patients). The addition of pioglitazone significantly improved the insulin sensitivity and increased the high-density lipoprotein cholesterol after 3 months. Although a reduction in the (FDG) uptake by pioglitazone on top of atorvastatin in carotid arteries with plaque showed marginally statistical significance in the entire patient group (atorvastatin plus pioglitazone; −0.10±0.07 and atorvastatin −0.06±0.04, p=0.058), pioglitazone showed a further reduction of the fluorodeoxyglucose (FDG) uptake among patients who had a baseline FDG uptake above the median (atorvastatin plus pioglitazone; −0.14±0.04 and atorvastatin −0.03±0.03, p < 0.001).@*CONCLUSIONS@#Pioglitazone demonstrated marginally significant anti-inflammatory effects in addition to moderate dose atorvastatin. This may have been due to the lack of power of the study. However, pioglitazone may have an anti-inflammatory effect in those patients with high plaque inflammation (Trial registry at ClinicalTrials.gov, NCT01341730).

Recurrent fetal postpartum stress induced cardiomyopathy after normal vaginal delivery / 고신대학교의과대학학술지

Stress induced cardiomyopathy is a disease that shows a dysfunction of the ventricle, but it can be rapidly reversible. It often occurs in older women primarily who suffers from emotional or physical stress. There are some case reports about postpartum stress induced cardiomyopathy. Most of the patients are recovered naturally within days to weeks. We report a case of a 37 years-old woman, who had experienced postpartum stress induced cardiomyopathy 8 years ago, revisited hospital because of cardiomyopathy after secondary delivery. Herein we report a rare case of recurrent stress induced cardiomyopathy after secondary normal vaginal delivery.

The Prognostic Value of the Left Ventricular Ejection Fraction Is Dependent upon the Severity of Mitral Regurgitation in Patients with Acute Myocardial Infarction

The prognostic value of the left ventricle ejection fraction (LVEF) after acute myocardial infarction (AMI) has been questioned even though it is an accurate marker of left ventricle (LV) systolic dysfunction. This study aimed to examine the prognostic impact of LVEF in patients with AMI with or without high-grade mitral regurgitation (MR). A total of 15,097 patients with AMI who received echocardiography were registered in the Korean Acute Myocardial Infarction Registry (KAMIR) between January 2005 and July 2011. Patients with low-grade MR (grades 0-2) and high-grade MR (grades 3-4) were divided into the following two sub-groups according to LVEF: LVEF 40% (n = 12,252 and 226, respectively). The primary endpoints were major adverse cardiac events (MACE), cardiac death, and all-cause death during the first year after registration. Independent predictors of mortality in the multivariate analysis in AMI patients with low-grade MR were age > or = 75 yr, Killip class > or = III, N-terminal pro-B-type natriuretic peptide > 4,000 pg/mL, high-sensitivity C-reactive protein > or = 2.59 mg/L, LVEF 40% were noted. MR is a predictor of a poor outcome regardless of ejection fraction. LVEF is an inadequate method to evaluate contractile function of the ischemic heart in the face of significant MR.

Type 4 dual left anterior descending coronary artery

No abstract available.

Myocardial Mechanics in a Rat Model with Banding and Debanding of the Ascending Aorta

BACKGROUND: Aortic banding and debanding models have provided useful information on the development and regression of left ventricular hypertrophy (LVH). In this animal study, we aimed to evaluate left ventricular (LV) deformation related to the development and regression of LVH. METHODS: Minimally invasive ascending aorta banding was performed in rats (10 Sprague Dawley rats, 7 weeks). Ten rats underwent a sham operation. Thirty-five days later, the band was removed. Echocardiographic and histopathologic analysis was assessed at pre-banding, 35 days of banding and 14 days of debanding. RESULTS: Banding of the ascending aorta created an expected increase in the aortic velocity and gradient, which normalized with the debanding procedure. Pressure overload resulted in a robust hypertrophic response as assessed by gross and microscopic histology, transthoracic echocardiography [heart weight/tibia length (g/m); 21.0 +/- 0.8 vs. 33.2 +/- 2.0 vs. 26.6 +/- 2.8, p < 0.001]. The circumferential (CS) and radial strains were not different between the groups. However, there were significant differences in the degree of fibrosis according to the banding status (fibrosis; 0.10 +/- 0.20% vs. 5.26 +/- 3.12% vs. 4.03 +/- 3.93%, p = 0.003), and global CS showed a significant correlation with the degree of myocardial fibrosis in this animal model (r = 0.688, p = 0.028). CONCLUSION: In this animal study, simulating a severe LV pressure overload state, a significant increase in the LV mass index did not result in a significant reduction in the LV mechanical parameters. The degree of LV fibrosis, which developed with pressure overload, was significantly related to the magnitude of left ventricular mechanics.

A Case of Three Consecutive Events of Acute Myocardial Infarctions in Three Different Vessels

A 51-year-old man was being admitted to the emergency department with chest pains. He had a history of acute myocardial infarction (MI) on two prior occasions and was successfully treated with drug eluting stents. He was diagnosed with 3 consecutive events of acute MI in 3 different vessels. The consecutive events of acute MI in different vessels are a very rare case. He did not have risk factors, such as coagulation abnormality, clopidogrel resistance, patient's compliance and vessel abnormality, except for his cigarette smoking. We reported the first case with 3 consecutive events of acute MI in each 3 vessels during a long-term interval.

A Case of Patent Ductus Arteriosus with Congestive Heart Failure in a 80-Year-Old Man

Patent ductus arteriosus (PDA) is a rare clinical finding in adult patients. Considering the increase in cases of PDA discovered incidentally on echocardiograms at young ages, and the life-shortening effect of PDA, it is rare to diagnose PDA in old patients. We report a case of an 80-year-old patient who experienced symptoms of congestive heart failure showed findings suggestive of PDA in echocardiogram and confirmed the diagnosis through a cardiac catheterization and a coronary angiography. After percutaneous occlusion of PDA with an Amplatzer duct occlusion device, symptoms related to congestive heart failure improved.

Comparison of Clinical and Imaging Characteristics and Outcomes between Provoked and Unprovoked Acute Pulmonary Embolism in Koreans

This study was performed to compare clinical and imaging parameters and prognosis of unprovoked pulmonary embolism (PE), provoked PE with reversible risk factors (provoked-rRF), and provoked PE with irreversible risk factors (provoked-iRF) in Koreans. Three hundred consecutive patients (mean age, 63.6 +/- 15.0 yr; 42.8% male) diagnosed with acute PE were included. The patients were classified into 3 groups; unprovoked PE, provoked-rRF, and provoked-iRF; 43.7%, 14.7%, and 41.7%, respectively. We followed up the patients for 25.4 +/- 33.7 months. Composite endpoint was all-cause mortality and recurrent PE. The provoked-iRF group had significantly higher all-cause mortality, mortality from PE and recurrent PE than the unprovoked and provoked-rRF groups (P 1.2 mg/dL; P 5 mg/L; P = 0.002; HR, 5.308; 95% CI, 1.824-15.447) and computed tomography (CT) obstruction index (P = 0.034; HR, 1.090; 95% CI, 1.006-1.181). In conclusion, provoked-iRF has a poorer prognosis than unprovoked PE and provoked-rRF. Renal insufficiency, high CRP, and CT obstruction index are poor prognostic factors in unprovoked PE.

Comparison of Clinical and Imaging Characteristics and Outcomes between Provoked and Unprovoked Acute Pulmonary Embolism in Koreans

This study was performed to compare clinical and imaging parameters and prognosis of unprovoked pulmonary embolism (PE), provoked PE with reversible risk factors (provoked-rRF), and provoked PE with irreversible risk factors (provoked-iRF) in Koreans. Three hundred consecutive patients (mean age, 63.6 +/- 15.0 yr; 42.8% male) diagnosed with acute PE were included. The patients were classified into 3 groups; unprovoked PE, provoked-rRF, and provoked-iRF; 43.7%, 14.7%, and 41.7%, respectively. We followed up the patients for 25.4 +/- 33.7 months. Composite endpoint was all-cause mortality and recurrent PE. The provoked-iRF group had significantly higher all-cause mortality, mortality from PE and recurrent PE than the unprovoked and provoked-rRF groups (P 1.2 mg/dL; P 5 mg/L; P = 0.002; HR, 5.308; 95% CI, 1.824-15.447) and computed tomography (CT) obstruction index (P = 0.034; HR, 1.090; 95% CI, 1.006-1.181). In conclusion, provoked-iRF has a poorer prognosis than unprovoked PE and provoked-rRF. Renal insufficiency, high CRP, and CT obstruction index are poor prognostic factors in unprovoked PE.

Two Cases of Percutaneous Intervention for Coronary Artery Bypass Graft Anastomoses With Paclitaxel-Eluting Balloon Catheters

Coronary artery bypass graft (CABG) intervention, particularly anastomosis site intervention, is challenging for interventional cardiologists. A paclitaxel-eluting balloon catheter (SeQuent Please) is a recently-introduced device capable of delivering paclitaxel homogeneously into the targeted vessel wall. We herein report our experience with two cases. In the first case, coronary angiography showed significant stenosis at the site of anastomosis between the saphenous vein graft and the left anterior descending artery (LAD). In the second case, coronary angiography showed significant stenosis at the site of anastomosis between the left internal mammary artery and the LAD. We performed percutaneous intervention of these CABG anastomoses using paclitaxel-eluting balloon catheters, and obtained favorable angiographic and clinical outcomes.

Spontaneous Visceral Artery Hemorrhage in a Patient with Systemic Lupus Erythematosus Combined with Antiphospholipid Syndrome: A Case Report / 대한류마티스학회지

Spontaneous visceral hemorrhage is a rare complication of systemic lupus erythematosus (SLE). We report here on a 55-year old male with SLE and who presented with acute abdominal pain due to bleeding of the hepatic artery and the splenic artery. Angiography revealed a spontaneous hemorrhage from branches of the hepatic artery and the splenic artery. We report here on a case of spontaneous recurrent non-traumatic hemorrhage of a visceral artery in a patient with secondary antiphospholipid syndrome (APS), and such a condition has not been previously described in a Korean patient with SLE.

Inflammatory Cloacogenic Polyp Mimicking Anorectal Malignancy / 대한소화기내시경학회지

Inflammatory cloacogenic polyp is a polypoid protruding lesion arising from the transitional zone of the anorectal junction. It has a distinctive endoscopic, histological appearance, but it may macroscopically resemble anorectal malignancy. It is important to beware of the possibility of adenoma and malignancy when finding lesions at the anorectal junction. The management of inflammatory cloacogenic polyp is endoscopic or surgical excision. We report here on a 62 year old man who had an anorectal polyp. The initial impression was hemorrhoid or anorectal malignancy. He underwent surgical intervention, and the histology showed inflammatory cloacogenic polyp.

Intracranial Hypotension with Spontaneous CSF Leakage in a Patient with Systemic Lupus Erythematosus / 대한류마티스학회지

Headaches are not only one of the 19 different neuropsychiatric syndromes in SLE but also the most common chief complaint of patients with neuropsychiatric lupus. Approximately 50% of patients with SLE are presumed to have neuropsychiatric phenomena during their illness. There're no specific serological, radiological or histological biomarkers to confirm the clinical diagnosis of neuropsychiatric lupus. Therefore, physicians tend to try controlling lupus activity especially when the origins of the headache in patients with lupus are difficult to define. However, neuropsychiatric lupus can only be diagnosed after excluding other causes which is the point. A 47-year-old woman with lupus presented to the emergency department with the sudden onset of postural headache with nausea and vomiting. Through CSF tapping and CT myelography, intracranial hypotension with spontaneous CSF leakage was revealed. Her symptoms promptly improved after therapy using an epidural blood patch. Intracranial hypotension with spontaneous CSF leakage is rare disease, and it has never been reported in patients with SLE before. This case emphasizes the importance of finding out the origin of a headache in patients with lupus.