Austrian Syndrome with a Delayed Onset of Heart Failure

A 59-year-old man treated with pneumococcal meningitis 4 months ago was hospitalized for acute heart failure and performed aortic valve replacement by rupture of aortic valve. The frequent association of pneumococcal meningitis and endocarditis is known as Austrian syndrome. Though Austrian syndrome is a clinically rare disease, the evolution of pneumococcal endocarditis is very aggressive and associated with high mortality, and early recognition for evidence of endocardial lesion in patients with pneumococcal meningitis is important to reduce the complications and mortality rate.

Left Transradial Coronary Angiography in a Patient With Dextrocardia

Although dextrocardia occurs rarely, the incidence of coronary artery disease is similar to the general population. Because of unfamiliarity with performing catheterization, transradial coronary angiography has seldom been performed in a patient with dextrocardia. We successfully performed left transradial coronary angiography in a patient with a right side heart using counter-directional torquing of the catheters and mirror-image angiographic angles.

Balloon Embolectomy of a Cylindrical Dissected Plaque That Complicated Performing Superficial Femoral Artery Angioplasty

We report here on a case of successfully removing a calcified plaque embolus that complicated performing angioplasty. A 67 year-old woman underwent percutaneous transluminal angioplasty for a stenosis of the right superficial femoral artery (SFA). The angiogram showed a marked stenosis at the mid-portion of SFA and diffuse circular calcification along the atheroma rim was seen on the computed tomographic angiography. Although balloon inflation was attempted on the lesion, it was not fully dilated. After repeated balloon inflations, a radiopaque calcified atheroma was detached from the arterial wall and it migrated proximally along with withdrawing the balloon. The embolus was too extensive to be pulled out through the catheter sheath; therefore, a small balloon was inflated at the distal end of the embolic atheroma to anchor it and the embolus was removed with the balloon and the sheath system via an arteriotomized puncture site. A huge cylindrical atheroma that measured 4 cm in length was successfully removed. The final angiography showed a widened target site without any dye leakage.

Comparison of the Effects of Nicorandil and Cocktail Solution to Prevent Radial Artery Spasm during Coronary Angiography

BACKGROUND AND OBJECTIVES: A radial artery spasm is one of the most common complications of coronary angiography during a transradial, causing considerable patient discomfort, which sometimes disturbs the procedure. This study was designed to evaluate the effects of nicorandil in the prevention of a radial artery spasm during coronary angiography. SUBJECTS AND METHODS: This was a randomized study to compare 4 mg of nicorandil and a 10 mL cocktail solution performed in 100 patients. Vasospasms of the radial artery, which were expressed as stenosis of the vessel diameter with a transradial approach and radial artery patency by pulse oximetry analysis one month later, were examined. RESULTS: Reductions in the systolic and diastolic blood pressures after administration of the spasmolytic agents were 15.8+/-11.8/ 8.4+/-8.0 and 20.5+/-13.6/6.7+/-6.2 in the for nicorandil and cocktail groups, respectively. Nicorandil induced a lesser decrease in the systolic BP than the cocktail, but without statistical significance (p=0.07). Both vasodilating agents showed a significant radial artery vasodilation following their intra-arterial administration (p<0.001 for all). The diameter of the radial artery showed a significant decrease in both groups following catheterization (p<0.05 for all). There were no significant differences between the two groups in terms of radial artery spasms (46 vs. 58% in nicorandil and cocktail groups, respectively, p=0.709). CONCLUSION: Nicorandil, with vasodilatory effects due to a dual mechanism was as effective as the cocktail solution in the vasodilation of the radial artery.

Risk Stratification of Patients with Minor Troponin-I Elevation Unassociated with Acute Myocardial Infarction

BACKGROUND AND OBJECTIVES: Although cardiac troponin I is widely used as a marker for myocardial infarction (MI), minor elevations of cardiac troponin I are also observed in other clinical situations. The prognostic factors for patients with these clinical features are not well established. The aim of this study was to discover the predictors of mortality for the patients who had minor troponin elevations without acute MI. SUBJECTS AND METHODS: We enrolled consecutive 154 patients from the emergency department or inpatient units who had a peak troponin I level greater than the lower limit of detectability (0.04 ng/mL), and the level was also less than the suggestive value of MI (0.6 ng/mL). They were with chest pain or nonspecific symptoms of circulatory abnormality, but they lacked the traditional features of acute MI. The endpoint was defined as death from all causes. The Cox proportional hazard model was used to test the relationship between the clinical and biochemical variables and the outcomes. RESULTS: During the follow-up period of 7.9+/-7.3 months, mortality occurred in 15 patients. Age, the creatine kinase myocardial isoform (CK-MB) level and the C-reactive protein (CRP) level as continuous variables had significant correlations with the occurrence of death. After adjusting for any possible confounders in the multivariate model, these variables remained as independent predictors of mortality: age (HR 1.07, CI 1.02-1.14, p=0.012), CK-MB level (HR 1.61, CI 1.16-2.24, p=0.005), and CRP level (HR 1.01, CI 1.00-1.01, p=0.025). CONCLUSION: Integration of the CK-MB and CRP levels, as well as age, can be used for risk-stratification in the patients showing minor troponin I elevation for reasons other than acute MI.

Risk Factors of Deep Vein Thrombosis and Pulmonary Embolism in Korean

BACKGROUND AND OBJECTIVES: Deep vein thrombosis and pulmonary embolism are both associated with a high mortality. However, in Korea, they are known as relatively rare diseases and are not sufficiently evaluated, so there is limitations in the proper approach toward their diagnosis and management. SUBJECTS AND METHODS: The risk factors, accompanying illness and family history of patients with deep vein thrombosis and pulmonary embolism, treated at Hallym University Sacred Heart Hospital, between January 1999 and July 2002, were analyzed. RESULTS: There were 113 patients with deep vein thrombosis and pulmonary embolism, comprised of 45 men and 68 women, 31 being older than 70 years of age (the largest portion). Of the 113 patients, 101 had identified causal illness causative diseases, but the other was no obvious risk factors. Overweight and obese turned out to be the most frequent risk factor. While there were 35% with one risk factor, 51.3, 10 and 3.7% had two, three or four risk factors, respectably. The recurrence rate was 20.3%, and that of women was 1.2 fold that of men, irrespectively of the risk factor. There were also two patients with a positive family history. CONCLUSION: The freguent risk factors and underlying diseases for deep vein thrombosis and pulmonary embolism were over-weight/obesity, antiphospholipid syndrome, cancer and a bed ridden state, in that order of frequency. As the individual risk factors of the patients overlapped in 61.5% cases, attention should be paid to overlapping risk factors. In order to reduce the complications of these diseases, each patient's risk factors should be carefully evaluated, and some patients should be advised to take life-long care.

Coronary Artery Size in Korean: Normal Value and its Determinants

BACKGROUND AND OBJECTIVES: Although the size of the coronary artery is known to be closely related to the outcome of coronary artery bypass grafting and percutaneous coronary intervention, its normal value and determinants have not been examined in Koreans. SUBJECTS AND METHODS: One hundred and twenty seven normal coronary arteriograms were carefully selected from 3,412 studied consecutively. Of these, 53 women and 23 men, with no abnormalities in their cardiac function and not using nitrates, were studied. The lumen diameter was measured at 10 segments in the epicardial coronary arteries. RESULTS: For men, the mean lumen diameter of the proximal left anterior descending and left circumflex coronary arteries were 3.88+/-0.39 and 3.45+/-0.47 mm, respectively, and were not affected by the anatomic dominance. However, the left main and proximal right coronary arteries varied between 4.44+/-0.49 and 5.18+/-0.32 mm (p<0.05) and 3.29+/-0.60 and 4.05+/-0.42 mm (p<0.05), respectively, by the anatomic dominance. Women had a smaller mean coronary artery size than men [for diameter, -7% (p<0.01);for cross-sectional area, -13% (p<0.01)], and the left ventricular (LV) mass was significantly associated with coronary artery diameter (p<0.05). From a multiple linear regression analysis, gender was an only independent predictor of the coronary artery size (p<0.05). CONCLUSION: We revealed normal coronary artery dimensions in Koreans. Although, body size, hypertension, use of calcium channel blockers, anatomic dominance and age had no effect on the size of the coronary artery, but the LV mass and gender were shown to have an effect. The multivariate regression analysis showed gender was an only independent predictor of the coronary artery size.

Clinical Significance of Atrioventricular Plane Displacement for Evaluating Left Ventricular Diastolic Dysfunction

BACKGROUND AND OBJECTIVES: Atrioventricular plane displacement (AVPD) has been used for evaluating systolic function. However, its relations with other echocardiographic variables reflecting diastolic function are not well documented. This study was designed to assess the relations between AVPD and those echocardiographic variables known to reflect diastolic function, especially using mitral annulus velocity. SUBJECTS AND METHODS: Eighty-seven patients with normal left ventricular (LV) systolic function (normal echocardiography group (Group I, n=44), concentric left ventricular hypertrophy (LVH) group (Group II, n=43)) and 51 patients with LV dysfunction (Group III) were studied. To evaluate the correlation with echocardiographic variables reflecting LV systolic and diastolic function, we measured mitral inflow velocity and mitral annulus Doppler tissue velocity. RESULTS: AVPD was correlated negatively with age, the ratio of early diastolic mitral inflow velocity and early diastolic mitral annulus velocity (E/E'), isovolumic relaxation time, and E/A ratio. AVPD was correlated positively with deceleration time, ejection fraction, and systolic mitral annulus velocity (S'). By multivariate analysis, AVPD was independently correlated with S' (beta=0.4, p<0.001) and E' (beta=0.5, p<0.001) in the normal LV function group, and with S' (beta=0.6, p<0.001) and E/E'(beta=-0.3, p=0.005) in the LV dysfunction group. CONCLUSION: AVPD may be used as a diagnostic tool for evaluating LV diastolic function.

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.

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.

Comparison analysis of an indirect measurement of friedwal formula method and direct measurment of immunoseparation method on low-density lipoprotein cholesterol measurement / 대한내과학회지

BACKGROUND: In 2001, the third report the National Cholesterol Education Program (NCEP) has concluded that LDL cholesterol levels should be a major goal for preventing coronary artery disease and atherosclerotic events. Those in the higher risk groups should then have lipoprotein analysis to determine LDL cholesterol levels. LDL cholesterol has traditionally been estimated by the Friedwald forrmula : LDL-C=total cholesterol-[high density lipoprotein cholesterol (HDL-C)+trigryceride/5]. However, when trigryceride level is >400 mg/dL, this formula is inaccurate. Therefore, We have compared the direct LDL cholesterol immunoseparation method with Friedwald formula from both normotriglyceridemic (triglyceride400 mg/dL). METHODS: The direct LDL cholesterol immunoseparation method was performed on 53 sera with triglyceride levels 61 to 1,684 mg/dL (classified as400 mg/dL : 31). Total cholesterol was measured enzymatic colorimetry. HDL cholesterol was measured in the supernatant after precipitating LDL by HDL cholesterol precipitating reagent containing dextran sulfate and magnesium chloride for serum. Direct LDL cholesterol was measured by immunoseparation method (Sigma Diagnostics, St Louis, Mo) that is based on selective absorption of HDL cholesterol and VLDL cholesterol by polystylene beads coated with goat polyclonal antibodies to human apolipoproteins. The cholesterol was measured by an enzamatic method on Hitachi 747. The linear regression and paird t-test were performed to evaluate the differences of data from Immunoseparation method and Friedwald formula. RESULTS: In triglyceride400 mg/dL, the LDL cholesterol value obtained by the direct LDL-C assay on the 31 frozen sera studied was significantly different from that of Friedwald formula (103+/-38.4; 50.4+/-56.2 mg/dL). Therefore, Friedwald formula is unreliable in triglyceride>400 mg/dL. CONCLUSION: Guidelines for treatment decisions, including diet and drug initiation, and therapeutic goals for high risk groups are based entirely on the LDL cholesterol level. At triglyceride levels >400 mg/dL, Friedwald fomula is inaccurate. Immunoseparation method is more rapid, higher specific, precise and helps monitor LDL lowering drugs and diets in triglyceride level>400 mg/dL.

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.

Budd-Chiari Syndrome Due to Antithrombin,Protein C and Protein S Deficiency and the Complete Obstruction of SVC / 대한흉부외과학회지

In this case, a 39 year-old man was admitted with Budd-Chiari syndrome associated with complete superior vena cava(SVC)obstruction causing general edema and hepatic failure. Conservative medical therapy was failed. And after the radiologist failed to invasive procedure of balloon dilatation, we attempted the inferior vena cava to right atrium bypass graft. Operation was done through median sternotomy and extended vertical oblique abdominal incision. A 24 mm Dacron tube was placed from the inferior vena cava just below the left renal vein to the right atrium without using the cardiopulmonary bypass pump. The patient's postoperative course was uneventful without signs of bleeding or anyother complications. We used anticoagulants at the postoperative first day. At the postoperative 26th day, we performed abdominal Doppler sonography and we confirmed that the graft patency was good. The patient was discharged with SVC obstructive symptoms but we noticed relief of SVC obstructive symptoms in the course of follow-up.

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.

Progression and Regression of Coronary Atherosclerosis-Clues to Pathogenesis from Serial Coronary Arteriography

BACKGROUND AND OBJECTIVES: Identification of coronary sites susceptible to progression or nonprogression might provide additional information to select medical or surgical treatment and furthermore for appropriate timing for percutaneous transluminal coronary angioplasty or coronary artery bypass graft. METHODS: We reviewed serial coronary arteriograms of 50 patients with coronary artery disease retrospectively. Patients were managed with standard treatment including anti-hypertensives, antiplatelets, lipid-lowering agents and other risk factor management by attending physician's decision. Patients who received percutaneous transluminal angioplasty, coronary artery bypass graft or thrombolysis were excluded. Cononary arteriographies were undertaken with average 33 months interval. Criteria for the progression and regression were the changes of the luminal diameter narrowing of the arterial segment by 20% or more reduction or increase, respectively. Results: Patients show progressive change, regressive change or no significant interval change in 50%, 12% and 30% of total 50 patients, respectively. Male gender, angiographic interval were the significant predictor of progressive change. In terms of coronary segment, stable segments are most frequent 52.2% (72/138) and progression in 40.2% (74/184), regression in 27.5% (38/138). Initial coronary lesions with low grade stenosis (less than 50%) have a tendency to progress than that of high grade stenosis (70% or more) Percentage diameter stenosis of new lesion are not related linearly with the interval between two sequential angiographies. CONCLUSION: Number of patients with progressive coronary arteriogram are more frequent than the patients with regressive change or no interval change. Progression and regression are frequent finding of serial coronary arteriography in usual clinical practice. Progression and regression are found frequently in the same patient at different coronary branches (16 patients). It suggested that the local factors may play an important role in the pathogenesis of coronary artery disease as well as systemic risk factors.

Two cases of Ticlopidine-induced neutropenia in patients with cardiovascular disease

Ticlopidine is an antiplatelet agent used as a drug to prevent the recurrence of cerebral infarction or ischemic heart disease. Close attention has recently been paid to the superiority of this drug to aspirin in the prevention of stroke. Its mechanism of action differs from aspirin, dipyridamole, and sulfinpyrazone. Inhibition of the adenosine diphosphate induced pathway of platelet aggregation, along with the activation of adenylate cyclase and suppression of platelet-activating factor and thromboxane A2, are the postulated mechanisms of action of ticlopidine. Because ticlopidine causes neutropenia and agranulocytosis in roughly 1% of treated patients, usually within the first 3 months of treatment, this drug has been reserved for patients intolerant to aspirin therapy. We reported two cases of ticlopidine-induced neutropenia and one patient hospitalized with severe neutropenia and pneumonia.

Two cases of Ticlopidine-induced neutropenia in patients with cardiovascular disease

Ticlopidine is an antiplatelet agent used as a drug to prevent the recurrence of cerebral infarction or ischemic heart disease. Close attention has recently been paid to the superiority of this drug to aspirin in the prevention of stroke. Its mechanism of action differs from aspirin, dipyridamole, and sulfinpyrazone. Inhibition of the adenosine diphosphate induced pathway of platelet aggregation, along with the activation of adenylate cyclase and suppression of platelet-activating factor and thromboxane A2, are the postulated mechanisms of action of ticlopidine. Because ticlopidine causes neutropenia and agranulocytosis in roughly 1% of treated patients, usually within the first 3 months of treatment, this drug has been reserved for patients intolerant to aspirin therapy. We reported two cases of ticlopidine-induced neutropenia and one patient hospitalized with severe neutropenia and pneumonia.

Serum Total Homocysteine as a Risk Factor for Patients with Coronary Artery Disease

BACKGROUND AND OBJECTIVES: Homocysteine is a metabolite of methionine metabolism with atherogenic and thrombotic properties. Increased blood homocysteine has been recognized as a risk factor for atherosclerotic coronary artery disease, but it is not much to be clarified in this country. MATERIALS AND METHOD: In a case-control study, we examine the relationship between the risk of atherosclerotic coronary artery disease and serum total homocysteine, folate, vitamin B12, vitamin B6, and other conventional risk factors. Thirty nine patients with significant stenosis of epicardial coronary artery and 20 healthy age-sex matched control subjects were included. Fasting venous blood was obtained and serum total homocysteine (tHCY) concentration was measured by high performance liquid chromatography and fluorescent detection method. RESULTS: Compared with control group, case group had higher tHCY concentrations (14.9+/-6.9 vs 10.8+/-4.2 mol/L, p<0.05) and lower folic acid concentration (6.7+/-3.6 vs 11.0+/-5.7 ng/mL,p<0.05). There were higher tHCY concentrations of patients with 2 vessel and 3 vessel disease than that of patients with 1 vessel disease (17.2+/-6.7 and 18.4+/-9.8 micro mol/L vs 12.4+/-3.9 micro mol/L,p<0.05). Vitamin B12 and vitamin B6 concentrations showed no significant difference between case group and control group. Compared with control group, there were more smokers (51.5% vs 25.0%, p<0.05), and patients with hypertension (39.4% vs 0%, p<0.001) and diabetes (30.3% vs 0%, p<0.001) in case group. Increased tHCY (tHCY over 14.7 mol/L) was an independent risk factor for atherosclerotic coronary artery disease (OR; 6.75, 95% CI; 1.15 - 40.99, p<0.05) together with smoking (OR; 5.4, 95% CI; 1.22 - 23.95, p<0.05). CONCLUSION: These data support the hypothesis that elevated serum tHCY concentration is a risk factor for Korean patients with atherosclerotic coronary artery disease, and low folate concentration may be responsible for elevated tHCY concentration.

Thromboembolism of Left Anterior Descending Artery Complicated during Angioplasty of Left Circumflex Artery: Report of 1 Case

Percutaneous transluminal coronary angioplasty(PTCA) has been widely applied in patients with coronary artery disease since 1977. Although coronary angioplasty has beeb shown to be safe and effective treatment strategy, acute closure & restenosis remain as major limitations of PTCA. Acute occlusion due to intracoronary thrombus accumulation during or immediately after coronary angioplasty is serious complication of PTCA, also, Intracoronary urokinase has been used to treat acute occlusion by intracoronary thrombus that complicated in PTCA and proved to be effective in restoring vessel preventing acute myocardial infarction. We report a case in which embolism of left anterior descending artery was complicated during angioplasty of left circumflex artery and managed with intracoronary infusion of urokinas.