Intracoronary Thrombolysis and Delayed Percutaneous Coronary Intervention for the Treatment of Large Coronary Thrombi in a Patient with Polycythemia Vera / 대한내과학회지

The benefit of thrombus aspiration during percutaneous coronary intervention in patients with acute myocardial infarction (AMI) is well established; however, the optimal management strategy for patients with a large thrombus burden after repeated thrombectomy (i.e., "failed" thrombectomy) is unknown. Here, we report the case of a 67-year-old male with polycythemia vera who was treated with intracoronary thrombolytic therapy in combination with mechanical thrombectomy. Repeated aspiration thrombectomy did little to reduce the coronary thrombus burden; thus, intracoronary urokinase infusions were applied to the thrombus-containing lesion. Repeat coronary angiography 4 days later revealed markedly improved antegrade flow in the infarct-related artery, and successful revascularization was performed. This case demonstrates the potential utility of intracoronary thrombolytic therapy for select AMI patients with a large thrombus burden who are in a hypercoagulable state.

Three-Dimensional Echocardiographic Views of Bicuspid Pulmonic Valve

No abstract available.

A Case of Primary Anti-Phospholipid Syndrome with Recurrent Renal Infarction / 대한내과학회지

Anti-phospholipid syndrome is characterized by the occurrence of venous or arterial thrombosis in the presence of anti-phospholipid antibodies and is associated with morbidity during pregnancy. Arterial thromboses are less common than venous thromboses and most frequently manifest with features consistent with ischemia or infarction. Only a few cases of arterial thrombosis with primary anti-phospholipid syndrome have been reported in Korea. We report a 41-year-old man with anti-phospholipid syndrome who had abdominal pain due to a recurrent renal infarction, and we review the literature on anti-phospholipid syndrome.

A Case of Acute Total Obstruction of the Left Main Coronary Artery Presenting with Atypical Momentary Electrocardiogram Changes

Acute total obstruction of the left main coronary artery (LMCA) is a serious emergency condition requiring prompt diagnosis and treatment. Unless properly treated, it will likely progress to cardiogenic shock and a high mortality rate. We report a case of acute LMCA total obstruction presenting with atypical momentary electrocardiogram (ECG) changes including right bundle branch block with left axis deviation, and ST-segment elevation in aVR and aVL. We focus on the unusual ECG changes associated with LMCA obstruction which should be noted in order to ensure revascularization without delay, especially when this condition is accompanied by cardiogenic shock.

A Case of Primary Cardiac Lymphoma Mimicking Acute Coronary and Aortic Syndrome

Primary cardiac lymphoma (PCL) is a rare disorder, but the incidence is increasing and its clinical manifestations are various. We report a case of PCL, which mimics an acute coronary and aortic syndrome. A 51 year-old female was presented with chest pain radiating to the back. Her initial electrocardiogram revealed T wave inversion in the leads of V 5-6, II, III and aVF. Additionally, cardiac troponin-T was slightly elevated. Chest radiography showed marked mediastinal widening. Computed tomography scan showed a huge pericardial mass. The histopathologic findings of the mass were compatible with diffuse large B cell lymphoma. She died of refractory ventricular tachycardia, probably, due to an extensive infiltration of PCL to the myocardium.

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

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

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

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

Primary Cardiac Angiosarcoma Presenting With Cardiac Tamponade

Primary cardiac angiosarcoma is a very rare disease with a poor prognosis. We report a case of a patient with a primary cardiac angiosarcoma who presented with cardiac tamponade; the angiosarcoma was successfully resected surgically.

Primary Cardiac Lymphoma Presenting With Atrioventricular Block

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

Early Detection of Perforation of the Right Ventricle by a Permanent Pacemaker Lead

Ventricular perforation is a rare complication of permanent cardiac pacemaker implantation. We report here on a 68-year-old woman with a dual chamber permanent pacemaker that had been implanted one month earlier, and she suffered cardiac perforation from the pacemaker lead. Frequent follow-up via12-lead surface electrocardiography and chest radiography and the proper work-up for pacemaker implantation are needed for detecting rare complications after pacemaker implantation.

A Case Report of Inoue Balloon Deformity Recognized during Percutaneous Mitral Valvuloplasty

Since the Inoue balloon was first introduced for percutaneous mitral valvuloplasty (PMV) in 1984, this procedure has come into widespread use because of its effectiveness, simplicity, and reduced exposure to X-ray radiation. It's the procedure's complications include cardiac tamponade, atrial septal defect, thromboembolism, ventricular perforation, mitral regurgitation, and rarely balloon rupture. We report a case of Inoue balloon deformity during PMV in 62-year old woman with rheumatic mitral stenosis. Echocardiography revealed severe rheumatic mitral stenosis with a valvular area of 0.95 cm2 (by pressure half-time method), and an Echo score of 10 points. The PMV with Inoue balloon 28 mm was performed. We inflated the balloon to 28 mm in diameter first, and to 29 mm second. A bulging deformity with asymmetrical overinflation of one side of both proximal and distal balloon was recognized. A bulging deformity at the proximal part of Inoue balloon after second inflation. Balloon was not ruptured. Following completion of the procedure, the mitral valve area increased to 1.8 cm2. Moderate mitral regurgitation (grade II) was newly developed. This may be the first case of asymmetrical one side inflation and focal bulging deformity reported in Korea.

Assessment of Myocardial perfusion in Patients with Acute Myocardial infarction

BACKGROUND: Unlike 99mTc-Sestamibi, microbubbles used during myocardial contrast echocardiography (MCE) exist only in the vascular space. Therefore, there may be a difference in the pattern of myocardial perfusion between MCE and 99mTc-Sestamibi Single-Photon Emission Computed Tomography (SPECT) in acute myocardial infarction (AMI). OBJECTIVES: The purpose of this study was to assess myocardial perfusion using MCE with intravenous infusion of perfluorocarbon-exposed sonicated dextrose albumin microbubbles (IV MCE), and to compare it with SPECT and MCE with intracoronary injection of sonicated Hexabrix (IC MCE). METHODS: Seventeen patients with AMI (male 13, age 59.5+/-8.8 years, anterior MI 10) underwent IV MCE at 8.1+/-3.7 days after onset. SPECT and IC MCE were also performed at 1.2+/-1.0 days and 2.0+/-1.5 days from IV MCE respectively. Any revascularization procedures were not performed between three studies. Perfusion defect by three methods was scored semiquantitatively as 1 : normal perfusion, 0.5 : moderate defect, and 0 : severe defect at 16 segments of the left ventricle. RESULTS: 1) Perfusion defect in infarction territory was detected in 15 patients with SPECT, 12 patients with IV MCE and 11 patients with IC MCE. 2) Concordance of perfusion score at each segment was 93% between IV MCE and IC MCE, 65% between IV MCE and SPECT, and 64% between IC MCE and SPECT. 3) With IV MCE, perfusion defect was observed in all 32 segments which were considered as having defect (score 0 and 0.5) by IC MCE. However, defect by IV MCE was found only in 31 out of 108 segments considered as having defect by SPECT. CONCLUSION: In the assessment of myocardial perfusion in pts with AMI, IV MCE and IC MCE showed similar results. However, there was some discrepancy in the extent of perfusion defect between MCE studies and SPECT.

Clinical Observation of Infective Endocarditis

BACKGROUND AND OBJECTIVES: The clinical pattern of infective endocarditis is constantly changing. Diagnosis and treatment of infective endocarditis were developed by recent diagnostic strategy (Duke criteria) and introduction of transesophageal echocardiography. The aim of this study was to compare the clinical character-istics of infective endocarditis in Sejong hospital to the previous report and was to investigate risk factor of heart failure, embolism and death. MATERIAL AND METHODS: All episodes hospitalized of infective endocarditis from January of 1990 to October of 1999 in Sejong hospital were reviewed retrospectively. The total cases of infective endocarditis was 80 cases in 78 patients. RESULTS: The male to female ratio was 1:1.05 (39 male, 41 female). The mean age was 42 years. Rheumatic heart disease was the most common predisposing heart disease in 28.8%, followed by prosthetic valve endocarditis. Streptococci were the most commonly isolated micro-organisms in 18 cases (45.0%), followed by staphylococci in 11 cases. Transesophageal echocardiography has a higher sensitivity than transthoracic echocardiography for detection of vegetation, abscess and paravalvular complication in endocarditis. In patients with echocardiographic vegetation and involvement of aortic valve, there was a statistically significant increase in the risk of heart failure. The factor that was associated with a statistically significant increase in the overall risk of embolization was not exist. Ten patients died (12.5%). Risk factor for death was left ventricular dysfunction. The incidence of death was more higher in patients with abscess and non-streptococcal endocarditis. CONCLUSION: Compared to the 1980's report, we observed increased mean age of patients, the decreasing trend of rheumatic heart disease as a predisposing heart disease and the decreasing incidence of streptococci as causative microorganism. Risk factors for congestive heart failure were aortic valve endocarditis and endocarditis with vegetation. Risk factor for death was left ventricular dysfunction.

Results of percutaneous transluminal coronary angioplasty of chronic total occlusion

BACKGROUND AND OBJECTIVE: Percutaneous transluminal coronary angioplasty of chronic total occlusion has been limited by a relatively low success rate and a high restenosis rate. This study investigated procedural outcome, factors predictive of procedural success and safety of coronary angioplasty for chronic total coronary occlusion. MATERIALS AND METHODS: The study population was composed of 45 lesions attempting PTCA with or without stent implantation for recanalization of chronic total coronary occlusion between January 1997 and July 1999. The clinical and angiographic data of the 45 lesions were reviewed. The results of successful PTCA in 28 lesions were compared with those in 17 lesions whose PTCA was failed. RESULTS: The overall success of balloon angioplasty and stenting was achieved in 28 lesions (62.2%) and did not differ significantly by clinical variables. The most common cause of failure of balloon angioplasty was inability to pass the guide wire across the occlusion( 14 of 23 lesions, 61%). Procedural success was more common in patients with occlusions with a tapered entry configuration(77.2% vs. 47.8%, p=.042), with lesions without side branches(82.3% vs. 50%, p=.03). Multiple logistic regression analysis identified the absence of side branch(p60%) of chronic total coronary occlusions can be successfully dilated by balloon angioplasty with or without stent implantation, with a major complication rate of 2.2%. Therefore, with careful patient selection, we need to try the aggressive recanalization for chronic total coronary occlusion.

Two cases of ruptured congenital sinus of Valsalva aneurysms dissecting into the interventricular septum in patients with cerebral infarction

Sinus of Valsalva aneurysms are rare cardiac anomalies and are usually caused by the separation of the aortic wall media from the valve ring tissue. These aneurysms frequently rupture into the low-pressure areas like the right ventricle and right atrium, rarely do they rupture into the left atrium, left ventricle, pericardial sac, or pulmonary artery. Cerebral infarction has been reported as a rare complication of unruptured sinus of Valsalva aneurysm. We experienced very rare two cases of Valsalva aneurysms of right coronary sinus dissecting into the interventricular septum in patients with cerebral infarction. In two cases these aneurysms ruptured into the left ventricle. These aneurysms were excised and the defect was closed with autopericardium. At the end of the surgical repair, coaptation was found to be insufficient and aortic valve replacement was undertaken.

One case of left anterior descending artery fistula-right ventricle complicating rotablator atherectomy with spontaneous occlusion in a following coronary angiogram

No abstract available.

A Case Report of Primary Cardiac Lymphoma: Diagnosis by Transvenous Biopsy

Primary cardiac lymphomas diagnosed antemortem are extremely rare. We present a case of primary cardiac lymphma diagnosed antemortem by transvenous biopsy under transesophageal echocardiographic guidance. The patient who was a 62 years old male presented with facial edema, dyspnea on exertion and syncope. The chest X-ray film showed double contour at right cardiac border and the ECG showed marked sinus bradycardia. Transesophageal echocardiography (TEE), chest computed tomography (CT) and magnetic resonance imaging (MRI) showed intracardiac tumor of right atrium, invasing interatrial septum and inlets of superior and inferior vena cava and lateral wall of right atrium. Abdominopelvic CT and bone scan failed to show any extracardiac location. Transvenous biopsy confirmed the diagnosis of malignant lymphoma (diffuse large cell, B cell type). After chemotherapy was begun, the tumor makedly shrunk and symptoms resolved. Primary cardiac lymphoma is extremely rare and almost uniformly fatal, but this case showed that early diagnosis and intensive che-motherapy might contribute to a better prognosis for patients with malignant lymphoma of the heart.

Real Time Determination of Left Atrial Volume by Automatic Boundary Detection: Comparison with Two-dimensional Echocardiographic Measurement

BACKGROUND: Echocardiographic automatic boundary detection(ABD) is a new on-line technique which automatically outlines the left atrial endocardial border and instantly calculates the left atrial area and volume from two dimensional echocardiographic images. To determine if left atrial volume can be derived using the ABD method, 70 patients with various etiology of heart disease(mean age 51) underwent complete echocardiographic examination with both the ABD method and conventional two-dimensional echocardiographic measurement. METHODS: End-systolic left atrial volume was obtained on-line from the apical four chamber view using ABD(ABD LAVOL). Left atrial length was also measured from an apical view. Left atrial volume was calculated using ellipsoid model(2D LAVOL) and method of disc(MANUAL LAVOL) by two-dimensional echocardiography. RESULTS: The end-systolic left atrial volume by ellipsoid model, method of disc and ABD were 87+/-31ml, 57+/-25 and 60+/-28ml, respectively. I.inear regression analysis revealed that the ABD LAVOL is closely correlated with 2D LAVOL and MANUAL LAVOL(ABD LAVOL vs 2D LAVOL, SEE=22ml, r=0.65, p<0.001; ABD LAVOL vs MANUAL LAVOL, SEE=6ml, r=0.97, p<0.001). CONCLUSIONS: ABD echocar-diography is a new on-line technique which may be used to accurately calculate left atrial volume in patients with various heart diseases.

Coronary Stenting for Long Lesions:Comparison of Three Different Types of Stent

BACKGROUND: Coronary stenting is known to reduce the rates of restenosis in focal lesions, but the efficacy of stents for long lesions have not been thoroughly defined. To evaluate the immediate and follow-up results of three different types of stents in lesions longer than 20mm, consecutive series of patients (pts) were reviewed. METHODS: Between February 1996 and January 1997, 123 patients (male 68.3%, mean age 57+/-10 years) with a total of 130 lesions underwent long stent : stenting. Excluding multiple stents and unplanned use for acute closure fifty-three pts (56 lesions) were treated with the Microstent II (M-II):30 pts (31 lesions) received the Less Shortening Wallstent (WA):and 40 pts (43 lesions) were treated by the Gianturco-Roubin II stent (GR-II). RESULTS: With the clinical success defined as 50% diameter stenosis at FU was 26% in M-II, 32% in WA and 38% in GR-II:there was no significant difference between the three stents. Target lesion revascularization (TLR) defined as CABG or target lesion PTCA at FU was 17.6% in M-II, 12% in WA and 23.1% in GR-II. Restenosis rate correlated closely with lesion length (p-value-0.03, Odds ratio-1.096) and small post-stent luminal diameter (p-value-0.002, Odds ratio-0.063) in a mu-ltivariable analysis. CONCLUSION: Coronary stenting for long lesions can be safely performed with acceptable complication rates using any of the three types of stents. Restenosis and late outcome was not related to type of stent.

Immediate Results of AVE GFX(R) Stent

Background: The AVE GFX(R) coronary stent, a corrugated ring-type premounted stainless-steel stent, is designed for improved flexibility and trackability with increased vessel support when compared to the current Micro-II stent. We report the immediate results of our experience with the GFX stent. The purpose of this study was to assess the feasibility, safety and efficacy of deployment of the premounted GFX stent in patients with complex coronary anatomy as well as their clinical outcomes within the first month. Method: Between April 1997 and August 1997, fifty-two GFX stents were deployed in the coronary arteries of forrty-nine patients (male 71.4%, mean age 60+/-8 years) with 52 lesions. Thirty-two patients had unstable angina pectoris, five had stable angina, and twelve had acute myocardial infarctions. Results: Results: The frequency of the used stents diameter was 3.0 mm in 23 (44.2%) patients, 3.5 mm in 22 (42.3%) patients, and 4.0 mm in 7 (13.5%) patients. The lengths of used stents were 18 mm (33 cases, 63.6%), 24 mm (17 cases, 32.7%) and 30 mm (2 cases, 3.8%). 2) Single stent implantation was achieved in 47 (92.1%) lesions; multiple stents were deployed in 4 (7.9%) lesions (a case with 2nd GFX stent and 3 lesions overlapped with other kinds of stents). 3) Successful deployment was achieved in 51/52 stents (98.1%) with one case of stent passing failure. Adjuvant high pressure balloon dilatations (over 12 atm) were needed in 14 cases (26.9%) to achieve optimal result. 4) No major adverse cardiac events (MI, repeat PTCA, CABG, death) occurred in this series of 49 consecutive patients within 4 weeks after procedure. Stents were deployed successfully in complex lesions including calcified and angulated (>45degrees) lesions or in lesions with proximal tortuosity; B2 (57.7%), C (28.8%) (procedural success rates and angiographic success rates were both 100%). 5) No subacute stent thrombosis occurred during hospital stay. Peristent dissections were performed in 2 cases distal-to-stent without significant compromise of blood flow. Of the 8 lesions with side branches, 1 side branch was occluded after stent deployment. 6) Mean lumen diameter of target lesion was increased from 0.79+/-0.41 mm to 3.19+/-0.41 mm (P<0.001) after stent implantation. Percent of diameter stenosis was decreased from 75.6+/-12.0% to??.6+/-12.9% (P<0.001) after stent implantation. Mean diameter of reference artery was 3.20+/-0.54 mm. Conclusion: GFX stent implantation can be achieved with high procedural success rate. With several favorable characteristics, good trackability, flexibility, and good vessel support, this new stent was deployed successfully in complex lesions for percutaneous coronary intervention. Follow-up data is needed to assess long term patency of this stent.