The efficacy and safety of drug-eluting balloons for the treatment of in-stent restenosis as compared with drug-eluting stents and with conventional balloon angioplasty

BACKGROUND/AIMS: Treatment of coronary in-stent restenosis (ISR) is still associated with a high incidence of recurrence. We aimed to compare the efficacy and safety of drug-eluting balloons (DEB) for the treatment of ISR as compared with conventional balloon angioplasty (BA) and drug-eluting stents (DES). METHODS: Between January 2006 and May 2012 a total of 177 patients (188 lesions, 64.1 ± 11.7 years old) who underwent percutaneous coronary intervention for ISR were retrospectively enrolled. Clinical outcomes were compared between patients treated with DEB (n = 58, 32.8%), conventional BA (n = 65, 36.7%), or DES (n = 54, 30.5%). The primary end point was a major adverse cardiac event (MACE), defined as a composite of cardiac death, myocardial infarction, and target lesion revascularization(TLR). RESULTS: Baseline characteristics were not different except for a history of previous MI, which was more frequent in patients treated by conventional BA or DES than in patients treated by DEB (40.0% vs. 48.1% vs. 17.2%, respectively, p = 0.002). The total incidences of MACEs were 10.7%, 7.4%, and 15.4% in patients treated by DEB, DES, or conventional BA, respectively (p > 0.05). TLR was more frequent in patients treated by conventional BA than in patients treated by DEB or DES, but this was not statistically significant (10.8% vs. 6.9% vs. 3.7%, p > 0.05 between all group pairs, respectively). CONCLUSIONS: This study showed that percutaneous coronary intervention using DEB might be a feasible alternative to conventional BA or DES implantation for treatment of coronary ISR. Further large-scaled, randomized study assessing long-term clinical and angiographic outcomes will be needed.

Thrombotic Occlusion of Stent Graft Limbs due to Severe Angulation of Aortic Neck in Endovascular Repair of Abdominal Aortic Aneurysm

Endovascular aneurysm repair (EVAR) is a safe alternative to open surgical repair for an abdominal aortic aneurysm. However, unfavorable aortic anatomy of the aneurysm has restricted the widespread use of EVAR. Anatomic limitation is most often related to characteristics of the proximal neck anatomy. In this report, we described a patient with a severely angulated proximal neck who underwent EVAR, but required repeat intervention because of thrombotic occlusion of stent graft limbs.

Efficacy of Inhaled Iloprost in Cor Pulmonale and Severe Pulmonary Hypertension Associated with Tuberculous Destroyed Lung

Chronic obstructive pulmonary disease (COPD) is one of the causes of cor pulmonale. Cor pulmonale patients with pulmonary hypertension have a significant lower survival rate than patients without. However, there is no conclusive treatment options in cor pulmonale and pulmonary hypertension associated with COPD until now. We report a patient with cor pulmonale and pulmonary hypertension associated with severe form of COPD and tuberculous destroyed lung who achieved marked clinical, functional and echocardiographic hemodynamic improvements with inhaled iloprost for six months.

Functional Class and Targeted Therapy Are Related to the Survival in Patients with Pulmonary Arterial Hypertension

PURPOSE: Pulmonary arterial hypertension (PAH) is an orphan disease showing poor prognosis. The purpose of study was to evaluate clinical factors influencing outcomes in PAH. MATERIALS AND METHODS: Patients who were diagnosed with PAH at a single center were reviewed retrospectively. Forty patients (34.9+/-14.5 years, 80% of female) were enrolled. RESULTS: Causes were congenital heart disease in 24 (60%), connective tissue disease in 8 (20%) and idiopathic PAH in 6 (15%). Sixteen patients (40%) were WHO functional class III or IV at the time of diagnosis. Twenty seven patients (67.5%) received molecular targeted therapy. During follow-up (53.6+/-45.5 months), 10 patients (25%) died and 1-, 2-, and 8 year survival rates were 91.3%, 78.7%, and 66.8%, respectively. As expected, median survival of patients with functional class I or II were significantly longer than patients with III or IV (p=0.041). Interestingly, patients with molecular targeted therapy showed longer survival than conventional therapy (p=0.021). CONCLUSION: WHO functional class at the time of diagnosis was the strong predictor of survival, and molecular targeted therapy could significantly improve the survival. Therefore, early screening and intensive management would be crucial to improve the prognosis in the patient with PAH.

A Comparison of Two Brands of Clopidogrel in Patients With Drug-Eluting Stent Implantation

BACKGROUND AND OBJECTIVES: Although generic clopidogrel is widely used, clinical efficacy and safety between generic and original clopidogrel had not been well evaluated. The aim of this study was to evaluate the clinical outcomes of 2 oral formulations of clopidogrel 75 mg tablets in patients with coronary artery disease (CAD) undergoing drug-eluting stent (DES) implantation. SUBJECTS AND METHODS: Between July 2006 and February 2009, 428 patients that underwent implantation with DES for CAD and completed >1 year of clinical follow-up were enrolled in this study. Patients were divided into the following 2 groups based on treatment formulation, Platless(R) (test formulation, n=211) or Plavix(R) (reference formulation, n=217). The incidence of 1-year major adverse cardiovascular and cerebrovascular event (MACCE) and stent thrombosis (ST) were retrospectively reviewed. RESULTS: The baseline demographic and procedural characteristics were not significantly different between two treatment groups. The incidence of 1-year MACCEs was 8.5% {19/211, 2 deaths, 4 myocardial infarctions (MIs), 2 strokes, and 11 target vessel revascularizations (TVRs)} in Platless(R) group vs. 7.4% (16/217, 4 deaths, 1 MI, 2 strokes, and 9 TVRs) in Plavix(R) group (p=0.66). The incidence of 1-year ST was 0.5% (1 definite and subacute ST) in Platless(R) group vs. 0% in Plavix(R) group (p=0.49). CONCLUSION: In this study, the 2 tablet preparations of clopidogrel showed similar rates of MACCEs, but additional prospective randomized studies with pharmacodynamics and platelet reactivity are needed to conclude whether generic clopidgrel may replace original clopidogrel.

The Effects of Statin and Niacin on Plaque Stability, Plaque Regression, Inflammation and Oxidative Stress in Patients With Mild to Moderate Coronary Artery Stenosis

BACKGROUND AND OBJECTIVES: The aim of this study was to compare the effects of a combination of niacin and simvastatin to simvastatin alone, on plaque regression and inflammatory makers. SUBJECTS AND METHODS: The study had a prospective, randomized design. Subjects were patients with intermediate coronary artery stenosis. A total of 28 patients received a combination of niacin 1,000 mg plus simvastatin 40 mg (N+S group, n=14); the other group received simvastatin 40 mg alone (S group, n=14). All patients had a baseline and a 9-month follow-up coronary angiogram and an intravascular ultrasound procedure. Parameters such as normalized total atheroma volume (nTAV) and percent atheroma volume (PAV) were analyzed before and after treatment as were inflammatory markers such as high sensitivity C-reactive protein (hs-CRP), Matrix me-talloproteinase-9 (MMP-9) and soluble CD40 ligand (sCD40L). RESULTS: There was no difference in baseline characteristics between the two groups. The nTAV and PAV in the N+S group before and after treatment were not different than those in the S group. But the degree of changes (delta) in nTAV in the N+S group was greater than that in the S group (-21.6+/-10.68 vs. 5.25+/-42.19, respectively, p=0.024). Also, the change in PAV in the NS group was higher than that in the S group (-1.2+/-2.5 vs. -0.6+/-5, respectively, p=0.047. Changes in hs-CRP, MMP-9, and sCD40L in the NS group were significantly greater than those of the S group (-0.71+/-1.25, 73.5+/-64.9, -1,970+/-1,925 vs. -0.32+/-0.96, 62.5+/-30.6, -1,673+/-2,628, respectively). CONCLUSION: The combination of niacin plus simvastatin decreases coronary plaque volume and attenuates the inflammatory response in patients with intermediate coronary artery stenosis.

Right Coronary Cusp Prolapse Resembling Subpulmonic Stenosis in an Old Adult Patient with Ventricular Septal Defect

Ventricular septal defect (VSD) can be associated with various complications such as aortic regurgitation (AR). AR in VSD come from a deficiency or hypoplasia of the conal septum which leads to abnormal apposition in diastole and prolapse of the poorly supported noncoronary or right coronary cusp through the VSD into the right ventricle resembling subpulmonic stenosis and subsequently results in distortion of the aortic valve and progressive AR. AR often increases in severity with age and it indicates a worse prognosis. Therefore, appropriate timing of surgical repair in progressive AR in VSD might be important. Until now, many earlier experiences about surgical repair of AR complicating VSD were on adolescents or young adults. We reported a case of AR in 48-year-old male patient with right coronary cusp prolapse complicating the subarterial type of VSD which was properly assessed by echocardiography and was successfully treated with surgical repair. Right coronary cusp or noncoronary cusp prolapse should be suspected in AR complicating VSD through proper echocardiographic assessment and the surgical repair on VSD and distorted aortic valve should be considered in the old patient, as well as the young.

Multidetector Computed Tomography for Evaluation of Ischemic Etiology and a Post-Unroofing Procedure for an Anomalous Origin of the Right Coronary Artery From the Left Sinus of Valsalva

No abstract available.

Coronary Artery Perforation Following Implantation of a Drug-Eluting Stent Rescued by Deployment of a Covered Stent in Symptomatic Myocardial Bridging

We successfully rescued a patient whose coronary artery perforated following implantation of a drug-eluting stent (DES), by deploying a stent-graft in symptomatic myocardial bridging. Our case demonstrated that coronary perforation could be handled without difficulty when perforated myocardial bridging is confined to the interventricular groove

Combined Open and Endovascular Repair for Aortic Arch Pathology

BACKGROUND AND OBJECTIVES: We describe our experience with combined open and endovascular repair in patients who have aortic arch pathology. SUBJECTS AND METHODS: This study is a retrospective analysis of 7 patients who underwent combined open and endovascular repair for aortic arch pathology. Medical records and radiographic information were reviewed. RESULTS: A total of 7 consecutive patients (5 men, 71.4%) underwent thoracic stent graft implantation. The mean age was 59.9+/-16.7 years. The indication for endovascular repair was aneurysmal degeneration in 5 patients, and rupture or impending rupture in 2 patients. In all 7 cases, supra-aortic transposition of the great vessels was performed successfully. Stent graft implantation was achieved in all cases. Surgical exposure of the access vessel was necessary in 2 patients. A total of 9 stent grafts were implanted (3 stent grafts in one patient). The Seal thoracic and the Valiant endovascular stent graft were implanted in 6 patients and 1 patient, respectively. There were no post-procedure deaths or neurologic complications. In 2 patients, bleeding and injury of access vessel were noted after the procedure. Postoperative endoleak was noted in 1 patient. One patient died at 10 months after the procedure due to a newly developed ascending aortic dissection. No patients required secondary intervention during the follow-up period. The aortic diameter decreased in 4 patients. In 3 patients, including 1 patient with endoleak, there was no change in aortic diameter. CONCLUSION: Our experience suggests that combined open and endovascular repair for aortic arch pathology is safe and effective, with few complications.

Real-Time 3-Dimensional Echocardiography of the Heart 13 Years After Partial Left Ventriculectomy

No abstract available.

Pachydermoperiostosis Accompanied by Heart Failure

Pachydermoperiostosis or primary hypertrophic osteoarthropathy is an uncommon disease of acromegaloid facial feature, but characterized by unique phenotype (digital clubbing and pachydermia) and distinctive radiographic appearances like periostosis. We experienced a case with complete form of pachydermoperiostosis accompanied by heart failure. He presented with typical features consisting of clubbing with enlargement of the hand, thickening of facial skin and periosteal new bone formation involving lower leg. Echocardiography revealed severely decreased left ventricular systolic function. Treatment with medications resulted in an improvement of cardiac function and symptom. There is no previous report documenting pachydermoperiostosis accompanied by heart failure. We report that case for the first time.

Echocardiographic Assessments of Left Atrial Strain and Volume in Healthy Patients and Patients With Mitral Valvular Heart Disease by Tissue Doppler Imaging and 3-Dimensional Echocardiography

BACKGROUND AND OBJECTIVES: The purpose of the current study was to assess left atrial (LA) physiology in relation to associations between LA volume change and regional tissue velocities and strains, and to extend this information to patients with mitral stenosis (MS) or mitral regurgitation (MR). SUBJECTS AND METHODS: Twenty-two healthy persons, 22 patients with moderate-to-severe MS, and 22 patients with moderate-to-severe MR were studied. Tissue velocities, strains, and time-volume curves of the LA were acquired using tissue Doppler imaging and 3-dimensional echocardiography. RESULTS: In healthy controls, the maximal LA volume was negatively correlated with the posterior wall longitudinal systolic strain (r=-0.45, p=0.03). The time-to-maximal LA volume was positively correlated with the time-to-posterior wall longitudinal peak strain (r=0.46, p=0.03) and the time-to-circumferential peak strain (r=0.59, p=0.004). The LA active emptying fraction (LAactEF) was positively correlated with the posterior wall longitudinal peak systolic and late diastolic tissue velocities. In patients with MS, the maximal LA volume was negatively correlated with the posterior wall radial peak systolic velocity and the longitudinal late diastolic velocity. In patients with MS, the LAactEF had an additional positive correlation with the anterior wall longitudinal and circumferential systolic velocities, whereas the patients with MR had an additional positive correlation between the LAactEF and the lateral wall longitudinal peak strain as compared with the healthy cantrols. CONCLUSION: LA longitudinal and circumferential deformations are more related than radial deformation to determining LA volume and function. The LA of patients with MS revealed a greater pathologic physiology than those of patients with MR.

Inferior Sinus Venosus Type Atrial Septal Defect Initially Presenting Pulmonary Hypertension on Transthoracic Echocardiography

Inferior sinus venosus type atrial septal defect (ASD) is a rare congenital cardiac deformity that occurs between the inferior vena cava and right atrium. Inferior sinus venosus defect is difficult to diagnose through transthoracic echocardiography because of its location which is infero-posterior to the fossa ovalis. Increasing pulmonary arterial pressure and pulmonary vascular resistance in patients with sinus venosus defect usually occur earlier than other types of ASD. We report a case of 19-year-old man who presented exertional dyspnea due to inferior sinus venous type ASD with mild pulmonary hypertension. In this case, we found clues from slight diastolic flattening of interventricular septum and shortened acceleration time of right ventricular outflow tract on initial transthoracic echocardiography, leading right heart catheterization and transesophageal echocardiography to reveal this rare type of ASD.

The prognostic value of NT-proBNP, Troponin I, and hs-CRP in patients with acute coronary syndrome / 대한내과학회지

BACKGROUND/AIMS: Elevated levels of N-terminal pro-B-type natriuretic peptide (NT-proBNP), troponin I, and high-sensitivity C-reactive protein (hs-CRP) are each associated with higher rates of death and recurrent myocardial ischemia in patients with acute coronary syndrome (ACS). We evaluated the prognostic value of NT-proBNP and a multi-marker risk approach with the simultaneous assessment of NT-proBNP, troponin I, and hs-CRP in patients with ACS. METHODS: We included 277 patients who were admitted for ACS between January and December 2006. We measured NT-proBNP, troponin I, and hs-CRP within 24 hours of the onset of symptoms. Patients were followed for a median of 559 days for cardiovascular events, including death, new myocardial infarction, heart failure, or rehospitalization for ACS. RESULTS: NT-proBNP was the most powerful predictor of clinical outcome among the biomarkers (HR 3.65, 95% CI 2.11-6.30), followed by the peak troponin I and hs-CRP (HR 2.08, 95% CI 1.12-3.87;HR 1.99, 95% CI 1.18-3.37, respectively), but not the baseline troponin I. A multi-marker risk approach with the simultaneous assessment of NT-proBNP, hs-CRP, and peak troponin I was significantly associated with cardiovascular events, especially the presence of three positive biomarkers (adjusted HR 4.20, 95% CI 1.39-12.67). CONCLUSIONS: NT-proBNP is the most powerful, independent predictor of clinical outcome among the cardiac biomarkers. Since the peak troponin I level provides more prognostic information than the baseline level, follow-up measurement of troponin I may be warranted for risk stratification. The multi-marker risk approach appears to have better prognostic performance than any marker in isolation.

Relationship between the Clinical Performance Examination and Associated Variables / 한국의학교육

PURPOSE: The purpose of this study was to identify the causal relationship between the following variables: basic science score, written examination score (Internal medicine and Pediatrics), clinical clerkship score (Internal medicine and Pediatrics), and affective factors (self-efficacy, anxiety, and perception of preparedness). METHODS: Forty-two medical students took the clinical performance examination (CPX) at the end of the first semester. One day before the CPX, the students completed a brief survey, which included 11 items that sampled their self-efficacy, preparedness and anxiety with regard to the CPX. The responses from the 38 identifiable surveys (90%), out of 42, were analyzed for this study. Structural equation modeling techniques were used to test the relationships between the variables. The students' basic science scores, clinical clerkship scores, and written examination scores were considered for this study. RESULTS: We found that self-efficacy influenced students' CPX scores indirectly through their preparedness and anxiety. Preparedness influenced students' CPX scores indirectly through their anxiety. Anxiety was predicated on self-efficacy directly or indirectly and it predicted CPX scores. The clinical clerkship scores affected the students' CPX scores indirectly. The written examination scores and basic science scores, however, did not impact the students' CPX scores directly or indirectly. The basic science scores, clinical clerkship scores, and written examination scores were not associated with self-efficacy. CONCLUSION: Our findings highlight the importance of clinical clerkship education and reasonable medical teaching methods in improving the student self-efficacy for the CPX.

Relationship between the Clinical Performance Examination and Associated Variables / 한국의학교육

PURPOSE: The purpose of this study was to identify the causal relationship between the following variables: basic science score, written examination score (Internal medicine and Pediatrics), clinical clerkship score (Internal medicine and Pediatrics), and affective factors (self-efficacy, anxiety, and perception of preparedness). METHODS: Forty-two medical students took the clinical performance examination (CPX) at the end of the first semester. One day before the CPX, the students completed a brief survey, which included 11 items that sampled their self-efficacy, preparedness and anxiety with regard to the CPX. The responses from the 38 identifiable surveys (90%), out of 42, were analyzed for this study. Structural equation modeling techniques were used to test the relationships between the variables. The students' basic science scores, clinical clerkship scores, and written examination scores were considered for this study. RESULTS: We found that self-efficacy influenced students' CPX scores indirectly through their preparedness and anxiety. Preparedness influenced students' CPX scores indirectly through their anxiety. Anxiety was predicated on self-efficacy directly or indirectly and it predicted CPX scores. The clinical clerkship scores affected the students' CPX scores indirectly. The written examination scores and basic science scores, however, did not impact the students' CPX scores directly or indirectly. The basic science scores, clinical clerkship scores, and written examination scores were not associated with self-efficacy. CONCLUSION: Our findings highlight the importance of clinical clerkship education and reasonable medical teaching methods in improving the student self-efficacy for the CPX.

Pseudo-no-Reflow Phenomenon in Carotid Artery Stenting using FilterWire EX: Successful Recovery by Aspiration Thrombectomy

Distal protection devices such as FilterWire EX have been widely used in carotid artery stenting, however, the large amount of atherothrombotic debris entrapped in the filter could reduce or stop antegrade flow. We present a case of pseudo-no-reflow phenomenon after postdilatation of the stent in a patient with asymptomatic carotid artery stenosis. After several passes using an Export Aspiration catheter, normal flow in the internal carotid artery was restored. Aspiration thrombectomy can successfully recover pseudo-no-reflow phenomenon.

Clinical Significance of Left Ventricular Torsional Parameters during Supine Bicycle Cardiopulmonary Exercise Echocardiography

BACKGROUND: Left ventricular (LV) torsion plays an important role in both LV systolic and diastolic function. Notwithstanding the fact that speckle tracking imaging echocardiography (STI) is a validated method to measure LV torsion, few data regarding the clinical significance of LV torsional parameters using STI on exercise capacity during exercise echocardiography were reported. METHODS: Fifty four participants completed the supine bicycle cardiopulmonary exercise echocardiography under a symptom-limited protocol. LV torsion was defined as the net difference between LV peak apical rotation, and basal rotation divided by LV diastolic longitudinal length. LV basal, and apical short-axis rotations at each stage were analyzed by STI. RESULTS: LV torsion measurement was feasible in 43/54 (80%) at peak exercise. The LV torsions were increased during exercise, and even until the recovery. Peak twisting, and untwisting velocities were significantly increased during exercise, but were decreased at recovery. As expected, baseline torsion was positively correlated with LV ejection fraction and baseline apical peak untwisting velocity has correlation with E/E' (r=0.50, p<0.01 and r=0.30, p<0.05, respectively). Interestingly, apical peak twisting velocity at peak exercise was significantly correlated with maximal O2 consumption and VO2 interval change (r=0.50, p<0.01 and r=0.33, p<0.05, respectively). CONCLUSION: It was feasible to measure LV torsion by STI at every step during exercise echocardiography, although the feasibility was relatively low at peak exercise. LV torsional parameters during exercise showed significant relations with exercise capacity as well as LV systolic and diastolic functions.

Global Circumferential Strain by 2-Dimensional Speckle Tracking Method for the Evaluation of the Left Ventricular Function

BACKGROUND AND OBJECTIVES: The speckle tracking method using 2-dimensional (2D) echocardiography is not affected by the tethering of neighboring segments and angulation. Global circumferential strain (GCS) of the left ventricle (LV) has been suggested as a systolic index and correlated with LV contractility. The purpose of this study was to investigate whether acute changes in preload affect global circumferential strain and to evaluate the usefulness of GCS by the speckle tracking method. SUBJECTS AND METHODS: 2D echocardiography was performed in 69 patients with end-stage renal disease before and after hemodialysis to measure the LV end-diastolic volume and LV ejection fraction. 2D images were acquired from the short-axis view of the mid-LV for the evaluation of GCS. RESULTS: Mean LV end-diastolic volume significantly decreased from 91.2+/-33.3 mL to 72.3+/-32.0 mL (p+/-0.05), and LV ejection fraction decreased from 63.6+/-13.1% to 60.0+/-11.2% (p=0.006) after hemodialysis. However, mean GCS showed no significant change after hemodialysis (17.2+/-5.3% vs. 16.6+/-4.7%, p=0.13). GCS was found to be well correlated with LV ejection fraction (r=0.54, p<0.05) and peak systolic mitral annular velocity (r=0.46, p=0.000), but not with LV preload (r=0.06, p=0.622). CONCLUSION: GCS using the speckle tracking method is a useful index for the evaluation of LV systolic function because it is not affected by acute preload change and is correlated with LV ejection fraction and peak systolic mitral annular velocity.