Is cardiovascular disease more common in Vietnam veterans exposed to agent orange? / 대한내과학회지

BACKGROUND: TCDD (2,3,7,8-tetrachlorodibenzo-p-dioxin), a material of agent orange, was reported as a deadly poison in spite of its presence at extremely small doses. It has been reported that TCDD can cause various kinds of cancers and harmful effects on humans. However, a correlation between exposure to TCDD and cardiovascular disease is not yet known. Thus, we intended to examine the correlation between TCDD exposure and cardiovascular disease through an analysis of coronary angiograms in veterans of the Vietnam War. METHODS: A consecutive 115 patients undergoing coronary angiograms between April 2004 and June 2005 at Gwangju Veterans Hospital were analyzed. The patients were divided into two groups: 57 patients exposed to TCDD (Group I, average age 59.2+/-4.2 years) and 58 patients that were not exposed to TCDD (Group II, Average age 60.1+/-5.6 years). The clinical and coronary angiographic findings were evaluated. RESULTS: Baseline clinical characteristics, inflammatory markers and echocardiographic parameters were not different between patients in the two groups. The incidence of diabetes (43.9% vs. 25.0%, p=0.035) and hyperlipidemia (47.4% vs. 27.6%, p=0.028) were higher in group I patients than group II patients. Significant coronary artery stenosis was more common in group I (45 cases, 78.9%) thanin group II (33 cases, 56.9%) (p=0.011). CONCLUSIONS: There was a higher incidence of diabetes, hyperlipidemia, and significant coronary artery stenosis in patients that underwent a diagnostic coronary angiogram that were previously exposed to TCDD.

A successful stenting of the coarctation of aorta in a patient with acute pulmonary edema / 대한내과학회지

Coarctation of aorta is a rare vascular disorder which is one of causes of secondary hypertension. Since the early 1990s stenting in the coarctation of aorta has been introduced as an alternative treatment method, there were a few cases which were treated by stent implantation for the coarctation of the aorta in Korea. But the case which was treated using stent in congestive heart failure with pulmonary edema has never been reported. We report on successful management of a 64-year-old female patient, who presented with acute heart failure and pulmonary edema due to severe aortic coarctation. After endotracheal intubation, aortogram was performed, which revealed a severe narrowing in the distal thoracic aorta with a peak systolic pressure gradient of 100 mmHg across the lesion. Stent implantation was performed with 24x100 mm self-expandable Nitinol-S stent after predilation with 10x40 mm balloon. After stenting, patient's symptom and sign of congestive heart failure were remarkably improved and endotracheal intubation tube was able to be removed. And no significant adverse cardiac events observed during a nine-month clinical follow-up.

The Clinical Effects of Abciximab Combined with Dalteparin for High-Risk Percutaneous Coronary Intervention in Patients with Acute Myocardial Infarction

BACKGROUND AND OBJECTIVES: The therapeutic efficacy of combined platelet glycoprotein IIb/IIIa receptor blocker with low molecular weight heparin (LMWH) is unknown for patients with acute myocardial infarction (AMI) and who underwent percutaneous coronary intervention (PCI). SUBJECTS AND METHODS: A total of 140 patients with AMI and who underwent high-risk PCI was divided into two groups: UFH (group I: 70 patients, 58.7+/-10.5 years of age), and dalteparin (group II: 70 patients, 59.6+/-9.8 years of age). The major adverse cardiac events (MACE) during hospitalization and during the 4 years after PCI were evaluated. RESULTS: The baseline clinical characteristics and angiographic characteristics were not different between the two groups. There were 62.9% totally occluded lesions with thrombus in both groups. Procedural success was achieved for 91.4% of the group I patients and for 90.0% of the group II patients. Any bleeding and hemorrhagic events were not different between the two groups. No significant intracranial bleeding was observed in both groups. The number of in-hospital MACEs was 7 (10.0%) in group I and 4 (5.7%) in group II. Four-year clinical follow-up was performed for 97% of the patients. As a result of the MACEs during the 4 years after PCI, death occurred in 6 (8.6%) patients in group I and in 7 (10.0%) patients in group II. Myocardial infarction occurred in 4 (5.7%) and 4 (5.7%) patients, respectively, target vessel revascularizations were done in 23 (32.9%) and 16 (22.9%) patients, respectively, and coronary artery bypass surgery was done in 3 (4.3%) and 1 (1.4%) patients, respectively. Overall, MACEs occurred in 33 (47.1%) patients of group I and in 26 (35.1%) patients of group II during the 4-year clinical follow-up (p=0.23). CONCLUSION: The long-term clinical outcome of dalteparin combined with abciximab is comparable with that of UFH plus abciximab for the high risk patients with AMI who receive PCI.

The Anticancer Effect and Mechanism of Photodynamic Therapy Using 9-Hydroxypheophorbide-alpha and 630 nm Diode Laser on Heterotransplanted Squamous Cell Carcinoma of Head and Neck / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: The 9-Hydroxypheophorbide-alpha(9-HpbD-alpha) is a new photosensitizer, derived from a plant in water. We conducted a series of experiments in vivo to evaluate the anticancer effect and mechanism of photodynamic therapy using 9-HpbD-alpha and 630 nm diode laser on squamous cell carcinoma. MATERIALS AND METHOD: SNU-1041 cell line was heterotransplanted into the subcutaneous space of nude mouse. When the tumors grew up to 400 mm3, the animals were randomly seperated into 4 groups: Group I (n=5) of the normal control group;Group II (n=10), which received interstitial injection of 0.007 microgram/mm3 of 9-HpbD-alpha;Group III (n=10), which received irradiation with 1.6 J/mm3 of light using diode laser;Group IV (n=10), which received interstitial injection of 0.007 microgram/mm3 of 9-HpbD-alpha followed by irradiation with 1.6 J/mm3 of light 6 hours after the injection. After photodynamic therapy (PDT), tumor tissue was harvested for histopathologic study under light microscopy and transmission electron microscope (TEM). RESULTS: PDT group (Group IV) showed significant remission rate (70 %), compared to control group (p<0.05). The microscopic findings of the tumor section were characterized by massive necrosis and some apoptotic cells among the normal cells. TEM showed different morphologic changes between necrotic and apoptotic cells. These findings were considered as the evidence of direct cytotoxicity of PDT using 9-HpbD-alpha and 630 nm diode laser. CONCLUSION: The results suggest that therapy using PDT, 9-HpbD-alpha and diode laser shows an anticancer effect. Its therapeutic mechanism appears to be based on necrosis that is caused by direct cytotoxicity.

The Effects of QRS Duration and Pacing Sites on the Acute Hemodynamic Changes during Right Ventricular Pacing

BACKGROUND: Has been reported that patients exhibiting prolonged paced QRS duration tend to have more serious heart disease, and the paced QRS duration can be an effective indicator of impaired left ventricular function. However, the acute and chronic hemodynamic effects of paced QRS duration and pacing sites during right ventricular (RV) pacing remain unknown. METHODS: A total of 14 patients who underwent electrophysiologic study for paroxysmal supraventricular tachycardia were examined. RV pacing was performed at 10 different sites with cycle lengths of 600 ms and 500 ms utilizing a 6-7F deflectable quadripolar electrode catheter. Systolic, diastolic, and mean blood pressures during pacing were measured once the blood pressure was stabilized. RESULTS: During RV pacing, blood pressures (systolic/diastolic/mean) decreased. The change of post-pacing QRS duration and pre-pacing the systolic blood pressure (SBP) were greater in the group with paced QRS duration. The differences overall were greater than 140 ms. The SBP decrease during pacing was larger in the group exhibiting paced QRS duration of greater than 140 ms. The SBP decrease during pacing showed relation to QRS duration during pacing (r=0.500, p=0.001), the change of QRS duration post-pacing (r=0.426, p=0.001), and SBP during sinus rhythm (r=0.342, p=0.001) on linear correlation analysis. The pacing site, on the other hand, did not affect acute hemodynamic changes during pacing. CONCLUSION: Ventricular pacing of less than 40 ms at the area of paced QRS duration is recommended.

The effects of TIMI flow before mechanical reperfusion therapy on the long term clinical outcomes in patients with acute ST-segment elevation myocardial infarction / 대한내과학회지

BACKGROUND: Epicardial infarct-related artery patency is reliably assessed by the Thrombolysis In Myocardial Infarction flow grade (TFG), and this index is associated with clinical outcomes after fibrinolytics or primary angioplasty in patients with acute myocardial infarction (AMI). The aim of this study was to examine long-term clinical outcomes according to the pre-procedural TFG in AMI after percutaneous coronary intervention (PCI). METHODS: A total of 132 patients with AMI who underwent PCI between July 2001 and December 2001 at Chonnam National University Hospital were divided into two groups according to the pre-procedural TFG: Group I (n=60, 62.7+/-9.2 years, male 66.7%) with TFG 0-1 and Group II (n=72, 61.6+/-11.1 years, male 68.1%) with TFG 2-3. RESULTS: Hypertension was more prevalent in Group I than that in Group II (56.7% vs. 27.8%, p=0.001) and cardiogenic shock on admission was more frequently observed in Group I than that in Group II (20.0% vs. 5.6%, p=0.011). The left ventricular ejection fraction was lower in Group I than that in Group II (42.6+/-10.5% vs. 50.5+/-12.1%, p=0.022). The levels of inflammatory markers such as C-reactive protein (CRP), erythrocyte sedimentation rate, fibrinogen, white blood cell and monocyte counts were higher in Group I than in Group II. On diagnostic coronary angiogram, complex lesion was more frequently observed in Group I than that in Group II (53.4% vs. 36.2%, por=0.5 mg/dL, age >or=70 years, triple vessel disease, low pre-interventional TFG (0-1) and post-interventional TFG (0-2). CONCLUSION: Low pre-procedural TFG is associated with hypertension, cardiogenic shock, left ventricular dysfunction, and high mortality, and low event-free survival during one-year clinical follow-up after PCI in AMI.

Clinical Characteristics of Hypervagotonic Sinus Node Dysfunction

BACKGROUND: Sinus node dysfunction (SND) is caused not only by intrinsic sinus node disease, but also by the extrinsic factors. Among the extrinsic factors, autonomic imbalance is most common. Symptomatic SND usually requires permanent pacemaker therapy. However, the clinical characteristics and patient response to medical therapy for hypervagotonic SND have not been properly clarified. MATERIALS AND METHODS: Thirty two patients (14 men, 18 women, 51 +/- 14 years) with hypervagotonic SND were included in this study, but those patients who had taken calcium antagonists, beta-blockers or other antiarrhythmic drugs were excluded. Hypervagotonic SND was diagnosed if the abnormal electrophysiologic properties of the sinus node were normalized after the administration of atropine (0.04 mg/kg). RESULTS: The presenting arrhythmias were 16 cases of sinus bradycardia (50.0%), 12 of sinus pause (37.5%), 3 of sinoatrial block (9.4%) and 1 of tachy-bradycardia (3.1%). Nine (28.1%) patients had hypertension, 7 (21.9%) smoked, 2 (6.3%) had diabetes mellitus, and 1 (3.1%) had hypercholesterolemia. Among the patients, 3 had no remarkable symptoms, 13 had dizziness, 7 had syncope, 3 had weakness and 6 had shortness of breath. Twenty five (78.1%) patients were treated with theophylline, 1 patient with tachy-bradycardia syndrome was treated with digoxin and propafenone, and 6 (18.8%) were treated with no medication. During the 43 +/- 28 month follow-up, 25 patients remained asymptomatic, but 6 who took no medication developed mild dizziness. One patient needed permanent pacemaker implantation owing to recurrent syncope despite of theophylline treatment. CONCLUSION: These results show that hypervagotonic SND has a benign course and most of the patients can be managed safely without implanting a pacemaker. (Ed note: I like the abstract. It is short and direct, as it should be.)

A New Porcine Model of Ischemic Heart Failure and Pathologic Findings by Intra-Coronary Injection of Ethanol

BACKGROUND AND OBJECTIVE: A new porcine model of acute myocardial infarction (AMI), ischemic heart failure and pathologic findings of coronary artery by a transcatheter intracoronary ethyl alcohol injection has been developed. MATERIALS AND METHODS: Twelve female pigs underwent a transcatheter injection in the left anterior descending artery (LAD), using alcohol, to produce an apicoanteriorseptal AMI. Low pressure ballooning using a 2.5 mm over-the-wire balloon, just above the second and first diagonal branches, followed by a 1 mL injection of 99.9% ethyl alcohol was administered to 8 and 4 pigs, respectively. Follow-up coronary and left ventricular (LV) angiograms and echocardiography were performed 4 weeks after the alcohol injection. Myocardial SPECT using 201Tl (and 99mTc-MIBI) and triphenyl tetrazolium chloride (TTC) stain were performed after sacrifice. The quantity of TTC stain and amount of 201Thallium uptake were compared using the Vision Workstation. The histopathological findings of the infarcted myocardium and coronary artery were demonstrated after 28 days. RESULTS: Procedure-related mortality was observed in two-pigs of the proximal LAD injection group. Four pigs suffered from ventricular tachycardia, which was converted into sinus rhythm by dc cardioversion. The four-week follow-up coronary angiography revealed persistently occluded LAD in all pigs. The LV angiogram showed akinetic movement in the apicoanteriorseptal wall with an ejection fraction of 46.5+/-3.3%. Myocardial SPECT revealed a perfusion defect in the apicoanterior wall of all pigs. The percentage area of perfusion defect was 22.2+/-3.06%. The TTC did not stain the myocardium in the apicoanterior wall. The percentage of non-stained myocardium was 23.5+/-2.70%. A histological examination revealed severe fibrosis in the infarcted myocardium and massive thrombus, with organization and calcification. CONCLUSION: The porcine model of acute myocardial infarction using an intracoronary ethanol injection into the distal LAD is safe, reliable and reproducible, and can be used for future research into myocardial regeneration and ischemic LV failure.

Successful Stent Grafting for a Coronary Aneurysm

The stent graft can be used for the treatment of coronary artery aneurysms, perforations, dissection and arteriovenous fistula. A 54-year-old man presented with progressively worsening chest pain for several months. A diagnostic coronary angiogram revealed critical stenosis with a huge aneurysmal sac (6.0x8.2 mm in size) in the proximal right coronary artery. We implanted two membrane covered stent grafts (3.0x16 mm, JoStent GraftMaster(r), JoMed, Germany) without complication. No visible coronary aneurysm or residual stenosis was demonstrated after stent grafting. A two-month follow-up coronary angiogram showed patent stent grafted right coronary artery.

Long-term predictive factors of major adverse cardiac events in patients with acute myocardial infarction complicated by cardiogenic shock / 대한내과학회지

BACKGROUND: Cardiogenic shock (CS) after acute myocardial infarction (AMI) is developed in 5~10% of patients and associated with high mortality. The aim of this study is to assess the predictive factors of major adverse cardiac events (MACE) in patients with AMI and CS. METHODS: Two hundred fifty five AMI patients with CS (66.0 +/- 11.0 years, M:F=156:99) out of 1,268 AMI patients, who admitted at Chonnam National University Hospital between July 2000 and June 2002, were analyzed according to clinical characteristics, coronary angiographic findings and MACE during admission and 1-year clinical follow-up. RESULTS: Among the enrolled patients, 129 patients survived without MACE (Group I, 64.2 +/- 10.6 years, M:F=76:53) and 126 patients had MACE (Group II, 68.1 +/- 10.0 years, M:F=80:46) during admission and 1-year follow-up period. There were significant differences in age (64.2 +/- 10.6 vs. 68.1 +/- 11.0 years, p=0.004) and previous MI history (0 vs. 17.4%, p<0.001). Left ventricular ejection fraction (EF) was lower in Group II (Group I vs. II: 49.1 +/- 13.0 vs. 39.1 +/- 12.9%, p<0.001). The levels of troponin (Tn) I and C-reactive protein (CRP) were higher in Group II (Group I vs. II: 29.2 +/- 7.72 vs. 50.8 +/- 5.17 ng/dL, p=0.017, 3.8 +/- 0.48 vs. 9.9 +/- 1.21 mg/dL, p<0.001 respectively). Left main stem lesion (LMSL) was more common in Group II than in Group I (0.7% vs. 22.0%, p=0.004). In-hospital death was associated with low Thrombolysis In Myocardial Infarction (TIMI) flow after coronary revascularization. CONCLUSION: Old age, previous MI history, high Tn and CRP, low EF and LMSL are associated with higher MACE in patients with AMI and CS. Coronary revascularization with TIMI 3 flow lowers in-hospital mortality.

The prognostic significance of statin therapy in acute myocardial infarction patients with left ventricular dysfunction / 대한내과학회지

BACKGROUND: Statins reduce mortality of patients with coronary artery disease. However, many trials have excluded patients with ischemic heart failure. Statins may have other beneficial effects besides cholesterol lowering, such as anti-inflammatory properties and improvement of endothelial function. The aim of this study was to determine the effects of statin therapy in acute myocardial infarction (AMI) patients with left ventricular (LV) dysfunction. METHODS: We studied 202 patients with AMI with LV dysfunction [ejection fraction (EF) below 40%] between January 2001 and June 2002. The patients were divided into two groups: Group I (n=106, 60.8 +/- 10.3 years, male 71.7%) who were treated with simvastatin and Group II (n=96, 60.9 +/- 10.4 years, male 78.1%) who were not treated with simvastatin. RESULTS: At six-month after percutaneous coronary intervention (PCI), LVEF was more improved in Group I than in Group II (30.8 +/- 10.0% to 42.4 +/- 10.7% vs 31.9% to 38.9%, p=0.042). The levels of total cholesterol, triglyceride and low density lipoprotein-cholesterol were more decreased and the level of high density lipoprotein-cholesterol was more increased in Group I than in Group II. The levels of C-reactive protein, fibrinogen, white blood cell and monocyte count were more decreased in Group I than in Group II. During one-year clinical follow-up, statin therapy was associated with a significant reduction in mortality (1.9% vs 7.5%, p=0.048), restenosis rate (25.7% vs 43.1%, p=0.033) and repeat PCI rate (25.7% vs 43.1%, p=0.033). The event-free survival rate was higher in Group I than in Group II (79.8% vs 57.0%, p=0.001). CONCLUSION: Statin therapy improves LV systolic function and decreases mortality, restenosis and repeat PCI in the AMI with LV dysfunction.

A study on determinants of the inducibility and maintenance of atrial fibrillation / 대한내과학회지

BACKGROUND: Atrial fibrillation (AF) is thought to beget AF by shortening atrial refractoriness and reversal of rate adaptation of atrial refractoriness. This phenomenon of electrophysiologic remodeling of the atria during AF has been reported to play a major role in inducibility and stability of AF. METHODS: Thirty-one patients with induced AF lasting >1 second during electrophysiologic study for documented or suspected supraventricular or ventricular tachycardia were included in this study. All the patients had no structural heart disease and history of AF. High right atrium (HRA) burst pacing or extra-stimulation was applied to induce AF. Eleven patients with AF sustained >or=3 min was grouped into Group I and 20 patients with AF <3 min into Group II. P wave duration and amplitude, left atrial (LA) size, atrial refractory period (ARP), intraatrial conduction time (IACT) from HRA electrode catheter to His bundle electrode catheter and characteristics of atrial activities during induced AF were compared between 2 groups. RESULTS: There was no difference in the distribution of underlying cardiac arrhythmias. P wave durations and amplitudes and echocardiographic LA sizes were similar between 2 groups. ARPs and IACTs in group I and II were similar (198.0 +/- 23.9 ms vs. 200.8 +/- 23.0 ms; 38.7 +/- 8.5 ms vs. 38.6 +/- 9.5 ms, respectively). During AF, mean interval of atrial activities in group I was significantly shorter than group II (156.6 +/- 24.2 ms vs. 187.6 +/- 28.0 ms, p<0.01). The degree of irregularity of atrial activities during AF was significantly higher in group I than group II (16.9 +/- 8.7 vs. 9.8 +/- 5.0, p<0.05). The duration of the atrial activities was wider in group I than group II (81.4 +/- 17.5 ms vs. 53.9 +/- 12.4 ms, p<0.001) and the amplitude was lower in group I than group II (56.1 +/- 36.0% vs. 109.0 +/- 51.8%, p<0.05), and the degree of fractionation was greater in group I than group II (4.8 +/- 1.1 vs. 3.2 +/- 0.5, p<0.05). CONCLUSION: These results suggest that shortening of atrial refractoriness and lengthening of local conduction time at the time of or shortly after induction of AF may play a major role in the induction and stabilization of AF.

The Clinical Effect of Intracoronary Adenosine and Nicorandil on No-reflow in Acute Myocardial Infarction during Percutaneous Coronary Intervention

BACKGROUND AND OBJECTIVES: This study aimed to clarify the role of combined intracoronary administration of adenosine and nicorandil in the no-reflow phenomenon. SUBJECTS AND METHODS: Thirty four patients (66+/-10 years, 19 male) who developed no-reflow phenomenon during percutaneous coronary intervention (PCI) between January 2000 and December 2002 were examined as the subjects of the study. We classified the subjects into two groups:group I (20 patients, 67+/-10 years, 10 male, nitrate alone) and group II [14 patients, 69+/-11 years, 9 male, combined intra-coronary administration of adenosine (24 microgram/mL), nicorandil (2 mg/mL), and nitrate]. In-hospital and 6-month major adverse cardiac events (MACE) after PCI were compared between the two groups. RESULTS: Mean age, sex, and risk factors were similar in both groups. Left ventricular ejection fraction was 49+/-7.4% in group I and 49+/-13.6% in group II (p=NS). The number of involved vessels, lesion type according to ACC/AHA classification, and TIMI flow rate were similar in both groups (p=NS). Incidence of dissection after balloon angioplasty, diameter and length of stent, and use of Reopro(r) did not differ during PCI. TIMI 3 flow was obtained in 10 (50%) out of 20 patients in group I and in 11 (78.6%) out of 14 patients in group II (p=0.033);blush score 3 was obtained in 8 (40%) patients in group I and in 10 (71.4%) patients in group II (p=0.01). In-hospital death did not occur in group II, but occurred in 4 patients in group I (p=0.041). MACE developed in an additional two patients in group I, and heart failure occurred in 6 (30%) and 3 (21.4%) patients in groups I and II, respectively, during a 6-month follow-up period (p=NS). CONCLUSION: Intracoronary administration of ade-nosine with nicorandil improves no-reflow in patients with AMI during PCI and enhances the short-term clinical outcome.

Acute Myocardial Infarction due to Coronary Arteriovenous Fistula in the Left Main and Anterior Descending Coronary Artery

A coronary arteriovenous fistula (CAVF) is an unusual anomaly in adults, and a CAVF arising from the left main and anterior descending arteries, presenting with acute myocardial infarction and cardiogenic shock, has not been reported. A 62 year-old male suffered from chest discomfort of 3-hour duration. His blood pressure at the emergency room was 70/40 mmHg, and an electrocardiogram showed marked ST segment depression in leads II, III and aVF, and from V3 to V6. The levels of creatinine kinase-MB and troponin I were 65 U/L and 4.36 ng/mL, respectively. A diagnostic coronary angiogram revealed no significant coronary stenosis, but large coronary arteriovenous fistulae originating from the left main and anterior descending coronary arteries to the main pulmonary artery. Surgical ligation for a CAVF was successfully performed, and a one-month follow-up coronary angiogram showed completely ligated fistulae.

Stent Graft for a Coronary Arteriovenous Fistula in Acute Myocardial Infarction

The stent graft has recently been used for the treatment of coronary artery aneurysms, perforations, dissection and arteriovenous fistula. An 81-year-old male presented with chest pain of 2-day duration. A 12-lead electrocardiogram showed atrial fibrillation and ST-T changes over the precordial leads. A diagnostic left coronary angiogram (CAG) revealed critical stenosis in the proximal left anterior descending coronary artery (LAD) and prestenotic dilatation with large coronary arteriovenous fistula draining into the main pulmonary artery. After predilation, a polytetrafluoroethylene (PTFE) covered stent graft (3.0x16 mm JoStent Graft Master(r), JoMed, Germany) for fistula and an additional conventional stent for just below the graft stented site of proximal LAD stenosis were implanted successfully. After stenting, no visible large fistula or remaining stenosis was demonstrated on CAG. The stent graft was deployed with a high success rate. The restenosis rate was not higher than expected for bare stents. However, as subacute occlusion may occur more frequently, long-term ticlopidine or clopidogrel treatment should be required.

A Successful Stenting of the Coarctation of the Distal Thoracic Aorta (Middle Aortic Syndrome) in an Adult

An isolated coarctation of the lower descending thoracic aorta in adults is a very rare vascular disorder. To the best of our knowledge, the treatment of a coarctation of the descending aorta (middle aortic syndrome) in an adult, using stenting, has never been reported in Korea. A 44 year-old male, suffering from claudication of the both legs for 25 years, was admitted to our hospital. An aortogram revealed a coarctation of the distal thoracic aorta at the T11 level, with a 60 mmHg peak systolic pressure gradient across the lesion. A balloon angioplasty, followed by an 18x40 mm stent implantation, was performed successfully. The peak systolic pressure gradient decreased from 60 mmHg to 15 mmHg. The patient's symptom was relieved after stenting, with no significant adverse events observed during a three-month clinical follow-up.

A Successful Stenting of the Coarctation of the Distal Thoracic Aorta (Middle Aortic Syndrome) in an Adult

An isolated coarctation of the lower descending thoracic aorta in adults is a very rare vascular disorder. To the best of our knowledge, the treatment of a coarctation of the descending aorta (middle aortic syndrome) in an adult, using stenting, has never been reported in Korea. A 44 year-old male, suffering from claudication of the both legs for 25 years, was admitted to our hospital. An aortogram revealed a coarctation of the distal thoracic aorta at the T11 level, with a 60 mmHg peak systolic pressure gradient across the lesion. A balloon angioplasty, followed by an 18x40 mm stent implantation, was performed successfully. The peak systolic pressure gradient decreased from 60 mmHg to 15 mmHg. The patient's symptom was relieved after stenting, with no significant adverse events observed during a three-month clinical follow-up.

Predictive factors of coronary lesion on preoperative diagnostic coronary angiography in korean patients with valvular heart disease / 대한내과학회지

BACKGROUND: The preoperative coronary angiography is required in some patients underwent valvular surgery. The purpose of this study was to evaluate predictive factors for coronary lesion and to determine the indication for preoperative coronary angiography in Korean patients with valvular heart disease (VHD). METHODS: Two hundreds eight patients (55.5 +/- 12.8 years, 99 male) with VHD underwent preoperative coronary angiography between January 1996 and January 2003 were analyzed the variables of age, gender, previous or current angina, hypertension, diabetes mellitus, smoking, dyslipidemia, obesity and familial predisposition according to the presence of coronary lesion. RESULTS: The prevalence of significant coronary artery disease in VHD patients was 26.4% (55/208). The probability of coronary lesion was higher in male above 55 years and in female above 65 years than in younger patients. The predictive factors of coronary lesion were previous or current angina (p<0.05), dyslipidemia (p<0.01), hypertension (p<0.05), previous angina (p<0.05), diabetes (p<0.01) and smoking (p<0.01) by multiple logistic regression analysis. CONCLUSION: Previous or current angina and at least one of the four risk factors (hypertension, smoking, dyslipidemia and diabetes) are predictors of coronary lesion, especially in elderly Korean patients with VHD (older than 55 years in male and 65 years in female).

The effects of QRS duration and pacing sites on the acute hemodynamic change during right ventricular pacing / 대한내과학회지

BACKGROUND: Intraventricular conduction disturbances, as manifested by increased QRS duration, are common in patients with advanced left ventricular (LV) dysfunction and adversely affect LV systolic and diastolic function. It has been reported that the patients with prolonged paced QRS duration have more serious heart disease, and the paced QRS duration can be a useful indicator of impaired LV function. Hemodynamic effects of paced QRS duration and pacing site during right ventricular (RV) pacing are unknown. METHODS: A total of 14 patients who underwent electrophysiologic study for paroxysmal supraventricular tachycardia at Chonnam National University Hospital were examined. All the patients had no structural heart disease. RV pacing was performed at 10 different sites with cycle length of 600 ms and 500 ms using a 6-7F deflectable quadripolar electrode catheter (Livewire, St. Jude Medical, Minneapolis, MN, USA). Systolic, diastolic, and mean blood pressures were measured after stabilization of blood pressure during pacing. RESULTS: Blood pressures (systolic/diastolic/mean) decreased from 146 +/- 31/95 +/- 28/125 +/- 23 mmHg to 128 +/- 33/80 +/- 25/107 +/- 20 mmHg, respectively. The change of QRS duration during pacing and the systolic blood pressure (SBP) before pacing were higher in the group with paced QRS duration greater than 140 msec (59.1 +/- 13.6 msec vs 84.9 +/- 18.7 msec, 141 +/- 30 mmHg vs 152 +/- 38 mmHg, p<0.001, p=0.011, respectively). The decrease of SBP during pacing was higher in the group with paced QRS duration greater than 140 msec (13 +/- 11 mmHg vs 24 +/- 14 mmHg, p=0.009). The decrease of SBP during pacing was related with QRS duration during pacing (r=0.500, p=0.001), the change of QRS duration during pacing (r=0.426, p=0.001), and SBP during sinus rhythm (r=0.342, p=0.001) on linear correlation analysis. Pacing site, however, did not affect acute hemodynamic change during pacing. The independent factors associated with the decrease of SBP during pacing were SBP before pacing and QRS duration during pacing. CONCLUSION: We concluded that acute deleterious hemodynamic effects of RV pacing are related with paced QRS duration but not with pacing site. Ventricuar pacing at the area of paced QRS duration less than 140 msec is recommended particularly in high risk patients.

The clinical effect of tirofiban with low molecular weight heparin in patients with acute non-ST segment elevation myocardial infarction / 대한내과학회지

BACKGROUN: Platelet activation and aggregation with resultant arterial thrombus formation play pivotal roles in the pathophysiology of acute coronary syndrome. We prospectively evaluated the long-term clinical effect of tirofiban, a specific inhibitor of the platelet glycoprotein IIb/IIIa receptor, with low molecular weight heparin (LMWH) in the treatment of non-ST segment elevation myocardial infarction (NSTEMI). METHODS: We divided consecutive 90 patients with NSTEMI who underwent percutaneous coronary intervention (PCI) between August 2001 and April 2002 at Chonnam National University Hospital into 2 groups: Group I (n=45: LMWH alone, 62.3 +/- 9.8 years, 32 male) and II (n=45: tirofiban with LMWH, 59.2 +/- 10.2 years, 36 male). Major adverse cardiac events (MACE) were analyzed between two groups at 7 days after admission, and during 3-month and 6-month clinical follow-up. RESULTS: Mean age, sex and risk factors were not different between two groups. Minor bleeding developed in 1 patient (2.2%) of each group (p=NS). Cardiac death occurred in 4 (8.9%) of group I and 3 patients (6.7%) of group II, and revascularization was required in one patient (2.2%) of each group until 7 days after admission (p=NS). During 3-month follow-up period, revascularization was required in 7 (15.6%) of group I and 5 patients (11.1%) of group II (p=NS). MACE during 6-month follow-up occurred in 11 patients (24.4%) of group I and 4 patients (8.9%) of group II (p=0.012): revascularization was required in 4 (8.9%), myocardial infarction occurred in 2 (4.4%), and cardiac death in 5 patients (11.1%) of group I, and revascularization in 1 (2.2%) and cardiac death in 3 patients (6.7%) of group II. CONCLUSION: Tirofiban with LMWH is safe without significant bleeding complications and improve long-term prognosis in patients with NSTEMI underwent PCI.