Characteristics of Function-Anatomy Mismatch in Patients with Coronary Artery Disease

BACKGROUND AND OBJECTIVES: Coronary lesions with mismatched functional and anatomical significance are not uncommon. We assessed the accuracy and predictors of mismatch between fractional flow reserve (FFR) and quantitative coronary angiography (QCA) analyses in patients with coronary lesions. SUBJECTS AND METHODS: A total of 643 lesions with pre-interventional FFR and QCA measurements were consecutively enrolled and divided into four groups using FFR or =50% as cutoffs for functional and anatomical significance, respectively. Accordingly, FFR >0.80 and DS > or =50%, and FFR < or =0.80 and DS <50% defined false-positive (FP) and false-negative (FN) lesions, respectively. RESULTS: Overall, 40.4% (260/643) of the lesions were mismatched, and 51.7% (218/414) and 18.3% (42/229) were FP and FN lesions, respectively. In a multivariate analysis, independent predictors of FP were non-left anterior descending artery location {odds ratio (OR), 0.36; 95% confidence interval (CI), 0.28-0.56; p<0.001}, shorter lesion length (OR, 0.96; 95% CI, 0.95-0.98; p<0.001), multi-vessel disease (OR, 0.47; 95% CI, 0.30-0.75; p=0.001), and larger minimal lumen diameter by QCA (OR, 2.88; 95% CI,1.65-5.00; p<0.001). Independent predictors of FN were multi-vessel disease (OR, 1.82; 95% CI, 1.24-5.27; p=0.048), aging (OR, 0.96; 95% CI, 0.93-0.99; p=0.034), smoking (OR, 0.36; 95% CI, 0.14-0.93; p=0.034), and smaller reference vessel diameter by QCA (OR, 0.30; 95% CI, 0.10-0.87; p=0.026). CONCLUSION: A mismatch between FFR and angiographic lesion severity is not rare in patients with coronary artery disease; therefore, an angiography-guided evaluation could under- or over-estimate lesion severity in specific lesion subsets.

Long-term outcomes of intravascular ultrasound-guided implantation of bare metal stents versus drug-eluting stents in primary percutaneous coronary intervention

BACKGROUND/AIMS: While drug-eluting stents (DESs) have shown favorable outcomes in ST-segment elevation myocardial infarction (STEMI) compared to bare metal stents (BMSs), there are concerns about the risk of stent thrombosis (ST) with DESs. Because intravascular ultrasound (IVUS) guidance may help optimize stent placement and improve outcomes in percutaneous coronary intervention (PCI) patients, we evaluated the impact of IVUS-guided BMS versus DES implantation on long-term outcomes in primary PCI. METHODS: In all, 239 STEMI patients received DES (n = 172) or BMS (n = 67) under IVUS guidance in primary PCI. The 3-year incidence of major adverse cardiac events (MACEs) including death, myocardial infarction (MI), target vessel revascularization (TVR), and ST was evaluated. RESULTS: There was no difference in all cause mortality or MI. However, the incidence of TVR was 23.9% with BMS versus 9.3% with DES (p = 0.005). Thus, the number of MACEs was significantly lower with DES (11.0% vs. 29.9%; p = 0.001). The incidence of definite or probable ST was not different (1.5% vs. 2.3%; p = 1.0). IVUS-guided DES implantation (hazard ratio [HR], 0.25; 95% confidence interval [CI], 0.08 to 0.78; p = 0.017), stent length (HR, 1.03; 95% CI, 1.00 to 1.06; p = 0.046), and multivessel disease (HR, 3.01; 95% CI, 1.11 to 8.15; p = 0.030) were independent predictors of MACE. CONCLUSIONS: In patients treated with primary PCI under IVUS guidance, the use of DES reduced the incidence of 3-year TVR versus BMS. However, all cause mortality and MI were similar between the groups. The incidence of ST was low in both groups.

The Efficacy of the Cystatin C Based Glomerular Filtration Rate in the Estimation of Safe Contrast Media Volume

BACKGROUND AND OBJECTIVES: The risk of contrast-induced nephropathy (CIN) is significantly influenced by baseline renal function and the amount of contrast media (CM). We evaluated the usefulness of the cystatin C (CyC) based estimated glomerular filtration rate (eGFR(CyC)) in the prediction of CIN and to determine the safe CM dosage. SUBJECTS AND METHODS: We prospectively enrolled a total of 723 patients who received percutaneous coronary intervention (PCI) and investigated the clinical factors associated with the development of CIN. Renal function was calculated as eGFR(CyC) and a modified diet in the renal disease (MDRD) equation, respectively. Systemic exposure of CM was calculated as CM volume to eGFR ratio. We conducted a regression analysis to evaluate the predictive role of CM volume to eGFR(CyC) for the risk of CIN. RESULTS: The incidence of CIN was 4.0% (29/723). The patients with CIN had a lower hemoglobin level, decreased renal function, and a higher CyC value, and had greater CM exposure. Through multivariate regression analyses, hemoglobin {odds ratio (OR) 0.743, p=0.032}, CM volume/eGFR(CyC) (OR 1.697, p=0.006) and CM volume/MDRD (OR 2.275, p<0.001) were found to be independent predictors for CIN. In the receiver operating characteristic curve analysis, fair discrimination for CIN was found at a CM volume/eGFR(CyC) level of 4.493 (C-statics=0.814), and at this value, the sensitivity and specificity were 79.3% and 80.0%, respectively. CONCLUSION: Both the CM volume/MDRD and CM volume/eGFR(CyC) method would be simple, useful indicators for determining the safe CM-dose based on eGFR value before PCI. However, there was no significantly different predictive value between creatinine and CyC based GFR estimations.

Stent Distortion Complicated by Intravascular Ultrasound Catheter Entrapment During Pullback Interrogation / 대한내과학회지

Entrapment of an intravascular ultrasound (IVUS) catheter during coronary intervention is rare, but can cause serious complications. Retrieval of an entrapped catheter can also lead to adverse results for implanted stents. We report a case in which the sheath tip at the guidewire exit port was entrapped and caused stent distortion during a post-stent IVUS procedure with automatic pullback.

Acute Stent Thrombosis and Heparin Induced Thrombocytopenia in a Patient With ST-Segment Elevation Myocardial Infarction

Heparin is an essential drug in the treatment of acute coronary syndrome and it is used during percutaneous coronary intervention (PCI). Heparin-induced thrombocytopenia (HIT), albeit a serious complication of heparin therapy characterized by thrombocytopenia and high risk for venous and arterial thrombosis, has rarely been previously reported during PCI. We report a case of an acute stent thrombosis due to an unusual cause, HIT during primary PCI, in a patient with acute myocardial infarction.

Trends in Oral Anticoagulation Therapy Among Korean Patients With Atrial Fibrillation: The KORean Atrial Fibrillation Investigation

BACKGROUND AND OBJECTIVES: Anticoagulation with vitamin K antagonists (VKAs) such as warfarin provides effective stroke prophylaxis in patients with atrial fibrillation (AF). We conducted a large multicenter survey of Korean patients with AF to determine trends in VKA use. SUBJECTS AND METHODS: Eligible patients were adults with AF that had been prescribed VKAs. Medical records from a total of 5616 patients {mean age 63.6+/-12.2 years, male 3150 (56.1%)} in 27 hospitals from Jan. 2001 to Oct. 2007 were reviewed. RESULTS: The mean international normalized ratio (INR) was 2.04+/-0.64, and mean dosage of VKA was 3.66+/-1.50 mg. Individuals in their sixties (1852 patients) accounted for about one third of patients studied. As patients grew older, INR increased and VKA dosage decreased. The dosage of VKA in male patients was larger than that in females for all ages. A total of 2146 (42.4%) patients had an INR of 2-3, and less than 40% patients in their sixties had an INR within optimal range. The dosage of oral anticoagulant for optimal INR level was 3.71 mg. CONCLUSION: In this study, less than half of the Korean patients with AF on VKA reached the therapeutic range of INR. Mean dosage of VKA was 3.66+/-1.50 mg, and the dosage of oral anticoagulant for optimal INR level was 3.71 mg, which decreased with age.

A case of aortoesophageal fistula after NSAID use / 대한내과학회지

Aortoesophageal fistula secondary to thoracic aortic aneurysm is an uncommon cause of gastrointestinal bleeding and is uniformly fatal without surgical intervention. We report a case of aortoesophageal fistula in an 83-year-old male who presented with massive hematemesis after 4 days of NSAID use. Endoscopy showed a kissing esophageal ulcer with a pulsating mass lesion in the mid esophagus. HRCT showed a fusiform aortic aneurysm in the descending aorta that was affecting the mid esophagus.

Marginal Fidelity And Fracture Strength Of Ips Empress 2(R) Ceramic Crowns According To Different Cement Types / 대한치과보철학회지

There has been increasing use of IPS Empress 2(R)owing to easy fabrication method, high esthetics similar to natural teeth, good marginal accuracy, and sufficient fracture strength. However, in clinical application, although a luting agent and the tooth cementation bonding procedure influence the marginal accuracy and fracture strength restoration, there has been a controversy in the selection of proper luting agent. This study was to measure the marginal fidelites and fracture strength of IPS Empress 2(R) crowns according to three cement types, Protec cem(R), Variolink II(R) and Panavia 21(R). After construction of 12 experimental dies for each group, IPS Empress 2(R)crowns were fabricated and luted the metal master die prepartion of the maxillary right premolar. Marginal gaps before cementation and after cementation were measured. Buccal incline on the functional cusp of specimens were loaded until the catastrophic failure and fracture strength was measured. The results of this study were as follows: 1. The range of gap was 34.04 +/- 4.84 micro meter before cementation and 37.88 +/- 5.00 micro meter after cementation, which showed significant difference by paired t-test (p0.05). 2. The difference in the results from marginal accuracy according to three cement types proved that The Variolink II(R) cement group had the least gap, 35.43 +/- 5.03 micro meter, and showed superior marginal accuracy while there existed statistic significance in Protec cem(R) cement group, 39.06 +/- 4.41 micro meter or Panavia 21(R)cement group, 39.16 +/- 4.39 micro meter by two-way ANOVA test and multiple range test (p<0.05). 3. The difference in the results from fractures strength testing according to three cement type groups proved to be statistically significant (p<0.05). The Variolink II(R) cement group shows the highest fracture strength of 1257.33 +/- 226.77 N, Panavia 21(R)cement group has 1098.08 +/- 138.45 N, and Protec cem(R) cement group represents the lowest fracture strength of 926.75 +/- 115.75 N. 4. Three different cement groups of different components showed acceptable marginal fidelity and fracture strength. It is concluded that IPS Empress 2(R)crowns luted using Variolink II(R) cement group had stronger fracture strength and smaller marginal gap than the other cement groups. Although Variolink II(R) resin cement seemed acceptable to clinical applications in IPS Empress 2(R)system, the IPS Empress 2(R)system still requires long-term research due to the lack of data in clinical applications