A Case of Spontaneous Common Iliac Atery Dissection / 고신대학교의과대학학술지

Spontaneous and isolated dissection of the limb arteries without involvement of the aorta is extremely rare, and has been reported previously in pregnant patients in association with collagen vascular disease, and in cases of high-energy trauma or intensive activity in athletes. There is no consensus yet on indications for medical or surgical therapeutic modality. Due to the rarity of spontaneous dissection of external iliac artery, its natural history has been poorly described. A healthy 50-year-old male with normotension was admitted with an acute onset of left flank pain. Left external iliac artery dissection was diagnosed by abdominal computed tomography.

Risk of Stent Stenosis after Implanting a First-Generation Drug-Eluting Stent and Drug Balloon Angioplasty / 대한내과학회지

In patients with coronary artery disease, coronary stenting with a drug-eluting stent (DES) is associated with lower rates of in-stent restenosis and re-surgery for the target lesion compared with a bare metal stent, while late stent thrombosis has emerged as a life-threatening complication in patients treated with a first-generation DES. As no treatment has been established for potentially fatal late stent thrombosis associated with a first-generation DES, we perform drug balloon angioplasty for patients with stent thrombosis and in-stent restenosis associated with DES. Here, we reported the cases with normal coronary artery flow after a 2-year follow-up.

Intractable Ventricular Arrhythmia Induced by Aconite and its Successful Treatment with Extracorporeal Membrane Oxygenation Support

Aconite, derived from the roots of certain aconitum species (Racunculaceae), is widely distributed in Korea. Aconitine, an extremely toxic substance present in aconite, has pharmacological effects, including anti-inflammatory, analgesic, and positive inotropic actions. Due to its relatively low safe dose, we sometimes encounter cases of serious aconite intoxication. The toxic compound mainly affects the CNS, heart, and muscle tissues, resulting primarily in cardiovascular complications. Aconite poisoning presents with a combination of neurological, cardiovascular, and gastrointestinal features. The main cause of death is severe cardiotoxicity causing refractory ventricular tachyarrhythmias and asystole. As there is no specific antidote, management of aconite poisoning is supportive. All patients require close monitoring of blood pressure and cardiac rhythm since ventricular arrhythmias may occur during the first 24 hours of poisoning, resulting in sudden deterioration in the patient's clinical condition. Extracorporeal membrane oxygenation (ECMO) has traditionally been utilized for perioperative cardiac failure and cardiomyopathies. More recently, the indications for ECMO have expanded to patients with acute cardiovascular decompression including intractable arrhythmias. We report on a patient who developed life threatening ventricular tachyarrhythmia after ingestion of herbal tablets containing aconite alkaloids. Our patient was resuscitated with intravenous infusion of amiodarone, repeated cardioversion/defibrillation, and mechanical circulatory support with ECMO.

Staphylococcus aureus Pericardial Abscess Presenting as Severe Sepsis and Septic Shock After Acupuncture Therapy

Pericardial abscess is an extremely rare complication of Staphylococcus aureus bacteremia. We report a case of a 72-year-old woman with multiple acupuncture scars on both knees who presented with shortness of breath and general weakness. Transthoracic echocardiography and pericardiocentesis confirmed the presence of pericardial fluid collection. Staphylococcus aureus grew in both pericardial fluid and blood. Although an aggressive medical treatment including intravenous antibiotics and percutaneous drainage, the patient died 2 days after admission.

A Case of Acute Cerebral Infarction in Adult Cor Triatriatum Sinistrum / 대한내과학회지

Cor triatriatum is a rare congenital malformation of the heart characterized by a fibromuscular membrane dividing the atrium into two distinct chambers. In the majority of cases, it is diagnosed in early childhood, whereas adult cases are extremely rare [1,2]. The hemodynamics of cor triatriatum are similar to those of mitral stenosis, which sometimes cause embolic infarction. We describe an unusual case of cor triatriatum sinistrum in a 48-year-old man who presented with relapsed embolic infarction.

Successful Treatment of an Iatrogenic Giant Femoral Artery Pseudoaneurysm With Percutaneous Thrombin Injection

A femoral artery pseudoaneurysm (FAP) is one of the most troublesome complications following invasive procedures related to the femoral arterial access. Post-procedure FAP rarely occurs; however, its occurrence tends to increase with the more frequently antiplatelet agents, anticoagulants, and larger-sized catheter used for interventional procedures. Traditionally, surgical repair has been considered as the standard treatment modality for FAP; however, less invasive methods currently exist such as blind manual or ultrasound-guided compression repair (UGCR) as well as percutaneous thrombin injection, both of which have replaced the need for surgery. We report a case of a giant pseudoaneurysm in a femoral artery, which had developed as a complication of stenting in a patient with carotid artery stenosis and ischemic heart disease, and was subsequently successfully treated using percutaneous thrombin injection.

Reproducibility of IntraLASIK Flap Thickness Measured with Optical Coherence Tomography

PURPOSE: To investigate the relationship among optical coherence tomography (OCT), ultrasound pachymetry, and Orbscan in central corneal thickness measurement and to evaluate the reproducibility of flap thickness using an IntraLase femtosecond laser. METHODS: Central corneal thickness was measured by OCT, ultrasound pachymetry, and Orbscan in 59 eyes of 30 patients before LASIK. After IntraLASIK, the corneal flap thickness measured using OCT was compared with the intended corneal flap thickness. RESULTS: Central corneal thickness measured by OCT was thinner than that measured by other instruments preoperatively, but there was no significant difference among these methods (p>0.01), and corneal thickness values obtained by ultrasound pachymetry and Orbscan correlated well with those obtained by OCT (r ranged from 0.804 to 0.889, p0.01). CONCLUSIONS: OCT is a relatively accurate instrument for measuring corneal thickness and can easily measure the corneal flap thickness after LASIK. Compared with the results of a previous study, the mean measured flap thickness in this study was more reproducible with the IntraLase femtosecond laser.

Giant Cell Myocarditis Manifested as Fulminant Myocarditis

A 42 year-old female with fulminant myocarditis became acutely ill following a distinct viral prodrome 2 weeks before her hospitalization. She had severe ventricular dysfunction and multiple foci of giant cell myocarditis on the histopathological study. She experienced severe hemodynamic compromise that required high-dose vasopressors, immunoglobulin and extracorporeal membrane oxygenation (ECMO). Although she was managed with aggressive pharmacologic and mechanical support and also heart transplantation, she died at hospital day 12.

Percutaneous Cardiopulmonary Support for Emergency In-Hospital Cardiac Arrest or Cardiogenic Shock

BACKGROUND AND OBJECTIVES: Percutaneous cardiopulmonary support (PCPS) provides hemodynamic stability for the treatment of patients suffering with cardiogenic shock or cardiac arrest, and it can be used in a wide variety of clinical settings without the need for chest exploration. In this study, we summarize a single center's experience with performing PCPS in the patients who suffered with severe cardiopulmonary failure. SUBJECTS AND METHODS: We retrospectively reviewed 30 consecutive patients with cardiac arrest or severe cardiogenic shock who received PCPS for cardiac resuscitation from November 2003 to July 2005. The self-priming, heparin-coated circuit of the Emergency Bypass System(R) was used in all the patients. Cannulation was performed via the femoral artery and vein with using an arterial (17 to 21 French) and venous cannula (21 to 28 French), percutaneously or with a small incision. RESULTS: The Indications for PCPS were: ischemic heart disease before coronary revascularization, myocardial disease, PCI-associated complications and post-operative hemodynamic collapse. Of the 30 patients we evaluated, 19 patients (63%) were successfully weaned off of the PCPS; 14 of these patients (47%) were later discharged from the hospital. For the survivors, the time interval from cardiac arrest or severe cardiogenic shock to the onset of PCPS was significantly shorter (p=0.01), and the urine output for the initial 24 hours was significantly higher (p=0.04). CONCLUSION: This retrospective analysis demonstrates the effectiveness of using PCPS for the treatment of critically unstable patients with cardiac arrest or cardiogenic shock. Larger scale studies of PCPS are now needed to confirm these findings.

Enhancement of Gene Delivery into Mouse Skeletal Muscle with Microbubble Destruction by Low-Frequency Ultrasound

BACKGROUND AND OBJECTIVES: The aim of this study was to investigate the value of microbubble destruction using low-frequency ultrasound for enhancing gene delivery to skeletal muscles of laboratory animals. MATERIALS AND METHODS: Lac-Z gene was injected into 21 mouse anterior tibialis muscles. Seven muscles received the gene only, and seven each received either 20-kHz ultrasound exposure or ultrasound-PESDA (perfluorocarbon-exposed sonicated albumin) destruction, respectively, following the injection; the extent of Lac-Z expression was then compared. Luciferase gene was injected into the muscles (N=80). The muscles were divided into two groups according to the mixture; in the first group saline was used as the mixture solute, with PESDA used in the second group. The groups were subdivided into two groups, one receiv 10 seconds of ultrasound at the injection site after injection, and the other that received no further intervention. Luciferase activities were measured and compared. RESULTS: The proportions of Lac-Z stained cells were 0, 5.7+/-1.2 and 7.7+/-1.7%, respectively, showing a significant stepwise increase microbubble destruction (p<0.05). Luciferase activities were as follows: Luciferase only (Group 1, N=17), 5727+/-2178 RLU/mg; luciferase plus PESDA (Group 2, N=17), 1170+/-470.7 RLU/mg; luciferase plus ultrasound (Group 3, N=17), 16480+/-5239 RLU/mg; and luciferase plus PESDA destruction (Group 4, N=17), 49910+/-16500 RLU/mg. The activity in group 4 was significantly higher than in group 1 (p<0.01), showing an 8.7-fold increase in gene delivery due to microbubble destruction. CONCLUSION: Microbubble destruction using low-frequency ultrasound is an efficient method for increasing the efficacy of direct gene delivery to skeletal muscles.

Balloon-Based Distal Protection Device Improves the Recovery of Left Ventricular Function after Primary Coronary Angioplasty

BACKGROUND AND OBJECTIVES: Despite the high success rate of primary angioplasty in cases of acute myocardial infarction (AMI), myocardial reperfusion can frequently be compromised, mainly due to distal embolization, which can be effectively prevented with the use of distal protection devices. The goal of this study was to see whether PercuSurge(r), a balloon-based distal protection device, could improve myocardial reperfusion and late clinical outcomes after primary coronary angioplasty. SUBJECTS AND METHODS: Between April 2002 and July 2003, 29 patients with AMI, within 12 hours of the onset of symptoms, were scheduled to undergo primary angioplasty using PercuSurge(r) (PS group). Thirty patients were selected as a control group by matching the 5 clinical and angiographic variables; the clinical status and coronary angiograms were also prospectively reviewed and analyzed. RESULTS: There were no significant differences in the baseline clinical and angiographic characteristics, including the left ventricular ejection fraction (LVEF) between two groups. The procedures were successful, without complications, in all patients from both groups. However, the PS group was associated with a significantly higher incidence of myocardial blush score of 3 (PS 58%, control 30%, p=0.001) and early ST-segment elevation resolution (PS 76%, control 47%, p=0.02) compared to the control group. The PS group also showed a greater LVEF at 60 days after the procedure (PS 51+/-5%, control 46+/-8%, p=0.007). There was no significant difference in the incidences of death or myocardial infarction between the two groups during the follow-up period. CONCLUSION: The use of the PercuSurge(r) was found to be safe and feasible during primary angioplasty, and this system also improved the recovery of the left ventricular function as well as myocardial reperfusion following primary coronary angioplasty.

Experiences with Emergency Percutaneous Cardiopulmonary Support in In-hospital Cardiac Arrest or Cardiogenic Shock due to the Ischemic Heart Disease / 대한흉부외과학회지

BACKGROUND: Percutaneous cardiopulmonary support (PCPS) provides passive support of gas exchange and perfusion, allowing the use of other methods of care for organ recovery, and saves lives of patients with severe cardiopulmonary failure in a wide variety of clinical settings with a minimal risk of bleeding and need for chest reexploration. We summarized a single center's experiences with PCPS in patients with cardiogenic shock or cardiac arrest due to the ischemic heart disease. MATERIAL AND METHOD: Among the 20 consecutive patients with cardiogenic shock or cardiac arrest from May 1999 to June 2005, Biopump(r) (Medtronic, Inc, Minneapolis, MN) was used in 7 patients and the self-priming, heparin-coated circuit of EBS(r) (Terumo, Japan) was applied to remaining 13 patients. Most of cannulations were performed percutaneously via femoral arteries and veins. The long venous cannulas of DLP(r) (Medtronic inc. Minneapolis, MN) or the RMI(r) (Edwards's lifescience LLC, Irvine, CA) were used with the arterial cannulae from 17 Fr to 21 Fr and the venous cannula from 21 Fr to 28 Fr. RESULT: The 20 consecutive patients who were severely compromised and received PCPS for the purpose of resuscitation were comprised of 13 cardiac arrests and 7 cardiogenic shocks in which by-pass surgery was performed in 11 patients and 9 ongoing PCIs under the cardiopulmonary support. The mean support time on the PCPS was 38+/-42 hours. Of the 20 patients implanted with PCPS, 11 patients (55%) have had the PCPS removed successfully; overall, 8 of these patients (40%) were discharged from the hospital in an average surviving time for 27+/-17 days after removing the PCPS and survived well with 31+/-30 months of follow-up after the procedure. CONCLUSION: The use of PCPS appears to provide the hemodynamic restoration, allowing the survival of patients in cardiac arrest or cardiogenic shock who would otherwise not survive, and patients receiving PCPS had a relatively long-term survival.

The Changes of Pacing Lead Impedance Over Time: Differences in the Atrial and Ventricular Leads

BACKGROUND AND OBJECTIVES: It has been suggested that lead impedance measurements with using real-time telemetry may offer a good estimation of the lead system integrity, and the serial measurement of the pacing lead impedance over time is a useful tool to monitor the pacing lead performance. However, there has been no consistent data about the changes of lead impedance over time. Therefore, we investigated the correlation of the direct lead impedance and the telemetered lead impedance, and the changes of lead impedance over time in both the atrial and ventricular leads. SUBJECTS AND METHODS: The direct and telemetered lead impedances were measured at the time of the initial implantation. One-hundred and five patients (mean age: 62.5+/-13.5 years, 47 males, 47 atrial leads and 105 ventricular leads) who were without lead failure for more than 4 years since the initial implantation were included in the study. Afterwards, the telemetered lead impedance was examined at 2-month and at 12-month after implantation and then annually for 4 years in all the patients at a pacemaker clinic. RESULTS: At the initial implantation, the direct lead impedance and the telemetered lead impedance were 470.2+/-12.2omega and 540.9+/-11.6omega, respectively, in the atrial leads (r=0.72, p<0.01) and 623.7+/-14.6omega and 717.1+/-17.3omega, respectively, in the ventricular leads (r=0.82, p<0.01). In the atrial leads, the mean telemetered lead impedance rose to 583.0+/-14.0omega (p<0.01 vs baseline) at 2 months and it stabilized thereafter (p=NS). In contrast, the mean lead impedance was decreased to 653.6+/-15.6omega (p<0.01 vs baseline) at the 2-month follow-up, and then it stabilized in the ventricular leads (p=NS). CONCLUSION: There was a good correlation between the direct and telemetered lead impedance, and there was a different tendency for the change of lead impedance during the lead maturation between the atrial and ventricular leads. The telemetered lead impedance was substantially stable since the 2 months after the implantation.

afety and Feasibility in Trans-radial Coronary Interventions for Chronic Total Occlusion

BACKGROUND AND OBJECTIVES: Recent advances in trans-radial coronary intervention (TRI) have shown a reduction in patient's morbidity. However, the role of TRI for a chronic total occlusion (CTO) is not well established. The aim of this study was to assess the safety and feasibility of TRI for a CTO. SUBJECTS AND METHODS: Sixty-three successive CTO lesions of more than 2 months duration were prospectively included in this registry between April 2002 and November 2003. Guiding catheters with strong back-up, stiff guide wires and supportive infusion catheters were actively used. The angiographic and procedural characteristics were prospectively evaluated. RESULTS: There were 45 male and 18 female patients, with a mean age of 59.8+/-9.5 years. The most common clinical diagnosis was stable angina (95.2%). The mean duration of the occlusions was 10.3+/-1.6 months. Procedural success was achieved in 53 lesions (84.1%). No cases were crossed over to transfemoral procedure. The most common cause of procedural failure was guide wire passage failure (7 lesions). The mean duration of occlusions was significantly longer in the failure group (7.5+/-1.1 versus 24.8+/-6.5 months, p<0.001). Bridging collateral vessels, long occlusions, calcification at lesion sites, a side branch at the occlusion site and blunt entry morphology were also statistically significant predictors for procedural failure. Procedure-related complications were noted in 6 patients (9.8%), which included coronary perforations (3.3%), severe dissections (3.3%), arrhythmia (1.6%) and branch artery occlusion (1.6%). No patients suffered from local complications, such as hematoma or radial artery occlusion. CONCLUSION: TRI for a CTO seems to be safe and feasible, with acceptable success and complication rates.

Predictors of Sinus Rhythm Restoration after Maze Operation and Relationship between Pre- and Post-operative Left Atrial Volume

BACKGROUND AND OBJECTIVES: The Maze operation is known to be an effective measure for restoring sinus rhythm in patients with atrial fibrillation (AF). The purpose of this study was to identify the relationship of pre- and post-operative left atrial volume (LAV) and diameter (LAD) with successful restoration of sinus rhythm in the Maze operation. SUBJECTS AND METHODS: The subjects for this study were 28 patients who underwent open-heart surgery in conjunction with the Maze-III operation for chronic AF from October, 2002, to April, 2003. Electrocardiographic and transthoracic echocardiographic studies were done pre-operatively and three months post-operatively. LAV and LAD were assessed and corrected for body surface area (LAV index=LAV/BSA, LAD index=LAD/BSA). RESULTS: Sinus rhythm was restored and maintained in 22 of the 28 patients (78.6%). Between the group with successful restoration of sinus rhythm (Group A;n=22) and the group with unsuccessful restoration (Group B;n=6), there was no difference in age, gender, and NYHA functional class. The duration of AF in group A was significantly shorter than that of B (3.6+/-2.7 years versus 15.8+/-7.5 years, p=0.003). Group A and B did not show any difference in pre-operative left ventricular ejection fraction. However, pre-operative LAV index in group A was significantly smaller than that of group B (80.7+/-22.4 mL/m2 versus 118.1+/-42.5 mL/m2, p=0.048). In group A, the LAV index (80.7+/-22.4 mL/m2 versus 52.8+/-14.7 mL/m2, p<0.001) and LAD index (35.4+/-5.3 mm/m2 versus 31.7+/-4.7 mm/m2, p=0.001) decreased significantly three months after the operation. In group B, however, no significant changes are found in the LAV index (118.1+/-42.5 mL/m2 versus 89.2+/-38.9 mL/m2, p=0.116) and LAD index (39.1+/-7.9 mm/m2 versus 36.2+/-9.2 mm/m2, p=0.144). CONCLUSION: Pre-operative LAV index measured by echocardiography and the duration of AF were significant predictors of successful sinus rhythm restoration after the Maze operation. Significant reduction of the LAV index after the Maze operation was found in patients whose rhythm was successfully restored and maintained.

N-Terminal Pro-B-Type Natriuretic Peptide as a Prognostic Marker in Acute Coronary Syndrome

BACKGROUND AND OBJECTIVES: Biochemical markers are useful for the prediction of cardiac events in patients with acute coronary syndrome (ACS). The N-terminal fragment of the BNP prohormone (NT-proBNP), which is synthesized by cardiac ventricles in response to increased wall stress, may be a prognostic marker in ACS. The relation between the NT-pro BNP levels on admission and major adverse cardiovascular events (MACEs) were assessed in a cohort of patients with ACS. SUBJECTS AND METHODS: Between October 2002 and April 2004, blood samples for the determination of NT-proBNP level were obtained on admission from 78 patients with ST-elevation myocardial infarction (STEMI), 32 with non-ST elevation MI(NSTEMI) and 66 with unstable angina (UA). Patients were followed concerning MACEs (death, MI, heart failure, stroke and revascularization) for a median of 7 months in median. RESULTS: 22 patients (13%) had events. The mean NT-proBNP level was significantly lower in the event-free survivors than in those with events (1342+/-1598 versus 6129+/-6522 pg/mL, p<0.0001). The optimal cut-off value of the NT-proBNP level using a receiver-operating-characteristic curve was 1445 pg/mL. The unadjusted risk ratio of patients with an NT-proBNP level greater than the threshold was 7.0 (95% confidence interval, 2.6 to 19.0). In a multivariate Cox regression model, including clinical background factors and other biochemical markers, the NT-proBNP level was the most powerful indicator of MACEs (risk ratio, 8.0 [95% confidence interval, 1.7 to 37.1]). The coronary angiographic Gensini score was also a predictor of prognosis in ACS (risk ratio, 3.8 [95% confidence interval, 1.0 to 14.0]). CONCLUSION: A single measurement of the NT-proBNP level on admission appears to be useful as a prognostic factor in the prediction of MACEs in patients after ACS.

A Randomized Comparison of Cilostazol Versus Ticlopidine Therapy After Elective Coronary Stent Implantaion

BACKGROUND: Percutaneous transluminal coronary angioplasty(PTCA) is a widely acceptable treatment for ischemic heart disease. Restenosis after successful PTCA, which develops in 20~30% of all patients, remains a serious late complication. This study was to evaluate the efficacy of cilostazol for the prevention of stent restenosis compared with ticlopidine. MATERIALS AND METHOD: Fifty three patients underwent coronary stent implantation were divided in to as group A(n=25) receiving 100mg aspirin and 200mg cilostazol and group B(n=28) receiving 100mg asprine and 500mg ticlopidine from Sep 1998 and Feb 1999 at Pusan Paik Hospital, Inje University. Clinical and laboratory evaluations were preformed at regular interval. RESULT: There were no differences in baseline characteristics between the two groups. Coronary artery restenosis was observed in 5(20.8%) in group A and 8(26%) in group B respectively, which were not statistically significant (p=NS). Minimal luminal diameter was 2.10+/-0.89mm in group A and 1.93+/-0.65mm in group B (p=NS). Two patients in group A had headache, while 6(21.4%) patients of group B developed side effects including thrombocytopenia in 2 patients, skin rash in 2 patents . There was no cardiac death during the follow-up period. CONCLUSION: Aspirin plus cilostazol may be safer and equally antithrombotic regimen compared results to aspirin plus ticolpidine after elective coronary stent implantation.

Cysteine carboxyl O-methylation of human placental 23 kDa protein

C-Terminal carboxyl methylation of a human placental 23 kDa protein catalyzed by membrane-associated methyltransferase has been investigated. The 23 kDa protein substrate methylated was partially purified by DEAE-Sephacel, hydroxyapatite and Sephadex G-100 gel filtration chromatographies. The substrate protein was eluted on Sephadex G-100 gel filtration chromatography as a protein of about 29 kDa. In the absence of Mg2+, the methylation was stimulated by guanine nucleotides (GTP, GDP and GTPgammaS), but in the presence of Mg2+, only GTPgammaS stimulated the methylation which was similar to the effect on the G25K/rhoGDI complex. AFC, an inhibitor of C-terminal carboxyl methylation, inhibited the methylation of human placental 23 kDa protein. These results suggests that the substrate is a small G protein different from the G25K and is methylated on C-terminal isoprenylated cysteine residue. This was also confirmed by vapor phase analysis. The methylated substrate protein was redistributed to membrane after in vitro methylation, suggesting that the methylation of this protein is important for the redistribution of the 23 kDa small G protein for its putative role in intracellular signaling.

A Case of Chronic Atrial Tachycardia Managed with Digoxin and Reserpine

No abstract available.

A Case of Glycogenosis I

No abstract available.