Prognosis According to the Timing of Percutaneous Coronary Intervention in an Acute Non-ST Segment Elevation Myocardial Infarction

BACKGROUND AND OBJECTIVES: An early invasive strategy with coronary angiography and revascularization is currently the recommended treatment for patients at high risk with an acute non-ST-segment elevation myocardial infarction (NSTEMI). In this early invasive strategy, percutaneous coronary intervention (PCI) is generally recommended within 48 hours, but there is little data on earlier intervention in intermediate risk patients. SUBJECTS AND METHODS: We studied retrospectively the past medical records of 118 patients at intermediate risk that were admitted at Pusan National University Hospital and were stratified by the time interval from chest pain onset to PCI (Group I: 48 h). Clinical outcomes were evaluated in terms of in-hospital and 12 months follow-up of a major adverse cardiac event (MACE). RESULTS: Baseline characteristics were not different statistically among the three groups, except for the use of tirofiban. There were no in-hospital deaths or myocardial infarctions (MI) in Group I and Group II patients, but there were three cases of in-hospital deaths in Group III patients. The incidence of a 12-month MACE was 0% in Group I patients, 6.7% (one revascularization) in Group II patients and 17.1% (3 deaths, 3 MIs, 7 revascularizations) in Group III patients (p=0.043). CONCLUSION: In acute NSTEMI, the incidence of a 12-month MACE was lower in the intermediate risk group when PCI was performed in the early period. Early PCI could be recommended in acute NSTEMI on the basis of the status of individual patients.

Risk factors for reflow disturbance phenomenon during percutaneous coronary intervention in patients with acute myocardial infarction / 대한내과학회지

BACKGROUND/AIMS: The reflow disturbance phenomenon is associated with poor functional and clinical outcomes for patients suffering with acute myocardial infarction (AMI). In the era of primary coronary intervention (PCI), accurately identifying those lesions that are at a high risk of no-reflow is of crucial importance. Therefore, we investigated the risk factors of the reflow disturbance phenomenon in AMI patients who underwent PCI. METHODS: From February 2003 to June 2005, the clinical and angiographic characteristics of 475 patients who had undergone PCI were reviewed retrospectively. RESULTS: 65 patients (13.7%) showed the reflow disturbance phenomenon and the reperfusion times of the reflow disturbance group ranged from 1 hour to 142 hours. On univariate analysis, an older age (p<0.001), low systolic blood pressure (p=0.01), no thrombolysis followed by PCI (p<0.001), primary PCI (p<0.001), less time to PCI (p=0.001), a high peak serum CK-MB level (p=0.013), angiographically visible thrombus (p=0.016), a low pre-TIMI grade (p=0.021) and ST segment elevation on the ECG (p=0.002) were the significant risk factors of the reflow disturbance phenomenon. An older age, a low systolic BP and angiographically visible thrombus were significant risk factors on multivariate analysis. CONCLUSION: An older age, low systolic blood pressure and angiographically visible thrombus were the independent risk factors for the reflow disturbance phenonmenon in AMI patients who undergo PCI.

Comparison of the Clinical and Angiographic Outcomes of Compromised Side Branches (Stent Jail) after Percutaneous Coronary Intervention between Sirolimus-Eluting Stents and Paclitaxel-Eluting Stents

BACKGROUND AND OBJECTIVES: Drug-eluting stents (DES) have been used worldwide for conducting safe and effective percutaneous coronary intervention (PCI) for treating coronary artery disease. However, the DES might cause a higher frequency of an acute side branch occlusion or stent jails near the target lesion after PCI than that with using bare metal stents (BMS). This may be due to the eluted drug or the thick stent struts. We evaluated the clinical and angiographic outcomes of compromised side branches (stent jail) after PCI and the frequency of side branch occlusion or stent jails between sirolimus-eluting stents (SES) and paclitaxel-eluting stents (PES). SUBJECTS AND METHODS: We analyzed the clinical results and angiographic findings of 47 patients who were treated with a SES and 45 patients who were treated with a PES. We only analyzed the left anterior descending artery (LAD) and its side branches that were more than one millimeter in diameter. Side branch occlusion was defined as the development of total occlusion or a reduction of the thrombolysis in myocardial infarction (TIMI) flow more than grade 1 after stenting. The peak cardiac enzyme levels were measured. We evaluated the clinical outcomes in the hospital and at the 6 month follow up. RESULTS: There were no significant differences of the baseline clinical demographics between the SES and the PES groups. The total length and diameter of the implanted stents were 42.85+/-15.3 mm vs. 41.68+/-13.3 mm (p=0.93) and 3.09+/-0.3 mm vs. 3.1+/-0.2 mm (p=0.69) in the SES group and PES group, respectively. On average, the number of side branches of the LAD were 2.00+/-0.9 vs. 2.13+/-0.8 and on angiography after stenting, side branch occlusion and reduction of the TIMI developed in 8.51% vs. 13.33% (p=0.46) and 17% vs. 15% (p=0.88) of the SES group and PES group, respectively. The laboratory data showed that the peak creatine kinase-MB (CK-MB) and troponin-I levels were 13.5+/-31 U/L vs. 15.6+/-33 U/L (p=0.77) and 6.3+/-15 ng/mL vs. 5.42+/-9 ng/mL (p=0.77), respectively. There were no clinical in-hospital events for either group. There were no statistically significant differences in major adverse cardiac events (MACEs) at the 6-month follow up (4.3% vs. 8.9%, respectively). CONCLUSION: The clinical and angiographic outcomes of compromised side branches (stent jail) after PCI and the frequency of side branch occlusion or stent jails between SES and PES were similar.

Metabolic Syndrome and Risk of In-Stent Restenosis: Clinical Outcomes in Patients Undergoing Percutaneous Coronary Intervention

BACKGROUND AND OBJECTIVES: Patients with metabolic syndrome (MS) have an increased risk of cardiovascular events. However, only limited studies are available on the effect of MS on restenosis and on the clinical outcome of patients undergoing percutaneous coronary intervention (PCI). The aim of this study is to assess the role of MS in the development of restenosis, and risk of a 6-month major adverse cardiac event (MACE) and a 12-month MACE, as well as the difference of outcome between the use of bare metal stents (BMSs) and the use of drug eluting stents (DESs). SUBJECTS AND METHODS: This is a one center, retrospective study. The study population comprised 151 patients undergoing percutaneous coronary intervention (PCI) with BMSs and 200 patients undergoing PCI with DESs. The study population was classified into two groups of patients with MS and patients without MS. RESULTS: The baseline clinical characteristics were similar in the two groups (with or without MS) except for hypertension, diabetes, body mass index, triglyceride level and high-density lipoprotein level. The frequency of in-stent restenosis of the patients that were implanted with BMSs or DESs was not different between two groups, based on a 6 month follow-up quantitative coronary angiographic analysis (BMSs: 30% vs 22.2%, p= 0.352; DES: 3.3% vs 2.2%, p=0.76; for patients with and without MS, respectively). The percent of patients with a 6-month MACE for patients implanted with BMSs was not statistically different for patients with or without MS (30% vs 22.2%, p=0.352) but the percent of patients with a 12-month MACE showed a statistically significant higher level for the MS group (38.6% vs 23.5%, p=0.044). The percent of patients with a 6-month MACE for patients implanted with DESs was also not statistically different between two groups (5.8% vs 1.7%, p= 0.123). CONCLUSION: Patients with MS undergoing BMSs or DESs implantation do not show higher levels of in-stent restenosis and levels of a 6-month MACE. The number of 12-month MACEs of patients implanted with BMSs is statistically higher, but the number of 6-month MACEs of patients implanted with DESs is not different for the MS group. We conclude that MS is not risk factor of in-stent restenosis in PCI but MS may influence the long-term clinical outcome in patients undergoing PCI.

Biochemical Analysis of Serum and Pericardial Fluid in Patients with Hemorrhagic Pericardial Effusion

BACKGROUND AND OBJECTIVES: Since echocardiography became a routine diagnostic tool, pericardial effusion has become a common clinical finding. The major causes of hemorrhagic pericardial effusion are malignancy and tuberculosis. However, it was unknown to the use of biochemical analysis of pericardial fluid and serum, for differentiation of malignancy from tuberculosis. To evaluate this, we investigated the biochemical analysis of pericardial fluid and serum in relation to the causes of pericardial tamponade. SUBJECTS AND METHODS: 46 patients who were admitted to Pusan National University Hospital from January 1, 1995, to April 30, 2002, and underwent both a pericardiocentesis and a pericardiostomy for the relif of cardiac tamponade, were included in this study. the pericardial fluid was routinely analyzed for the following: gross appearance, cell count, glucose, total protein(P), lactate dehydrogenase(LDH), cytology, gram stain, cultures for bacteria and mycobacterium, pericardial fluid to serum ratios of total protein and lactate dehydrogenase,(p/s TP, p/s LDH, respectively). RESULTS: f the 46 patients who underwent both pericardiocentesis and pericardiostomy, for the relief of cardiac tamponade, 33 patients(71.7%) had hemorrhagic pericardial effusion. The common causes of hemorrhagic pericardial effusion were malignancy(51.5%) and tuberculosis(33.3%) but, those of nonhemorrhagic pericardial effusion were idiopathic (38.5%). Cell counts were higher in hemorrhagic than nonhemorrhagic group(p=.029). Serum LDH(sLDH) was higher in malignant than tuberculous group(p=.001) but, serum total protein(sTP) was higher in tuberculous group(p=.004). Compared malignant group with tuberculosis group in patients with hemorrhagic pericardial effusion, p/s ratio of LDH and sTP were higher in tuberculous group (p=.029, p=.017), but sLDH was higher in malignant group(p=0.002). CONCLUSION: It is difficult to differentiate tuberculosis from malignancy only on the basis of the biochemical analysis of pericardial fluid in hemorrhagic pericardial effusion. However, the analysis of both pericardial fluid and serum may make it possible to evaluate the cause of pericardial effusion.

A Case of Endoscopic Removal of Choledocholithiasis in a Patient with Situs Inversus Totalis / 대한소화기내시경학회지

Situs inversus totalis is a rare condition with a genetic predisposition that is autosomal recessive. We report an elderly patient with situs inversus, multiple choledocholithiasis, and he was treated via endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy, and then his multiple CBD stones were removed with basket and balloon. This paper further expands the application of these techniques and shows that they can be safely and effectively applied in the setting of situs inversus, although attention must be paid to the details of left-right reversal.

Survival and Prognostic Factors in Patients with Primary Pulmonary Hypertension

OBJECTIVES: Primary pulmonary hypertension (PPH) that affects predominantly young and productive people is a progressive fatal disease of unknown cause. The objectives of this study were to characterize mortality in patients with PPH and to investigate the factors associated with their survival. METHODS: Thirteen patients with PPH were enrolled between 1988 and 1996 and followed-up through July 1999. Measurements at diagnosis included hemodynamic and pulmonary function variables in addition to information on demographic data and medical history. RESULTS: 1) The mean age of the patients with PPH enrolled into the study was 36.1+/-9.3 years with female predominance. 2) The estimated median survival was 3.4+/-0.6 years. 3) Decreased cardiac index was the only significant predictor of mortality (Cox proportional hazards model). CONCLUSION: Patients with PPH have a poor survival expectancy. In this limited study with a small number of patients, mortality is largely associated with decreased cardiac index.

Infected Endocarditis Related Pacemaker leads: A Case Report

The infected endocarditis related permanent pacemaker occurs rare and most of them occur at generator pocket but endocarditis related permanant pacemaker lead itself occurs very rarely. The rate of infection after pacemaker implantation is reported as 0.13-7% or 0.13-19.9% and mortality rate is up to 24-33%. Focal inflammation of generator pocket is easily detected but it is difficult to diagnose endocarditis related pacemaker lead and it has poor prognosis. Especially, early diagnosis is most important because endocarditis related pacemaker is fatal. Thirteen years ago, a womon was inserted the permanent pacemaker and then only generator was removed after one month. We report a case that we had removed the pacemaker lead by open thoracostomy and cardiopulmonary circulation to treat endocarditis related pacemaker lead.

Heart Rate Variability in Inappropriate Sinus

BACKGROUND: Inappropriate sinus tachycardia(IST) manifests chronic nonparoxysmal sinus tachycardia in healthy individuals and is characterized by consistently elevated heart rate and exaggerated responses to minimal physical activity. Heart rate variability(HRV) using 24-hour Holter monitoring represents one of the methods of evaluating the harmony of autonomic nervous system activity. So, authors investigate the autonomic nervous system activity by the HRV in patients with IST. METHODS: We compared the pattern of cardiac sympathetic and parasympathetic activity through the time domain analysis of heart rate variability with 24-hour Holter monitoring between 23 patients with IST and 23 healthy control subjects. None of the patients had organic heart disease as determined by routine laboratory examination and echocardiography. And then, time domain measures(mean NN, SDNN, SDANN, SD, rMSSD, pNN50) were analyzed. RESULTS: The mean age of patients and control were 38+/-10 and 37 9 years, respectively(p=S). The mean clinical heart rate of patients and control was 104 5/min and 72+/-5/min, respectively(p<0.05). Among the time domain indices, mean of all normal RR intervals(mean NN), standard deviation of all normal RR intervals(SDNN), standard deviation of mean RR interval(SDANN), mean of standard deviations of all normal RR intervals(SD), root mean square successive differences between adjacent normal RR intervals(rMSSD), and percent of difference between adjacent normal RR intervals(pNN50) in the patient group were significantly shorter compared to control group(p<0.01). CONCLUSION: In IST, cardiac vagal influence on the heart rate is blunted.

Changes of pulmonary function in patients with mitral stenosis after percutaneous mitral balloon valvuloplasty

BACKGROUND: The patients with mitral stenosis are generally accompanied with impaired pulmonary function. The aim of this study was to evaluate the changes of pulmonary function after percutaneous mitral balloon valvuloplasty (PMV) in that patients. METHODS: PMV was performed in 36 patients with mitral stenosis in Pusan National University Hospital and hemodynamic, echocardiographic and pulmonary function test data before and after PMV were analyzed. RESULT: After PMV, NYHA functional class was improved from 2.2+/-0.6 to 1.2+/-0.4 (p<0.001). The mean left atrial pressure and mean pulmonary arterial pressure significantly decreased from 14.5+/-6.2 mmHg to 5.7+/-4.4 mmHg(p<0.001) and from 25.3+/-10.9 mmHg to 15.5+/-7.4 mmHg (p<0.001), respectively. Cardiac output was slightly decreased from 5.34+/-1.31 L/min to 5.28+/-1.25 L/min (p=0.50). Mean mitral pressure gradient decreased from 13.5+/-5.8 mmHg to 4.4+/-2.1 mmHg (p<0.001) and mitral valvular area significantly increased from 0.86+/-0.19 cm2 to 1.71+/-0.28 cm2 (p<0.001). In pulmonary function test, only MVV and PEF was significantly improved from 77.2+/-23.8% to 88.4+/-27.9% (p<0.01) and 87.1+/-26.8% to 97.5+/-26.4% (p<0.01), respectively. But, VC, FEV1, FEF25-75% and FVC were not changed significantly. In exercise treadmil test, exercise duration was significantly improved from 482.0+/-266.2 sec to 718.0+/-287.5 sec (p<0.001). CONCLUSION: We observed the results of better hemodynamic changes and exercise capacity after PMV. But, there was no significant improvement in pulmonary function after PMV. In our opinion, irreversible pulmonary changes and hemodynamic effect on pulmonary function should be considered.

Etiologies and prognostic factors of chronic cor pulmonale / 결핵

BACKGROUND: The aims of this study were to assess the etiologies, survival and prognositic factors of patients with chronic cor pulmonale visited Pusan National University Hospital. METHODS: This study included 103 patients with chronic cor pulmonale. There were 67 men and 36 women. The diagnosis of chronic cor pulmonale was primarily based on the presence of underlying lung disorder and echocardiographic finding of enlarged or hypertrophied right ventricle. Other clinical data including patients' symptoms and signs, findings of arterial blood gas analysis, hematologic and biochemical laboratory and pulmonary function test were assessed. RESULTS: The most common underlying lung disorder was pulmonary tuberculosis (59.2%) and chronic obstructive pulmonary disease was the next (28.2%). The survival rate was 57% in one year, 45% in two years, and 34% in three years. The prognostic factors were maximal voluntary ventilation(MVV), forced vital capacity(FVC), FEV1, serum Na, vital capacity(VC), serum albumin and peak expiratory flow(PEF) in univariate analysis. And in multivariate analysis, serum albumin(p=0.0144) and VC(p=0.0078) were statistically significant. CONCLUSION: Pulmonary tuberculosis was the most important underlying lung disorder in chronic cor pulmonale. The survival rate was 57% in one year, 45% in two years, and 34% in three years. Serum albumin(p=0.0144) and VC(p=0.0078) were statistically significant prognostic factors.