Unguided De-Escalation Strategy From Potent P2Y 12 Inhibitors in Patients Presented With ACS: When, Whom and How?

no abstract available.

Clinical outcomes of endovascular treatment for ruptured thoracic aortic disease

Background/Aims@#Untreated rupture of the thoracic aorta is associated with a high mortality rate. We aimed to review the clinical results of endovascular treatment for ruptured thoracic aortic disease. @*Methods@#We retrospectively reviewed data on 37 patients (mean age, 67.0 ± 15.18 years) treated for ruptured thoracic aortic disease from January 2005 to May 2016. The median follow-up duration was 308 days (interquartile range, 61 to 1,036.5). The primary end-point of the study was the composite of death, secondary intervention, endoleak, and major stroke/paraplegia after endovascular treatment. @*Results@#The etiologies of ruptured thoracic aortic disease were aortic dissection (n = 11, 29.7%), intramural hematoma (n = 7, 18.9%), thoracic aortic aneurysm (n = 14, 37.8%), and traumatic aortic transection (n = 5, 13.5%). Three patients died within 24 hours of thoracic endovascular aortic repair, and one showed type I endoleak. The technical success rate was 89.2% (33/37). The in-hospital mortality rate was 13.5% (5/37); no deaths occurred during follow-up. The composite outcome rate during follow-up was 37.8% (14/37), comprising death (n = 5, 13.5%), secondary intervention (n = 5, 13.5%), endoleak (n = 5, 13.5%), and major stroke/paraplegia (n = 3, 8.1%). Left subclavian artery revascularization and proximal landing zone were not associated with the composite outcome. Low mean arterial pressure (MAP; ≤ 60 mmHg, [hazard ratio, 13.018; 95% confidence interval, 2.435 to 69.583, p = 0.003]) was the most significant predictor and high transfusion requirement in the first 24 hours was associated with event-free survival (log rank p = 0.018). @*Conclusions@#Endovascular treatment achieves high technical success rates and acceptable clinical outcome. High transfusion volume and low MAP were associated with poor clinical outcomes.

Erratum: Correction of Figure in the Article: Normal Reference Plots for the Bioelectrical Impedance Vector in Healthy Korean Adults

The present erratum notice corrects one figure of the article.

Normal Reference Plots for the Bioelectrical Impedance Vector in Healthy Korean Adults

BACKGROUND: Accurate volume measurement is important in the management of patients with congestive heart failure or renal insufficiency. A bioimpedance analyser can estimate total body water in litres and has been widely used in clinical practice due to its non-invasiveness and ease of results interpretation. To change impedance data to volumetric data, bioimpedance analysers use equations derived from data from healthy subjects, which may not apply to patients with other conditions. Bioelectrical impedance vector analysis (BIVA) was developed to overcome the dependence on those equations by constructing vector plots using raw impedance data. BIVA requires normal reference plots for the proper interpretation of individual vectors. The aim of this study was to construct normal reference vector plots of bioelectrical impedance for Koreans. METHODS: Bioelectrical impedance measurements were collected from apparently healthy subjects screened according to a comprehensive physical examination and medical history performed by trained physicians. Reference vector contours were plotted on the RXc graph using the probability density function of the bivariate normal distribution. We further compared them with those of other ethnic groups. RESULTS: A total of 242 healthy subjects aged 22 to 83 were recruited (137 men and 105 women) between December 2015 and November 2016. The centers of the tolerance ellipses were 306.3 Ω/m and 34.9 Ω/m for men and 425.6 Ω/m and 39.7 Ω/m for women. The ellipses were wider for women than for men. The confidence ellipses for Koreans were located between those for Americans and Spaniards without overlap for both genders. CONCLUSION: This study presented gender-specific normal reference BIVA plots and corresponding tolerance and confidence ellipses on the RXc graph, which is important for the interpretation of BIA-reported volume status in patients with congestive heart failure or renal insufficiency. There were noticeable differences in reference ellipses with regard to gender and ethnic groups.

Safety and Efficacy of an Aortic Arch Stent Graft with Window-Shaped Fenestration for Supra-Aortic Arch Vessels: an Experimental Study in Swine

BACKGROUND AND OBJECTIVES: Thoracic endovascular aortic repair exhibits limitations in cases where the aortic pathology involves the aortic arch. We had already developed a fenestrated aortic stent graft (FASG) with a preloaded catheter for aortic pathology involving the aortic arch. FASG was suitable for elective cases. MATERIALS AND METHODS: An aortic arch stent graft with a window-shaped fenestration (FASG-W) for supra-aortic arch vessels is suitable for emergent cases. This study aims to test a FASG-W for supra-aortic arch vessels and to perform a preclinical study in swine to evaluate the safety and efficacy of this device. Six FASG-Ws with 1 preloaded catheter were advanced through the iliac artery in 6 swine. The presence of endoleak and the patency and deformity of the grafts were examined with computed tomography (CT) at 4 weeks postoperatively. A postmortem examination was performed at 8 weeks. The mean procedure time for FASG-W was 27.15±4.02 minutes. The mean time for the selection of the right carotid artery was 5.72±0.72 minutes. RESULTS: Major adverse events were not observed in any of the 6 pigs who survived for 8 weeks. For the FASG-W, no endoleaks, no disconnection, and no occlusion of the stent grafts were observed in the CT findings or the postmortem gross findings. CONCLUSION: The procedure with the FASG-W was able to be performed safely in a relatively short procedure time and involved an easy technique. The FASG-W was found to be safe and convenient for use in this preclinical study of swine.

The predictive value of echocardiography for chronic thromboembolic pulmonary hypertension after acute pulmonary embolism in Korea

BACKGROUND/AIMS: Chronic thromboembolic pulmonary hypertension (CTEPH) is a life-threatening complication after acute pulmonary embolism (APE) and is associated with substantial morbidity and mortality. This study aimed to investigate the incidence of CTEPH after APE in Korea and to determine echocardiographic predictors of CTEPH. METHODS: Among 381 patients with APE confirmed by chest computed tomography (CT) between January 2007 and July 2013, 246 consecutive patients with available echocardiographic data were enrolled in this study. CTEPH was defined as a persistent right ventricular systolic pressure (RVSP) greater than 35 mmHg on echocardiography during follow-up and persistent pulmonary embolism on the follow-up CT. RESULTS: Fifteen patients (6.1%) had CTEPH. The rate of right ventricular (RV) dilatation (66.7% vs. 28.1%, p = 0.002) and the RVSP (75.5 mmHg vs. 39.0 mmHg, p < 0.001) were significantly higher in the CTEPH group. D-dimers, RV dilatation, RV hypertrophy, RVSP, and intermediate-risk APE were associated with the risk of CTEPH after APE (odds ratio [OR] 0.59, 5.11, 7.82, 1.06, and 4.86, respectively) on univariate analysis. RVSP remained as a significant predictor of CTEPH on multivariate analysis (OR, 1.056; 95% confidence interval, 1.006 to 1.109; p = 0.029). CONCLUSIONS: This study showed that the incidence of CTEPH after APE in Korea was 6.1% and that initial RVSP by echocardiography was a strong prognostic factor for CTEPH.

Preoperative Enoxaparin versus Postoperative Enoxaparin Thromboprophylaxis in Hip Fracture Surgery: Is Preoperative Enoxaparin Safe to Use? / 대한정형외과학회잡지

PURPOSE: The purpose of this study was to evaluate the safety and efficacy of pre- and postoperative initiation of enoxaparin in treatment of hip fracture. MATERIALS AND METHODS: In this study, we enrolled 629 consecutive patients with hip fracture who Pusan National University Hospital between March 2009 and March 2014. Of these patients, 414 patients (65.8%) met the final inclusion criteria. Enoxaparin was administered subcutaneously at 40 mg once daily starting 48 hours after surgery in 156 patients (group A), and immediately after admission in 258 patients (group B). The incidence of symptomatic venous thromboembolism (VTE) and risk of bleeding during hospitalization period were compared between groups. RESULTS: The incidence of symptomatic VTE during the hospitalization period was 7.1% (11 patients) in group A and 5.4% (14 patients) in group B. No significant difference in the rate of symptomatic VTE was found between the groups (unadjusted odds ratio [OR], 0.756; 95% confidence interval [CI], 0.334–1.710; adjusted OR, 0.554; 95% CI, 0.212–1.449). The incidence of symptomatic deep-vein thrombosis and pulmonary embolism (including fatal and non-fatal) did not significantly differ between groups. However, fatal pulmonary thromboembolism developed in two cases in group A and one patient expired postoperatively due to pulmonary hemorrhage in group B. Major bleeding and all-cause death did not differ between groups. CONCLUSION: Preoperative starting chemical thromboprophylaxis may be considered in the elderly patients with hip fracture who have risk factors for venous thromboembolism.

Cardiac Tamponade and Pericarditis in Type B Intramural Hematoma: a Case Report / 대한내과학회지

We report the case of a patient with cardiac tamponade and pericarditis in type B intramural hematoma. A 75-year-old woman was admitted to the emergency department presenting with general weakness and dizziness for several hours and hemodynamic collapse. Thoracic echocardiography and computed tomography (CT) showed a large pericardial effusion and aortic intramural hematoma but no evidence of aortic dissection. Therefore, we concluded that the intramural hematoma did not involve the ascending aorta and thus immediately performed pericardiocentesis. Follow-up CT showed no pericardial effusion or specific changes in the range or depth of the intramural hematoma, and she was discharged continuing colchicines and ibuprofen therapy for acute pericarditis. Cardiac tamponade in type B intramural hematoma is extremely rare. Prompt diagnosis and initial treatment resulted in a substantial improvement in clinical status.

Effects of Intracoronary Administration of Autologous Adipose Tissue-Derived Stem Cells on Acute Myocardial Infarction in a Porcine Model

PURPOSE: Adipose-derived stem cells (ADSCs) are known to be potentially effective in regeneration of damaged tissue. We aimed to assess the effectiveness of intracoronary administration of ADSCs in reducing the infarction area and improving function after acute transmural myocardial infarction (MI) in a porcine model. MATERIALS AND METHODS: ADSCs were obtained from each pig's abdominal subcutaneous fat tissue by simple liposuction. After 3 passages of 14-days culture, 2 million ADSCs were injected into the coronary artery 30 min after acute transmural MI. At baseline and 4 weeks after the ADSC injection, 99mTc methoxyisobutylisonitrile-single photon emission computed tomography (MIBISPECT) was performed to evaluate the left ventricular volume, left ventricular ejection fraction (LVEF; %), and perfusion defects as well as the myocardial salvage (%) and salvage index. At 4 weeks, each pig was sacrificed, and the heart was extracted and dissected. Gross and microscopic analyses with specific immunohistochemistry staining were then performed. RESULTS: Analysis showed improvement in the perfusion defect, but not in the LVEF in the ADSC group (n=14), compared with the control group (n=14) (perfusion defect, -13.0+/-10.0 vs. -2.6+/-12.0, p=0.019; LVEF, -8.0+/-15.4 vs. -15.9+/-14.8, p=0.181). There was a tendency of reducing left ventricular volume in ADSC group. The ADSCs identified by stromal cell-derived factor-1 (SDF-1) staining were well co-localized by von Willebrand factor and Troponin T staining. CONCLUSION: Intracoronary injection of cultured ADSCs improved myocardial perfusion in this porcine acute transmural MI model.

A Coronary Intramural Hematoma Presenting with ST-Elevation Myocardial Infarction in an Elderly Man / 대한내과학회지

An intramural hematoma is a rare, challenging cause of myocardial infarction generally seen in middle-aged females with no atherosclerotic risk factors. Intravascular ultrasound is useful in diagnosing and managing intramural hematomas. Here, we present anintramural hematoma presenting with ST-elevation myocardial infarction without definite intimal dissection in an elderly man who was diagnosed using intravascular ultrasound and managed accordingly.

Hybrid Treatment of an Aortic Arch Aneurysm with an Aberrant Right Subclavian Artery / 대한내과학회지

Aberrant right subclavian artery (ARSA) is a rare congenital anomaly but is the most common of the congenital vascular anomalies of the aortic arch. We report the case of a 68-year-old female undergoing chemotherapy for multiple myeloma who had a large thoracic aortic aneurysm (7.4 cm) with ARSA. She was treated with a hybrid procedure that combined a left common carotid-to-subclavian artery bypass with a "thoracic endovascular aortic repair (TEVAR)" because of the risk associated with a thoracotomy. A stent graft was deployed in the proximal part of the descending aorta to cover the thoracic aortic aneurysm after a left common carotid-to-subclavian bypass was made to restore blood flow in the left arm. There was no endoleak on digital subtraction angiography. Hybrid therapy can be performed successfully for the treatment of thoracic aortic aneurysm with ARSA.

Effects of Low Dose Pioglitazone on Restenosis and Coronary Atherosclerosis in Diabetic Patients Undergoing Drug Eluting Stent Implantation

PURPOSE: Thiazolidinediones are insulin-sensitizing agents that reduce neointimal proliferation and the adverse clinical outcomes associated with percutaneous coronary intervention (PCI) in patients with diabetes mellitus (DM). There is little data on whether or not low dose pioglitazone reduces adverse clinical outcomes. MATERIALS AND METHODS: The study population included 121 DM patients with coronary artery disease and they were randomly assigned to 60 patients taking 15 mg of pioglitazone daily in addition to their diabetic medications and 61 patients with placebo after the index procedure with drug-eluting stents (DESs). The primary end points were rate of in-stent restenosis (ISR) and change in atheroma volume and in-stent neointimal volume. The secondary end points were all-cause death, myocardial infarction (MI), stent thrombosis and re-PCI. RESULTS: There were no statistical differences in the clinical outcomes and the rate of ISR between the two groups [all-cause death; n=0 (0%) in the pioglitazone group vs. n=1 (1.6%) in the control group, p=0.504, MI; n=2 (3.3%) vs. n=1 (1.6%), p=0.465, re-PCI; n=6 (10.0%) vs. n=6 (9.8%), p=0.652, ISR; n=4 (9.3%) vs. n=4 (7.5%), p=1.000, respectively]. There were no differences in changes in neointimal volume, percent neointimal volume, total plaque volume and percent plaque volume between the two groups on intravascular ultrasonography (IVUS) study. CONCLUSION: Our study demonstrated that low dose pioglitazone does not reduce rate of ISR, neointimal volume nor atheroma volume in DM patients who have undergone PCI with DESs, despite the limitations of the study.

The Modified Chimney Technique With a Thoracic Aortic Stent Graft to Preserve the Blood Flow of the Left Common Carotid Artery for Treating Descending Thoracic Aortic Aneurysm and Dissection

While thoracic endovascular aortic repair is an effective treatment option for descending thoracic aorta pathology, it does have limitations. The main limitation is related to the anatomical difficulties when disease involves the aortic arch. A fenestrated, branched aortic stent graft and hybrid operation has been introduced to overcome this limitation, but it is a custom-made device and is time consuming to manufacture. Furthermore, these devices cannot be used in an emergency setting. We report two patients with massive descending thoracic aortic aneurysm and ruptured aortic dissection very near the aortic arch who underwent a procedure which we named the modified chimney technique. The modified chimney technique can be used as a treatment option in such an emergency situation or as a rescue procedure when aortic pathology is involved near the supra-aortic vessels.

Successful Treatment of a Ruptured Aortic Arch Aneurysm Using a Hybrid Procedure

Aortic rupture has a high mortality rate and can be considered a medical emergency. The standard treatment for aortic rupture is surgical repair. An aortic stent graft for a ruptured descending aorta is considered an effective alternative treatment. However, an aortic stent graft is difficult when the aortic aneurysm is in the aortic arch due to supra-aortic vessels. We report on a patient with a ruptured aortic arch aneurysm treated with a hybrid procedure, which involved a carotid to carotid bypass operation and an aortic stent graft. A 71-year-old male patient visited our cardiovascular center suffering from hemoptysis. The chest CT and aortography showed a 9 cm sized aortic arch aneurysm 0.5 cm distal to the left subclavian artery and a hemothorax in the left lung. The patient refused to undergo a full open operation. We performed a carotid to carotid bypass in advance, and two pieces of aortic stent grafts were placed across the left carotid artery and left subclavian artery. The follow up CT showed the aortic stent grafts, no endoleaks and no thrombus in the aortic arch aneurysm. The patient was discharged from the hospital without complication.

Endovascular Management of Acute Total Occlusion of the Aorta

Acute total occlusion of the aorta is a rare and clinically critical condition requiring aggressive immediate diagnosis and treatment. A 73-year-old male was seen at our hospital complaining of pain sensation in both legs. Under the likely impression of an acute total occlusion of the aorta, emergency abdominal aortogram was done, which revealed total occlusion of the distal aorta and both iliac arteries. Intra-arterial thrombolysis with urokinase was attempted for 48 hours as intervention during the acute stage is highly related to distal thromboembolic events. Follow-up angiography showed improved arterial flow but residual stenosis at both the common iliac arteries. Self-expandable nitinol stents were inserted at both the iliac arteries by the v-kissing technique resulting in a satisfying outcome as seen on angiography without complications. The patient was discharged without additional medical problems. From our experience, we conclude that the use of intra-arterial thrombolysis with percutaneous transluminal angioplasty is an alternative to the conventional surgical approach in treating acute total occlusion of the aorta.

Multiple coronary artery-left ventricular fistulas in a patient with left ventricular hypertrophy / 대한내과학회지

Congenital coronary artery fistulas between a coronary artery and a cardiac chamber occur in 0.2% of diagnostic cardiac catheterizations and usually arise when the right coronary artery drains into a right heart structure, such as the right atrium, right ventricle, or pulmonary artery. Fistulas draining into the left ventricle are uncommon. We report a case of multiple coronary artery-left ventricular microfistulas with eccentric septal hypertrophy presented as squeezing chest pain and discomfort at rest. This was diagnosed by coronary angiography and transthoracic echocardiography.

Post-operative Bleeding due to Acquired Hemophilia Successfully Treated with Recombinant Factor VIIa: Case Report

Acquired hemophilia is a rare but potentially life-threatening hemorrhagic disorder caused by the development of autoantibodies against coagulation factor VIII. Concentrates of human factor VIII, desmopressin, activated prothrombin complex concentrates, recombinant activated factor VII can all be used to control episodes of acute bleeding. The recent availability of bypassing agents like recombinant activated factor VII has been shown to be clinically safe and effective as treatment for acute bleeding. In this case report, a 67 year-old male patient with Rh negative blood type developed gross hematuria and bleeding after transurethral resection due to prostatic hypertrophy. After vesicocutaneous fistular reduction operation, post-operative bleeding was presented. The acute bleeding was controlled successfully by the combined treatment with recombinant activated factor VII (Novo seven(R)) and prednisone.

Takayasu's Arteritis Involving the Ostia of Three Large Coronary Arteries

Takayasu's arteritis can involve the ostia of coronary arteries. We report a patient with Takayasu's arteritis involving the ostia of three large coronary arteries who was successfully treated by percutaneous coronary intervention (PCI) with a drug-eluting stent (DES) and had a good clinical outcome after 12 months. A 37-year-old male with unstable angina was admitted to our cardiovascular center. The patient had Takayasu's arteritis and an aortic valve replacement with a metallic valve due to severe aortic regurgitation 7 years previously. Coronary angiography (CAG) showed a 95% discrete eccentric luminal narrowing at the ostia of the large left anterior descending (LAD) and left circumflex (LCX) arteries, and a 99% discrete eccentric luminal narrowing at the ostium of the large right coronary artery (RCA). The patient was treated with prednisolone for 14 days. Two large paclitaxel-eluting stents (PES) were then implanted in the distal left main coronary artery using the kissing stent technique. After 6 months, a CAG did not reveal restenosis or recurrent coronary artery disease. Thus, PCI with a DES for patients with significant coronary involvement secondary to Takayasu's arteritis is an effective and an alternative treatment when coronary bypass grafting is not option.

A Case of a Pancreatic Abscess Complicating Endoscopic Sphincterotomy / 대한소화기내시경학회지

Endoscopic sphincterotomy (EST) has gained wide acceptance as a valuable tool for the management of disease of the pancreas and biliary tract. Complications associated with an EST include bleeding, perforation, pancreatitis and cholangitis, and the incidence of complications is approximately 5~10%. A pancreatic abscess can develop rarely after an EST and tends to have a more complicated course, resulting in higher morbidity and mortality. We report a case of a pancreatic abscess that complicated an EST in a 61-year-old woman with a primary common bile duct stone. The patient was successfully cured by treatment with the use of broad-spectrum antibiotics. Although a pancreatic abscess is one of the rare delayed complications that can develop after an EST, it should be considered in the differential diagnosis of patients with a complaint of abdominal pain after an EST because of a high mortality rate and the need for prompt management

A Granular Cell Tumor Located in the Gastric Cardia / 대한소화기내시경학회지

First described in 1926 by Abrikossoff, a granular cell tumor is a benign lesion and commonly involves the skin, connective tissue, and breast, but rarely the esophagus. The origin of granular cell tumors is controversial. The tumor is thought to arise from a Schwann cell origin, based on characteristics such as the positive expression of S-100 protein determined by immunohistochemical staining. A 29-year-old female was referred from the local clinic because of a polypoid lesion in the gastric cardia. After performing endoscopy and endoscopic ultrasonography, a 1.5 cm submucosal tumor covered with normal mucosa was found in the gastric cardia. Endoscopic mucosal resection revealed a tumor that initiated in the esophagus, and grew into the cardia. Immunohistochemical analysis revealed strong positive staining for S-100 protein, confirming the presence of a granular cell tumor.