Design of Korean Noninvasive Risk Evaluation Study for Sudden Cardiac Death from Infarction or Heart Failure: Myocardial infarction study of K-REDEFINE registry

BACKGROUND AND OBJECTIVES: Despite significant advances in the treatment of acute myocardial infarction (MI), the prevention of sudden cardiac death (SCD), the most common mode of death in patients with MI, remains challenging. Furthermore, previous Korean MI registries did not address the issue of post-MI SCD. Additional risk stratifiers of post-MI SCD are still required to compensate for the limitation of using left ventricular ejection fraction to predict lethal arrhythmic events. SUBJECTS AND METHODS: We designed the first Korean prospective nationwide multicenter registry primarily focused on SCD; the Korean noninvasive Risk Evaluation study for sudden cardiac DEath From INfarction or heart failurE (K-REDEFINE). The registry consists of 2 groups of patients presenting with (1) acute MI or (2) acute heart failure (HF) at 25 tertiary referral cardiovascular centers. The primary endpoint of the MI group study of K-REDEFINE registry is the incidence and risk factors of post-MI SCD. In particular, the association between the risk of SCD and non-invasive Holter-based electrocardiogram (ECG) variables will be evaluated, such as T-wave alternans (marker of repolarization heterogeneity) and heart rate turbulence/variability (a marker of autonomic function). Other secondary study outcomes include atrioventricular arrhythmias, HF-related admission, repeated myocardial ischemic events, stroke, and overall deaths. CONCLUSION AND PERSPECTIVE: The K-REDEFINE registry will provide new prospects for the better management of MI patients with high risk of SCD by clarifying the burden and predictors of SCD and the clinical utility of various non-invasive ambulatory ECG-based variables in risk stratification for SCD in this patient population.

Where We Can Find Bypass Tract in Ebstein's Anomaly?; a Case of Successful Ablation of Bypass Tract in Ebstein's Anomaly

In patients with Ebstein's anomaly, the localization of accessory pathways may be impeded by abnormal local electrograms recorded along the atrialized right ventricle and by the presence of multiple accessory pathways. We report a case of 50-year-old man diagnosed with Ebstein's anomaly with Wolff-Parkinson-White syndrome who presented with recurrent palpitations. He was referred to our institution for radiofrequency catheter ablation of paroxysmal supraventricular tachycardia. Transthoracic echocardiography revealed the tricuspid valve displaced into the right ventricle, consistent with Ebstein's anomaly. The electrophysiology study showed a right posterolateral accessory pathway. The optimal ablation site was located not in the atrioventricular line of the atrialized ventricular portion, but in the original atrioventricular line.

Flecainide-Induced Torsade de Pointes Successfully Treated with Intensive Pharmacological Therapy

Flecainide acetate is a potent class IC anti-arrhythmic drug with a major sodium channel blocking effect. Flecainide toxicity can cause myocardial impairment and precipitate circulatory collapse. It may also result in life-threatening arrhythmia, although cases of flecainide-induced torsades de pointes are rare. Furthermore, the electrical and hemodynamic deteriorations observed during flecainide toxicity may not respond to conventional treatments. In the present study, we report the case of a 20-year-old Korean man with flecainide poisoning, who presented with hypotension. The patient was successfully treated with sodium bicarbonate, amiodarone, MgSO₄, and lidocaine, with no recourse to extracorporeal therapy. Although there is no standard therapy for flecainide toxicity, this report demonstrates that intensive pharmacological treatment is beneficial in cases of flecainide overdose.

Design of Korean Noninvasive Risk Evaluation Study for Sudden Cardiac Death from Infarction or Heart Failure: Heart failure study of K-REDEFINE registry

BACKGROUND AND OBJECTIVES: Sudden cardiac death (SCD) is one of the most common causes of death in patients with heart failure (HF). However, there are no available data on SCD in previous Korean HF registries. Additionally, although widely used, the utility of left ventricular (LV) ejection fraction (EF) in risk stratification for SCD is limited. SUBJECTS AND METHODS: The Korean non-invasive Risk Evaluation study for sudden cardiac DEath From INfarction or heart failurE (KREDEFINE) is the first Korean prospective, nationwide multicenter registry, primarily focused on SCD. The registry consists of 2 groups of patients presenting with (1) acute HF or (2) acute myocardial infarction (MI) at 25 tertiary referral cardiovascular centers. Using the HF-group data of the K-REDEFINE registry, the incidence and risk factors of SCD in patients with HF will be assessed. In particular, the efficacy of Holter-based ECG variables, such as T-wave alternans (marker of repolarization heterogeneity) and heart rate turbulence/ variability (maker of autonomic function), in risk stratification for SCD will be evaluated. Other cardiovascular outcomes will also be analyzed, including atrioventricular arrhythmias, HF-related admission, stroke, and overall deaths. CONCLUSION AND PERSPECTIVE: The K-REDEFINE registry will pave the way for better management of patients with HF at high risk of SCD by elucidating the burden and risk factors of SCD and the clinical utility of various non-invasive ambulatory ECG-based parameters in risk stratification for SCD in this patient population.

Additive Beneficial Effects of Valsartan Combined with Rosuvastatin in the Treatment of Hypercholesterolemic Hypertensive Patients

BACKGROUND AND OBJECTIVES: We compared the efficacy and safety of valsartan and rosuvastatin combination therapy with each treatment alone in hypercholesterolemic hypertensive patients. SUBJECTS AND METHODS: Patients who met inclusion criteria were randomized to receive 1 of the following 2-month drug regimens: valsartan 160 mg plus rosuvastatin 20 mg, valsartan 160 mg plus placebo, or rosuvastatin 20 mg plus placebo. The primary efficacy variables were change in sitting diastolic blood pressure (sitDBP) and sitting systolic blood pressure (sitSBP), and percentage change in low-density lipoprotein-cholesterol (LDL-C) in the combination, valsartan, and rosuvastatin groups. Adverse events (AEs) during the study were analyzed. RESULTS: A total of 354 patients were screened and 123 of them were finally randomized. Changes of sitDBP by least squares mean (LSM) were -11.1, -7.2, and -3.6 mm Hg, respectively, and was greater in the combination, as compared to both valsartan (p=0.02) and rosuvastatin (p<0.001). Changes of sitSBP by LSM were -13.2, -10.8, and -4.9 mm Hg, and was greater in the combination, as compared to rosuvastatin (p=0.006) and not valsartan (p=0.42). Percentage changes of LDL-C by LSM were -52, -4, and -47% in each group, and was greater in the combination, as compared to valsartan (p<0.001), similar to rosuvastatin (p=0.16). Most AEs were mild and resolved by the end of the study. CONCLUSION: Combination treatment with valsartan and rosuvastatin exhibited an additive blood pressure-lowering effect with acceptable tolerability, as compared to valsartan monotherapy. Its lipid lowering effect was similar to rosuvatatin monotherapy.

Erratum to: Additive Beneficial Effects of Valsartan Combined with Rosuvastatin in the Treatment of Hypercholesterolemic Hypertensive Patients

In this article, on page 230, Fig. 2A needs to be corrected.

Successful Ablation of Resistant Left Lateral Accessory Pathway and Coexisting Atypical Atrioventricular Nodal Reentrant Tachycardia

A 41-year-old male was presented with drug-resistant supraventricular tachycardia. Electrophysiological study confirmed that the supraventricular tachycardia was caused by dual atrioventricular nodal pathways and a left lateral accessory pathway (AP). The left lateral AP was resistant to traditional endocardial ablation, but was successfully eliminated by radiofrequency ablation via the intracoronary sinus approach.

Late-Onset Postpneumonectomy Empyema Presenting as Right-Sided Heart Failure: Extrinsic Right Atrial Compression

Although it is rare, the right atrium can be encroached on by abnormal mediastinal structures, including aortic aneurysms, carcinomas, hepatic cysts and diaphragmatic paralysis. Extrinsic compression of the right atrium causes significant hemodynamic compromise and can lead to fatal outcomes. We describe the case of a 66-year old man with a past history of pulmonary tuberculosis that had undergone right pneumonectomy 40 years previously. He then presented with signs and symptoms of right-sided heart failure. These new signs and symptoms were recognized to be secondary to extrinsic compression of the right atrium, which was due to late-onset postpneumonectomy empyema, and the signs and symptoms were successfully relieved by performing open drainage of the empyema.

A Rare Case of Aortic Valve Myxoma: Easy to Confuse With Papillary Fibroelastoma

Myxoma of the aortic valve is an exceedingly uncommon condition. In this article, we report the case of a 72-year-old man with myxoma arising from the aortic valve. We extirpated the mass and repaired the aortic valve with the patient under cardiopulmonary bypass. The postoperative course was uneventful. Histological examination confirmed that the mass was a myxoma.

Familial Occurrence of Atrioventricular Nodal Reentrant Tachycardia in a Mother and Her Son

Atrioventricular nodal reentrant tachycardia (AVNRT), caused by a reentry circuit involving fast and slow atrioventricular nodal pathways, is one of the most common types of paroxysmal supraventricular tachycardias. While familial Wolff-Parkinson-White syndrome has been well recognized, familial AVNRT has been rarely reported. We report a familial occurrence of AVNRT in a mother and her son, who were symptomatic and successfully treated with radiofrequency catheter ablation of slow pathway.

Development of a Coronary Aneurysm at a Sirolimus-Eluting Stent-Implanted Lesion in a Patient With Churg-Strauss Syndrome

A coronary aneurysm (CA) can occur in sirolimus-eluting stent (SES)-implanted coronary lesions. Although several possible mechanisms have been suggested, the precise pathogenesis of a CA in SES-implanted lesions is still unknown. We report a patient with Churg-Strauss syndrome who underwent successful percutaneous coronary intervention with SES and then experienced a CA in an SES-implanted coronary lesion. We describe the CA characteristics through the use of coronary angiography, coronary 64-multidetector computed tomography, and intravascular ultrasound and discuss the etiological factors for the CA in this patient.

Stenting of the Left Main Coronary Artery in a Patient With Takayasu's Arteritis

Management of Takayasu's arteritis of the left main coronary artery (LMCA) is difficult because of the possibility of restenosis. Clinically significant stenotic lesions must be considered anatomical correlation. Many studies have reported that the management of stenotic lesions of the LMCA with endoluminal stenting and balloon angioplasty and de-novo stenting is safe and effective for patients with Takayasu's arteritis. We report the case of a patient with Takayasu's arteritis of the LMCA. The patient had undergone two consecutive percutaneous coronary interventions because of recurrent restenosis of in-stent lesions, and eventually underwent coronary artery bypass graft (CABG) surgery for myocardial infarction in the same lesion. We suggested treatment with CABG because the pathophysiology of Takayasu's arteritis is different from that of atherosclerotic stenosis.

The Management of Cardiovascular Abnormalities in Patient With LEOPARD Syndrome

LEOPARD syndrome (LS) is a rare hereditary disorder in Asian countries. This syndrome consists of multiple systemic abnormalities. In particular, characteristic cardiovascular effects in LS may include variable clinical manifestations from benign to life-threatening courses. The cardiac effects of this syndrome consist of left ventricular hypertrophy (LVH), pulmonary stenosis (PS), coronary artery dilatation and electrocardiogram(ECG) abnormalities. Since there are few LS patients who have undergone a complete cardiovascular evaluation, the nature and clinical prognosis of cardiovascular abnormalities in this syndrome remain uncertain. Also, there have been few reports on therapeutic strategies for cardiovascular abnormalities in LS. Here we describe a case of LS who presented with multiple cardiovascular problems and underwent successful surgical and medical treatment.

The Pulmonary Embolism Severity Index in Predicting the Prognosis of Patients With Pulmonary Embolism

BACKGROUND/AIMS: Many prognostic models have been developed to help physicians make medical decisions on treating patients with pulmonary embolism. Among these models, the Pulmonary Embolism Severity Index (PESI) has been shown to be a successful risk stratification tool for patients with acute pulmonary embolism. The PESI, however, had not been applied to patients with pulmonary embolism in Korea. METHODS: The patients included in this study were diagnosed by computed tomography at Inje University's Ilsan Paik Hospital between December 1999 and March 2007. Risk stratification for the patients was performed using the PESI. The mortality rate was calculated according to each PESI risk class. RESULTS: Of the 90 patients enrolled in this study, ten were assigned to PESI class I, 29 to PESI class II, 22 to PESI class III, eight to PESI class IV, and ten to PESI class V. The mortality rate after 30 days in each class was 0, 10.3, 9.1, 0, and 50% (p=0.0016), respectively, whereas the respective hospital mortality rate was 4.8, 13.8, 13.6, 12.5, and 50% (p=0.0065). The overall mortality was 9.5, 27.6, 31.8, 50.0, and 60%, respectively (p=0.0019). The mortality rate was significantly associated with the PESI class. CONCLUSIONS: The PESI class was found to be significantly correlated with the 30-day mortality rate, hospital mortality, and overall mortality. Our data indicate that the PESI can be used to predict the prognosis of patients with pulmonary embolism and in making medical decisions regarding the treatment of patients with pulmonary embolism.

Preoperative and Postoperative Evaluation of Multiple Giant Coronary Aneurysms by the Use of Coronary CT Angiography with 64-MDCT: A Case of Multiple Giant Coronary Aneurysms Treated with Aneurysmectomy and Coronary Artery Bypass Surgery

A coronary artery aneurysm is an uncommon disorder and is seen as a characteristic dilatation of a localized portion of the coronary artery. Clinical manifestation of a coronary artery aneurysm varies from an asymptomatic presentation to sudden death of a patient. Although coronary aneurysms are typically diagnosed by the use of coronary angiography, a new generation of coronary 64-slice multidetector computed tomography (64-MDCT) scanners have successfully been used for evaluating this abnormality in a noninvasive manner. In the present case, we performed coronary 64-MDCT scanning preoperatively and postoperatively on a patient with multiple giant coronary aneurysms. The use of coronary 64-MDCT may provide an evaluation technique not only for diagnosis but also for follow-up after surgery for this condition.

A case of metastatic mycotic pseudoaneurysms that developed after aortic surgery / 대한내과학회지

Multiple mycotic pseudoaneurysms that develop after aortic surgery are a rare infectious complication. The clinical course of this disease is severe and associated with a high mortality. Few published cases have described mycotic pseudoaneurysms that are localized mainly in the brain, heart, and aorta. In this case, a 33-year-old woman was admitted with abdominal pain and mild fever after graft surgery for a ruptured thoracic aorta that occurred following a vehicle accident. Thoracoabdominal computed tomography (CT), angiography, and transesophageal echocardiography (TEE) demonstrated multiple pseudoaneurysms and thromboembolic obstructions in the thoracic aorta and its branches. She was treated with anticoagulation, coil embolization, and surgical resection. Microscopically, a resected pseudoaneurysm showed the characteristic features of fungal colonies with thrombi. This patient has been well for 2 months after removing the pseudoaneurysms and treatment with systemic antifungal agents.

Diagnostic accuracy of 64-slice multidetector CT coronary angiography for the evaluation of coronary artery disease / 대한내과학회지

BACKGROUND/AIMS: Invasive coronary angiography remains the gold standard in the diagnosis of coronary artery disease. However, multidetector CT (MDCT) coronary angiography is an emerging technique that is available for the non-invasive detection of coronary artery stenoses. While the diagnostic accuracy of first generation MDCT is limited, recently released 64-slice MDCT has yielded promising results due to increased temporal and spatial resolution. The objective of this study was to investigate the diagnostic accuracy of non-invasive 64-slice MDCT for coronary artery disease. METHODS: One hundred one patients (63 males and 38 females; mean age, 63.7+/-10.5 years) undergoing conventional coronary angiography were included in this study. All coronary arteries, including the distal segments and side branches, were analyzed for the presence of significant stenosis (> or =50% diameter stenosis) and compared with of the quantitative coronary angiographic findings. RESULTS: Of the 1,440 coronary artery segments studied, 1,348 segments were assessed quantitatively by both MDCT and conventional coronary angiography (94%). Two hundred nine significant stenoses were detected by conventional coronary angiography. On a segment-based analysis, the senisitivity, specificity, and positive and negative predictive values of 64-slice MDCT were 96, 97, 85, and 99%, respectively. On a vessel-based analysis, the sensitivity, specificity, and positive and negative predictive values of 64-slice MDCT were 96, 97, 85, and 99%, respectively. The corresponding values obtained on a patient-based analysis were 100, 94, 97, and 100%, respectively. Coronary calcification was the major cause of false-positive findings. CONCLUSIONS: This study demonstrated that 64-slice MDCT coronary angiography is of similar accuracy as conventional coronary angiography for the detection of coronary artery disease. In selected groups of patients, 64-slice MDCT may replace the more invasive coronary angiography.

Three Cases of Arterial Occlusion That Occurred After the Use of Angioseal(R)

Femoral arterial closure devices are now commonly used after both diagnostic and therapeutic coronary procedures. They have been shown to reduce the time to ambulation and to decrease the length of the hospital stay. Angioseal is a commercially available femoral artery closure device that has been approved by the Food and Drug Administration (FDA). The device sandwiches an intra-arterial absorbable anchor on the luminal side of the vessel and a thrombin plug on the surface of the vessel with using a self-cinching stitch. We report here on three patients who presented with acute and delayed arterial occlusive complications that were found to be due to an Angioseal anchor that was not appropriately reabsorbed.

Two Cases of Successful Primary Percutaneous Coronary Intervention in Patients With an Anomalous Right Coronary Artery Arising From the Left Coronary Cusp

An anomalous origin of the right coronary artery (RCA) from the left coronary cusp is a rare congenital anomaly. Because of the unusual location and the noncircular luminal orifice of this anomaly, cannulation of this artery during coronary angiography and percutaneous coronary intervention (PCI) poses significant technical difficulties when using the currently available guiding catheters. Primary PCI should be performed as quickly as possible when a patient displays this condition. When we face the situation of an anomalous artery during primary PCI, it takes a much longer time to open the occluded artery. We report here on two cases of successful primary PCI with using manually manipulated catheters and Ikari type guiding catheters in 2 patients who both had an anomalous RCA arising from the left coronary cusp.

A Case of Abciximab Induced Acute Profound Thrombocytopenia Resulting in Compartment Syndrome of the Forearm from Massive Bleeding at the Brachial Artery Access Site

Abciximab is one of the glycoprotein IIb/IIIa receptor inhibitors, and it is known to be effective for preventing and treating the thrombotic complications of percutaneous coronary intervention (PCI). On the other hand, there is an increasing risk of hemorrhagic complications when using abciximab, especially in the case of abciximab-induced thrombocytopenia. Acute profound thrombocytopenia is a rare, but life threatening adverse reaction to abciximab, and it can even occur within a few hours of the first exposure. We report here on a case of 56 year-old woman who experienced massive bleeding of her brachial artery access site. This was caused by abciximab-induced acute profound thrombocytopenia after performing PCI concomitant with using abciximab.