Spontaneous Closure of Iatrogenic Coronary Artery Fistula to Left Ventricle After Septal Myectomy for Hypertrophic Obstructive Cardiomyopathy

Cases of iatrogenic coronary artery fistulas draining into the left ventricle after surgical myectomy for hypertrophic obstructive cardiomyopathy have been published as sporadic reports. However, its management scheme and prognosis are not clear because of the low incidence. A 46-yr-old woman was hospitalized for evaluation of chest pain and shortness of breath for 3 months. Transthoracic echocardiographic examination showed typical hypertrophic obstructive cardiomyopathy with a peak pressure gradient of 71 mmHg across the left ventricular outflow tract. The patient underwent surgical septal myectomy. Postoperative color Doppler imaging revealed a diastolic blood flow from the interventricular septal myocardium to the left ventricular cavity, i.e. iatrogenic coronary artery fistula to the left ventricle. Ten days later, the fistula closed spontaneously which was diagnosed by transthoracic echocardiography and confirmed by coronary angiography.

Clinical Outcome of Cardiac Surgery in Octogenarians

The purpose of this study was to investigate the operative results and the clinical outcomes for octogenarians who underwent cardiac surgery. Twenty consecutive octogenarians who had cardiac operations at Samsung Medical Center from October 1994 through December 2004 were included in the study. The medical records were retrospectively reviewed and the follow-up results were obtained by the interview. The patients were 15 men and 5 women, and their mean age was 83.1 yr (range: 80-89 yr). The surgical priority was urgent for 5 patients and it was elective for 15 patients. Coronary artery bypass grafting (CABG) was performed in 14 patients, valve surgery was performed in 4 patients and CABG plus valve surgery was performed in 2 patients. There was one hospital death on day one after urgent CABG in an 80-yr-old man who had left main coronary artery occlusion. There were three deaths during the follow-up. Sudden death occurred in one patient at 2 months after valve surgery, and there were two non-cardiac deaths at 12 and 14 months, respectively, after CABG. Non-fatal postoperative complications occurred in 2 of 5 urgent patients and in 3 of 15 electives. The survival rate for the 19 hospital survivors at 24 months after surgery was 80% and the mean follow-up period was 22.5 months (range: 1-58 months). In conclusion, cardiac surgery could be performed within acceptable limits of the risk and its long-term results could be expected to be favorable for the octogenarians.

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.

A Case of Traumatic Acute Pericarditis Mimicking Acute Myocardial Infarction, Caused by Swallowing Fishhook

A patient, with severe chest pain and isolated ST segment elevation, was evaluated in order to differentiate ischemic heart disease, such as acute myocardial infarction. A fishhook was incidentally found during coronary angiography, chest CT and esophagoscopy. With this information, the patient was re-interviewed, and it was learned that the patient had swallowed the fishhook from cooked fish after fishing trip. The patient was diagnosed as traumatic acute pericarditis with acute mediastinitis, associated with esophageal and pericardial perforation. The patient was successfully treated by surgical treatment drainage and adequate antibiotic use. We report a case of traumatic acute pericarditis, which mimicked an acute myocardial infarction, with a review of the literature.

Echocardiographic Findings and Clinical Manifestations of Hypertrophic Cardiomyopathy: Including 3 Cases of Anomalous Insertion of Papillary Muscle

OBJECTIVES: Hypertrophic cardiomyopathy (HCM) has been of great interest to clinicians because of its diverse clinical, morphologic, pathophysiologic and molecular genetic manifestations. We investigated the frequencies and clinical manifestations according to the types in Maron's classification of HCM. METHODS: Patients with HCM who were seen at our institution from June 1999 to July 2001 were retrospectively reviewed. Echocardiographic patterns were classified by Maron's classification. RESULTS: Of 62 patients (M/F=39/23, 56+/-14.8 years), 6 patients (9.7%) were type I (relatively mild left ventricular hypertrophy confined to the anterior portion of ventricular septum), 10 patients (16.1%) were type II (hypertrophy of the anterior and posterior septum in the absence of free-wall thickening), 25 patients (40.3%) were type III (diffuse hypertrophy of substantial portion of both the ventricular septum and anterolateral free wall), 1 patients (1.6%) were type IV (hypertrophy in the posterior septum or anterolateral free wall) and 20 patients (32.3%) were type V (apical hypertrophy). Compared with western countries in which the type III was most common, type III was also most common in Korea, but type V was more common in Korea. Systolic anterior motion of mitral leaflet (SAM) were noted in 12 patients in which 10 patients had type III. 43 of 62 patients (69.4%) had chest pain (33.9%), dyspnea on exertion (30.6%), palpitation (1.6%) and syncope (3.2%). 19 of 62 patients (30.6%) had no subjective symptoms, and there was no significant statistical difference between types. Three of 62 patients had anomalous insertion of papillary muscle at mitral valve. SUMMARY: The most common type was type III, and SAM was found mostly in type III. Anomalous insertion of papillary muscle was noted in 3 out of 62 cases. There was no differences in subjective symptom between the types.

A Case of Acute Myocardial Infarction Associated with Spontaneous Coronary Artery Dissection

A spontaneous coronary artery dissection is a rare cause of acute myocardial ischemia. However, its precise etiology, pathogenesis, prevalence and treatment is unclear. The clinical presentation of a spontaneous coronary artery dissection can be sudden death or an acute coronary syndrome and sometimes no symptoms are present. We report a case of a 39-year-old man with a spontaneous coronary artery dissection in the right coronary artery. He presented with a history of chest pain persisting for 4 hours. The initial electrocardiogram showed a ST segment elevation in lead II III and aVF. He received intravenous urokinase, but no improvement in his symptoms was observed and the electrocardiographic changes did not resolve. A rescue coronary angiogram was performed, which demonstrated an area of dissection in the distal right coronary artery with resultant TIMI II flow. A 3.5x36 mm MAC stent was deployed across the lesion. After implanting the stent, the remainder of his stay was uncomplicated and he has remained asymptomatic at the time of this review.

Clinical Characteristics of the Patients with Myocardial Rupture after Acute Myocardial Infarction

BACKGROUND AND OBJECTIVES: Myocardial ruptures, including: ventricular free wall rupture (VFWR) and ventricular septal rupture (VSR), after acute myocardial infarction (AMI), are fatal complications. Recently, ubiquitous use of echocardiographs, and other imaging techniques, allows us to diagnose these complications in the antemortem period. Thus, this study retrospectively evaluated the clinical characteristics of patients with myocardial ruptures following AMI. SUBJECTS AND METHODS: 620 patients that had had AMIs, between January 1999 and June 2001, were analysed for the purpose of this study. Myocardial ruptures were diagnosed from their clinical symptoms, echocardiographs, and pericardiocenteses or cardiac catheterizations. The clinical characteristics of the patients with myocardial ruptures (n=15) were compared to those patients with myocardial infarction, without rupture (n=397), from their Q waves. RESULTS: The patients with myocardial ruptures were older than those without (67+/-9.7 years vs 60+/-11.7 years, p<0.05), and ruptures were more frequent in women (66.7% vs 25.2%, p<0.001). The frequency of systemic hypertension, DM, and the distribution of infarction sites were similar in both groups. Also, clinical characteristics between patients with VFWR, and those with VSR, were similar. Of the patients with VFWR (n=8), 7 suddenly died, and 1 was alive directly following surgery. Of the patients with VSR (n=7), 4 died. CONCLUSION: Myocardial rupture is a fatal complication of AMI, which is more frequent in women, and the patients with ruptures, in our study, were older than those without.

Clinical and Echocardiographic Findings in Patients who Underwent Mitral Valve repair Surgery

No abstract available.