Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation

No abstract available.

Impact of Framingham Risk Score, Flow-Mediated Dilation, Pulse Wave Velocity, and Biomarkers for Cardiovascular Events in Stable Angina

Although the age-adjusted Framingham risk score (AFRS), flow-mediated dilation (FMD), brachial-ankle pulse wave velocity (baPWV), high-sensitivity C-reactive protein (hsCRP), fibrinogen, homocysteine, and free fatty acid (FFA) can predict future cardiovascular events (CVEs), a comparison of these risk assessments for patients with stable angina has not been reported. We enrolled 203 patients with stable angina who had been scheduled for coronary angiography (CAG). After CAG, 134 patients showed significant coronary artery disease. During 4.2 yr follow-up, 36 patients (18%) showed CVEs, including myocardial infarction, de-novo coronary artery revascularization, in-stent restenosis, stroke, and cardiovascular death. ROC analysis showed that AFRS, FMD, baPWV, and hsCRP could predict CVEs (with AUC values of 0.752, 0.707, 0.659, and 0.702, respectively, all P<0.001 except baPWV P=0.003). A Cox proportional hazard analysis showed that AFRS and FMD were independent predictors of CVEs (HR, 2.945; 95% CI, 1.572-5.522; P=0.001 and HR, 0.914; 95% CI, 0.826-0.989; P=0.008, respectively). However, there was no difference in predictive power between combining AFRS plus FMD and AFRS alone (AUC 0.752 vs. 0.763; z=1.358, P=0.175). In patients with stable angina, AFRS and FMD are independent predictors of CVEs. However, there is no additive value of FMD on the AFRS in predicting CVEs.

Evaluation of Short-Term Use of N-Acetylcysteine as a Strategy for Prevention of Anthracycline-Induced Cardiomyopathy: EPOCH Trial - A Prospective Randomized Study

BACKGROUND AND OBJECTIVES: We investigate to determine whether N-acetylcysteine (NAC) can prevent anthracycline-induced cardiotoxicity. SUBJECTS AND METHODS: A total of 103 patients were enrolled in this prospective randomized open label controlled trial. They are patients first diagnosed with breast cancer or lymphoma, who require chemotherapy, including anthracycline like adriamycine or epirubicine. Patients were randomized to the NAC group {n=50; 1200 mg orally every 8 hours starting before and ending after the intravenous infusion of anthracycline in all chemotherapy cycles (3-6)} or the control group (n=53). Primary outcome was the decrease in left ventricular ejection fraction (LVEF) absolutely > or =10% from the baseline and concomitantly <50% at 6-month. Composite of all-cause death, heart failure and readmission were compared. RESULTS: The primary outcome was not significantly different in the NAC and control groups {3/47 (6.4%) vs. 1/52 (1.9%), p=0.343}. The mean LVEF significantly decreased in both the NAC (from 64.5 to 60.8%, p=0.001) and control groups (from 64.1 to 61.3%, p<0.001) after the completion of whole chemotherapy. The mean LVEF change did not differ between the two groups (-3.64% in NAC vs. -2.78% in control group, p=0.502). Left ventricular (LV) end systolic dimension increased with higher trend in NAC by 3.08+/-4.56 mm as compared with 1.47+/-1.83 mm in the control group (p=0.064). LV end diastolic dimension did not change in each group and change does not differ in both. Peak E, A and E/A ratio change and cardiac enzymes were comparable in two groups. Cumulative 12-month event rate was 6% and 3.8% in the NAC group and the control group, respectively, with no difference (p=0.672). CONCLUSION: We cannot prove that NAC prevents anthracycline-induced cardiomyopathy.

Myopericarditis in a Korean Young Male With Systemic Lupus Erythematosus

Myocardial involvement with clinical symptoms is a rare manifestation of systemic lupus erythematosus (SLE), despite the relatively high prevalence of myocarditis at autopsies of SLE patients. In this review, we report the case of a 19-year-old male SLE patient who initially presented with myopericarditis and was successfully treated with high dose of glucocorticoids.

Use of Nafamostat Mesilate as an Anticoagulant during Extracorporeal Membrane Oxygenation

Although the incidence of bleeding complications during extracorporeal membrane oxygenator (ECMO) support has decreased in various trials, bleeding is still the most fatal complication. We investigated the ideal dosage and efficacy of nafamostat mesilate for use with ECMO in patients with acute cardiac or respiratory failure. We assessed 73 consecutive patients who received ECMO due to acute cardiac or respiratory failure between January 2006 and December 2009. To evaluate the efficacy of nafamostat mesilate, we divided the patients into 2 groups according to the anticoagulants used during ECMO support. All patients of nafamostat mesilate group were male with a mean age of 49.2 yr. Six, 3, 5, and 3 patients were diagnosed with acute myocardial infarction, cardiac arrest, septic shock, and acute respiratory distress syndrome, respectively. The mean dosage of nafamostat mesilate was 0.64 mg/kg/hr, and the mean duration of ECMO was 270.7 hr. The daily volume of transfused packed red blood cells, fresh frozen plasma, and cryoprecipitate and the number of complications related to hemorrhage and thrombosis was lower in the nafamostat mesilate group than in the heparin group. Nafamostat mesilate should be considered as an alternative anticoagulant to heparin to reduce bleeding complications during ECMO.

Austrian Syndrome with a Delayed Onset of Heart Failure

A 59-year-old man treated with pneumococcal meningitis 4 months ago was hospitalized for acute heart failure and performed aortic valve replacement by rupture of aortic valve. The frequent association of pneumococcal meningitis and endocarditis is known as Austrian syndrome. Though Austrian syndrome is a clinically rare disease, the evolution of pneumococcal endocarditis is very aggressive and associated with high mortality, and early recognition for evidence of endocardial lesion in patients with pneumococcal meningitis is important to reduce the complications and mortality rate.

Paraesophageal Hernia with Small Bowel Strangulation

Paraesophageal hernias are usually classified into three distinct types: type I, sliding hernias; type II, paraesophageal hernias; type III, a combination of type I and II. Herniation of other abdominal organs can be classified as type IV, and is a rare situation at the esophageal hiatus. We report herein a 73-year-old female patient who presented with epigastric pain and diagnosed as type IV paraesophageal hernia. Initial evaluation was focused on myocardial ischemia. There was no evidence of myocardial ischemia in the coronary angiography, but follow-up chest X-ray revealed air-fluid levels in the left mediastinum suggested hiatal hernia. On computed tomography, herniation and strangulation of proximal jejunum into the hemithorax via left diaphragmatic defect was found. After reduction of small bowel and resection of strangulated segment, the defect was closed. Fluid collection in the hernia sac was detected at postoperative day nine, but she was discharged without complication.

Acute Respiratory Failure Treated with Veno-venous Extracorporeal Membrane Oxygenation / 결핵및호흡기질환

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) during severe acute respiratory failure helps to recover the pulmonary function. This study evaluated our experience with veno-venous ECMO in adult patients with acute respiratory failure. METHODS: From January 2007 to July 2009, ECMO was used on 54 patients. Of these 54 patients, 7 were placed on veno-venous ECMO for acute respiratory failure. The indications of ECMO were based on the lung dysfunction measured as a PaO2/FiO2 ratio <100 mm Hg on FiO2 of 1.0, or an arterial blood gas pH <7.25 due to hypercapnia despite the optimal treatment. EBS(R), Bio-pump(R), and Centrifugal Rotaflow pump(R) were used and all cannulations were performed percutaneously via both femoral veins. When the lung function was improved, an attempt was made to wean on ECMO at moderate ventilator settings followed by decannulation. RESULTS: Five of the 7 patients were male and the mean age was 46.3+/-18.3. The causes of acute respiratory failure were 3 cases of pneumonia, 2 near-drownings, 1 pulmonary hemorrhage due to acute hepatic failure and 1 mercury vapor poisoning. The mean support time of ECMO was 17.3+/-13.7 days. Of the 7 patients implanted with ECMO, 5 patients (71%) were weaned off ECMO and 3 patients (43%) survived to hospital discharge after a mean 89.6 hospital days. CONCLUSION: The early use of ECMO for acute respiratory failure in adults due to any cause is a good therapeutic option for those unresponsive to the optimal conventional treatments.

Veno-Venous Extracorporeal Membrane Oxygenation of Acute Respiratory Failure due to Near-drowning: 2 case reports / 대한흉부외과학회지

Extracorporeal membrane oxygenation (ECMO) during acute respiratory failure due to any cause aids in the recovery of respiratory function. The use of ECMO for acute respiratory failure due to near drowning was reported to be a successful therapeutic option in those patients who do not respond to optimal conventional therapies. We performed veno-venous ECMO for 2 acute respiratory failures due to near-drownings. All cannulations were performed percutaneously via both femoral veins. The 2 patients were successfully weaned off ECMO, but one patient experienced diffuse hypoxic brain damage and a subarachnoid hemorrhage.

A case involving the use of nafamostat mesilate as an anticoagulant during extracorporeal membrane oxygenation in acute myocardial infarction / 대한내과학회지

It is essential during extracorporeal membrane oxygenation (ECMO) to extend the activated clotting time (ACT) using anticoagulants to prevent blood clot formation. Traditionally, heparin has been used as an anticoagulant during ECMO. Hemorrhaging due to systemic heparinization is considered a major complication of ECMO. A 48-year-old man was admitted due to cardiogenic shock with acute myocardial infarction. ECMO was instituted because of recurrent ventricular tachycardia and refractory shock. We used nafamostat mesilate (Futhan) as an anticoagulant to reduce hemorrhagic complications. The total bypass time was 153 h. The average dose of nafamostat mesilate was 2.64+/-1.11 mg/kg/h; the average ACT was 128.68+/-21.24 seconds. Only a few units were transfused, and there was no oxygenator failure or hemorrhagic complications. Thus, nafamostat mesilate may reduce the need for transfusions and hemorrhagic complications during ECMO.

A case of transient mid-ventricular ballooning syndrome / 대한내과학회지

Transient left ventricular apical ballooning syndrome is also known as takotsubo cardiomyopathy, and this is characterized by transient wall-motion abnormalities involving the left ventricular apex without significant stenosis on the coronary angiogram. We report here on a new variant of transient left ventricular ballooning in which only the mid-ventricle was affected. The patient initially presented with dyspnea and she had wall-motion abnormalities involving the mid-ventricle with hypercontractility of the apical and basal segments in the absence of a significant coronary artery stenosis. Emotional or physical stress or other preceding triggering factors might play a key role in this cardiomyopathy, but the precise etiology remains unknown. So far, the cases of this syndrome have been reported only among the North America Caucasian population and the Japanese population.

A Case of Left Ventricular Thrombi in a Patient with Active Ulcerative Colitis and Normal Left Ventricular Systolic Function

Patients with ulcerative colitis(UC) can experience various extraintestinal complications in their course of disease, such as skin lesions, arthritis, cholangitis, ocular manifestation. Thrombosis may occur in 1.2~7.5% of patients, and it is known that the mortality is up to 25%. The sites of thrombosis are usually in deep veins, such as veins of lower extremities, pelvic venous plexus. But, on rare occasion, thrombosis can occur in cerebral veins, and result in cerebral infarct and hemorrhage. It is known that left ventricular(LV) thrombi can be developed when LV dysfunction exists, but it is extremely rare that LV thrombi occur in patients with normal LV function. So far, in patients with UC, there were a lot of cases complicated with venous thrombosis but arterial thrombosis was uncommon. Moreover, there was the only one case of LV thrombi with normal LV function in patient with UC. Accordingly, we report one case of LV thrombi with hemorrhagic cerebral infarct despite normal LV function in a patient with UC.

Effect of a Unilateral Ankle Brace on Postural Sway and Limb Load Asymmetry

OBJECTIVE: This study was designed to evaluate the effect of ankle bracing (Aircast) on postural sway and limb load asymmetry (LLA) in normal adults. METHOD: 263 healthy subjects volunteered. These subjects were performed the balance test on three different conditions, 1st test fulfilled without ankle brace, 2nd test with aircast on one ankle and 3rd test with aircast on the other ankle. All subjects were divided into two groups; younger( or = 65 years) group. Postural sway and body weight distribution were recorded while the subjects were standing on two adjacent force platforms during 30 seconds trial. All subjects chose a comfortable stance with feet apart and asked to look straight ahead at a fixed point in a quiet room. RESULTS: There were significant differences not only in LLA but also in postural sway between younger and older group. The difference of postural sway and LLA in older group was more prominent that in younger group (p<0.05). CONCLUSION: The results indicated that ankle bracing improved postural sway irrespective of age. Moreover in older group, ankle bracing on one ankle that was in the absence of LLA improved postural sway by far.

Comparison of the Effects of Nicorandil and Cocktail Solution to Prevent Radial Artery Spasm during Coronary Angiography

BACKGROUND AND OBJECTIVES: A radial artery spasm is one of the most common complications of coronary angiography during a transradial, causing considerable patient discomfort, which sometimes disturbs the procedure. This study was designed to evaluate the effects of nicorandil in the prevention of a radial artery spasm during coronary angiography. SUBJECTS AND METHODS: This was a randomized study to compare 4 mg of nicorandil and a 10 mL cocktail solution performed in 100 patients. Vasospasms of the radial artery, which were expressed as stenosis of the vessel diameter with a transradial approach and radial artery patency by pulse oximetry analysis one month later, were examined. RESULTS: Reductions in the systolic and diastolic blood pressures after administration of the spasmolytic agents were 15.8+/-11.8/ 8.4+/-8.0 and 20.5+/-13.6/6.7+/-6.2 in the for nicorandil and cocktail groups, respectively. Nicorandil induced a lesser decrease in the systolic BP than the cocktail, but without statistical significance (p=0.07). Both vasodilating agents showed a significant radial artery vasodilation following their intra-arterial administration (p<0.001 for all). The diameter of the radial artery showed a significant decrease in both groups following catheterization (p<0.05 for all). There were no significant differences between the two groups in terms of radial artery spasms (46 vs. 58% in nicorandil and cocktail groups, respectively, p=0.709). CONCLUSION: Nicorandil, with vasodilatory effects due to a dual mechanism was as effective as the cocktail solution in the vasodilation of the radial artery.

Arterial Stiffness, Malnutrition and Inflammation in Chronic Hemodialysis Patients / 대한신장학회잡지

BACKGROUND: In ESRD patients, malnutrition and atherosclerosis are strongly associated with inflammation resulting in MIA (Malnutrition-Inflammation-Atherosclerosis) syndrome. As compared with atherosclerosis, arteriosclerosis or arterial stiffening is another important cardiovascular risk factor. Therefore, we speculated on the presence of new MIA syndrome, which is composed of malnutrition, inflammation and arteriosclerosis, and evaluated causal relations among them in 70 chronic hemodialysis patients (age 53+/-13 years, male 53%, diabetes 40%). METHODS: As an indicator of arterial stiffness, brachial-ankle pulse wave velocity (PWV) was measured using a plethysmography. PWV index (measured PWV/nomogram based theoretical PWV) was then calculated to adjust confounding effects of age, blood pressure, and gender by using the PWV nomogram obtained in nonuremic population with same age, blood pressure, and gender. Nutritional status was assessed by serum albumin level, subjective global assessment (SGA) and normalized protein catabolic rate (nPCR). Extracellular fluid and intracellular fluid volume ratio (ECF/ICF) were determined using bioimpedance analysis. The presence of an inflammation was assessed by serum high sensitivity C-reactive protein (CRP) level. RESULTS: PWV index correlated positively with log transformed CRP (LnCRP) level, ECF/ICF and negatively with SGA, nPCR and serum albumin level. Serum albumin level correlated positively with nPCR, BUN, hemoglobin level and negatively with LnCRP level, age and ECF/ICF. Diabetic patients had higher PWV index and lower albumin level than non-diabetic patients. In multiple regression analysis, only LnCRP level was a significant common determinant of the both PWV index (R2=0.419; p >0.001) and serum albumin level (R2=0.543; p<0.001). CONCLUSION: Increased CRP levels are independently associated with arterial stiffening and hypoalbuminemia. Inflammation might be a linking mechanism of arterial stiffening and malnutrition in chronic hemodialysis patients.

Increased Blood Pressure and Loss of Consciousness after Stellate Ganglion Block: A case report

A 59 year-old female patient suffered from complex regional pain syndrome in left hemiplegia, was managed to stellate ganglion block (SGB) with 5 ml of 1 % lidocaine. The SGB was performed twice previously, with no side effects. And the third SGB was done in the same manner after negative aspiration testing. Two minutes later, she developed respiratory difficulty with increased blood pressure. Immediately airway management was performed by mask ventilation with oxygen. But ten minutes later, she developed respiratory arrest with unconsciousness and intubation was performed. Soon she recovered spontaneous respiration and the blood pressure returned to the former level. Despite taking all precautions during SGB, complications such as respiratory arrest and hypertension may occur even in the hands of an experienced physician. Therefore, before starting SGB, all resuscitation drugs and equipment must be ready for use in case any emergency develops.

The Pre-test for Development of Insole which Maintains Constant Temperature in Shoe

OBJECTIVE: To investigate the change in plantar skin temperature in normal subjects wearing five different kinds of insoles. METHOD: Twenty normal subjects were chosen and were made to walk on a treadmill for five 30-minute sessions wearing the same shoes, and wearing five different kinds of insoles (four types were endothermic insoles, but one type was a normal insole) respectively. Subjects sat on a chair for 10 minutes before and after walking. The plantar skin temperature was recorded on 4 sites (from channel 1 to 4) on each left insole. The plantar skin temperature was recorded every 10 seconds for a total of 50 minutes, with T-type Thermocouple(R). RESULTS: There were no statistical differences in the change of plantar skin temperature for each insole before, during and after walking. No statistical differences in subjective thermal sense and Borg Rating on perceived exertion scale for each insole before, during and after walking. Time in peak plantar temperature was 25.9~28.3 minutes (after subjects starts walking), wearing normal insole. CONCLUSION: There was no statistical difference in the change of plantar skin temperature for the five different kinds of insoles However, we found this method to be effective in examining plantar skin temperature during walking.

Change in Skin Temperature according to Distance of Spraying Cold-jet Stream

OBJECTIVE: To examine the effects of changing the distance of spraying cold-jet stream (CS) on pain threshold and skin temperature. METHOD: Twenty one volunteers were examined. -30 degrees C cold-air was applied from 5 cm and 10 cm away to the skin of the right wrist. The following parameters were taken to measure the efficiency of the application: the cooling time for the subject to express pain (1st period), the rewarming time for skin temperature to rise to 20 degrees C at room temperature (2nd period), the re-cooling time again (3rd period), 4th, 5th and 6th time again. RESULTS: Skin temperature that subjects expressed pain was significantly at 10 cm distance than 5 cm. The rewarming speed of skin temperature was slower and slower according to repeat cold-air therapy in two groups. But there is no difference of rewarming time between 10 cm distance and 5 cm. CONCLUSION: There was no difference in rewarming time between 10 cm and 5 cm, hence, applying CS from 5 cm distance for a short period of time would be the more efficient method in terms of time-saving.

Depressed Inflammatory Response to Repeated Angioplasty in Unstable Angina Patients with an In-Stent Restenosis

BACKGROUND: Inflammation plays a key role in the pathogenesis of an in-stent restenosis because it promotes neointimal proliferation. This study was performed to determine responses of the C-reactive protein (CRP) in unstable angina patients with an in-stent restenosis undergoing repeated percutaneous transluminal coronary angioplasty (re-PTCA). METHODS: The study subjects (unstable angina) were classified into 2 groups:Group A (n=30, 15 men, mean age 62 years) had a re-PTCA for an in-stent restenosis lesion and Group B (n=60, 33 men, mean age 63 years) underwent a stent implantation for a de novo lesion. RESULTS: The baseline CRP levels in group A were significantly lower than in group B, as well as 6 and 24 hours after intervention. Twenty four hours after intervention, the CRP levels increased (>4 mg/L) in 3 out of 30 patients (10%) of group A but increased in 32 out of 60 patients (53%) in group B (p<0.001). The differences in the CRP levels between the baseline and 24 hours after intervention were significantly lower in group A than in group B (0.8 and 2.15 mg/L, respectively, p<0.001). In group B, the serum CRP levels 24 hours after intervention were significantly higher than the baseline levels (p<0.05), but not in group A. CONCLUSION: The CRP expression level is significantly lower in unstable angina patients undergoing a re-PTCA for an in-stent restenosis than those undergoing a stent implantation for a de novo lesion.

Quantification of Regional Wall Motion Abnormality Using Myocardial Strain in Acute Myocardial Infarction

BACKGROUND AND OBJECTIVES: Several echocardiographic methods, such as ejection fraction, fractional shortening, and Doppler tissue imaging (DTI), have been developed to quantify systolic function but all had several important limitations. The purpose of this study was to quantify the regional wall motion abnormality, using strain, in an acute myocardial infarction, compared with a visual estimation. SUBJECTS AND MEHTODS: Forty-five patients, with acute anterior (n=28) and inferior myocardial (n=17) infarctions, who underwent color DTI, were examined using longitudinal strain and standard echocardiography, and the results were compared with 54 normal controls. A total of 594 segments [3 segments (apical, mid and basal portion) of septum and inferior wallx99 patients] were evaluated. RESULTS: In the normal control group, the strain was uniformly distributed in all segments (-20%~-23%). In the infarction groups, the strain was negatively related with the wall motion score. The strain of the apical segments and mid-septum was decreased in the anterior wall infarctions, and the strain of basal septum and mid to basal inferior wall was decreased in the inferior wall infarctions. The dyskinetic segments showed positive strain. CONCLUSION: This study validates strain as a superior method for the quantification of the regional wall motion abnormality in an acute myocardial infarction than visual estimation.