Infected Thrombus of the Bioprosthetic Aortic Valve with Distal Arterial Embolization after 3 Years of Valve Replacement Surgery

Current guidelines recommend the use of warfarin in the first 3 months after bioprosthetic valve replacement and suggest long-term anticoagulation only in patients with obvious risk factors for thrombosis. Despite at low risk of thromboembolism, we present a case of a 72-year-old male patient with infected thrombus at bioprosthetic aortic valve with distal arterial embolization after 3 years of replacement surgery. The incidence of asymptomatic bioprosthetic valve thrombosis (BPVT) may be higher than anticipated and active surveillance echocardiography is needed to early detect BPVT before leading to fatal complication.

Exercise-Induced Intrapulmonary Arteriovenous Shunt in a Patient Complaining of Dyspnea during Strenuous Exercise

A 51-year-old highly fit man presented for dyspnea with strenuous aerobic exercise. The patient was asymptomatic and all tests were normal at rest. With increasing exercise intensity, he suddenly complained of dyspnea and showed a severe exercise-induced hypoxemia with an excessive alveolar-arterial oxygen tension difference. In agitated saline contrast echocardiography at peak exercise, a large amount of left to right shunt was identified after > 5 cardiac cycles, which suggests the presence of exercise-induced intrapulmonary arteriovenous shunt in this patient.

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.

Successfully Treated Femoral Artery Thrombosis in a Patient with Minimal Change Nephrotic Syndrome / 전남의대학술지

In contrast to widely recognized venous thrombotic complications, peripheral arterial thrombosis as a complication of nephrotic syndrome, especially without preceding iatrogenic venous puncture, corticosteroid treatment, or coagulation factor abnormalities, has rarely been reported in adult female patients. We report the case of a 39-year-old woman who presented with pain in the right lower leg accompanied by minimal change nephrotic syndrome. Lower-extremity angiography showed total occlusion of the right superficial femoral artery. Thrombectomy was performed with a balloon catheter, and the thrombi were successfully aspirated. Our experience indicates that even if few traditional risk factors for atherosclerosis are identified, a high index of suspicion and aggressive treatment of arterial thrombosis in adult nephrotic syndrome are crucial to minimize serious ischemic injuries.

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.

Successfully Treated Femoral Artery Thrombosis in a Patient with Minimal Change Nephrotic Syndrome / 전남의대학술지

In contrast to widely recognized venous thrombotic complications, peripheral arterial thrombosis as a complication of nephrotic syndrome, especially without preceding iatrogenic venous puncture, corticosteroid treatment, or coagulation factor abnormalities, has rarely been reported in adult female patients. We report the case of a 39-year-old woman who presented with pain in the right lower leg accompanied by minimal change nephrotic syndrome. Lower-extremity angiography showed total occlusion of the right superficial femoral artery. Thrombectomy was performed with a balloon catheter, and the thrombi were successfully aspirated. Our experience indicates that even if few traditional risk factors for atherosclerosis are identified, a high index of suspicion and aggressive treatment of arterial thrombosis in adult nephrotic syndrome are crucial to minimize serious ischemic injuries.

Left Atrial Mechanical Function and Stiffness in Patients with Paroxysmal Atrial Fibrillation

BACKGROUND: Abnormalities in the left atrial (LA) structure and function may develop in patients with paroxysmal atrial fibrillation (AF). We sought to determine the contribution of LA mechanical function, including LA stiffness, to AF by comparing patients with paroxysmal AF with normal control subjects, and to evaluate whether LA mechanical function and stiffness are related with the structural changes of LA. METHODS: Sixty-four paroxysmal AF patients (57 +/- 13 years, 59% male) were studied, using a speckle tracking echocardiography, and were compared with 34 age-, gender-, and left ventricular (LV) mass-matched controls (53 +/- 14 years, 61% male). LA volume indices, expansion index for reservoir function, active emptying fraction for contractile function, mitral annular velocities, and global longitudinal LA strain were measured. The ratio of E/e' to LA strain was used as an index of LA stiffness. RESULTS: Patients with paroxysmal AF had similar LV volume indices, ejection fraction, and diastolic function, when compared with that of the normal controls. However, paroxysmal AF patients showed increased LA volume indices and decreased LA reservoir function, but similar contractile function. LA stiffness was increased in patients with paroxysmal AF than in the control subjects (0.40 +/- 0.25 vs. 0.29 +/- 0.10, p = 0.002), and was related with LA volume indices and reservoir function. CONCLUSION: Patients with paroxysmal AF have decreased LA reservoir function and increased stiffness, in comparison with that of the control subjects. LA stiffness was significantly related with LA volume indices and reservoir function. LA stiffness can be used for the assessment of LA function in patients with paroxysmal AF.

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.

Left Transradial Coronary Angiography in a Patient With Dextrocardia

Although dextrocardia occurs rarely, the incidence of coronary artery disease is similar to the general population. Because of unfamiliarity with performing catheterization, transradial coronary angiography has seldom been performed in a patient with dextrocardia. We successfully performed left transradial coronary angiography in a patient with a right side heart using counter-directional torquing of the catheters and mirror-image angiographic angles.

Diabetic Cardiomyopathy / 당뇨병

Cardiovascular disease is the most common cause of death in patients with diabetes mellitus (DM). In particular, the focus of many studies has been on ischemic heart disease, as it is a eading cause of death in diabetic patients. However, independent of coronary artery disease, DM can also lead to cardiac structural and functional changes, supporting the presence of diabetic cardiomyopathy. The pathologic mechanismin the development of diabetic cardiomyopathy is multifactorial including metabolic disturbance, myocardial fibrosis, microvascular disease, and autonomic dysfunction. Functionally, diabetic patients have a higher prevalence of LV (left ventricle) diastolic dysfunction. Because most diabetic patients with early myocardial disease have a wide spectrum of diastolic dysfunction at rest, assessment of LV functional reserve during exercise is helpful for early identification of myocardial dysfunction. Recent research has demonstrated that LV diastolic functional reserve (DFR) assessed by diastolic stress echocardiography was significantly reduced in patients with DM, compared with a control group, suggesting DFR might be an early indicator of diabetic cardiomyopathy. Glycemic control might be the most important and basic therapeutic strategy for preventing the development of diabetic cardiomyopathy. However, more extensive studies are needed to garner further evidence of preventive and therapeutic strategies of diabetic cardiomyopathy.

A Hidden Pressure Gradient That can be Easily Passed Over in Prosthetic Mitral Valve

No abstract available.

Depressed-Type of Early Colon Cancer with Extensive Lymph Node Metastasis

Early colorectal cancer (ECC) is defined as invasive tumor limited to the colonic and rectal mucosa or submucosa, regardless of the presence or absence of lymph node metastasis. The incidence of lymph node metastasis in ECC ranges from 0 to 15.4%, and risk factors include depth of submucosal invasion, growth patterns (polypoid or non-polypoid), histologic subclassification, and lymphatic invasion. Of non-polypoid growth patterns, the depressed types of colorectal cancer have higher malignant potential than polypoid types, even for small sizes. Unfortunately, this type is also difficult to detect on colonoscopic examination. In this report, we describe a case of depressed type ECC with extensive lymph node metastasis without regional lymph node involvement.

Efficacy of Repeated Hepatic Arterial Infusion Chemotherapy in Advanced Hepatocellular Carcinoma with Portal Vein Tumor Thrombosis / 대한간학회지

BACKGROUND/AIMS: The aim of this study is to elucidate the efficacy of repeated hepatic arterial infusion chemotherapy (HAIC) and different chemotherapeutic regimens for treating patients having advanced hepatocellular carcinoma (HCC) with portal vein tumor thrombosis (PVTT). METHODS: From Jan. 1999 and Dec. 2003, a total of 103 patients diagnosed as having HCC with PVTT, but without extrahepatic spreading, were enrolled in this study. They were stratified into two groups. Group I (67 patients) received intraarterial cisplatin (CDDP, 80 mg/m2 for 2 hours on Day 1), Group II (36 patients) received intraarterial CDDP (60 mg/m2 for 2 hours on Day 2) and 5-fluorouracil (5-FU, 500 mg/m2 for 5 hours on Day 1-3). They were scheduled to receive at least three consecutive courses of the HAIC at 1 month intervals. RESULTS: Among the 66 patients who completed the protocol, one (2.5%) and seven (17.5%) patients of group I, and one (3.8%) and four (15.4%) of group II, exhibited complete and partial responses, respectively. The median survival period of all the patients was 6 months. Group II showed a tendency to improve the median survival compared to group I (8.5 vs 5.0 months, respectively, P=0.45). The most common adverse reaction was nausea (58.2%). However, an elevation of the total bilirubin level was more frequent in Group I than in Group II (61.3% vs 20.7%, respectively, P<0.05). CONCLUSIONS: Repeated HAIC using CDDP achieved favorable results in a few patients with HCC with PVTT, and additional 5-FU may be useful.

A Carcinoembryonic Antigen-Secreting Adenocarcinoma Arising in Tailgut Cyst : Clinical Implications of Carcinoembryonic Antigen

Tailgut cysts (TGCs) are rare congenital cysts that occur in the retrorectal or presacral spaces. Although most tailgut cysts have been reported as benign, there have been at least 9 cases associated with malignant change. We report herein on an unusual case of a 40-year-old woman with a carcinoembryonic antigen (CEA) -producing adenocarcinoma arising within a TGC who underwent surgical resection and local radiation therapy. Despite the complete resection, metastatic adenocarcinoma developed five months after surgery. CEA-producing adenocarcinoma from a TGC is extremely rare and only two cases, including this case, have been reported in the English medical literature. Besides CEA, the serum levels of CA 19-9 became markedly elevated in this patient. Given that the serum CEA level decreased to the normal range after complete resection of tumor and that the tumor recurrence was associated with a rebound of the CEA serum level, our case shows that serial measurements of serum CEA can be used for treatment planning and for assessing the patient's treatment response for this rare disease.