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.

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.

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.

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.

Three-dimensional image of patent ductus arteriosus reconstructed by 64-slice multidetector CT / 대한내과학회지

No abstract available.

Correlations between the Left Ventricular Diastolic Function and Aortic Stiffness in Healthy Aged Subjects

BACKGROUND AND OBJECTIVES: Arterial stiffness and wave reflections increase with advancing age, and the systolic and pulse pressures are elevated. These changes in aortic stiffness and pulse wave velocity with aging may change the cardiac function. The diastolic function of the left ventricle declines with aging even in normal healthy subjects too. This investigation was designed to assess the correlations between the left ventricular diastolic function and arterial stiffness with using echocardiography including doppler tissue imaging (DTI) and an applanation tonometer. SUBJECTS AND METHODS: The subjects were 100 healthy volunteers who had normal left ventricular systolic function and no major cardiovascular risk factors such as hypertension, hypercholesterolemia, diabetes, obesity and smoking. The left ventricular diastolic function was assessed with the mitral inflow indexes and DTI, and the pulmonary venous return was measured by echocardiography. The central aorta blood pressure, the augmentation index (AIx) and the pulse wave velocity (PWV) were evaluated by using an applanation tonometer (SphygmoCoR system). RESULTS: With advancing age, the left mitral E/A ratio decreased (r=-.738, p<0.05) and the DTI early/late diastolic velocity (E'/A') ratio decreased (r=-.759, p<0.05), which showed a significant change of the left ventricular diastolic function. The Aix (r=.406, p<0.05) and PWV (r=.614, p<0.05) increased with aging. The PWV correlated significantly with the E/A ratio (r=-.593, p<0.05) and the E'/A' ratio (r=-.559, p<0.05). CONCLUSION: This study showed that increases of the large conduit vessel stiffness with aging are associated with a decline of the left ventricular diastolic function in healthy subjects.

A Case of Spontaneous Left Atrial Intramural Hematoma Causing Vaso-occlusive Cardiogenic Shock

Intramural hematoma of the cardiac muscle is a rare clinical condition. Only a few cases have been reported in the medicosurgical conditions related to post cardiac surgery, chest trauma and dissecting aneurysms of the aorta. Moreover, there are few cases of spontaneous left atrial intramural hematoma and they may occur in the medical conditions related to calcified mitral annulus dissection or amyloidosis. We experienced a case of spontaneous intramural left atrial hematoma in a 29 year-old male resulting in vaso-occlusive cardiogenic shock. We report the clinical manifestation and treatment of this case with a review of literatures.

Effect of N-Acetylcysteine in Prevention of Contrast-Induced Nephropathy after Coronary Angiography

BACKGROUND AND OBJECTIVES: Contrast-induced nephropathy (CIN) is associated with increased morbidity and mortality in coronary angiography. Although the mechanism is unclear, N-acetylcysteine (NAC) is known to protect against CIN. Preliminary studies with NAC have found conflicting results for the prevention of CIN in patients undergoing coronary angiography. This study was designed to evaluate the efficacy and safety of NAC for the prevention of CIN in patients undergoing coronary angiography. SUBJECTS AND METHODS: 48 patients with chronic renal insufficiency (mean [+/-SD] serum creatinine concentration, 2.06+/-0.56 mg/dL), who were undergoing coronary angiography with a nonionic, low-osmolar contrast agent, were prospectively studied. Patients were randomly assigned to receive either the antioxidant, NAC (600 mg orally twice daily), and 0.45% saline intravenously (n=25), before and after administration of contrast agents, or saline only (n=23). The renal function parameters were assessed 48 hour before and after radiocontrast media administration. RESULTS: 14 of the 48 patients (29%) showed an increase in the 0.5 mg/dL serum creatinine concentration after 48 hours of contrast media administration: 4 of the 25 patients in the NAC group (16%) and 10 of the 23 in the control group (43%; p=0.036; relative risk, 0.37; 95% confidence interval, 1.04 to 7.79). In the NAC group, the mean serum creatinine concentration insignificantly increased (p=0.54), from 2.2+/-0.8 to 2.3+/-0.9 mg/dL, after 48 hours of contrast media administration; whereas, in the control group, the mean serum creatinine concentration significantly increased (p=0.011), from 1.9+/-0.4 to 2.2+/-0.8 mg/dL. The absolute change in serum creatinine concentration was significantly greater in the control than the NAC group (p=0.044). CONCLUSION: Prophylactic oral administration of the antioxidant NAC, along with hydration, prevents the decrease in the renal function induced by a nonionic, low-osmolality contrast agent in patients with chronic renal insufficiency.

Case of Variant Angina diagnosed with 24-hour Holter monitoring / 대한내과학회지

No abstract available.

Percutaneous Coronary Intervention versus Coronary Artery Bypass Grafting for Diabetics with Multivessel Coronary Artery Disease: The Korean Multicenter Revascularization Registry (KORR)

This study was designed to assess the relative merits of percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in multivessel coronary artery disease (MVCAD), particularly for Korean diabetics. Among 3,279 patients with MVCAD who were recommended for revascularization were enrolled from nine centers in Korea, 2,154 were selected after statistical adjustments for the disparities between two groups. Survival rates were not significantly different for three years between two groups. Among diabetic patients, the three-year mortality rate in PCI group was 1.9-fold higher than that of CABG group, although it was not statistically significant (PCI 19.8%, CABG 11.4%, p=0.14). The three-year mortality rate was similar between the two groups in non-diabetics (PCI 8.3%, CABG 10.0%, p=0.50). The 30-day rate of cerebrovascular event was higher in CABG group, for both diabetic (CABG 3.6%, PCI 0.0%, p<0.001) and non-diabetic patients (CABG 2.4%, PCI 0.0%, p<0.001). Short- and long-term revascularization rates were higher in PCI group than in CABG group. As a conclusion, this Korean registry demonstrates that PCI was associated with comparable survival rates and lower short-term morbidity, but a greater requirement for repeated revascularization compared with CABG in Korean diabetics.

Reversal of arterial stiffness by treatment with the angiotensin receptor antagonist irbesartan in essential hypertension / 대한내과학회지

BACKGROUND: Alterations of mechanical properties in the vasculature may contribute to complications of hypertension. Since angiotensin II plays a pivotal role in these vascular abnormalities, we tested the hypothesis that the AT1 angiotensin receptor antagonist irbesartan, in contrast to the beta-blocker atenolol, would correct artery stiffness in essential hypertensive patients. METHODS: Thirty untreated essential hypertensive patients (48 +/- 7 years, range 35-65; 72% male) were randomly assigned in a single-blind fashion to irbesartan or atenolol treatment for 6 months. Fifty one age/sex-matched normotensive subjects were also studied. Systemic arterial stiffness (augmentation index; AI) was measured by the pressure transfer function using radial pulse tonometry. RESULTS: Both treatments reduced blood pressure (BP) to a comparable degree (irbesartan: 160 +/- 19/105 +/- 13 to 133 +/- 16/92 +/- 10 mmHg, p<0.01; atenolol: 166 +/- 17/113 +/- 9 to 132 +/- 15/90 +/- 8 mmHg, p<0.01). Other hemodynamic parameters of peripheral and central arteries showed similar degree of reduction, except significant reduction of central pulse pressure with irbesartan treatment (42 +/- 20 to 29 +/- 8 mmHg, p=0.01 vs 41 +/- 14 to 34 +/- 12 mmHg of atenolol treatment). After 6-month treatment, systemic arterial stiffness (AI) was significantly reduced from 28 +/- 11 to 21 +/- 11% (p=0.01) after irbesartan but atenolol treatment showed no change (from 29 +/- 8 to 29 +/- 13%). Reversal of arterial stiffness correlated mostly with reduction of central pulse pressure (r=0.63, p<0.01). CONCLUSION: The AT1 angiotensin antagonist irbesartan corrected the altered arterial stiffness from patients with essential hypertension by reduction of central pulse pressure, whereas the beta-blocker atenolol had no effect.

Percutaneous Coronary Intervention versus Coronary Artery Bypass Grafting for Patients with Multivessel Coronary Artery Disease: The Korean Multicenter Revascularization Registry(KORR)

BACKGROUND AND OBJECTIVE: Despite many multicenter trials on percutaneous coronary intervention (PCI), versus coronary artery bypass surgery (CABG), in multivessel coronary artery disease (MVCAD), the most appropriate treatment remains a matter of debate. Moreover, studies comparing the 2 strategies in eastern society are rare. The aim of this study was to assess the relative merits of PCI and CABG in MVCAD in the post-stent era. SUBJECTS AND METHODS: Patients, with MVCAD, indicated for revascularization were enrolled from 9 centers in Korea. Out of the 3,279 patients in the registry, 2102 (CABG 609 patients, PCI 1,493 patients) were selected for a comparison of their outcomes, after a statistical adjustments for the disparity for 6 independent risk factors, for the prognosis between the two groups. RESULTS: There was no significantly different in the 3 year survival rates between PCI and CABG groups. In the diabetic patients, the 3-year mortality rate in PCI group was 1.6-fold higher than in the CABG group, although it was not statistically significant (PCI 19.8%, CABG 12.5%, p=0.24). The incidence of cerebrovascular events (CVE) was higher in the CABG group. The thirty-day death rate, myocardial infarction or CVE were higher in the CABG group (PCI 1.3%, CABG 4.2%, p<0.001). Both the long and short-term revascularization rates were higher in PCI group compared to CABG group. CONCLUSION: Our Korean registry demonstrated a comparable survival rate between the PCI and CABG groups. A PCI was associated with a lower early morbidity, but with a greater need for repeated revascularization compared to a CABG.

Analysis of P Wave Signal-Averaged Electrocardiogram in Patients with Paroxysmal Atrial Fibrillation

BACKGROUND AND OBJECTIVES: The diagnosis of paroxysmal atrial fibrillation (PAF) and the prediction of its recurrence are sometimes difficult. There have been several recent studies attempting to detect patients at risk for PAF while in sinus rhythm by using the P wave signal-averaged ECG. We undertook to define an appropriate technique of P wave signal-averaged ECG and to estimate the reproducibility of the test. Additionally, we estimated the usefulness of P wave signal-averaged ECG in patients at risk for PAF. SUBJECTS AND METHODS: Forty-five patients with PAF were included in the study undertaken between March 1997 and June 1998. Twelve-lead surface ECG and P wave signal-averaged ECG were performed in the patients. The total P wave duration was measured by the P wave signal-averaged ECG using P wave template and least-square fit filter. The same process was followed in forty sex- and age-matched controls. RESULTS: The measurement of P wave duration with P wave signal-averaged ECG was highly reproducible. The measured P wave duration showed significant prolongation in the patient group at cutoff frequencies of 20 Hz and 30 Hz (123.6+/-15.3 vs. 114.8+/-14.5 msec, p=0.009 at 20 Hz, 120.1+/-17.8 vs. 107.5+/-18.8 msec, p=0.002 at 30 Hz). An abnormal P wave duration defined as over 120 msec in duration by P wave signal-averaged ECG was able to detect PAF with a sensitivity of 60%, specificity of 73%, positive predictive value of 71%, and a negative predictive value of 62%. CONCLUSION: A prolonged P wave duration as measured by P wave signal-averaging technique may be a simple noninvasive marker of risk for the development of atrial fibrillation.

Impact on Long-term Adverse Cardiac Events of Troponin T or Creatine Kinase-MB Release after Percutaneous Transluminal Coronary Angioplasty

BACKGROUND AND OBJECTIVES: The impact on long-term adverse cardiac events of troponin T (TnT) or creatine kinase-MB (CK-MB) release after percutaneous transluminal coronary angioplasty (PTCA) is not well defined. The purpose of the study is to evaluate the effect of elevated TnT or CK-MB on the late major adverse cardiac events [MACE ; Q wave myocardial infarction (MI), revascularization, or cardiac death]. SUBJECTS AND METHODS: Study population were 207 consecutive patients (M : F=148 : 59, mean 60.8+/-9.2 years) who underwent PTCA. Patients with acute MI, unstable angina with abnormal levels of TnT or CK-MB, or newly developed Q MI after PTCA were excluded. Cardiac enzyme levels were measured before and 8, 24 hours after PTCA for CK-MB, and before and 16 hours after PTCA for TnT. Group I (n=181, 87.4%) had normal levels of both after PTCA. Group II (n=26, 12.6%) had abnormal levels of CK-MB (>or=16 U/L) and/or TnT (>or=0.2 ng/mL). 1-year follow-up was available in 201 (97.1%) patients. RESULTS: Incidence of non-Q MI after PTCA was 26/207 (12.6%). Major complications such as acute coronary occlusion, side branch occlusion, and major dissection were significantly associated with elevation of TnT or CK-MB after PTCA (p=0.01). However, elevation of CK-MB or TnT was not significantly associated with late MACE by Kaplan-Meier survival curve (p=0.46). During 1-year follow-up, event free rate of group I and II were 76.6% and 69.2%, respectively. CONCLUSION: Acute coronary occlusion, side branch occlusion, or major dissection can increase the level of TnT or CK-MB after PTCA. But, elevation of CK-MB or TnT after PTCA dose not significantly influence on late MACE.