A Case of Left Atrial Free-Floating Thrombus / 계명의대학술지

A 74-year-old woman who had paroxysmal atrial fibrillation without mitral stenosis was hospitalized for syncope and right-sided weakness. Echocardiography revealed a large free-floating thrombus in the left atrium, sometimes prolapsing partially into the left ventricle in diastole. Because of her poor neurological status, she was managed with anticoagulation. On the 12th day, the thrombus had disappeared on the follow-up echocardiography, and aortoiliac embolization was later detected on computed tomography. Unfortunately, she developed various complications of stroke and limb infarction, and died after 4 months of hospital care. In addition to this case report, we reviewed a total 70 cases of left atrial free-floating thrombus. Atrial fibrillation and mitral pathology were two major causative factors. All the cases, except 1, were confirmed on echocardiography. The most common presentation that led to echocardiography was systemic embolization, followed by heart failure. Others were acute hemodynamic decompensation from mitral obstruction, chest pain, palpitation, and bacteremia. Cardiac thrombectomy was the preferred treatment modality with favorable outcomes.

A Case of Pleural Effusion and Pulmonary Edema Caused by Calcium Channel Blockers in a Patient of Systemic Hypertension

Calcium channel blockers (CCBs) are very popular drugs to lower blood pressure (BP) without significant side effects. A 72-year-old man admitted for uncontrolled hypertension. He had history of hypertension, atrial fibrillation with slow ventricular response, angina, abdominal aortic aneurysm, and stage 3 chronic kidney disease. He had taken several anti-hypertensives, such as amlodipine 5 mg, perindopril 8 mg, and indepamide 1.5 mg. To control BP, nifedipine 120 mg was added. Then pulmonary edema and pleural effusion was developed. Echocardiography showed preserved left ventricular ejection fraction and mild mitral regurgitation. Fluid restriction and high dose furosemide did not cease pleural fluid accumulation. Thus a total of 4 times of thoracentesis were done and all fluid analyses revealed transudate. We thought that pleural effusion and pulmonary edema was induced by CCBs and discontinued the drugs. He recovered quickly and finally discharged in a stable condition.

Coronary artery vasospasm after atrial septal defect surgery / 영남의대학술지

Coronary vasospasm is one of the fatal complications that may occur in patients undergoing open heart surgery. To date, however, there are not many cases in this series and no definite pathophysiology has been documented. We experienced a case of coronary artery vasospasm after atrial septal defect (ASD) surgery and then successfully treated it with both transbrachial intra-aortic balloon pump and percutaneous cardiopulmonary support. Only several hours after ASD surgery, the patient exhibited the cardiovascular collapse, the ST-segment elevation, followed by ventricular fibrillation and normal coronary angiography findings. It is important to make a differential diagnosis of coronary artery vasospasm in patients presenting with ST-segment elevation who had no notable coronary artery diseases. This case indicates that clinicians should be aware of the possibility that the coronary artery vasospasm may also occur in patients undergoing ASD surgery.

Dilated Cardiomyopathy Secondary to Hypothyroidism: Case Report with a Review of Literatures

To date, it has been well documented that there is a relationship between alterations in thyroid hormones and cardiac dysfunction. We experienced a case of a 36-year-old man with dilated cardiomyopathy (DCM) accompanied by undiagnosed primary hypothyroidism. In the current case, there was a significant improvement in the cardiac function following heart failure management and thyroid hormone replacement. Our case highlights that clinicians should consider the possibility of hypothyroidism as a cause of DCM.

Erratum: A Case of Myopathy, Encephalopathy, Lactic Acidosis and Stroke-Like Episodes (MELAS) Syndrome with Intracardiac Thrombus

The title has been spelled incorrectly: "MEALS" should have appeared as "MELAS".

A Case of Myopathy, Encephalopathy, Lactic Acidosis and Stroke-Like Episodes (MEALS) Syndrome with Intracardiac Thrombus

Myopathy, encephalopathy, lactic acidosis and stroke-like episodes (MELAS) is a multisystem clinical syndrome manifested by mitochondrial myopathy, encephalopathy, lactic acidosis and recurrent stroke-like episodes. A 27-year-old female with MELAS syndrome presented with cerebral infarction. Echocardiography revealed a thrombus attached to the apex of the hypertrophied left ventricle, with decreased systolic function. The embolism of the intracardiac thrombus might have been the cause of stroke. There should be more consideration given to the increased possibility of intracardiac thrombus formation when a MELAS patient with cardiac involvement is encountered.

A Case of Severe Coronary Spasm Associated with 5-Fluorouracil Chemotherapy

Cardiotoxicity associated with 5-fluorouracil (FU) is an uncommon, but potentially lethal, condition. The case of an 83-year-old man with colon cancer who developed chest pain during 5-FU infusion is presented. The electrocardiogram (ECG) showed pronounced ST elevation in the lateral leads, and the chest pain was resolved after infusion of nitroglycerin. A coronary angiogram (CAG) revealed that the patient had significant atherosclerosis in the proximal left circumflex artery. Coronary artery spasm with fixed stenosis was considered, and a drug-eluting stent was implanted. After 8 hours, the patient complained of recurring chest pain, paralleled by ST elevation on the ECG. The chest pain subsided after administration of intravenous nitroglycerin followed by sublingual nifedipine. Repeated CAG showed patency of the previous stent. This case supports the vasospastic hypothesis of 5-FU cardiac toxicity, indicating that a calcium channel blocker may be effective in the prevention or treatment of 5-FU cardiotoxicity.

A Case of Infected Left Atrial Myxoma With Concomitant Mitral Valve Endocarditis

Myxoma is the most common primary tumor in the heart. Cardiac myxomas can present in various manners including embolization and fever, sometimes simulating endocarditis. However, they are rarely infected. We report here a case of an infected left atrial myxoma that seeded a normal mitral valve and atypically presented with multiple embolic events in the lower extremities along with multiple splenic and a cerebellar infarction.

Acute Idiopathic Hemorrhagic Pericarditis with Cardiac Tamponade as the Initial Presentation of Acquired Immune Deficiency Syndrome

This paper presents a case of cardiac tamponade with idiopathic hemorrhagic pericarditis as the initial symptom of human immunodeficiency virus (HIV) infection. A 29-year-old male came to the emergency room with a sudden onset of dizziness. Upon arrival, he was hypotensive although not tachycardic, and his jugular venous pressure was not elevated. His chest X-rays revealed a mild cardiomegaly. Transthoracic echocardiography revealed a large amount of pericardial effusion with a diastolic collapse of the right ventricle, a dilated inferior vena cava with little change in respiration, and exaggerated respiratory variation of mitral inflow velocities, representing echocardiographic evidence of cardiac tamponade. After pericardiocentesis, his blood pressure improved to 110/70 mmHg without inotropics support. Serial 12-lead electrocardiograms during hospitalization revealed upwardly concave diffuse ST-segment elevation followed by a T-wave inversion suggestive of acute pericarditis. Pericardial fluid cytology and cultures for bacteria, mycobacteria, adenovirus, and fungus were all negative. HIV enzyme-linked immunosorbent assay (ELISA) was positive and confirmed by Western blot. The CD4 cell count was 168/mm3. Finally, the diagnosis of cardiac tamponade due to HIV-associated hemorrhagic pericarditis was made. It was concluded that HIV infection should be considered in the diagnosis of unexplained pericardial effusion or cardiac tamponade in Korea.

A Case of Cogan's Syndrome With Angina

Cogan's syndrome is a rare systemic inflammatory disease and can be diagnosed on the basis of typical inner ear and ocular involvement with the presence of large vessel vasculitis. We report a case of Cogan's syndrome with stable angina resulting from coronary ostial stenosis caused by aortitis.

A Case of Fabry Cardiomyopathy

In the absence of hypertension, hypertrophic cardiomyopathy is the most common cause of left ventricular hypertrophy (LVH). However, it has been reported that up to 3% of males with unexplained LVH have Fabry disease, an X-linked disorder of glycophospholipid metabolism that is due to a deficiency in the lysosomal enzyme alpha-galactosidase A (alpha-Gal A). A 44-year-old man was admitted to our hospital with palpitations. He had a history of chronic renal failure diagnosed at age 33 followed by kidney transplantation performed at our institution 2 years later, as well as long-standing hypohidrosis. His medications included prednisolone (5 mg daily), mycophenolate mofetil (1,000 mg, bid), and cyclosporine (150 mg, bid). On hospital day two, an echocardiogram demonstrated increased left ventricular wall thickness (septal wall thickness of 28 mm, posterior wall thickness of 20 mm). Diastolic dysfunction was noted on transmitral flow patterns and tissue Doppler imaging. The patient was found to have low plasma alpha-Gal A activity. A previously reported H46R missense mutation was detected in his alpha-Gal A gene and the patient was subsequently diagnosed with Fabry disease.

A Case of Hemolytic Anemia Following Mitral Valve Repair

Hemolytic anemia is one of the findings representative of prosthesis dysfunction after valve surgery. A 67-year-old man, who underwent mitral annular ring plasty one week ago, was admitted with shortness of breath and fatigue. Hematological studies revealed a Coombs'-negative hemolytic anemia with a hemoglobin 7.9 g/dl, hematocrit of 17.1%, haptoglobin of 1.0 mg/dl, LDH 5148 U/L, total bilirubin of 3.1 mg/dl (direct of 0.71 mg/dl), and a peripheral blood smear demonstrating mechanical hemolysis with red cell fragmentation. Transesophageal echocardiogram revealed a turbulent jet of mitral regurgitation hitting the annuloplasty ring. The patient returned to the operating room for mitral valve replacement, and thereafter which the hemolytic anemia resolved.

Cases of Swallow Syncope Induced by the Activation of Mechanorecepters in the Lower Esophagus

Swallowing is a rare cause of neurally mediated syncope. The mechanism of swallow syncope that contributes to hypotension, bradycardia, or to both is complex. A 59-year-old man had experienced a recurrent loss of consciousness during swallowing of carbonated beverages or sticky foods. Another 59-year-old man had complained of intermittent syncope just after eating foods. These two patients had no significant structural or functional abnormalities in the esophagus or heart. Both cases showed bradycardia when the lower esophagus was stretched by balloon inflation. The activation of mechanoreceptors in the lower esophagus can be regarded as an initiating factor of these cardioinhibitions. The patients were treated with permanent pacemaker implantation and instructed to change eating habits, respectively.

A Closed Right Atrial Septal Aneurysm Suspected as a Tumor: 1 case report / 대한흉부외과학회지

A 70-year-old man with aphasia due to ischemic cerebral events by thromboemboli was admitted. The cause of thromboemboli was investigated, and transesophageal echocardiography and chest MRI revealed an encapsulated cystic mass in the right atrium, not circulating. It was a homogeneous cystic mass suggesting a tumor (Myxoma) rather than thrombus. Right atrial mass was resected together with partial atrial septum under the normothermic cardiopulmonary bypass. Histologically it was an atrial septal aneurysm, closed on itself, filled with blood. We report this rarely seen case with a review of the literatures.

A case of abnormally exposed nodular shaped-bronchial vessel occurred massive hemorrhage during bronchoscopy / 결핵

A 43 years old woman with a previous history of healed tuberculosis presented with a recurrent hemoptysis. On a broncoscopy inspection, three nodular shaped mass-like lesions (0.5cm in diameter) were found on the right lower lobar bronchus. Massive hemoptysis occurred when the specimen were taken during bronchoscopy. The bleeding could not be controlled by non-surgical treatment. Consequently, she underwent a right lower lobectomy in order to control the bleeding. The patient died of respiratory failure 3 days later. A brochoscopic biopsy revealed an abnormal blood vessel just beneath the bronchial respiratory epithelium.

A case of abnormally exposed nodular shaped-bronchial vessel occurred massive hemorrhage during bronchoscopy / 결핵

A 43 years old woman with a previous history of healed tuberculosis presented with a recurrent hemoptysis. On a broncoscopy inspection, three nodular shaped mass-like lesions (0.5cm in diameter) were found on the right lower lobar bronchus. Massive hemoptysis occurred when the specimen were taken during bronchoscopy. The bleeding could not be controlled by non-surgical treatment. Consequently, she underwent a right lower lobectomy in order to control the bleeding. The patient died of respiratory failure 3 days later. A brochoscopic biopsy revealed an abnormal blood vessel just beneath the bronchial respiratory epithelium.

Cases of hypothermia with Osborne's J wave on ECG / 대한내과학회지

Authors report two cases of hypothermic patients with Osborne's J wave on electrocardiogram. A 46-year-old male with liver cirrhosis was brought to the emergency room by ambulance due to comatous mental status. On exammination, the body temperature was below 35 degree C. By rewarming using warm normal saline intravenous infusion and hot pack application on the chest, his body temperature rose up to 36 degree C and regained consciousness. Later, he expired with afterdrop phenomenon. Another 41-year-old stuporous quadriplegic male with post-traumatic cerebral palsy was brought to the emergency room by his family complaining weakness and vomiting. On exammination, the body temperature was below 35degree C. He was rewarmed using warm normal saline intravenous infusion and hot pack application on the chest. However, he could not regain his normal body temperature and expired due to irreversible shock.

Comparison of serum lipid profiles and total antioxidant status in vegetarian and non-vegetarian groups / 대한내과학회지

BACKGROUND: Previous studies have demonstrated that modified or oxidized lipoproteins play a key role in the process of atherogenesis, particularly in hyperlipidemic individuals. Low density lipoprotein(LDL) is modified by oxygen free radical from damaged tissue or inflammatory cells. Further changes in the LDL molecule lead to an oxidized form (oxidized LDL), which is recognized by the macrophage scavenger receptor. Scavenger receptors on macrophages recognize and bind oxidized LDL. As uptake continues, the macrophages change to lipid-laden foam cells, the components of the fatty streak, which is the precursor atherosclerotic lesion. Antioxidants are known to prevent modification of LDL by free radicals and possibly also atheroma formation. This study was designed to compare the total antioxidant status and other lipid profiles in vegetarian and non-vegetarian groups in Korean adults to see the effect of diet modification on antioxidant status. METHODS: 174 vegetarian and 150 non-vegetarian male adults were recruited for lipid test including total cholesterol, triglycerides, HDL-cholesterol, LDL-cholesterol, lipoprotein(a), and total antioxidant status during annual routine physical examination. RESULT: 1) Total antioxidant status was significantly high in vegetarian group(1.390+/-0.288 mmol/L) compared to non-vegetarian group(1.155+/-0.290 mmol/L)(p< 0.001). 2) In non-vegetarian group, total antioxidant status was significantly low in smokers(1.041+/-0.288 mmol/L) compared to non-smokers(1.227+/-0.328 mmol/L)(p< 0.001). 3) Correaltions between lipid profiles and total antioxidant status in vegetarian and combined groups were not significant. CONCLUSION: Total antioxidant status in vegetarian group was significantly higher compared to non-vegetarian group. Among non-vegetarian group, smoker group showed lower total antioxidant status compared to non-smoker group. And there was no significant correlations between lipid profiles and total antioxidant status.

Safety of Percutaneous Right Coronary Intervention without Temporary Pacemaker: Prospective Study

BACKGROUND: The prophylactic use of temporary pacemaker during coronary intervention has been markedly decreased since 1980's. There is, however, few systematic report focusing on right coronary intervention in which temporary pacemaker would be most beneficial. Moreover, there has been marked development in coronary intervention recent years that risk and benefit of prophylactic pacemaker should be reconsidered. METHOD: We performed right coronary artery intervention without prophylactic use of temporary pacemaker in 100 successive patients in Samsung Medical Center. Patients with previous AV block and rotational atherectomy cases were excluded. The incidence of all complications and changes of blood pressure as well as heart rate during coronary intervention were examined prospectively. RESULTS: The lesion type was B2 or C in 52% and intracoronary thrombus was found in 18% of patients. Nevertheless, there was neither life threatening bradycardia nor new onset arrhythmia in any patient during right coronary intervention. CONCLUSION: These data suggest that omission of prophylactic use of temporary pacemaker may be safe in right coronary intervention only if excluding previous patients with high degree atrioventricular block and rotational atherectomy cases. This approach may reduce procedure time and cost as well as pacemaker-associated complications.

Change of Clinical Outcome in Patients with Unstable Angina according to Early Revascularization Therapeutic Strategy

BACKGROUND AND OBJECTIVES: It has been well known that the Braunwald classification is an appropriate clinical parameter in the prediction of the outcome in patients with unstable angina. However, the ability of the classification to predict prognosis of unstable angina according to treatment strategy is not established. We evaluated the relation between severity of angina on admission and outcome of primary unstable angina with early invasive strategy. MATERIALS AND METHOD: 148 patients (M 85, F 63, age 61+/-10) with suspected unstable angina were divided into three subgroups on the basis of the Braunwald classification on admission. The patients were followed up to 6 months prospectively if the final diagnosis was primary unstable angina. Early invasive strategy was used for the treatment of unstable angina. Major cardiac events were assessed during hospitalization and 6 months follow-up period according to the Braunwald classification. RESULTS: Unstable angina was diagnosed in 95 patients (64%). Among these patients, 89 patients with primary unstable angina were followed up to 6 months. Clinical characteristics including number of patients, mean age, sex ratio, risk factors, coronary angiographic findings and revascularization rate during hospitalization were not different in three subgroups of these patients. Among these patients, early coronary revascularizations was performed in 67 patients (75%) and 2 (2%) deaths/myocardial infarctions occurred during hospitalization. During the follow-up period, 1 (1%) myocardial infarction/death and 12 (13%) revascularizations occurred. Cardiac event rate (death, myocardial infarction or revascularization) was not different during hospitalization and 6 months follow-up period among subgroups of severity class. CONCLUSION: Clinical outcome should be reevaluated after early coronary intervention to predict cardiac event in patients with unstable angina.