Circadian variation of exercise test response and diagnostic significance of non-pharmacological provocation tests in patients with vasospastic angina / 대한내과학회지

BACKGROUND: Exercise tests (ET), hyperventilation tests (HVT) and cold pressor tests (CPT) have been used to induce coronary artery spasm. However their diagnostic significance and the circadian variation of exercise test response in patients with vasospastic angina are still uncertain. METHODS: To elucidate the circadian variation of ET response and to evaluate the diagnostic significance of non-pharmacological provocation tests, 21 consecutive patients with pure vasospastic angina were studied. Six ETs were performed in the early morning, late morning, and late afternoon in consecutive days, 2 HVTs and 2 CPTs in the early morning. The circadian distribution and types of angina (at rest, on physical activity, or both) from before admission to after discharge (mean follow-up periods 19+/-9 months) were evaluated by clinical history, clinical records and Holter recordings. Circadian distribution of anginal attacks recorded through the all observation periods were classified into 3 patterns (morning and night : MN, morning and afternoon or evening : M+F/E, morning, night and afternoon and/or evening : MN+F/E). RESULTS: One hundred and eleven ETs (39 early morning, 38 late morning, 34 late afternoon tests), 35 HVTs and 33 CPTs were performed. ETs showed 14 positive responses (36%) in the early morning, 14 (37%) in the late morning and 12 (35%) in the late afternoon without any circadian variation. Among the 11 patients who underwent all 6 exercise tests, 3 patients (27%) showed at least one positive response in the early morning, 4 (36%) in the late morning and 4 (36%) in the late afternoon. Subgroups of the subjects according to the types and activity of angina and the numbers of spastic artery also failed to show any circadian variation in ET response, but M+F/E group of circadian pattern of angina showed a peak of positive response in the early morning (p<0.05). HVTs showed significantly higher positive response (23/35, 66%, p<0.05) than ETs (14/39, 36%) and CPTs showed significantly lower positive response (2/33, 6%, p<0.01) than ETs in the early morning. Double tests with more than 1 positive response couldn't increase the positive response in ETs (9/19, 47%), and CPTs (2/14, 14%) but increased significantly in HVTs(15/16, 94%, p<0.05), particularly in the group with low activity (7/8, 86%, p<0.01). ETs showed ST segment elevation in 29 (72%) and depression in 11 (28%) of the 40 positive tests, HVTs in 21 (91%) and 2 (9%) of the 23 positive tests and CPTs in 2 (100%) and 0 (0%) of the 2 positive tests. The ST segment elevation was significantly higher in HVTs than in ET (p<0.05). CONCLUSION: These findings suggest that the exercise test in the early morning do not increase positive response and is not a sensitive diagnostic test associated with occasional depression of ST segment, but hyperventilation test, especially if repeated, is a very sensitive test with predominant elevation of ST segment in patients with vasospastic angina.

Initial and late results of Freedom coronary stent

OBJECTIVES: Initial and late results after implantation of Freedom stents, a balloon expandable stainless steel coil stents were evaluated. METHODS: From Jun. 1996 to Nov. 1997, we implanted 123 Freedom stents in 122 lesions in 117 patients and performed follow-up coronary angiograms at 7.0 3.6 months after stents placement. Clinical courses after stenting and follow-up coronary angiographic findings were evaluated. Comparison of clinical, angiographic, and procedural factors according to the presence or absence of restenosis was performed. RESULTS: In 117 patients who underwent stents implantation, major complications were not observed. Follow-up coronary angiograms were performed in 47 stents in 41 patients (35+ACU-). Among 47 stents, angiographic significant restenosis (percent diameter stenosis +AD4- 50+ACU-) was observed in 13 (28+ACU-). Mean age in 41 patients was 59 9 years, with 27 male patients (66+ACU-). Indications for stents implantation were de novo lesions in 18 (38+ACU-), suboptimal results after PTCA in 18 (38+ACU-), bail-out lesions in 4 (9+ACU-) and restenotic lesions in 7 (15+ACU-). Lesion types by AHA/ACC classification were A in 1 (1+ACU-), B1 in 10 (21+ACU-), B2 in 17 (36+ACU-), and C in 19 (40+ACU-). Average lesion length was 13.7 9.0 mm, stent diameter 3.0 0.3 mm, and stent length 24.6 9.0 mm. There were no significant differences of the clinical, angiographic, and procedural characteristics according to the presence or absence of restenosis. CONCLUSION: Freedom coronary stents implantation is safely performed in various morphology of coronary lesions and no significant predictive factors on restenosis in follow-up coronary angiogram were observed.

Diagnostic Significance of ECG Ergonovine Provocation Test in Patients with Vasospastic Angina

BACKGROUND: The diagnostic significance of ECG ergonovine test and the incidence of vasospastic angina in patients with chest pain are still uncertain. METHODS: From May 1998 to June 1999, 133 consecutive patients with chest pain were admitted for diagnostic coronary angiography. ECG ergonovine provocation tests were performed in 64 patients who have a clinical history suggesting vasospatic angina, including 27 of 28 patients with vasospastic angina documented electrocardiographically, or who's coronary angiographic findings could not be explained by their clinical history. Ergonovine was administered intravenously in incremental dose of 0.05, 0.1, 0.2, 0.3, 0.4 mg up to total cumulative dosage of 1.0mg during coronary angiography(41 cases), in the exercise laboratory(21 cases) or both(2 cases). RESULTS: Of 133 patients with chest pain, vasospastic angina was documented in 32(24%), unstable angina in 52(34%), stable angina in 10(8%), and others in 39(29%). Angiography demonstrated coronary spasm in 4 additional patients as well as 22 patients with vasospastic angina documented electrocardiographically, but ergonovine tests in the exercise laboratory showed positive response in 5 of 6 patients with vasospastic angina documented. Among the 25 patients with coronary spasm proved angiographically during ergonovine test, ECG findings at the time of coronary spasm were ST segment elevation in 21(84%), depression in 1(4%) and no change in 3(12%) patients, who had branch vessel spasm, 3 vessel spasm or incomplete spasm on coronary angiogram. Of the 31 patients with vasospastic angina who underwent ergonovine tests, positive response occurred in 24(77%) after a cumulative dose of 0.4mg. However the other 4(13%) had no ECG changes even after the higher dose(>0.4mg) of ergonovine. CONCLUSION: This results suggest that vasospastic angina appear to be a common cause of chest pain, and ECG ergonovine test with high dose can improve diagnostic sensitivity but cannot detect some patients with vasospastic angina.

Long-term Circadian Patterns of Angina Attacks and Non-pharmacological Provocation Tests Responses in Patients with Vasospastic Angina

BACKGROUND AND OBJECTIVES: The relationship of cold pressor, hyperventilation and exercise test responses to circadian patterns and types of angina in vasospastic angina have still not been known. The aim of this study was to identify subgoups of patients who have similar clinical features and provocation test response. MATERIALS AND METHODS: Twenty-one consecutive patients with pure vasospastic angina were studied. Six exercise tests were performed in the early morning, late morning, and late afternoon in consecutive days, and 2 hyperventilation tests and 2 cold pressor tests in the early morning. Circadian distribution and types of angina(at rest, on physical activity or both) were evaluated by clinical history, clinical records and ambulatory ECG recordings during admission and follow-up periods(mean 19+/-9 months). RESULTS: Three patterns of circadian distribution of anginal attacks were identified during all observation periods together(morning and night: MN n=, morning and afternoon or evening: M+/E n=, morning, night and afternoon and/or evening: MN+/E n=1). Exercise test was positive in 36%(40/111) without circadian variation, hyperventilation test in 66%(23/35) and cold pressor test in 6%(2/33). Neither hyperventilation test nor cold pressor test was related to circadian patterns, types or activity of angina, or numbers of spastic artery. But positive exercise test increased significantly in patients with angina on physical activity(43% vs 21%, p<0.05), high activity(57% vs 18%, p<0.01), multivessel spasm(50% vs 27%, p<0.05 ) and circadian patterns of M+/E and MN+/E(29%, 55% vs 4%, p<0.05, p<0.01). All patients with MN had rest angina and single vessel spasm. All 6 patients with M+/E had angina both at rest and on physical activity and 5 single vessel spasm. Eight of 11 patients with MN+/E had angina both at rest and on physical activity and 8 multivessel spasm. CONCLUSION: These findings suggest that hyperventilation test is highly sensitive in vasospastic angina without any relationship to clinical features, but exercise test response is related well to circadian patterns of angina attacks which are associated with characteristic clinical features.

A Case of Acute Purulent Pericarditis with Pericardial Performation by Esophageal Foreign Body

Purulent pericarditis is an infrequent but fulminant and frequently lethal disease. Purulent pericarditis tends to occur as direct extension of bacterial pneumonia or empyema in past. In recently, purulent pericarditis tends to occur in adult via contiguous spread from an early postoperative infection after thoracic surgery or trauma, infection related to infective endocarditis, extension from a subdiaphragmatic suppurative source, and hematogenous spread during bacteremia. Endogenous causes of purulent pericarditis are frequently characterized as esophageal perforations. Common causes of esophageal perforations related to purulent pericaditis which usually develop in association with mediastinitis, pneumonia and empyema include corrosive esophagitis, complication after esophageal and tracheal instrumentation and Boerhaave's syndrome. There is very little reference to the development of pericarditis in associated with esophageal perforation which does not directly communicate with the pericardium. while, although most uncommon, it is well documented that the esophagus can perforate directly into the pericardium and produce pericarditis. We experienced a case of acute purulent pericarditis after esophageal and pericardial perforation by a small fish bone in a previously healthy man. The patient was treated successfully with systemic antibiotics and pericardiotomy.

Changes of the carotid artery Doppler flow velocity pattern after sublingual nitroglycerin in patients with hypertension

OBJECTIVE: To evaluate the applicability of carotid Doppler echography for the assessment of changes of peripheral hemodynamics in the hypertensives. SUBJECTS: 28 hypertensives (17 males, 11 females), mean age of 64 yrs and 40 normal controls (24 males, 16 females) mean age of 49 yrs. METHODS: We recorded the right common carotid arterial Doppler flow velocity (BFV) pattern and measured the peak velocities of the percussion wave (P) and late rising tidal wave (T), the ratio of the two (P/T), the time interval between the two peaks corrected by heart rate (P-Tc), systolic flow velocity integral (FVI) and carotid artery diameter (CAD) before and after 0.4 mg dose of subligual nitroglycerin (NTG). RESULTS: 1) In hypertensives, the P wave velocity showed lower and P-Tc interval shorter than those of the normal controls at baseline. 2) After NTG, the P-Tc and P/T increased, but the T and FVI decreased significantly in both groups of subjects. 3) The P/T ratio was less significantly increased after NTG in the hypertensives than in the controls. These results suggest that NTG might have been involved in concomitant reduction and delay of the wave reflection from the peripheral vessels, preferentially in the normal subjects than in hypertensives. CONCLUSIONS: The carotid Doppler echography can be useful for the evaluation of the changes of hemodynamics in the peripheral vessel such as carotid artery in hypertensive subjects.

Initial and Follow-up Results of Freedom (TM) Stent

BACKGROUND: The Freedom (TM) stent, which is one of recently developed balloon-expandable coil stents, has advantages of low profile and good trackability and flexibility. We evaluated the initial results and the late restenosis rate of Freedom (TM) stent in patients with coronary artery disease. METHOD: A total of 40 Freedom stents were implanted in 32 consecutive patients (38 lesions). The clinical diagnosis of the subjects were stable angina in 1 patient, unstable angina in 19, and acute myocardial infarction in 12. The indications of stenting were primary stenting in 11 stents, suboptimal result after PTCA in 26, and bailout procedure in 1. A mean diameter of reference artery was 3.1 mm (SD, +/-0.4) and mean of lesion length was 10.9 mm (SD, +/-5.6). Stents were implanted with a mean maximal balloon pressure of 12.1 atm (SD, +/-2.2). Follow-up angiography was done at least 3 months (mean duration, 8.7+/-3.7) after stenting for 28 lesions of 22 patients. RESULTS: All 40 stents were implanted safely except one, which was complicated with side branch occlusion. There was no case of stent thrombosis and clinical success rate was 97% (31/32). Minimal luminal diameter (MLD) was increased from 0.7 (SD, +/-0.4) to 3.0 mm (SD, +/-0.4) and % of diameter stenosis (%DS) was decreased from 78 (SD, +/-13) to 2% (SD, +/-5) immediately after stenting. The overall restenosis rate was 28% (8/28). The restenosis rate was increased in the complex lesions (complex, 38% vs simple, 0%: p=0.05) and lesion of small vessel ( or = 3.0 mm, 20%:p=0.11). CONCLUSION: FreedomTM stent is safe and feasible in patients with various morphology of coronary lesions including small and tortuous arteries, and in lesion associated with side branches. But lesions of small vessel and complex morphology are tend to be associated with higher rates of restenosis.

Patterns of Exercise-induced Coronary Spasm in Patients with Variant Angina: Results, Correlation with Clinical Features

BACKGROUND: Exercise-induced coronary spasm is occasionally recognized in patients with variant angina, but the patterns of exercise-induced coronary spasm and its relation to clinical features are still not clear. METHODS: Eight consecutive patients with variant angina without significant stenosis of the coronary artery performed serial treadmill exercise tests during early morning, late morning, and in the afternoon. The subjects repeated the tests after administration of atropine and doxazosin or phentolamine. RESULTS: (Upon drug administration), anginal episodes with ST-segment changes (elevation 5, depression 1) Occurred repeatedly in 6 of the 8 patients during early morning; the episodes occurred in only 2 patients during the afternoon exercise test. Four patients showed exercise-induced angina and ST-segment changes during early morning but not in the afternoon, and 2 of them showed mild episodes of exercise-induced angina and ST-segment changes during late morning. Three of the four patients had the characteristic clinical history of angina in early morning during usual activities but not during daytime activities despite the activities being more strenuous. Another 2 patients showed both exercise-induced ST-segment elevation and angina in early morning and afternoon, and they had the characteristic history of more episodes at night and in early morning but only occasionally in the daytime with or without relation to activity. One of the two patients showed intermittent ST-segment elevation during the exercise test. The other two patients had exercise-induced episodes neither in the early morning nor in the afternoon; they had a characteristic history of episodes only at night during sleep but never in the early morning nor in the daytime. Atropine did not suppress the exercise-induced angina in 4 of 5 patients studied. Doxazosin or phentolamine suppressed the exercise-induced episodes in 3 of 5 patients studied but aggravated spontaneous episodes in 3 patients. CONCLUSION: These data suggest that there's possibility of presence of different patterns of exercise-induced coronary spasm, which may be induced by different mechanisms from those in spontaneous episodes in patients with variant angina.

A Case of Torsade de Pointes after Treatment with Terfenadine and Ketoconazole

Torsade de pointes (TdP) is a form of polymorphic ventricular tachycardia that is associated with prolongation of the QT interval. Although it occurs in many clinical settings, torsade de pointes is most commonly caused by drugs. The second generation antihistamines, including terfenadine and astemizole, have little sedation or other adverse effects on the CNS. They have been used widely to treat various allergic diseases, but it has been reported that overdoses or combinations with antifungal agents or macrolide antibiotics may lead to TdP. We report a case of TdP that occured during com-bination therapy of terfenadine and ketoconazole.

Arotic Atherosclerotic Plaques as a Potential Embolic Sources in Patients with Cryptogenic Stoke

BACKGROUND: The atherosclerotic plaque in the thoracic aorta has been considered as a potential source of cerebral or peripheral embolization. Especially, complex type of atherosclerotic plaques in the thoracic aorta have strongly been associated with cerebral embolism in ischemic stroke and transesophageal echocardiography(TEE) is a useful diagnostic tool for evaluation of thoracic aorta atherosclerosis. The aim of this study was to evaluate the prevalence and significance of complex type of thoracic atherosclerotic plaques in the patients with cryptogenic stroke who have neither cardiac source nor significant carotid atherosclerosis. METHOD: From 1993 to 1998, TEE and carotid Doppler sonography were performed in 58 consecutive patients with ischemic stroke and in 30 control patients without ischemic stroke. We divided the former into two groups. One is known-cause stroke(n=37) group and the other is Cryptogenic stroke group(n=21). We evaluated cardiogenic source of embolism, thoracic aorta atherosclerotic plaques as well as carotid atherosclerosis by carotid Doppler sonography and TEE. Aortic atherosclerosis was classified as grade 1: normal-appearing aortic intima, grade 2: extensive intimal thickening, grade 3: sessile atheroma protruding 5mm, and grade 5: mobile atheroma. Carotid atherosclerosis was categorized as significant if luminal stenosis of either common carotid artery or internal carotid artery is greater than 50%. RESULTS: 1) There was no statistically significant difference among the three groups in age, gender, diabetes mellitus, hyperlipidemia and smoking. 2) Hypertension was more common in the cryptogenic stroke group(p<0.05). Atrial fibrillation was more common in the known-cause and control group than in the cryptogenic group(p<0.005). 3) The carotid atherosclerosis was found in 7(12%) out of 58 consecutive patients with ischemic stroke. 4) The thoracic aortic atherosclerotic plaque was located primarily on descending aorta. The complex type of plaque was found in 8(38%) out of 21 patients with cryptogenic stroke. The complex type of plaque was found in 10(27%) out of 37 patients with known-cause stroke. The complex type of plaque was found in 3(10%) out of 30 patients with known-cause stroke. CONCLUSION: These results suggest that complex type of thoracic atherosclerotic plaques in cryptogenic stoke can be considered as potential source of ischemic stroke and we suggest that a patient with cerebral embolism without a source identified by the routine transthoracic echocardiograpy or carotid sonography shoud undergo transesophageal echocardiography to evaluate the thoracic aorta atheroma.

A Case of Descending Thoracic Aortic Pseudoaneurysm Associated with Thoracolumbar Pedicle Screw Removal

Vascular injuries after spine surgery may result in acute life-threatening hemorrhage, chronic arteriovenous fistula, or pseudoaneurysm formation. The interval between injury and rupture may range from seconds to years, and accordingly, a high index of suspicion is needed to make the diagnosis. Although acute and delayed vascular injury caused by placement of posterior pedicle screw fixation has been reported, the potential for large vessel disruption during posterior pedicle screw removal has been rarely reported. This case report concerns a 50-year-old man who developed an descending thoracic aortic pseudoaneurysm after posterior pedicle screw removal, diagnosed by chest computed tomography(CT) scan and transesophageal echocardiography(TEE).

Usefulness of Dobutamine Stress Echocardiography for Identification of Viable Myocardium in Acute Myocardial Infarction

BACKGROUND: In patients with acute myocardial infarction(MI), dysfunctional myocardium at rest after successful reperfusion may represent either necrotic or viable myocardium. And the latter can be recovered contractility after revascularization or medication. OBJECTIVE: To evaluate the efFectiveness of the dobutamine stress echocardiography(DSE) for identifying viable but dysfunctional myocardium in acute MI before revascularization. METHOD: Twelve patients with acute MI after thrombolytic therapy underwent Tc-99m-tetrofosmin dipyridamole myocardial SPECT(Single Photon Emission Computed Tomography) and DSE before coronary angiography in 7~12 hospital days, and they were followed up for recovery of contractile reserve by two-dimensional echocardiography after revascularization procedure or medication. Regional wall motion abnorrnality was scored from l(normal) to 4(dyskinesia). Dobutamine responsiveness was defined as irnprovement or aggravation of regional wall motion in dyssynergic segment during any stage of dobutamine infusion. Reversible ischemia by SPECT was defined as increased perfusion defect after dipyridamole and interpreted by radiologist. Dobutamine responsiveness on DSE and reversible ischemia on myocardial SPECT were matched and compared each other. RESULTS: Of 69 dyssynergic segments, 38(55%) recovered contractility during follow up echocardiography after revascularization or medication. In 30(79%, sensitivity) of these latter segments, regional wall motion had changed during dobutamine. However, 31(45%) did not recovered contractility and 25(81%, specificity) of thern had not changed during dobutamine. Of 36 dobutamine responsive dyssynergic segments, 30(83%, positive predictive accuracy) had recorved contractility. In 25(76%, negative predictive accuracy) of 33 dobutamine non-responsive segments had not recovered contractility. Reversible ischemia on myocardial SPECT showed less sensitive(67%) and specific(56%) for detection of potentially recoverable myocardium than DSE. And positive(68%) and negative predictive accuracy(56%) also showed significantly lower than DSE. CONCLUSION: DSE can identify dyssynergic but recoverable myocardial segement for risk stratification before intervention in acute MI. Dobutamine responsiveness of dyssynergic segment is superior to reversible ischemia on myocardial SPECT for prediction of wall motion improvement after MI irrespective of intervention or medical therapy.

Two Cases of Asymptomatic Ruptured Aneurysm of the Sinus of Valsalva Confirmed by Transesophageal Echocardiography

Ruptured aneurysm of sinus of Valsalva is an uncommon congenital lesion, which was first reported in 1840 by Thurman. Its incidence is representing up to 3.5% of patients undergoing congenital heart disease surgery. Predominant symptoms are dyspnea, palpitation, and chest pain, present above the half. An early diagnosis is helpful because of the favorable surgical prognosis. Echocardiography remains useful in detecting abnormalities, and provides important information prior to cardiac catheterization and surgery. Cardiac catheterization and angiography are necessary for diagnosis of receiving chamber and associated lesions such as ventricular septal defect, aortic regurgitation, and other congenital abnormalities. The effective treatment is surgery. Without operation, cause of death are heart failure or bacterial endocarditis. We report two cases of asymptomatic ruptured aneurysm of sinus of Valsalva, confirmed by transesophageal echocardiography, and cardiac catheterization. The corrective surgery was performed without complication.

A Case of Malignant Mesenchymoma of the Heart

Malignant mesenchymomas by definition are composed of two or more cellular types that would ordinarily derive from primitive mesenchyme. They grow rapidly, recur frequently, metastasize, and can be found in a wide variety of locations. Malignant mesenchymomas as primary cardiac tumor are extremely rare with poor prognosis. Only 15 cases of cardiac malignant mesenchymoma were reported in worldwide literature in 1961-1992. We report a case of primary cardiac malignant mesenchymoma in 58 year-old female patient admitted due to hemoptysis and mild exertional dyspnea.

A Case of Takayasu's Arteritis Associated with Stenosis of Both Subelavian Arteries and Both Renal Arteries

Takayasu's arteritis(TA) is a nonspecific areritis of unknown etiology affecting segmentally the aorta and its main branches, which result in stenosis, occlusion or aneurysm of involved arteries. The clinical manifestations present with a variety of symptoms such as headache, dyspnea on exertion, pain and weakness of extremities, pulse deficit, and hypertension according to involves arteries. Usually it can be managed by medical or surgical treatment, and recently by percutaneous transluminal balloon angioplasty. The type III classified by Lupi-Herrena and associates is the most frequent variety of TA. However the case of type III involving both subclavin arteries and both renal arteries has rarely been reported. We experienced a case of TA involving both subcalvian arteries, and both renal arteries presented with paroxysmal hypertension and right flank pain, in which the stenosis of both subclavian arteries were managed by percutaneous transluminal balloon angioplasty and the stenosis and occlusion of both renal arteries were successfully managed by aorto-renal bypass surgery with autogenous right iliac artery and synthetic vessel(Gortex). The patient was discharged uneventfully.

Left Ventricular Systolic Function Indexes by Echocardiography in Hypertensive Subjects

BACKGROUND: The evaluation of cardiac performance is very important to management and prognostication in hypertensive patients. Although ejection phase indexes have been used for assessing left ventricular systolic function they are highly dependent on cardiac loading conditions. In addition, these load-dependent indexes may not differentiate accurately between the effects of altered loading canditions and intrinsic abnormalities in contractile function of cardiac muscle. In recent years, the end-systolic pressure to volume of dimension relations have emerged as a reliable measure of the myocardial contractility. The authors studied the changes of end-systolic pressure to volume or dimension relations according to pre-load and after-load by using the Echocardiogram. METHODS: By 2-D and M-mode Echocardiogram we measured the ratio of end-systolic wall stress to end-systolic volume index(EWS/ESVI), peak systolic pressure or end-systolic dimension of left ventricle(PSP/ESD), peak systolic pressure to end-systolic volume index(PSP/ESVI) to assess myocardial contractility in 139 normal subjects and 55 patients with untreated essential hypertension. Then we compare these indexes to systemic blood pressure & left ventriclular end-diasolic dimension. RESULTS: 1) EF, %FS, and mVcf were similar in both groups, but PSP/ESD, PSP/ESVI, EWS/ESVI for the hypertensive group were greater than that for the normal group. 2) There was poor relation between arterial blood pressure and EWS/ESVI than oter load independent indexes in both groups. 3) There was poor reation between left ventricle end diastolic dimension than oter load independent indexes in both groups. CONCLUSION: The ratio of end-systolic wall stress to end-systolic volume index(EWS/ESVI) is a relible load independent index to assess myocardial contractility in hypertension.

Two Cases of Cor Triatriatum Associated with Acute Onset Dyspnea in Old Age

Cor triatriatum is a rare congenital heart disease. In the calssic form the left atrium is divided into two chambers by a fibromuscular diaphragm covered by endocardium. The dorsal chamber receives the pulmonary veins, and the ventral chamber gives rise to the left atrial appendage and leads to the mitral valve. Even though the calssic case of cor triatriatum clinically looks like pulmonary venous obstruction, the association, location, and size of the ASD, as well as other cardiac anomalies, may influence symptoms, making the diagnosis difficult. The diagnosis of cor triatriatum is made chiefly from two-dimensional echocardiography and transesophageal echocardiography. The diagnosis can be established by the surgical exploration. In this paper we will report two cases of non-obstruction or triatriatum and review of literature was made.

A Case of Cerebral Mycotic Aneurysm Complicated with Subarachnoid Hemorrhage due to Infective Endocarditis

The relationship between infective endocarditis and mycotic aneurysm formation appers clear : In about two to ten percent of patients with infective endocarditis harbor septic intracranial aneurysms. But the pathogenesis, natural course and management of these lesions remains controversial. Aggressive medical treatment of the underlying infected cardiac valve or surgical replacement therapy have significantly reduced the morbidity and mortality rates associated with infective endocarditis. Clinical predictors of mycotic aneurysm, especially neurologic prodromes prior to rupture have been ill-defined since most series contain few patients or include patients with infective aneurysms who have no infective endoarditis. Similarly there has been no consensus regarding the indications and timing of cerebral angiography in patients with infective endocarditis. We have experienced a case of cerebral mycotic aneurysm complicated with subarachnoid hemorrhage due to infective endocarditis in a 29 year-old female patient, who admitted to our hospital because of the pain and paralysis of sudden onset in right forearm, which was diagnosed by echocardiography, brain computed tomography and 4-vessel cerebral angiography. The patient died of sudden rupture of mycotic aneurysm in the 7th hospital day despite intensive medical treatment. We report one case of cerebral mycotic aneurysm with a brief of literature.

Relation of Left Ventricular Mass to Body Size and Left Ventricular Wall Stress in Normal Adults

BACKGROUND: Increased left ventricular mass in patients with essential hypertension, coronary artery disease, chronic renal failure or in general population has been suggested as a useful predictor of increased cardiovascular morbidity and mortality. Many studies have reported that left ventricular mass is correlated postively with body size. Thereafter normalization of left ventricular studies, but it is uncertain which is appropriate. This study was designed to determine the appropriate method for normalization of left ventricular mass to exclude influence of body size in normal adults. METHODS: We measured left ventricular mass 100 normal adults by M-mode echocardiogram using ASE cube method without(Devereux and Reichek's method) and with correction(Devereux and Alonso's method). Left ventricular mass were normalized for body weight, height, body surface area, body surface area1.5, height2.0 and height2.7 RESULTS: 1) Left ventricular mass by Devereux and Reichek's method correlated well with that by Devereux and Alonso's method(r=1.0,p<0.001). 2) Corrected left ventricular mass correlated well with weight(r=0.64, p<0.001), height(r=0.49, p<0.05), body surface area(r=0.53, p<0.01) and body mass index(r=0.58, p<0.001). 3) Correlation coefficients of left ventricular mass/weight with weight, of ventricular mass/height with height, of ventricular mass/height2.0 with height, of ventricular mass/height2.7 with height, of ventricular mass/body surface area with body surface area and of ventricular mass/body surface area1.5 with body surface area were 0.12, -0.05, -0.29, -0.42, 0.13 and -0.11 respectively. 4) Peak systolic wall stress correlated with age and left ventricular mass, but end systolic wall stress did not correlated with left ventricular mass. CONCLUSIONS: The current indexation method of left ventricular mass for height may reduce the variability associated with body size. Furthermore, it could be used reliably in normal Korean adults.

Transesophageal Echocardiographic Evaluation for Potential Sources of Embolism in the Patients with Ischemic Stroke

BACKGROUND: It has been reported that about one-sixth of all cerebral infarcts are due to cerebral embolism of cardic origin. But transthoracic echocardiographic examination(TTE) of patients with embolic strokes has made low yield for identifying the cause of cardiac or extracardiac source of embolism. Recently, transesophageal echocardiography(TEE) has been proved to be more sensitive than TTE for that purpose. We have studied to detect the potential sources of embolism and to asess the diagnostic yield of TEE in the patient with ischemic strokes. METHOD: Thirty-nine patients with recent cerebral ischemic events(19 men, 20 women, mean age 61), and thirty-eight control patients with other cardiac disease(14 men, 24 women, mean age 52) were examined by both TTE and biplane TEE. For detection of patent foramen ovale, transesophageal contrast echocardiography using 10 ml of agitated saline was performed in all patients. Thoracic aorta, arch of aorta, and ascending aorta were examined during pull back of esophageal probe. RESULTS: 1) TEE is superior to TTE for detection of potential sources pf embolism in the ischemic stroke patients(82 vs 21%, p < 0.001). 2) The potential sources of embolism diagnosed by TEE in the ischemic stroke patients were as follows : 18 aortic atherosclerotic plaque or clot, 11 left atrial(LA) spontaneous echo contrast, 8 LA appendage thrombus, 6 LA thrombus, 6 atrial septal aneurysm, 6 mitral stenosis, 3 patent foramen ovale and 1 prosthetic valve. 3) TEE is the unique procedure to diagnose aortic lesions, LA spontaneous echo contrast, atrial septal aneurysm and patent foramen ovale. 4) The incidence of the aortic lesions by TEE is significantly higher in the patients with ischemic stroke than in the controls(46 vs 11%, p < 0.01). CONCLUSION: Transesophageal echocardiography is useful for detection of potential cardiac and extracardiac sources of embolism compared with TTE and is a unique method for diagnosing aortic atherosclerotic lesion, left atrial spontaneous echo contrast, atrial septal aneutysm, patent foramen ovale and small left atrial appendage thrombus.