Improved intra-atrial conduction delay after successful ablation for atrial fibrillation by scar homogenization in right atrium.

Atrial fibrosis in the right atrium (RA) presenting as a low-voltage zone might be the mechanism of atrial fibrillation (AF) and intra-atrial conduction delay. The impact of scar homogenization in RA on intra-atrial conduction delay is unknown. We describe a patient with paroxysmal AF and significant intra-atrial conduction delay with repetitive atrial flutter, triggered from the lateral free wall in the RA between the significant low-voltage zone and slow conduction area after pulmonary vein isolation. Linear ablation along the trabeculated lateral free wall in the RA to homogenize the scar was successfully performed, and the intra-atrial conduction delay improved ultimately.

Ventricular fibrillation and sudden cardiac arrest in apical hypertrophic cardiomyopathy: Two case reports.

BACKGROUND: Apical hypertrophic cardiomyopathy (HCM) is considered to have a benign prognosis in terms of cardiovascular mortality. This serial case report aimed to raise awareness of ventricular fibrillation (VF) and sudden cardiac death (SCD) in apical HCM. CASE SUMMARY: Here we describe two rare cases of apical HCM that presented with documented VF and sudden cardiac collapse. These patients were previously not recommended for primary prevention using implantable cardioverter-defibrillator (ICD) therapy based on current guidelines. However, both received ICD therapy for the secondary prevention of SCD. CONCLUSION: These cases illustrate serious complications including VF and aborted sudden cardiac arrest in apical HCM patients who are initially not candidates for primary prevention using ICD implantation based on current guidelines.

Angiotensin-Converting Enzyme Inhibitors Provide Better Long-Term Survival Benefits to Patients With AMI Than Angiotensin II Receptor Blockers After Survival Hospital Discharge.

AIM: Renin-angiotensin-aldosterone system inhibitors (RASIs) are widely used in high-risk cardiovascular (CV) diseases, including acute myocardial infarction (AMI). However, it is not yet clear which class of RASIs provides specific benefits to patients with AMI. The present study aimed to evaluate whether angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II type 1 receptor blockers (ARBs) had any different effects on long-term CV and all-cause mortality in patients with AMI who received either agent from admission and were discharged alive from the hospital. METHODS: We analyzed data of patients with AMI from the Korea Acute Myocardial Infarction Registry-National Institutes of Health registry. Cardiovascular and all-cause mortality at 12 months after AMI were assessed. RESULTS: Among 12 481 patients with AMI who were discharged alive, RASI treatment was as follows: ACEIs (n = 5910), ARBs (n = 4009), and no RASI (n = 2562). After adjustment for multiple factors, compared with no RASI therapy, ACEI therapy was associated with lower hazard ratios (HRs) for 1-year CV and total mortality rates, whereas ARB therapy was not. In a direct comparison, compared with ARB treatment, ACEI treatment was associated with lower HRs (95% confidence interval) for CV and total mortality: 0.562 (0.420-0.753) and 0.567 (0.451-0.713), respectively. The superiority of ACEI to ARB was also observed across several subgroups. The mortality differences between the 2 treatment groups were reproduced in a propensity-score matched analysis (n = 2855 each). CONCLUSIONS: Our study of a recent AMI registry data revealed that ACEI therapy in patients with AMI was associated with better long-term survival benefits than ARB therapy.

Early Response after Catheter Ablation of the Epicardial Substrate in a Patient with Brugada Syndrome Can Be Predicted by High Precordial Leads.

A 52-year-old male with Brugada syndrome presented with repeated and appropriate shock from an implantable cardioverter defibrillator (ICD). Catheter ablation for substrate elimination targeting low-voltage, complex, and fractionated electrocardiograms and late potentials in the epicardial right ventricular outflow tract was successfully performed. Brugada phenotype in the right precordial leads from the third intercostal space disappeared in the early stage after catheter ablation and that from the standard fourth intercostal space disappeared later. He remained free from ventricular fibrillation over the next fourteen months. We suggest that this novel ablation strategy is effective in Brugada syndrome patients with ICD, and early response after catheter ablation can be predicted by high precordial leads.

Torsades de Pointes associated with QT prolongation after catheter ablation of paroxysmal atrial fibrillation.

A 79-year-old woman who underwent catheter ablation for paroxysmal atrial fibrillation presented with Torsades de Pointes (TdP). Aggravation of prolonged QT interval which is most likely due to neural modulation by catheter ablation, played major role in the initiation of TdP. The patient was successfully treated with isoproterenol during acute stage and discharged after stabilization without implantation of permanent pacemaker or implantable cardioverter defibrillator.

Newly developed post-operative atrial fibrillation is associated with an increased risk of late recurrence of atrial fibrillation in patients who underwent open heart surgery: Long-term follow up.

BACKGROUND: Herein is sought to determine whether the occurrence of post-operative atrial fibrillation (POAF) increases the risk of late recurrence of atrial fibrillation (AF) in patients undergoing open heart surgery (OHS). METHODS: This study included 938 patients (56.7 ± 13.1 years old, 550 males) with no history of AF who underwent OHS. All patients were monitored continuously for development of POAF after surgery until the time of hospital discharge and received clinical follow up with serial evaluation of rhythm status. RESULTS: Among the total population, POAF occurred in 207 (22.1%) patients and late AF in 88 (9.4%) patients during the mean follow up period of 78.1 ± 39.1 months. Development of late AF oc¬curred more frequently in patients with POAF than in those without [29.0% (60/207) vs. 3.8% (28/731), p < 0.01]. Higher septal E/e' ratio (HR 1.04, 95% CI 1.00-1.08, p = 0.04) was an independent predic¬tor of late occurrence of AF and an episode of POAF (HR 27.12, 95% CI 8.46-86.96, p < 0.01) was the most powerful predictor. CONCLUSIONS: POAF is significantly associated with an increased risk of late AF recurrence during long-term follow up. Careful concern regarding late recurrence of AF with serial evaluation of rhythm status is required in patients with POAF.

The role of insulin resistance and metabolic risk factors on culprit coronary plaque.

BACKGROUND: Detailed relationships between insulin resistance (IR) and vulnerable plaque are not clear, therefore, we sought the role of IR and metabolic risk factors on culprit coronary plaque. METHODS: Plaque components at a region of interest (ROI, 10mm) were analyzed by virtual histology intravascular ultrasound. IR was defined as quantitative insulin sensitivity check index (QUICKI) ≤ 0.33. Seven metabolic risk factors (5 risk factors for metabolic syndrome defined by ATP III, history of smoking, and hsCRP) for IR were determined. RESULTS: The data for 150 (males 104) patients were analyzed. Patients with IR (n = 69) had greater necrotic core (NC) at the ROI (21.2 ± 15.8mm(3) vs 15.7 ± 11.9 mm(3), p = 0.02) than in patients without IR (n = 81). The NC at the ROI was correlated with QUICKI (r = -0.16, p = 0.05), HbA1c (r = 0.24, p < 0.01), body mass index (r = 0.17, p = 0.04), presence of diabetes mellitus (r = 0.29, p < 0.001), hsCRP (r = 0.17, p = 0.04) and the numbers of risk factors for IR (r = 0.41, p < 0.001). The multivariate analysis revealed that the numbers of risk factors for IR was an independent factor for the NC at the ROI (beta coefficient = 0.44, p = 0.003), but QUICKI was not (beta coefficient = -0.01, p = 0.94). CONCLUSIONS: Instead of a single measurement of IR index or each metabolic risk factor, clustering of risk factors for IR plays an important role on plaque vulnerability. CONDENSED ABSTRACT: We investigated the role of insulin resistance (IR) on culprit coronary plaque. Patients with IR had a greater amount of necrotic core in culprit coronary lesions than in patients without IR. Rather than a single measurement of IR index or each metabolic risk factor, clustering of metabolic risk factors for IR plays an important role in plaque vulnerability in patients with coronary artery disease. Our study demonstrates the role of IR on culprit coronary plaque and highlights the importance of the clustering of metabolic risk factors for IR in vulnerable plaque pathogenesis.

Functional class and targeted therapy are related to the survival in patients with pulmonary arterial hypertension.

PURPOSE: Pulmonary arterial hypertension (PAH) is an orphan disease showing poor prognosis. The purpose of study was to evaluate clinical factors influencing outcomes in PAH. MATERIALS AND METHODS: Patients who were diagnosed with PAH at a single center were reviewed retrospectively. Forty patients (34.9±14.5 years, 80% of female) were enrolled. RESULTS: Causes were congenital heart disease in 24 (60%), connective tissue disease in 8 (20%) and idiopathic PAH in 6 (15%). Sixteen patients (40%) were WHO functional class III or IV at the time of diagnosis. Twenty seven patients (67.5%) received molecular targeted therapy. During follow-up (53.6±45.5 months), 10 patients (25%) died and 1-, 2-, and 8 year survival rates were 91.3%, 78.7%, and 66.8%, respectively. As expected, median survival of patients with functional class I or II were significantly longer than patients with III or IV (p=0.041). Interestingly, patients with molecular targeted therapy showed longer survival than conventional therapy (p=0.021). CONCLUSION: WHO functional class at the time of diagnosis was the strong predictor of survival, and molecular targeted therapy could significantly improve the survival. Therefore, early screening and intensive management would be crucial to improve the prognosis in the patient with PAH.

Early repolarization is associated with atrial and ventricular tachyarrhythmias in patients with acute ST elevation myocardial infarction undergoing primary percutaneous coronary intervention.

BACKGROUND: Recent studies found that early repolarization (ER) is significantly more common in survivors of aborted sudden cardiac death. We hypothesized that ER might be more common in patients with ST elevation myocardial infarction (STEMI) who have complications of atrial and ventricular arrhythmias. METHODS: This study included 266 patients with acute STEMI undergoing primary percutaneous coronary intervention. Twelve-lead electrocardiograms were analyzed for ER, defined as J-point elevation ≥ 0.1 mV and "notching" and "slurring" of the terminal part of the QRS complex in at least 2 lateral or inferior leads. Acute and late atrial and ventricular arrhythmic events were evaluated. RESULTS: The ER pattern was observed in 76 patients (28.6%). Atrial arrhythmia [21/76 (27.6%) vs. 22/190 (11.6%), p=0.001] and ventricular arrhythmia [16/76 (21.1%) vs. 16/190 (8.4%), p=0.004] were more frequently complicated in patients with ER than those without during hospitalization. ER was a significant independent predictor of developing atrial (HR=2.682, 95% CI=1.355-5.310, p=0.005) and ventricular arrhythmia (HR=2.936, 95% CI=1.360-6.335, p=0.006). Three patients with ER and ventricular fibrillation expired during hospitalization [3.9% (3/76) vs. 0% (0/190), p=0.023]. However, the presence of ER did not affect the late recurrence of atrial and ventricular arrhythmia. CONCLUSIONS: The ER pattern is commonly observed in patients with STEMI and associated with atrial and ventricular tachyarrhythmia during acute setting.

Efficacy of inhaled iloprost in cor pulmonale and severe pulmonary hypertension associated with tuberculous destroyed lung.

Chronic obstructive pulmonary disease (COPD) is one of the causes of cor pulmonale. Cor pulmonale patients with pulmonary hypertension have a significant lower survival rate than patients without. However, there is no conclusive treatment options in cor pulmonale and pulmonary hypertension associated with COPD until now. We report a patient with cor pulmonale and pulmonary hypertension associated with severe form of COPD and tuberculous destroyed lung who achieved marked clinical, functional and echocardiographic hemodynamic improvements with inhaled iloprost for six months.

Efficacy and safety of aspirin, clopidogrel, and warfarin after coronary artery stenting in Korean patients with atrial fibrillation.

There are limited data on the optimal antithrombotic therapy for patients with atrial fibrillation (AF) who undergoing coronary stenting. We reviewed 203 patients (62.6 % men, mean age 68.3 ± 10.1 years) between 2003 and 2012, and recorded clinical and demographic characteristics of the patients. Clinical follow-up included major adverse cardiac and cerebrovascular events (MACCE) (cardiac death, myocardial infarction, target lesion revascularization, and stroke), stent thrombosis, and bleeding. The most commonly associated comorbidities were hypertension (70.4 %), diabetes mellitus (35.5 %), and congestive heart failure (26.6 %). Sixty-three percent of patients had stroke risk higher than CHADS2 score 2. At discharge, dual-antiplatelet therapy (aspirin, clopidogrel) was used in 166 patients (81.8 %; Group I), whereas 37 patients (18.2 %) were discharged with triple therapy (aspirin, clopidogrel, warfarin; Group II). The mean follow-up period was 42.0 ± 29.0 months. The mean international normalized ratio (INR) in group II was 1.83 ± 0.41. The total MACCE was 16.3 %, with stroke in 3.4 %. Compared with the group II, the incidence of MACCE (2.7 % vs 19.3 %, P = 0.012) and cardiac death (0 % vs 11.4 %, P = 0.028) were higher in the group I. Major and any bleeding, however, did not differ between the two groups. In multivariate analysis, no warfarin therapy (odds ratio 7.8, 95 % confidence interval 1.02-59.35; P = 0.048) was an independent predictor of MACCE. By Kaplan-Meier survival analysis, warfarin therapy was associated with a lower risk of MACCE (P = 0.024). In patients with AF undergoing coronary artery stenting, MACCE were reduced by warfarin therapy without increased bleeding, which might be related to tighter control with a lower INR value.

Predictors of recovery of left ventricular systolic dysfunction after acute myocardial infarction: from the korean acute myocardial infarction registry and korean myocardial infarction registry.

BACKGROUND AND OBJECTIVES: We investigated the predictors of the recovery of depressed left ventricular ejection fraction (LVEF) in patients with moderate or severe left ventricular (LV) systolic dysfunction after acute myocardial infarction (MI). SUBJECTS AND METHODS: We analyzed 1307 patients, who had moderately or severely depressed LVEF (<45%) on echocardiography soon after acute MI and who underwent a follow-up echocardiography, among 27369 patients from the Korea Working Group on the Myocardial Infarction Registry. Patients were categorized into two groups according to recovery of LVEF: group I with consistently depressed LVEF (<45%) at the follow-up echocardiography and group II with a recovery of LVEF (≥45%). RESULTS: Recovery of LV systolic dysfunction was observed in 51% of the subjects (group II, n=663; ΔLVEF, 16.2±9.3%), whereas there was no recovery in the remaining subjects (group I, n=644; ΔLVEF, 0.6±7.1%). In the multivariate analysis, independent predictors of recovery of depressed LVEF were as follows {odds ratio (OR) [95% confidence interval (CI)]}: moderate systolic dysfunction {LVEF ≥30% and <45%; 1.73 (1.12-2.67)}, Killip class I-II {1.52 (1.06-2.18)}, no need for diuretics {1.59 (1.19-2.12)}, non-ST-segment elevation MI {1.55 (1.12-2.16)}, lower peak troponin I level {<24 ng/mL, median value; 1.55 (1.16-2.07)}, single-vessel disease {1.53 (1.13-2.06)}, and non-left anterior descending (LAD) culprit lesion {1.50 (1.09-2.06)}. In addition, the use of statin was independently associated with a recovery of LV systolic dysfunction {OR (95% CI), 1.46 (1.07-2.00)}. CONCLUSION: Future contractile recovery of LV systolic dysfunction following acute MI was significantly related with less severe heart failure at the time of presentation, a smaller extent of myonecrosis, or non-LAD culprit lesions rather than LAD lesions.

Inadvertently Developed Ventricular Fibrillation during Electrophysiologic Study and Catheter Ablation: Incidence, Cause, and Prognosis.

BACKGROUND AND OBJECTIVES: Ventricular fibrillation (VF) can inadvertently occur during electrophysiologic study (EPS) or catheter ablation. We investigated the incidence, cause, and progress of inadvertently developed VF during EPS and catheter ablation. SUBJECTS AND METHODS: We reviewed patients who had developed inadvertent VF during EPS or catheter ablation. Patients who developed VF during programmed ventricular stimulation to induce ventricular tachycardia or VF were excluded. RESULTS: Inadvertent VF developed in 11 patients (46.7±9.3 years old) among 2624 patients (0.42%); during catheter ablation for atrial fibrillation (AF) in nine patients, frequent ventricular premature beats (VPBs) in one, and Wolff-Parkinson-White (WPW) syndrome were observed in one. VF was induced after internal cardioversion in six AF patients due to incorrect R-wave synchronization of a direct current shock. Two AF patients showed spontaneous VF induction during isoproterenol infusion while looking for AF triggering foci. The remaining AF patient developed VF after rapid atrial pacing to induce AF, but the catheter was accidentally moved to the right ventricular (RV) apex. A patient with VPB ablation spontaneously developed VF during isoproterenol infusion. The focus of VPB was in the RV outflow tract and successfully ablated. A patient with WPW syndrome developed VF after rapid RV pacing with a cycle length of 240 ms. Single high energy (biphasic 150-200 J) external defibrillation was successful in all patients, except in two, who spontaneously terminated VF. The procedure was uneventfully completed in all patients. At a mean follow-up period of 17.4±15.5 months, no patient presented with ventricular arrhythmia. CONCLUSION: Although rare, inadvertent VF can develop during EPS or catheter ablation. Special caution is required to avoid incidental VF during internal cardioversion, especially under isoproterenol infusion.

Repeated Aborted Sudden Cardiac Death with Long QT Syndrome in a Patient with Anomalous Origin of the Right Coronary Artery from the Left Coronary Cusp.

A 15-year-old female with a prior history of aborted cardiac death and surgical correction of anomalous origin of the right coronary artery (RCA) presented with polymorphic ventricular tachycardia. Her electrocardiogram after defibrillation was suggestive of congenital long QT syndrome (LQTS). The patient was treated with a ß-blocker and remained free from ventricular arrhythmia during the follow-up of more than 6 months. Here, we present the case of a young female with repeated aborted cardiac death accompanied by anomalous origin of the RCA and congenital LQTS for the first time.

A comparison of two brands of clopidogrel in patients with drug-eluting stent implantation.

BACKGROUND AND OBJECTIVES: Although generic clopidogrel is widely used, clinical efficacy and safety between generic and original clopidogrel had not been well evaluated. The aim of this study was to evaluate the clinical outcomes of 2 oral formulations of clopidogrel 75 mg tablets in patients with coronary artery disease (CAD) undergoing drug-eluting stent (DES) implantation. SUBJECTS AND METHODS: Between July 2006 and February 2009, 428 patients that underwent implantation with DES for CAD and completed >1 year of clinical follow-up were enrolled in this study. Patients were divided into the following 2 groups based on treatment formulation, Platless® (test formulation, n=211) or Plavix® (reference formulation, n=217). The incidence of 1-year major adverse cardiovascular and cerebrovascular event (MACCE) and stent thrombosis (ST) were retrospectively reviewed. RESULTS: The baseline demographic and procedural characteristics were not significantly different between two treatment groups. The incidence of 1-year MACCEs was 8.5% {19/211, 2 deaths, 4 myocardial infarctions (MIs), 2 strokes, and 11 target vessel revascularizations (TVRs)} in Platless® group vs. 7.4% (16/217, 4 deaths, 1 MI, 2 strokes, and 9 TVRs) in Plavix® group (p=0.66). The incidence of 1-year ST was 0.5% (1 definite and subacute ST) in Platless® group vs. 0% in Plavix® group (p=0.49). CONCLUSION: In this study, the 2 tablet preparations of clopidogrel showed similar rates of MACCEs, but additional prospective randomized studies with pharmacodynamics and platelet reactivity are needed to conclude whether generic clopidgrel may replace original clopidogrel.

Rosuvastatin combined with ramipril significantly reduced atheroma volume by anti-inflammatory mechanism: comparative analysis with rosuvastatin alone by intravascular ultrasound.

BACKGROUND: We tested the effects of rosuvastatin combined with ramipril on atheroma volume and its mechanism in de novo, intermediate coronary artery disease. METHODS: Subjects were randomly assigned to 2 treatment groups (rosuvastatin alone group; 20mg/day, combined group; rosuvastatin 20mg/day and ramipril 10mg/day). Total atheroma volume per 10mm segment (TAV/10mm), percent atheroma volume per 10mm segment (PAV/10mm) in entire indexed segments and TAV(most10), PAV(most10) in a 10mm subsegment with the greatest disease by intravascular ultrasound, and lipids, metabolic parameters (adiponectin, insulin sensitivity), biomarkers (hsCRP, matrix metalloproteinase-9) were analyzed at baseline and at 9-12 months follow-up. RESULTS: A total of 40 patients (rosuvastatin group; 21, combined group; 19), 46 lesions (rosuvastatin group; 24, combined group; 22) were finally analyzed. Rosuvastatin alone significantly reduced TAV/10mm (-7.8 ± 17.4%, p<0.001) but did not change PAV/10mm, TAV(most10), PAV(most10) after therapy. In combined group, TAV/10mm, TAV(most10), PAV(most10) were significantly reduced after therapy (-10.7 ± 11.5%, -13.4 ± 14.5%, -2.7 ± 5.8%, p<0.001, <0.001 and p=0.04) but PAV/10mm did not change. The magnitude of changes of all IVUS derived parameters did not differ significantly between 2 groups. Of interest, the most important factor for the changes of PAV(most10) was the percent changes of LDL cholesterol (ß=0.23, 95% CI [0.07-0.39], p=0.007) in rosuvastatin alone group and the changes in hsCRP (ß=1.89, 95% CI [0.63-3.14], p=0.005) and baseline fasting blood glucose (ß=0.06, 95% CI [0.01-0.11], p=0.02) in combined group by multivariate analysis. CONCLUSIONS: Rosuvastatin combined ramipril therapy significantly reduced atheroma volume that was related with anti-inflammatory effects.