Clinical outcomes of early closure versus conservative strategy after diagnosis with atrial septal defect: a nationwide population-based cohort study.

OBJECTIVES: The long-term clinical benefits of atrial septal defect (ASD) closure remain controversial. We aimed to compare long-term clinical outcomes between patients who underwent early surgical closure after ASD diagnosis and those who did not. METHODS: Using the Korean National Health Insurance Service database, we identified patients with isolated ASDs diagnosed between 1 January 2003 and 31 December 2006. The ASD patients who underwent closure surgery within 6 months after diagnosis were allocated to the early-closure group and the rest were allocated to the conservative-strategy group. The primary outcome was all-cause mortality. Secondary outcomes were atrial flutter/fibrillation (AFF) and ischaemic stroke. RESULTS: Among patients without a history of AFF or stroke, 1644 patients in the early-closure group were propensity score matched to 1644 patients in the conservative-strategy group and their median follow-up durations were 12.9 and 12.8 years, respectively. The early closure was associated with a significantly lower risk of mortality (hazard ratio, 0.55 [95% confidence interval, 0.43-0.70]). In an age-stratified analysis, significant mortality reductions in the early-closure group were found in patients aged 40 years or older. The risk of AFF was significantly higher in the early-closure group, which might be mainly ascribed to postoperative transient AFF, while there was no difference in ischaemic stroke between the 2 groups. CONCLUSIONS: Our data suggest that timely ASD closure without delay is necessary for ASD patients without previous history of clinical events, especially in patients aged 40 years or older.

Quantitative segmental analysis of myocardial perfusion to differentiate stress cardiomyopathy from acute myocardial infarction: A myocardial contrast echocardiography study.

BACKGROUND: Both stress cardiomyopathy (SCMP) and acute myocardial infarction (AMI) present with similar clinical symptoms and signs, and apical akinesis. HYPOTHESIS: Quantitative segmental analysis of myocardial contrast echocardiography (MCE) helps to differentiate AMI from SCMP. METHODS: Real-time MCE was performed in 33 consecutive patients who presented with an acute symptom/sign and a new apical akinesis on echocardiography. In 18 left ventricular (LV) myocardial segments, a replenishment curve was obtained in each segment to measure peak plateau myocardial contrast intensity (MCI) (A) and the replenishment curve slope (ß). The calibrated MCI was also measured in each segment. RESULTS: Among 33 patients, 22 were diagnosed with SCMP and 11 were diagnosed with AMI according to comprehensive diagnostic criteria. A, ß, Aß, and the calibrated MCI were lower in akinetic than in normokinetic segments in both the SCMP and AMI groups. In the akinetic segments, A, ß, Aß, and the calibrated MCI in SCMP patients were each higher than those in AMI patients. In patient-based analyses, areas under the ROC curves of A, ß, Aß, and the calibrated MCI for diagnosing AMI were 0.769, 0.607, 0.822, and 0.934, respectively. The optimal cutoff values to diagnose AMI were Aß < 3.7 dB/sec (sensitivity 82%, specificity 82%) and a calibrated MCI < -23 dB (sensitivity 91%, specificity 95%). CONCLUSIONS: Although myocardial perfusion is relatively reduced in the akinetic segments of SCMP, a quantitative segmental analysis of myocardial perfusion using MCE helps to discriminate AMI from SCMP.

The Role of Post-Resuscitation Electrocardiogram in Patients With ST-Segment Changes in the Immediate Post-Cardiac Arrest Period.

OBJECTIVES: The authors aimed to evaluate the role of post-resuscitation electrocardiogram (ECG) in patients showing significant ST-segment changes on the initial ECG and to provide useful diagnostic indicators for physicians to determine in which out-of-hospital cardiac arrest (OHCA) patients brain computed tomography (CT) should be performed before emergency coronary angiography. BACKGROUND: The usefulness of immediate brain CT and ECG for all resuscitated patients with nontraumatic OHCA remains controversial. METHODS: Between January 2010 and December 2014, 1,088 consecutive adult nontraumatic patients with return of spontaneous circulation who visited the emergency department of 3 tertiary care hospitals were enrolled. After excluding 245 patients with obvious extracardiac causes, 200 patients were finally included. RESULTS: The patients were categorized into 2 groups: those with ST-segment changes with spontaneous subarachnoid hemorrhage (SAH) (n = 50) and those with OHCA of suspected cardiac origin group (n = 150). The combination of 4 ECG characteristics including narrow QRS (<120 ms), atrial fibrillation, prolonged QTc interval (≥460 ms), and ≥4 ST-segment depressions had a 66.0% sensitivity, 80.0% specificity, 52.4% positive predictive value, and 87.6% negative predictive value for predicting SAH. The area under the receiver-operating characteristic curves in the post-resuscitation ECG findings was 0.816 for SAH. CONCLUSIONS: SAH was observed in a substantial number of OHCA survivors (25.0%) with significant ST-segment changes on post-resuscitation ECG. Resuscitated patients with narrow QRS complex and any 2 ECG findings of atrial fibrillation, QTc interval prolongation, or ≥4 ST-segment depressions may help identify patients who need brain CT as the next diagnostic work-up.

Characteristics of early repolarization parameters and prognostic implications in the general ambulatory Korean population.

BACKGROUND: We tested a hypothesis that the 2 fundamental components of early repolarization (ER), J wave and ST elevation (STE) might have different prevalence and prognostic implications. METHODS: The study population comprised 26,345 general ambulatory Korean subjects (mean 48.0±10.2years old, 53.2% male) who underwent medical checkups from January 2002 to December 2002. ER was found in 2950 subjects (11.2%), who were divided into 3 groups (J [J wave only, n=1874, 7.1%], JST [both J wave and STE, n=489, 1.8%], and ST [STE only, n=587, 2.3%]). RESULTS: The prevalence of STE decreased with age, whereas J waves remained at a constant level in all age groups. The most common pattern of ER was the J pattern, with a horizontal/descending ST segment in the inferior leads; in lateral precordial leads, ST or JST patterns with ascending ST segments were more common. During the mean follow-up of 126.0±11.1months, a total of 710 subjects died (2.7%). Subjects in the J group were at higher risk (Hazard ratio 1.60, 95% confidence interval 1.27-2.01, p<0.001), while those in the JST and ST groups showed similar survival outcomes compared to controls without J waves or STE. CONCLUSIONS: J waves and STE showed different age and lead distributions and prognostic implications. The presence of the J wave itself was associated with a higher relative risk of mortality. However, due to the low event rate, its clinical significance appears to be limited.

The exercise heart rate profile in master athletes compared to healthy controls.

Endurance exercise protects the heart via effects on autonomic control of heart rate (HR); however, its effects on HR indices in healthy middle-aged men are unclear. This study compared HR profiles, including resting HR, increase in HR during exercise and HR recovery after exercise, in middle-aged athletes and controls. Fifty endurance-trained athletes and 50 controls (all male; mean age, 48·7 ± 5·8 years) performed an incremental symptom-limited exercise treadmill test. The electrocardiographic findings and HR profiles were evaluated. Maximal O2 uptake (52·6 ± 7·0 versus 34·8 ± 4·5 ml kg(-1)  min(-1) ; P<0·001) and the metabolic equivalent of task (15·4 ± 1·6 versus 12·2 ± 1·5; P<0·001) were significantly higher in athletes than in controls. Resting HR was significantly lower in athletes than in controls (62·8 ± 6·7 versus 74·0 ± 10·4 beats per minute (bpm), respectively; P<0·001). Athletes showed a greater increase in HR during exercise than controls (110·1 ± 11·0 versus 88·1 ± 15·4 bpm; P<0·001); however, there was no significant between-group difference in HR recovery at 1 min after cessation of exercise (22·9 ± 5·6 versus 21·3 ± 6·7 bpm; P = 0·20). Additionally, athletes showed a lower incidence of premature ventricular contractions (PVCs) during exercise (0·0% versus 24·0%; P<0·001). Healthy middle-aged men participating in regular endurance exercise showed more favourable exercise HR profiles and a lower incidence of PVCs during exercise than sedentary men. These results reflect the beneficial effect of endurance training on autonomic control of the heart.

Impact of cardiac rehabilitation on angiographic outcomes after drug-eluting stents in patients with de novo long coronary artery lesions.

Cardiac rehabilitation (CR) can reduce cardiovascular mortality and morbidity in coronary artery disease. Long coronary artery lesions may be associated with adverse outcomes after drug-eluting stent (DES) implantation. The purpose of this study was to evaluate angiographic outcomes after a comprehensive CR program in patients with DESs for long coronary artery lesions. A total of 576 patients treated with DESs for long (≥25 mm) coronary lesions were enrolled in this prospective CR registry. Comprehensive CR programs were successfully performed in 288 patients (50%). The primary end point was in-stent late luminal loss at the 9-month angiographic follow-up. There were few significant differences between the CR and non-CR groups in terms of baseline characteristics, including clinical, angiographic, and procedural variables. The rate of in-stent late luminal loss in the CR group was 35% less than in the usual care group (0.19 ± 0.33 mm in CR vs 0.29 ± 0.45 mm in non-CR, difference 0.08 mm, 95% confidence interval 0.01 to 0.16, p = 0.02) at the 9-month follow-up. After propensity-matched analysis (224 pairs), the results were consistent (0.18 ± 0.31 mm in CR vs 0.28 ± 0.41 mm in non-CR, difference 0.10 mm, 95% confidence interval 0.02 to 0.18, p = 0.02). The CR group showed a significant improvement in the overall risk profile compared with the non-CR group, including current smoking, biochemical profiles, depression, obesity, and exercise capacity. In conclusion, the comprehensive CR program significantly reduced late luminal loss after DES implantation for long coronary lesions. This may be associated with significant improvements in exercise capacity and overall risk profile.

Discrepancy between mitral valve areas measured by two-dimensional planimetry and three-dimensional transoesophageal echocardiography in patients with mitral stenosis.

OBJECTIVE: To compare mitral valve area (MVA) measurements obtained by 2D transthoracic planimetry and 3D transoesophageal echocardiography (TOE) in patients with mitral stenosis (MS), and to determine the causes of discrepancies between the two techniques. DESIGN: Reliability and agreement study. SETTING: Tertiary referral centre. PATIENTS: Eighty-seven patients with MS. METHODS: MVA was determined by transthoracic 2D planimetry and 3D TOE. Clinical and echocardiographic variables were evaluated. The angle (Mα) between the lines of the true mitral valve (MV) tip and the echo beam-to-MV tip was measured at early diastole from the parasternal long-axis view obtained from 2D echocardiography. RESULTS: Although MVA measurements using 2D planimetry and 3D TOE showed good agreement (intraclass correlation coefficient, 0.853; p<0.001), 2D planimetry overestimated MVA by 0.19±0.2 cm(2) compared with 3D TOE (p<0.001). Left atrial (LA) dimension obtained from the parasternal long-axis view at end-systole (p=0.012), Mα (p<0.001), and left ventricular ejection fraction (p=0.022) were independent determinants of the MVA difference (MVA by 2D-MVA by 3D TOE; MVA(2D-3D)) according to multiple linear regression analysis. The LA dimensions correlated with Mα (r=0.352, p=0.001). The best cut-off values for predicting significant overestimation by 2D planimetry (MVA(2D-3D)>0.2 cm(2)) were LA dimension ≥49 mm (78% sensitivity, 72% specificity) and Mα≥9.5° (56% sensitivity, 89% specificity). CONCLUSIONS: Because 2D planimetry tends to overestimate MVA, 3D TOE should be considered for accurate MVA assessment, especially in patients with a large LA and large Mα.

The vena contracta in functional tricuspid regurgitation: a real-time three-dimensional color Doppler echocardiography study.

BACKGROUND: The aims of this study were to evaluate the three-dimensional features and geometric determinants of the vena contracta (VC) in functional tricuspid regurgitation (TR) and to identify optimal width cutoff values for assessing functional TR severity. METHODS: Real-time three-dimensional full-volume and color Doppler and two-dimensional Doppler echocardiographic images were obtained in 52 patients with various degrees of functional TR and in sinus rhythm. The tricuspid valve and right ventricle were geometrically analyzed. VC widths parallel to the septal-lateral and anteroposterior directions, VC area, and effective regurgitant orifice area (EROA) using proximal isovelocity surface area methods on real-time three dimensional color Doppler images were measured. RESULTS: The septal-lateral VC width was 0.39 ± 0.37 cm smaller than the anteroposterior VC width (P < .001). VC widths and area were strongly correlated with EROA. The optimal cutoff values for the septal-lateral VC width, anteroposterior VC width, and VC area were 0.63 cm, 0.76 cm, and 0.37 cm(2), respectively, for moderate functional TR (EROA ≥0.2 cm(2)) and were 0.84 cm, 1.26 cm, and 0.57 cm(2), respectively, for severe functional TR (EROA ≥0.4 cm(2)). Multiple linear regression analyses showed that the septal leaflet tenting angle and septal-lateral annular diameter independently determined septal-lateral VC width, while the anterior leaflet tenting angle and anteroposterior annular diameter independently determined the anteroposterior VC width. CONCLUSIONS: Different VC width cutoff values should be applied according to the plane of view in functional TR, because the VC cross-sectional shape is ellipsoidal with a long anteroposterior direction. VC widths are determined by annular dilation and leaflet tenting in the corresponding directions.

Geometric changes after tricuspid annuloplasty and predictors of residual tricuspid regurgitation: a real-time three-dimensional echocardiography study.

AIMS: We sought to demonstrate geometric changes in the tricuspid valve (TV) apparatus after tricuspid annuloplasty (TAP) and to identify predictors of residual tricuspid regurgitation (TR) in patients with functional TR using real-time three-dimensional echocardiography (RT3DE). METHODS AND RESULTS: RT3DE and two-dimensional colour Doppler echocardiography were performed in 59 consecutive patients before and 4.7 ± 2.1 days after TAP. The tenting angles of the three leaflets were significantly increased, whereas tenting volume, annulus diameters, and septal-lateral right ventricular inlet dimension decreased after TAP. By multiple stepwise linear regression analysis, tenting volume (P < 0.001) and antero-posterior annulus diameter (P = 0.043) before TAP were major predictors of residual TR assessed using distal jet area. When TR severity was quantified by vena contracta width, tenting volume (P < 0.001) before TAP was the only independent predictor. Pre-TAP tenting volume ≥1.68 mL (sensitivity of 86%, specificity of 73%), and ≥2.30 mL (sensitivity of 100%, specificity of 84%) were the best cut-off values predicting severe residual TR quantified using distal jet area and vena contracta width, respectively. After TAP, tenting volume and pulmonary artery systolic pressure were major determinants of residual TR. CONCLUSION: Tenting angles of all three leaflets increase, whereas annulus diameters decrease, after TAP. Pre-TAP tenting volume and antero-posterior annulus diameter measured using RT3DE are independent predictors of residual TR severity, and measurement of these parameters may help to identify patients at high risk for severe residual TR, for whom TV replacement should possibly be initially considered.

Major predictors of long-term clinical outcomes after coronary revascularization in patients with unprotected left main coronary disease: analysis from the MAIN-COMPARE study.

BACKGROUND: The clinical characteristics that identify high-risk subsets of patients with unprotected left main coronary artery disease undergoing percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) have not been well established. METHODS AND RESULTS: Between January 2000 and June 2006, 2240 patients with unprotected left main coronary artery disease underwent PCI (n=1102) or CABG (n=1138). Twenty-six preprocedural parameters were evaluated by univariate and multivariate Cox regression analysis to identify independent predictors of all-cause mortality and target-vessel revascularization. Interaction tests were performed to compare heterogeneities of effects of preprocedural parameters depending on the revascularization methods. During follow-up (median of 3.1 years), 187 patients died (78 PCI and 109 CABG) and 149 patients had target-vessel revascularization (121 PCI and 28 CABG). EuroSCORE > or =6 was an independent predictor of death in both groups. Additional independent predictors were chronic renal failure and previous congestive heart failure in the PCI group and age > or =75 years, atrial fibrillation, right coronary artery disease, and left main distal bifurcation disease in the CABG group. Interaction analysis showed no heterogeneities of the effects of variables depending on the revascularization methods. Independent predictors of target-vessel revascularization were acute coronary syndrome and left main distal bifurcation disease in the PCI group and history of coronary intervention in the CABG group. The interaction between previous PCI and treatment remained after adjustment for all independent predictors of target-vessel revascularization (interaction P=0.0345). CONCLUSIONS: Several clinical characteristics were identified as important preprocedural predictors of long-term adverse outcomes after percutaneous or surgical revascularization in patients with unprotected left main coronary artery disease.

Very late stent thrombosis of sirolimus-eluting stent combined with late stent malapposition and aneurysm formation.

Late complications of drug-eluting stent, such as stent malapposition or aneurysm formation have emerged major concern. However, there is no available standard therapeutic guideline about them because the clinical course of those is variable and long-term follow- up data is not sufficient. A case presented here is acute ST-elevation myocardial infarction as a result of very late stent thrombosis developed in a patient with stent malapposition and peri-stent aneurysm formation 52 months after sirolimus-eluting stent implantation. In conclusion, more careful long-term follow-up studies are required to access the significance of these late vascular pathologic changes.

[A case of allopurinol-induced granulomatous hepatitis with ductopenia and cholestasis].

Allopurinol-induced hypersensitivity syndrome is characterized by an idiosyncratic reaction involving multiple-organs, which usually begins 2 to 6 weeks after starting allopurinol. In rare cases, the adverse reactions to allopurinol are accompanied by a variety of liver injury, such as reactive hepatitis, granulomatous hepatitis, vanishing bile duct syndrome, or fulminant hepatic failure. Here we report a case with granulomatous hepatitis and ductopenia. A 69-year-old man with chronic renal failure, hyperuricemia, and previously normal liver function presented with jaundice, skin rash, and fever 2 weeks after taking allopurinol (200 mg/day). In histopathology, a liver biopsy specimen showed mild spotty necrosis of hepatocytes, marked cholestasis in parenchyma, and some granulomas in the portal area. There were vacuolar degeneration in the interlobular bile ducts and ductopenia in the portal tracts. Pathologic criteria strongly suggested the presence of allopurinol-induced granulomatous hepatitis with ductopenia and cholestasis. The patient fully recovered following the early administration of systemic corticosteroid therapy.

[A case of recurrent pneumatosis cystoides intestinalis associated with recurrent pneumoperitoneum].

Pneumatosis cystoides intestinalis is an uncommon condition of unknown etiology, characterized by the presence of multiple gas filled cysts in the gastrointestinal tract. Many different causes of pneumatosis cystoides intestinalis have been proposed, including mechanical, pulmonary, and bacterial causes. Approximately 85% of cases are thought to be secondary to coexisting disorders of the gastrointestinal tract or the respiratory system. The condition has been associated with the therapeutic uses of lactulose, steroids, and various cancer chemotherapeutic regimens. Lactitol is a disaccharide analogue of lactulose which is available as a pure crystalline powder. There are three previous case reports suggestive of lactulose causing pneumatosis intestinalis. We report a case of recurrent pneumatosis cystoides intestinalis associated with benign recurrent pneumoperitoneum developed probably secondary to lactitol therapy.