Clinical outcome of statin plus ezetimibe versus high-intensity statin therapy in patients with acute myocardial infarction propensity-score matching analysis.

BACKGROUND: It is unclear whether simvastatin-ezetimibe could be an alternative therapy to high-intensity statin therapy in high-risk patients. The aim of this study was to compare the clinical outcomes of simvastatin-ezetimibe and high-intensity statin therapy in patients with acute myocardial infarction (AMI), and especially in those with high-risk factor. METHODS: A total of 3520 AMI patients in the KAMIR (Korea Acute Myocardial Infarction Registry) were classified into simvastatin-ezetimibe group (n=1249) and high-intensity statin group (n=2271). Multivariate analysis and propensity-score matching analysis were performed. The primary endpoint was major adverse cardiac events (MACE) at 12-months follow-up. RESULTS: In overall AMI patients, MACE occurred in 116 patients (9.3%) in simvastatin-ezetimibe group and 116 patients (5.1%) in high-intensity statin group. The difference in MACE between groups was driven by repeat revascularization (5.9% vs. 2.2%). After propensity matching analysis, simvastatin-ezetimibe was associated with a higher incidence of MACE than high-intensity statin therapy (adjusted hazard ratio: 3.090, 95% confidence interval: 1.715 to 5.566, p<0.001). However, in patients with high-risk factors, such as diabetes, old age, or heart failure, simvastatin-ezetimibe had similar incidence of MACE compared with high-intensity statin therapy in further adjusted analysis. CONCLUSIONS: In overall AMI patients, high-intensity statin therapy had better clinical outcomes than simvastatin-ezetimibe. However, in patients with high-risk factor, simvastatin-ezetimibe had comparable clinical outcomes to high-intensity statin therapy. Therefore, simvastatin-ezetimibe could be used as an alternative to high-intensity statin therapy in such patients.

Influence of Thromboxane A2 on the Regulation of Adenosine Triphosphate-Sensitive Potassium Channels in Mouse Ventricular Myocytes.

BACKGROUND AND OBJECTIVES: Adenosine triphosphate (ATP)-sensitive potassium (KATP) channels play an important role in myocardial protection. We examined the effects of thromboxane A2 on the regulation of KATP channel activity in single ventricular myocytes. SUBJECTS AND METHODS: Single ventricular myocytes were isolated from the hearts of adult Institute of Cancer Research (ICR) mice by enzymatic digestion. Single channel activity was recorded by excised inside-out and cell-attached patch clamp configurations at -60 mV holding potential during the perfusion of an ATP-free K-5 solution. RESULTS: In the excised inside-out patches, the thromboxane A2 analog, U46619, decreased the KATP channel activity in a dose-dependent manner; however, the thromboxane A2 receptor antagonist, SQ29548, did not significantly attenuate the inhibitory effect of U46619. In the cell-attached patches, U46619 inhibited dinitrophenol (DNP)-induced KATP channel activity in a dose-dependent manner, and SQ29548 attenuated the inhibitory effects of U46619 on DNP-induced KATP channel activity. CONCLUSION: Thromboxane A2 may inhibit KATP channel activity, and may have a harmful effect on ischemic myocardium.

Performance Enhancement of Silicon Alloy-Based Anodes Using Thermally Treated Poly(amide imide) as a Polymer Binder for High Performance Lithium-Ion Batteries.

The development of silicon-based anodes with high capacity and good cycling stability for next-generation lithium-ion batteries is a very challenging task due to the large volume changes in the electrodes during repeated cycling, which results in capacity fading. In this work, we synthesized silicon alloy as an active anode material, which was composed of silicon nanoparticles embedded in Cu-Al-Fe matrix phases. Poly(amide imide)s, (PAI)s, with different thermal treatments were used as polymer binders in the silicon alloy-based electrodes. A systematic study demonstrated that the thermal treatment of the silicon alloy electrodes at high temperature made the electrodes mechanically strong and remarkably enhanced the cycling stability compared to electrodes without thermal treatment. The silicon alloy electrode thermally treated at 400 °C initially delivered a discharge capacity of 1084 mAh g(-1) with good capacity retention and high Coulombic efficiency. This superior cycling performance was attributed to the strong adhesion of the PAI binder resulting from enhanced secondary interactions, which maintained good electrical contacts between the active materials, electronic conductors, and current collector during cycling. These findings are supported by results from X-ray photoelectron spectroscopy, scanning electron microscopy, and a surface and interfacial cutting analysis system.

Epithelioid Hemangioendothelioma Arising from Interanl Jugular Vein Mimicking Cervical Metastatic Lymphadenopathy.

Epithelioid hemangioendothelioma (EHE) is a relatively rare and moderately aggressive type of vascular tumor. We describe a case of EHE that presented in a 24-year-old woman as a palpable nodule in the left cervical area. Radiological examinations and fine-needle aspiration cytology led to a preliminary diagnosis of metastatic lymphadenopathy with an unknown primary site. However, during surgery, we determined that the nodule was an intra-vascular tumor arising from the left internal jugular vein. The histopathological examination revealed cords of epithelioid endothelial cells distributed in a hyaline stroma, compatible with a diagnosis of EHE.

Comparison of Resolute zotarolimus-eluting stents versus everolimus-eluting stents in patients with metabolic syndrome and acute myocardial infarction: propensity score-matched analysis.

BACKGROUND: Despite common use of second-generation drug-eluting stents in treating patients with coronary artery disease, there is lack of data comparing these stents exclusively in patients with acute myocardial infarction (AMI), especially with metabolic syndrome (MetS), which is highly prevalent in AMI and potential to worsen clinical outcomes. The aim of this study was to compare clinical outcomes of everolimus-eluting stent (EES) and Resolute-zotarolimus-eluting stent (R-ZES) in AMI patients with MetS, in terms of stent-related and patient-related outcomes. METHODS: A total of 3942 AMI patients in the KAMIR (Korea Acute Myocardial Infarction Registry) were grouped according to the presence of MetS and stent type: EES (N=1582) and R-ZES (N=255) in MetS (1837). Target lesion failure (TLF) and patient-oriented composite events (POCE) at 1 year were evaluated. RESULTS: In MetS patients, TLF (3.7% vs. 2.7%, p=0.592) and POCE (7.9% vs. 6.7%, p=0.764) were similar between EES and R-ZES. Also in Non-MetS patients, TLF (3.9% vs. 3.1%, p=0.307) and POCE (6.4% vs. 7.3%, p=0.866) were similar between 2 groups. TLF was similar between MetS and Non-MetS patients (3.6% vs. 3.8%), while POCEs (7.7% vs. 6.6%) were higher in MetS. Propensity-score matching analysis showed similar results between stent groups in MetS and Non-MetS. In multivariate analysis, left ventricular ejection fraction and symptom-to-door time were independent predictors of TLF and POCE in MetS patients with AMI. CONCLUSIONS: In MetS patients with AMI, EES and R-ZES showed excellent performance and safety. However, patient-oriented composite events were relatively high, suggesting more efforts to improve them.

Efficacy and Safety of Pancreatobiliary Endoscopic Procedures during Pregnancy.

BACKGROUND/AIMS: Endoscopic therapy with endoscopic retrograde cholangiopancreatography (ERCP) has been suggested as an effective diagnostic and therapeutic tool for biliary and pancreatic disorders during pregnancy. In this report, we describe our experiences with pancreatobiliary endoscopic procedures during pregnancy. METHODS: We reviewed ERCP and endoscopic ultrasonography (EUS) procedures that were performed at a single tertiary care referral center between January 2002 and October 2013. Medical records were reviewed for the procedure indication, the duration of fluoroscopy, postprocedure complications, etc. Pregnancy outcomes and fetal complications were identified by chart review and phone calls to patients. RESULTS: A total of 10 ERCPs and five EUSs were performed in 13 pregnant patients four of whom underwent the procedure in the first trimester, eight in the second trimester, and one in the third trimester. Indications for endoscopic therapy included gallstone pancreatitis, obstructive jaundice with common bile duct (CBD) stone, asymptomatic CBD stone, pancreatic cyst, choledochal cyst, and acute cholecystitis. Only one patient had a complication, which was postprocedural hyperamylasemia. Two patients underwent an artificial abortion, one according to her own decision and the other due to an adverse drug reaction. CONCLUSIONS: ERCP seems to be effective and safe for pregnant women. Additionally, EUS can be an alternative to ERCP during pregnancy.

Natural course of an untreated metastatic perirectal lymph node after the endoscopic resection of a rectal neuroendocrine tumor.

Lymph node metastasis is rare in small (i.e., <10 mm) rectal neuroendocrine tumors (NETs). In addition to tumor size, pathological features such as the mitotic or Ki-67 proliferation index are associated with lymph node metastasis in rectal NETs. We recently treated a patient who underwent endoscopic treatment of a small, grade 1 rectal NET that recurred in the form of perirectal lymph node metastasis 7 years later. A 7-mm-sized perirectal lymph node was noted at the time of the initial endoscopic treatment. The same lymph node was found to be slightly enlarged on follow-up and finally confirmed as a metastatic NET. Therefore, the perirectal lymph node metastasis might have been present at the time of the initial diagnosis. However, the growth rate of the lymph node was extremely low, and it took 7 years to increase in size from 7 to 10 mm. NETs with low Ki-67 proliferation index and without mitotic activity may grow extremely slowly even if they are metastatic.

Reliable femoral chronic total occlusion model using a thin biodegradable polymer coated copper stent in a porcine model.

Chronic total occlusions (CTOs) are common in patients with peripheral arterial disease (PAD). This study aimed to examine the feasibility and reliability of a CTO induced by a thin biodegradable polymer (polyglycolic acid) coated copper stent in a porcine femoral artery. Novel thin biodegradable polymer coated copper stents (9 mm long) were crimped on an angioplasty balloon (4.5 mm diameter × 12 mm length) and inserted into the femoral artery. Histopathologic analysis was performed 35 days after stenting. In five of six stented femoral arteries, severe in-stent restenosis and total occlusion with collateral circulation were observed without adverse effects such as acute stent thrombosis, leg necrosis, or death at 5 weeks. Fibrous tissue deposition, small vascular channels, calcification, and inflammatory cells were observed in hematoxylin-eosin, Carstair's, and von Kossa tissue stains; these characteristics were similar to pathological findings associated with CTOs in humans. The neointima volume measured by micro-computed tomography was 93.9 ± 4.04 % in the stented femoral arteries. CTOs were reliably induced by novel thin biodegradable polymer coated copper stents in porcine femoral arteries. Successful induction of CTOs may provide a practical understanding of their formation and application of an interventional device for CTO treatment.

Retrospective analysis of thoracoscopic surgery for esophageal submucosal tumors.

BACKGROUND: Surgical enucleation is the treatment of choice for esophageal submucosal tumors (SMTs) with symptomatic, larger, or ill-defined lesions. The enucleation of SMTs has traditionally been performed via thoracotomy. However, minimally invasive approaches have recently been introduced and successfully applied. In this study, we present our experiences with the thoracotomic and thoracoscopic approaches to treating SMTs. METHODS: We retrospectively reviewed 53 patients with SMTs who underwent surgical enucleation between August 1996 and July 2013. Demographic and clinical features, tumor-related factors, the surgical approach, and outcomes were analyzed. RESULTS: There were 36 males (67.9%) and 17 females (32.1%); the mean age was 49.2±11.8 years (range, 16 to 79 years). Histology revealed leiomyoma in 51 patients, a gastrointestinal stromal tumor in one patient, and schwannoma in one patient. Eighteen patients (34.0%) were symptomatic. Fourteen patients underwent a planned thoracotomic enucleation. Of the 39 patients for whom a thoracoscopic approach was planned, six patients required conversion to thoracotomy because of overly small tumors or poor visualization in five patients and accidental mucosal injury in one patient. No mortality or major postoperative complications occurred. Compared to thoracotomy, the thoracoscopic approach had a slightly shorter operation time, but this difference was not statistically significant (120.0±45.6 minutes vs. 161.5±71.1 minutes, p=0.08). A significant difference was found in the length of the hospital stay (9.0±3.2 days vs. 16.5±5.4 days, p<0.001). CONCLUSION: The thoracoscopic enucleation of submucosal esophageal tumors is safe and is associated with a shorter length of hospital stay compared to thoracotomic approaches.

Current Status of Coronary Intervention in Patients with ST-Segment Elevation Myocardial Infarction and Multivessel Coronary Artery Disease.

Primary percutaneous coronary intervention (PCI) is a standard interventional treatment modality for ST-segment elevation myocardial infarction (STEMI). Diagnostic coronary angiogram during PCI reveals multivessel coronary artery disease in about half of patients with STEMI, and it is difficult to make decision on the extent of intervention in these patients. Although revascularization for the infarct-related artery only is still effective for STEMI patients, several studies have reported the efficacy of multivessel revascularization during primary PCI, as well as in a staged PCI procedure. Clinicians should consider clinical aspects such as initial cardiogenic shock and myocardial viability when performing primary multivessel intervention, including the risks and benefits of multivessel revascularization in patients undergoing primary PCI. This review describes the current status of performing multivessel PCI in patients with STEMI and proposes an optimal revascularization strategy based on the previous literature.

A case of isolated pulmonary mucormycosis in an immunocompetent host.

Mucormycosis is a rare fungal disease that holds a fatal opportunistic fungal infection in diabetes mellitus, hematological malignancy, and immunocompromised host. Isolated pulmonary mucormycosis is extremely rare. Optimal therapy is a combined medical-surgical approach and a management of the patient's underlying disease. Herein, we report a case-study of isolated pulmonary mucormycosis which was being presented as multiple lung nodules in a patient with no underlying risk factors. Considering that the patient had poor pulmonary functions, we treated him with only antifungal agent rather than a combined medical-surgical approach. After treatment with antifungal agent for six months, the nodules of pulmonary mucormycosis were improved with the prominent reductions of size on the computed tomography.

Sunitinib treatment for metastatic renal cell carcinoma in patients with von hippel-lindau disease.

Von Hippel-Lindau (VHL) disease is an autosomal dominant disease that produces a variety of tumors and cysts in the central nervous system and visceral organs, including renal cell carcinoma (RCC). RCC in patients with VHL disease does not frequently metastasize, therefore, the response to treatment and prognosis of metastatic RCC developed in patients with VHL disease has not been reported. Sunitinib is an oral, multitargeted receptor tyrosine kinase inhibitor with antiangiogenic and antitumor activity. Here, we report on four patients with metastatic RCC in VHL disease who received sunitinib and achieved partial responses that have lasted for a prolonged period of time.

Mid- to Long-term Results of Surgical Treatment of ASD in Patients over 60 Years Old.

BACKGROUND: There is controversy about the benefit of surgical correction of an atrial septal defect (ASD) in patients over 60 years old. The purpose of this study was to determine whether surgical treatment is beneficial in those 60 years of age or older. MATERIALS AND METHODS: We reviewed the clinical course of 57 patients (mean age: 63.54±5.59 years) diagnosed with an isolated secundum ASD after the age of 60. The 24 patients (group A) who underwent surgical repair were compared with the 33 patients (group B) who were treated non-surgically. The mean follow-up period was 6.8±4.5 years. RESULTS: One operative death, 5 late deaths (20.8%) in group A, and 9 deaths (27.3%) in group B occurred in the study period. Symptomatic improvement was noted in 18 patients (75%) of group A after surgery. However 13 patients (39.4%) of group B showed symptomatic improvement during the follow-up period (p=0.012). The incidence of new atrial arrhythmia of the two groups was significantly different (16.7% vs 36.7%, p=0.038). The actuarial 10 year survival rate was 79% in group A and 73% in group B. CONCLUSION: Although surgical correction of ASD did not increase survival in patients over 60 years old, the surgical outcomes of ASD showed low operative mortality and resulted in symptomatic improvement in the majority of these patients. This study has shown the benefits of surgical closure of ASD even in advanced age in comparison to medical treatment.

Varix of the right atrium.

A 68-year-old female patient was referred for the evaluation of an incidentally detected asymptomatic cardiac mass. Imaging studies showed a 3.0 x 2.4 cm, well circumscribed, round, cystic mass with a calcified nodule that was attached to the lower rim of the fossa ovalis in the right atrium. Under cardiopulmonary bypass, the right atrium was opened to reveal a well circumscribed, dark bluish, pedunculated mass. Histologically, the specimen was a unilocular cyst lined by flattened endothelium, with peripheral fibrin clots and dystrophic calcification of the wall. Immunohistochemical staining of the lining cells was positive for cluster designation 34, which represents hematopoietic progenitor cell antigen. The final pathologic diagnosis was compatible with varix of the heart, which should be considered for a cystic mass with a calcified nodule located in the right atrium, near the lower rim of the fossa ovalis.

Skeletonized gastroepiploic artery as a composite graft for total arterial revascularization.

BACKGROUND: Despite the purported advantages of using a gastroepiploic artery graft during coronary artery bypass, insufficient potential flow capacity and vasospasm remain major concerns. We assessed the efficacy and results of using a skeletonized composite gastroepiploic artery graft in situations in which bilateral internal thoracic and radial arteries could not be used. METHODS: Between January 2000 and August 2002, 37 patients (25 men, 12 women; mean age, 59.9 years) underwent grafting with composite grafts using a skeletonized left internal thoracic artery plus the gastroepiploic artery. Coronary angiograms were performed in the immediate (median, 14 days, 36 patients) and early (median, 348 days, 32 patients) postoperative periods. Off-pump coronary artery bypass grafting was performed in all but 2 patients. RESULTS: There were no deaths. The respective postoperative patencies of the left internal thoracic artery and gastroepiploic artery were 36 of 37 (97.2%) and 73 of 75 (97.3%) at the immediate period, and 34 of 34 and 62 of 67 (92.5%) at the early period. During follow-up, only 1 patient required percutaneous intracoronary intervention for gastroepiploic artery occlusion. CONCLUSIONS: Skeletonized composite gastroepiploic artery grafts showed satisfactory clinical and angiographic results in situations in which bilateral internal thoracic and radial arteries could not be used. Although it needs longer follow-up, these early results demonstrated that the gastroepiploic artery may be a useful option in some situations of total arterial revascularization, used either as an in situ or as a composite graft.

Long-term predictive factors of major adverse cardiac events in patients with acute myocardial infarction complicated by cardiogenic shock.

BACKGROUND: Cardiogenic shock (CS) after acute myocardial infarction (AMI) develops in 5-10% of patients and it is associated with high mortality. The aim of this study is to assess the predictive factors of mortality for patients with AMI and CS. METHODS: Two hundred fifty five AMI patients with CS (the mean age was 66.0 +/- 11.0 years, M:F=156:99) out of 1268 AMI patients who admitted at Chonnam National University Hospital between July 2000 and June 2002 were analyzed according to the clinical characteristics, coronary angiographic findings and MACE during admission and for the 1-year clinical follow-up. RESULTS: Among the enrolled patients, 129 patients survived without MACE (Group I, mean age 64.2 +/- 10.6 years, M:F=76:53), and 126 patients had MACE (Group II, mean age 68.1 +/- 10.0 years, M:F = 80:46) during admission or during the 1-year follow-up period. There were significant differences in age between the Groups I and II (64.2 +/- 10.6 vs. 68.1 +/- 11.0 years, respectively, p = 0.004) and the previous MI history (0 vs. 17.4%, respectively, p<0.001). The left ventricular ejection fraction (EF) was lower in Group II (Group I vs. II: 49.1 +/- 13.0 vs. 39.1 +/- 12.9%, p < 0.001). The levels of troponin (Tn) I and C-reactive protein (CRP) were higher in Group II (Group I vs. II: 29.2 +/- 7.72 vs. 50.8 +/- 5.17 ng/dL, p = 0.017, 3.8 +/- 0.48 vs. 9.9 +/- 1.21 mg/dL, p < 0.001 respectively). Left main stem lesion (LMSL) was more common in Group II than in Group I (0.7% vs. 22.0%, respectively, p = 0.004). In-hospital death was associated with low Thrombolysis In Myocardial Infarction (TIMI) flow after coronary revascularization. CONCLUSION: Old age, a previous MI history, high Tn and CRP, low EF and LMSL are associated with higher MACE for patients with AMI and CS. Coronary revascularization with TIMI 3 flow lowers the in-hospital mortality.

Successful stenting for congenital coarctation of the distal thoracic aorta (middle aortic syndrome) in an adult.

We report a successful stent implantation for a coarctation lesion of the lower thoracic aorta in a 44-year-old male. This patient had suffered from claudication of both legs for 30 years. An aortogram revealed a coarctation of the distal thoracic aorta at T11 level with 60 mmHg peak systolic pressure gradient of across the lesion. A balloon angioplasty followed by an 18 mm x 40 mm sized stent implantation was performed successfully. The peak systolic gradient across the coarctation decreased from 60 to 15 mmHg. The patient's symptom was relieved immediately after stenting. No significant or adverse events were observed during 7 months clinical follow-up. Follow-up aortogram after 7 months revealed no restenosis with an improved pressure gradient. Adults with congenital coarctation of the descending thoracic aorta can be successfully treated by stent implantation.

Predictive factors of major adverse cardiac events in acute myocardial infarction patients complicated by cardiogenic shock undergoing primary percutaneous coronary intervention.

BACKGROUND: The aim of this study was to assess in-hospital mortality and major adverse cardiac events (MACE) during long-term clinical follow-up of patients who developed cardiogenic shock (CS) after acute myocardial infarction (AMI) and who underwent primary percutaneous coronary intervention (PCI). METHODS AND RESULTS: The data from 147 patients with CS after AMI (61.7 +/-10.4 years, M:F =156:99) who underwent primary PCI at Chonnam National University Hospital between January 1999 and December 2002 were analyzed: clinical characteristics, coronary angiographic findings and mortality during admission, and MACE during a 1-year clinical follow-up. Of the enrolled patients, 121 patients survived (group I, M:F =94:27) and 26 died (group II, M:F =14:12) during admission. By binary logistic regression analysis, in-hospital death was associated with low Thrombolysis In Myocardial Infarction (TIMI) flow after coronary revascularization (p=0.02, odds ratio (OR) =1.3). Eighty-nine patients (60.5%) survived without MACE during the 1-year clinical follow-up and MACE was associated with a C-reactive protein (CRP) of more than 1 mg/dl (p=0.002, OR =6.3) and low TIMI flow after coronary revascularization (p<0.001, OR =7.8). CONCLUSIONS: Primary PCI achieving TIMI 3 flow reduces in-hospital death in AMI with CS. High concentration of CRP and low TIMI flow are associated with MACE during long-term clinical follow-up.