Decompression Illness in Divers With or Without Patent Foramen Ovale : A Cohort Study.

BACKGROUND: In previous studies, the prevalence of patent foramen ovale (PFO) has been reported to be higher in scuba divers who experienced decompression illness (DCI) than in those who did not. OBJECTIVE: To assess the association between PFO and DCI in scuba divers. DESIGN: Prospective cohort study. SETTING: Tertiary cardiac center in South Korea. PARTICIPANTS: One hundred experienced divers from 13 diving organizations who did more than 50 dives per year. MEASUREMENTS: Participants had transesophageal echocardiography with a saline bubble test to determine the presence of a PFO and were subsequently divided into high- and low-risk groups. They were followed using a self-reported questionnaire while blinded to their PFO status. All of the reported symptoms were adjudicated in a blinded manner. The primary end point of this study was PFO-related DCI. Logistic regression analysis was done to determine the odds ratio of PFO-related DCI. RESULTS: Patent foramen ovale was seen in 68 divers (37 at high risk and 31 at low risk). Patent foramen ovale-related DCI occurred in 12 divers in the PFO group (non-PFO vs. high-risk PFO vs. low-risk PFO: 0 vs. 8.4 vs. 2.0 incidences per 10 000 person-dives; P = 0.001) during a mean follow-up of 28.7 months. Multivariable analysis showed that high-risk PFO was independently associated with an increased risk for PFO-related DCI (odds ratio, 9.34 [95% CI, 1.95 to 44.88]). LIMITATION: The sample size was insufficient to assess the association between low-risk PFO and DCI. CONCLUSION: High-risk PFO was associated with an increased risk for DCI in scuba divers. This finding indicates that divers with high-risk PFO are more susceptible to DCI than what has been previously reported and should consider either refraining from diving or adhering to a conservative diving protocol. PRIMARY FUNDING SOURCE: Sejong Medical Research Institute.

Recurrent Decompression Illness Even After the Closure of Patent Foramen Ovale in a Diver.

Patent foramen ovale (PFO) is a risk factor for the development of decompression illness (DCI) and a therapeutic target for preventing the recurrence of DCI because nitrogen bubbles generated during diving can be paradoxically embolized through the PFO. Here, we report the case of a diver who experienced recurrent DCI even after a successful PFO closure. (Level of Difficulty: Advanced.).

Impact of Intracranial Atherosclerotic Stenosis on the Prognosis in Acute Ischemic Stroke Patients with Cardioembolic Source.

BACKGROUND AND AIM: In recent days, intracranial atherosclerotic stenosis (IAS) has been reportedly related to recurrent stroke and mortality in the total patient population with ischemic stroke. However, its impact on the prognosis of the patients with cardioembolic source is not yet established. This study attempted to investigate whether IAS was associated with poor outcome in stroke patients with cardioembolic source. METHODS: Overall, 223 patients with acute ischemic stroke and cardioembolic source were included in this study. IAS was defined as ≥ 50% stenosis on enhanced MRA, and cardioembolic sources were detected by ECG and echocardiography. Follow-up data were obtained from outpatient medical records and/or telephone interviews. RESULTS: Overall, 60 major clinical events causing poor outcome occurred in 58 patients (26.0%). Patients with IAS had significantly higher rates of death and stroke recurrence than those without IAS (p = 0.015 and 0.046 each by log rank test). The multivariate Cox proportional hazards regression analysis showed that IAS was significantly related to the poor outcome (hazard ratio 1.725, 95% confidence interval 1.020-2.920, p = 0.042). CONCLUSIONS: In acute ischemic stroke patients with cardioembolic source, IAS may be considered a marker of a high risk of stroke recurrence or death.

Difference in the prognostic significance of N-terminal pro-B-type natriuretic peptide between cardioembolic and noncardioembolic ischemic strokes.

BACKGROUND AND AIM: Because B-type natriuretic peptide is a powerful predictor of heart failure, its capability to predict a fatal outcome in stroke might be limited to the cardioembolic stroke subtype. In this study, we attempt to ascertain the difference in the prognostic value of N-terminal pro-B-type natriuretic peptide (NT-proBNP) between cardioembolic and noncardioembolic stroke subgroups. METHODS: 410 acute stroke patients were included. According to the presence of a cardioembolic source (CES), there were 221 patients with CES and 189 patients without CES. Logistic regression analysis was performed to ascertain the association between NT-proBNP and 6-month mortality/functional outcome in each group. RESULTS: The mean age of our patients was 67.2 years (range, 18-97 years). NT-proBNP was a multivariate independent predictor of mortality in the CES group alone, whereas it was only a univariate predictor of 6-month mortality in the total patient and non-CES groups with its association disappearing in the multivariate model. In addition, it was only a univariate predictor of good functional outcome in all of the groups. CONCLUSIONS: Our data suggest that NT-proBNP can more reliably predict 6-month mortality in patients with cardioembolic stroke than in patients with other stroke subtypes.

Usefulness of anticoagulant therapy in the prevention of embolic complications in patients with acute infective endocarditis.

BACKGROUND: The use of anticoagulant therapy (ACT) in patients with acute infective endocarditis (IE) remains a controversial issue. Our study attempts to estimate the impact of ACT on the occurrence of embolic complications and the usefulness of ACT in the prevention of embolism in IE patients. METHODS: The present authors analyzed 150 patients with left-sided IE. Embolisms including cerebrovascular events (CVE) and the use of ACT were checked at the time of admission and during hospitalization. RESULTS: 57 patients (38.0%) experienced an embolic event. There was no significant difference in the incidence of CVE and in-hospital mortality between patients with and without warfarin use at admission, although warfarin-naïve patients were significantly more likely to have large (>1 cm) and mobile vegetation. In addition, there was no significant difference in the incidence of postadmission embolism and in-hospital death between patients with and without in-hospital ACT. On multivariate logistic regression analysis, ACT at admission was not significantly associated with a lower risk of embolism in patients with IE. CONCLUSIONS: The role of ACT in the prevention of embolism was limited in IE patients undergoing antibiotic therapy, although it seems to reduce the embolic potential of septic vegetation before treatment.

Clinical significance of cerebrovascular complications in patients with acute infective endocarditis: a retrospective analysis of a 12-year single-center experience.

BACKGROUND: Cerebrovascular complications (CVCs) frequently occur in patients with acute infective endocarditis (IE). The aim of this study is to describe the clinical findings of CVCs and to evaluate the impact of CVCs on long-term mortality in patients with IE. METHODS: We retrospectively analyzed 144 patients who fulfilled the modified Duke's criteria for definite left-sided IE. CVCs were classified into minor (silent cerebral embolism, TIA and stroke with an initial modified Rankin scale ≤ 2) or major (an initial modified Rankin scale ≥ 3) CVCs. Cox proportional hazards model was used for mortality analysis. Hazard ratio (HR) and 95% confidence interval (CI) were obtained. RESULTS: The mean age of the 144 patients (96 males and 48 females) was 49.1 years (range 6-85 years). A CVC was found in 37 (25.7%) patients. Of these, 25 were treated with surgical therapy. The patients who underwent early surgery within 2 weeks after stroke had a statistical trend toward a higher risk of postoperative brain hemorrhage (50% versus 4.8%, P = 0.057 by Fisher exact test). The minor CVC group had a similar risk of death as the no-CVC group (P = 0.803; HR 0.856; CI 0.253-2.894), whereas the major CVC group had a higher mortality (P = 0.013; HR 2.865; CI 1.254-6.548) than the no-CVC group. In the multivariate analysis, major CVC (P = 0.002; HR 3.893; CI 1.649-9.194) was a significant predictor of mortality in IE patients, together with advanced age (P = 0.005; HR 3.138; CI 1.421-6.930) and prosthetic valve IE (P = 0.008; HR 2.819; CI 1.315-6.044). CONCLUSIONS: IE can give rise to various forms of CVC, most frequently, acute ischemic brain lesions. In our study, major CVC was associated with high risk of mortality although total CVC was not significantly related to the risk of death in patients with IE.

Double accessory left atrial chordae tendineae resulting in mitral regurgitation.

The presence of accessory left atrial chordae tendineae inserting into the mitral valve leaflet is extremely rare. Two long and thin accessory chordae tendineae, one arising from the left atrial dome and the other from the inferior interatrial septum, were incidentally identified during corrective surgery for severe mitral regurgitation from A3 prolapse. Triangular resection of the A3 portion of the anterior mitral valve leaflet including the double accessory chordae tendineae and primary repair followed by posterior ring annuloplasty was successfully performed.

Device closure of a large atrial septal defect in a patient with severe pulmonary arterial hypertension after 1 year use of an oral endothelin receptor antagonist.

The presence of severe pulmonary arterial hypertension (PAH) in patients with atrial septal defect (ASD) is still thought to preclude shunt closure, although there are several reports of good clinical outcomes after vasodilator therapy. We report the case of a young woman with ASD and severe PAH who was able to successfully undergo percutaneous shunt closure following 1 year use of the oral endothelin receptor antagonist, bosentan.

Eleven years of experience with the neurologic complications in Korean patients with acute aortic dissection: a retrospective study.

BACKGROUND: This study attempts to explore the clinical features, possible mechanisms and prognosis of the neurologic complications in patients with acute aortic dissection (AD). METHODS: Medical records of 278 consecutive patients with AD (165 with type A and 113 with type B dissection) over 11.5 years were retrospectively analyzed for clinical history, CT findings, neurologic complications and outcome. Neurologic complications were classified into early-onset or delayed-onset complications. Independent t-test or Chi-square test (or Fisher exact test) was used for comparing the different groups. Multivariable logistic regression analysis was performed to determine the independent association between variables. RESULTS: The mean age of the included patients (145 male and 133 female) was 59.4 years (range 19-91 years). 41 patients (14.7%) had a neurologic complication, which included 21 with early-onset complication and 23 with delayed-onset complication, including 3 with both. Advanced age and classic type of dissection were independently associated with the neurologic complication in patients with type A dissection. The most frequent manifestation was ischemic stroke (26 patients, 9.4%), followed by hypoxic encephalopathy (9, 3.2%), ischemic neuropathy (5, 1.8%), spinal cord ischemia (5, 1.8%), seizure (2, 0.7%), hoarseness (1, 0.4%) and septic encephalopathy (1, 0.4%). Overall in-hospital mortality was 10.1%, whereas the complicated group had a mortality rate of 43.9%. Renal impairment, pulse deficit, neurologic complication and nonsurgical treatment were independent variables for determining in-hospital mortality in patients with type A dissection. CONCLUSIONS: The dominance of neurologic symptom in the early stage of AD may make its early diagnosis difficult. Besides chest pain and widened mediastinum in chest x-ray, variable neurologic symptoms including left hemiparesis with asymmetric pulse and hypotension may suggest underlying AD.

The Brachial Ankle Pulse Wave Velocity is Associated with the Presence of Significant Coronary Artery Disease but Not the Extent.

BACKGROUND AND OBJECTIVES: Arterial stiffness is well known as an important risk factor for cardiovascular disease. At our institution, we assessed the association between arterial stiffness, as determined by brachial ankle pulse wave velocity (baPWV), and the extent of coronary artery disease (CAD), as detected by conventional coronary angiography (CAG) in patients who visited the outpatient clinic for angina without any previous history of heart disease. In addition, we evaluated if the level of baPWV could predict the revascularization as a clinical outcome. SUBJECTS AND METHODS: On a retrospective basis, we analyzed the data of 651 consecutive patients who had undergone baPWV and elective CAG for suspected CAD between June 2010 and July 2011, at a single cardiovascular center. RESULTS: The baPWV was one of the statistically meaningful predictors of significant CAD (diameter of stenosis >50%) in addition to male gender, age, the level of high density lipoprotein-cholesterol, and hemoglobin A1c in multivariate analysis. However, baPWV was not the significant predictor of revascularization. When the extent of CAD was classified into following 4 groups; no significant CAD, 1-, 2- and 3-vessel disease, there was significant difference of baPWV between the significant and non-significant CAD group, but there was no difference of baPWV among the 3 significant CAD groups, although there was a trend toward the positive correlation. CONCLUSION: Although baPWV was an independent predictor of significant CAD, it was neither associated significantly with the extent of CAD nor with the risk of revascularization. Therefore, baPWV has a limited value for portending the severity of CAD in patients with chest pain.

Right coronary artery to left ventricular fistula associated with infective endocarditis of the mitral valve.

A 27-year-old man with bacterial endocarditis of the mitral valve and embolic episodes was bound to have a large right coronary artery fistula communicating with the left ventricle, immediately inferior to the posterior mitral annulus. The perforation of the posterior leaflet and coronary arteriovenous fistula was identified using two-dimensional Doppler echocardiography. The diagnosis was confirmed by coronary angiography, and the patient underwent a successful operation.

A Case of a Pulmonary Arteriovenous Malformation With Ebstein's Anomaly.

A pulmonary arteriovenous malformation (PAVM) is a rare pulmonary vascular anomaly presenting as dyspnea or recurrent epistaxis. Ebstein's anomaly (EA), a congenital cardiac malformation, is also a rare condition. There have been no reports concerning the co-existence of PAVM with hereditary hemorrhagic telangiectasia (HHT) and EA. A 40-year-old woman was admitted with a 2-month history of increasing dyspnea and several years of recurrent epistaxis. On transthoracic echocardiography, she was diagnosed with EA and agreed to undergo surgical treatment. A chest CT angiography showed a 12-mm serpiginous vascular structure suspicious for a PAVM and a liver CT suggested HTT. Although it is unclear whether or not a concurrent PAVM and EA have an embryologic or genetic relationship, we report a case of a PAVM with EA. Further genetic and embryonic studies are needed to identify a possible relationship of the two medical conditions.

Pulmonary hemorrhage after percutaneous coronary intervention with abciximab therapy.

Abciximab has a key role in the treatment of patients with acute coronary syndromes undergoing percutaneous coronary intervention; however, an increased risk of bleeding complications is well recognized. We report a case of serious pulmonary hemorrhage after use of abciximab therapy. A definitive indication and treatment guideline should be available to minimize serious bleeding complications. Additionally, respiratory symptoms should be monitored closely for early detection of serious pulmonary hemorrhage in patients receiving abciximab therapy during percutaneous coronary intervention.