Usefulness of an Implantable Loop Recorder in Diagnosing Unexplained Syncope and Predictors for Pacemaker Implantation.

BACKGROUND: An implantable loop recorder (ILR) is an effective tool for diagnosing unexplained syncope (US). We examined the diagnostic utility of an ILR in detecting arrhythmic causes of US and determining which clinical factors are associated with pacemaker (PM) implantation. METHODS: This retrospective, multicenter, observational study was conducted from February 2006 to April 2018 at 11 hospitals in Korea. Eligible patients with recurrent US received an ILR to diagnose recurrent syncope and document arrhythmia. RESULTS: A total of 173 US patients (mean age, 67.6 ± 16.5 years; 107 men [61.8%]) who received an ILR after a negative conventional workup were enrolled. During a mean follow-up of 9.4 ± 11.1 months, 52 patients (30.1%) had recurrent syncope, and syncope-correlated arrhythmia was confirmed in 34 patients (19.7%). The ILR analysis showed sinus node dysfunction in 24 patients (70.6%), supraventricular tachyarrhythmia in 4 (11.8%), ventricular arrhythmia in 4 (11.8%), and sudden atrioventricular block in 2 (5.9%). Overall, ILR detected significant arrhythmia in 99 patients (57.2%) irrespective of syncope. Among patients with clinically relevant arrhythmia detected by ILR, PM implantation was performed in 60 (34.7%), an intra-cardiac defibrillator in 5 (2.9%), and catheter ablation in 4 (2.3%). In a Cox regression analysis, history of paroxysmal atrial fibrillation (PAF) (hazard ratio [HR], 2.34; 95% confidence interval [CI], 1.33-4.12; P < 0.01) and any bundle branch block (BBB) (HR, 2.52; 95% CI, 1.09-5.85; P = 0.03) were significantly associated with PM implantation. CONCLUSION: ILR is useful for detecting syncope-correlated arrhythmia in patients with US. The risk of PM is high in US patients with a history of PAF and any BBB.

Changes in prevalence of Helicobacter pylori infection after subtotal gastrectomy.

BACKGROUND/AIMS: There have been few reports comparing pre and postoperative prevalence of Helicobacter pylori infection and gastritis in patients with gastric cancer surgery. METHODOLOGY: Seventy patients with primary gastric cancer were identified to be infected with Helicobacter pylori preoperatively and tested for Helicobacter pylori infection after subtotal gastrectomy. We analyzed changes in Helicobacter pylori infectivity and histological features of gastric mucosa. RESULTS: The overall spontaneous regression rate of Helicobacter pylori infection was 38.6% (27/70). The mean time between surgery and follow-up tests was 1.02±0.5 years. The activity and chronic inflammation scores were significantly decreased in regression group. In non-regression group, there was no significant difference in activity scores, but the chronic inflammation score was significantly increased. There were no significant changes in atrophic gastritis and intestinal metaplasia scores in either group. The grade of Helicobacter pylori infection was significantly decreased in non-regression group. CONCLUSIONS: The spontaneous regression rate of Helicobacter pylori infection after subtotal gastrectomy was 38.6% (27/70), it occurred in larger scale of patients and it occurred earlier (1.02±0.5 years) than in previous studies. We suggest that further prospective study on spontaneous regression rate of Helicobacter pylori infection after subtotal gastrectomy and its mechanism is needed in the future.

The correlation of endoscopic and histological diagnosis of gastric atrophy.

PURPOSE: Gastric atrophy is a premalignant condition. The aim of this study was to evaluate the correlation between histological and endoscopic findings of atrophy, and to analyze the affecting factors. METHODS: Atrophy was graded by endoscopy, and biopsy was performed in the antrum and body for the diagnosis of atrophy according to the Sydney system in the 1,330 subjects. RESULTS: Both endoscopic and histological atrophy increased in proportion to age (P < 0.001). The prevalence of endoscopic atrophy was significantly lower than that of histological atrophy especially below 50 years of age. The sensitivity and specificity of endoscopy for the diagnosis of atrophy based on histological diagnosis of atrophy were 61.5 and 57.7% in the antrum, and were 46.8 and 76.4% in the body of the stomach. Multivariate analysis showed that an age <50 (OR 0.38, 95% CI 0.25-0.61) and a PG I/II ratio >3 (OR 0.50, 95% CI 0.35-0.71) in the antrum, and an age < 50 (OR 0.43, 95% CI 0.19-1.00) and a CRP > 5 mg/dl (OR 0.53, 95% CI 0.30-0.94) decreased the sensitivity of the endoscopic diagnosis of atrophy in the body. CONCLUSIONS: A high index of suspicion of gastric atrophy is important in the young age group, and confirmation of the diagnosis by histology is necessary.

Successful resection of a giant left ventricular pseudoaneurysm developed later after mitral valve replacement.

We present a case of successful surgical resection of a giant left ventricular (LV) pseudoaneurysm that developed 5 yr after mitral valve replacement (MVR). A 59-yr-old female was admitted with exertional chest pain radiating to left arm and back. 64-slice multidetector computed tomography (MDCT) revealed significant stenosis on the ostium of the first diagonal branch of the left anterior descending coronary artery and also a huge pseudoaneurysm compressing the right atrium and the inferior vena cava. She underwent resection of the pseudoaneurysm, and the pseudoaneurysm tunnel was repaired from the inside of LV cavity by removing the previously inserted prosthetic valve, followed by redo MVR together with coronary arterial bypass grafting (CABG) for a single-vessel disease. At the 6-month follow-up, the patient continued to do well without any complications.

Successful percutaneous coronary intervention with extracorporeal membrane oxygenation support after right coronary artery dissection in an eisenmenger syndrome patient.

The presentation of coronary artery disease in a patient with Eisenmenger syndrome (ES) is relatively rare. Cardiogenic shock due to coronary artery dissection during percutaneous coronary intervention (PCI) can be more critical in these patients. Here, we report a case of successful PCI under mechanical circulation support in a patient with ES who experienced potentially fatal right coronary artery dissection. This case emphasizes that use of extracorporeal membrane oxygenation (ECMO) can lead to successful management of critical complication during PCI, and that the immediate decision to apply of ECMO is important in ES patients who face impending cardiogenic shock with acute heart failure.

Successful rescue of a perforated chronic total occlusion using retrograde technique.

Percutaneous coronary intervention of chronic total occlusion (CTO) is one of the greatest challenges in coronary interventions. Retrograde wiring is suggested as a solution to improve the success rate of intervention for CTO. We experienced the coronary perforation during antegrade wiring at the CTO lesion and sealed it using retrograde wiring and antegrade stenting in a patient who underwent coronary arterial bypass grafting. We found that, in selected cases, the retrograde wire technique may provide a valuable rescue option for perforated CTO in a patient having a retrogradely accessible conduit vessel.

Simultaneous left and right ventricular apical thrombi after occlusion of the wrapped left anterior descending artery.

Left ventricular (LV) thrombus formation is a well-known complication of acute myocardial infarction (AMI) and is reported to occur in 5-8% of patients who have anterior or apical myocardial infarction. However, right ventricular (RV) thrombus has not previously been reported after AMI. We describe a 54-year-old woman who presented with an ST-elevation myocardial infarction due to occlusion of the distal left anterior descending artery, which wrapped around the apex and led to simultaneous LV and RV apical thrombi. .

Relationship between the ST-Segment Resolution and Microvascular Dysfunction in Patients Who Underwent Primary Percutaneous Coronary Intervention.

OBJECTIVES: Incomplete ST-segment elevation resolution (STR) occasionally occurs despite successful revascularization of epicardial coronary artery after primary percutaneous coronary intervention (PPCI). The aim of this study was to evaluate the relationship between the degree of STR and the severity of microvascular dysfunction. METHODS: A total of 73 consecutive patients with ST-segment elevation myocardial infarction (STEMI) who underwent successful PPCI were evaluated. Serial 12-lead electrocardiography was performed at baseline and at 90 minutes after PPCI. Microvascular dysfunction was assessed by index of microvascular resistance (IMR) immediately after PPCI. RESULTS: Patients were classified into 2 groups: 50 patients with complete STR (STR ≥50%) and 23 patients with incomplete STR (STR <50%). The incomplete STR group had a higher IMR value and lower left ventricular ejection fraction (LVEF), compared with the complete STR group. The degree of STR was significantly correlated with IMR (r = -0.416, P=0.002) and LVEF (r = 0.300, P=0.011). These correlations were only observed in patients with left anterior descending artery (LAD) infarction but not observed in patients with non-LAD infarction. A cutoff IMR value was 27.3 for predicting incomplete STR after PPCI. CONCLUSION: Incomplete STR after PPCI in patients with STEMI reflects the presence of microvascular and left ventricular dysfunction, especially in patients with LAD infarction.

Transcatheter aortic valve replacement in a patient with anomalous origin of the left coronary artery.

Transcatheter aortic valve replacement (TAVR) is widely performed in patients with severe aortic stenosis (AS), having a high surgical risk. However, reports of TAVR performed in patients with anomalous coronary arteries are rare. In existing literature, several complications including coronary obstruction are reported. In this study, we report a 77-year-old female patient with severe AS and anomalous origin of the left coronary artery from the right coronary sinus, who successfully underwent TAVR. .

A delayed, unusual non-cardiogenic pulmonary edema after intravascular administration of non-ionic, low osmolar radiocontrast media for coronary angiography.

Non-cardiogenic pulmonary edema (NCPE) is a rare adverse reaction to iodinated radiocontrast media (RCM), in which all previous cases were immediate reactions. A 56-year-old male was given iopamidol, a non-ionic, low osmolar RCM, during coronary artery angiography. He developed pulmonary edema and fever a day after the procedure. Despite diuretic therapy, the patient's pulmonary edema worsened and his high fever persisted. The patient's pulmonary edema was eventually resolved with intravenous steroid treatment. We interpreted the patient's condition as NCPE manifesting as a delayed reaction to RCM. To our knowledge, our case is the first to show NCPE as a delayed hypersensitivity reaction.

Medical findings in women with anorexia nervosa in a korean population.

OBJECTIVE: Eating disorders are a common clinical problem among young women in Asian countries. The aim of this study is to determine the medical effects of anorexia nervosa (AN) in the Korean population. METHODS: We comprehensively investigated medical complications including haemodynamic, haematologic, endocrine, and bone density abnormalities in 67 Korean women with AN, together with 194 healthy Korean women of comparable age with a cross-sectional design. RESULTS: In AN, 36.9% were anaemic, 50.8% were leukopenic, 35.5% were hypoproteinemic, 7.9% were hypokalemic, 9.5% had increased alanine aminotransferase, 6.3% were hyperbilirubinemia, 14.5% were hypercholesterolemia, 14.8% had decreased triiodothyronine. Osteopenia at any one site was identified in 43.3% and an additional 13.4% had osteoporosis. The lowest-ever body mass index was the main determinant of bone mineral density. CONCLUSION: Our data in Korean patients with AN show high frequencies of laboratory abnormalities for medical complications. This study emphasizes the importance of recognizing AN as a medical risk in young Korean women.

A case of fabry cardiomyopathy.

In the absence of hypertension, hypertrophic cardiomyopathy is the most common cause of left ventricular hypertrophy (LVH). However, it has been reported that up to 3% of males with unexplained LVH have Fabry disease, an X-linked disorder of glycophospholipid metabolism that is due to a deficiency in the lysosomal enzyme alpha-galactosidase A (alpha-Gal A). A 44-year-old man was admitted to our hospital with palpitations. He had a history of chronic renal failure diagnosed at age 33 followed by kidney transplantation performed at our institution 2 years later, as well as long-standing hypohidrosis. His medications included prednisolone (5 mg daily), mycophenolate mofetil (1,000 mg, bid), and cyclosporine (150 mg, bid). On hospital day two, an echocardiogram demonstrated increased left ventricular wall thickness (septal wall thickness of 28 mm, posterior wall thickness of 20 mm). Diastolic dysfunction was noted on transmitral flow patterns and tissue Doppler imaging. The patient was found to have low plasma alpha-Gal A activity. A previously reported H46R missense mutation was detected in his alpha-Gal A gene and the patient was subsequently diagnosed with Fabry disease.

Congenital angiodysplasia in a woman presenting with idiopathic jejunal varicosis on angiography.

Angiography is a useful diagnostic tool in cases with massive gastrointestinal bleeding such as angiodysplasia and varicosis when endoscopy is not available. Angiodysplasia and varicosis have distinguishable characteristic features on angiography, such as the presence of a nidus, visible late-draining veins, and the typical vascular tuft. We recently treated a rare case of congenital angiodysplasia without the characteristic angiodysplasia features on angiography. Instead, the patient presented with a very rare case of idiopathic jejunal varicosis. A 42-year-old woman visited the emergency room with the chief complaint of melena for three days and a hemoglobin level of 5.9 g/dL. An abdominal CT angiogram showed varicosis at the jejunal mesentery. Angiography of the superior and inferior mesenteric arteries showed tortuous and dilated jejunal and ileal branches during the venous phase, suggesting a vascular malformation such as varicosis of the jejunum. Surgical exploration with intraoperative endoscopy revealed diffuse engorged veins and a 1.0-cm-diameter superficial ulcer covered with a blood clot that was 70 cm from the ligament of Treitz. A 100-cm segment of jejunum was resected. Histological examination revealed that the lesion was angiodysplasia, not varicosis. The final diagnosis was congenital angiodysplasia.

Right-sided myxomas with extramedullary hematopoiesis and ossification in Carney complex.

The authors report the case of multiple right-sided myxomas in a 42-year-old man with Carney complex. He had previously been diagnosed as Cushing's syndrome and undergone resection of pituitary adenoma at the age of 21. After 10 years, bilateral adrenalectomy had been performed with recurrence of Cushing's syndrome. Recently, he complained of palpitation and intracardiac masses were detected. On physical examination, he had nevi on the lips and in the oral cavity. A tiny eyelid nodule was noted and histopathological analysis confirmed the diagnosis of skin myxoma. Thyroid ultrasonography revealed multiple hypoechoic nodules, which were confirmed pathologically as follicular adenomas. Scrotal ultrasonography also revealed small multiple testicular tumors. Echocardiography demonstrated intracardiac masses in right atrium and right ventricle. Right atriotomy revealed a right atrial mass attached to the annulus of the tricuspid valve and another mass arising from the interatrial septum. In right ventricle, a polypoid mass arose from the anterior leaflet of the tricuspid valve. Also, there were multiple tiny to small masses on the interatrial septum. The masses were completely excised and the tricuspid valve was repaired with annuloplasty. Histopathological analysis confirmed myxomas with foci of extramedullary hematopoiesis and ossification.

Spontaneous rupture of idiopathic thymic abscess with a markedly increased CA-125 level.

We report a rare case of spontaneous rupture of idiopathic thymic abscess into the pleural cavity. A 64-year-old woman was admitted to hospital with pleuritic retrosternal chest pain. Chest roentgenograms disclosed a small amount of bilateral pleural effusion, the examination of which exposed a sterile serous exudate with a markedly increased CA-125 level. Chest computed tomography revealed a large anterior mediastinal cystic mass with bilateral pleural effusions. Following complete resection of the mass, the histological examination revealed cavitary lesion with necrotic thymic tissue and inflammatory infiltrate surrounded by fibrous wall. The immunohistochemical staining for CA-125 displayed strong positivity at the Hassall's corpuscles. Cyst fluid also revealed a highly elevated CA-125 level. Her serum CA-125 concentration two months after surgery had fallen to 28 IU/L. She is now doing well without recurrence of the cyst five months after surgery.