Association of height loss and cardiovascular disease: Data from a large Korean cohort.

Background: Height declines with age, and its degree differs among individuals. Despite epidemiologic evidence for the inverse relationship between adult height and cardiovascular disease (CVD) incidence, the clinical significance of height loss in CVD remains to be elucidated. Therefore, this study investigated the association between height loss and CVD incidence. Methods: In total, 127,573 Korean participants were enrolled; their heights were monitored from 2002 to 2011. The annual height loss (cm/year) was the difference between the first and last height measurements within the observation period divided by the number of years. The participants were classified as Group 1 (height loss: <0.3 cm/year; n = 102,554), Group 2 (height loss: 0.3- < 0.6 cm/year; n = 17,324), or Group 3 (height loss: ≥0.6 cm/year; n = 7,695). Results: The cumulative major adverse cardiac and cerebral event (MACCE: cardiac death, non-fatal myocardial infarction, and unplanned hospitalization for heart failure or stroke) incidence rate was 3.6% for Group 1, 4.5% for Group 2, and 5.2% for Group 3. Group 2 (hazard ratio [HR] = 1.27, 95% confidence interval [CI] = 1.17-1.37) and Group 3 (HR = 1.46, 95% CI = 1.32-1.62) had a significantly higher incidence of MACCE than Group 1. In the model adjusted for age, sex, comorbidities, income level, body mass index, smoking, and drinking status, the MACCE risk was higher in Group 2 (HR = 1.11, 95% CI = 1.07-1.20) and Group 3 (HR = 1.25, 95% CI = 1.13-1.39) than in Group 1. Conclusion: The degree of height loss was independently associated with CVD occurrences in the Korean population.

Height Is Associated with Dyslipidemia in Korean Premenopausal Women: Data from the Korea National Health and Nutrition Examination Survey.

BACKGROUND: The association between height and cardiovascular disease (CVD) has been reported in epidemiological studies for decades; however, the mechanism for this relationship is still unclear. We previously reported that dyslipidemia was associated with adult height in Korean men without CVD. OBJECTIVES: This study explored the potential -relationship between height and dyslipidemia in premenopausal women. METHODS: This study used data from the 2007-2016 Korea National Health and Nutritional Examination Survey (KNHANES). We identified 16,361 premenopausal women aged ≥19 years without a history of CVD (myocardial infarction/stroke) or cancer. Fasting total cholesterol, triglyceride, and high-density lipoprotein cholesterol (HDL-C) levels were measured. Dyslipidemia was further classified as hypercholesterolemia (total cholesterol level ≥240 mg/dL or treatment with lipid-lowering medications), hypertriglyceridemia (triglyceride level ≥200 mg/dL), and low HDL-C (HDL-C level <40 mg/dL). Subjects were divided into four groups by their height (<155, 155-159.9, 160-164.9, and ≥165 cm), and the prevalence of dyslipidemia was compared. RESULTS: Multiple regression analysis revealed that short premenopausal women had a higher likelihood of hypercholesterolemia (ptrend = 0.002), hypertriglyceridemia (ptrend = 0.010), and low HDL-C (ptrend = 0.002) when adjusted for age, comorbidities, waist circumference, health-related habits, and economic status. CONCLUSION: There was a dose-dependent correlation between adult height and adverse lipid profile in premenopausal Korean women who did not have CVD. This finding could serve as further evidence that dyslipidemia can be a link between shortness and CVD.

Comparison of Intracardiac Echocardiography and Transesophageal Echocardiography for Image Guidance in Percutaneous Patent Foramen Ovale Closure.

Background and Objectives: Transesophageal echocardiography (TEE) guidance is the current gold standard for catheter-based procedures in the treatment of structural heart diseases. Intracardiac echocardiography (ICE), which can be performed under local anesthesia, has been recently introduced and is becoming more widely used. We aimed to compare the efficacy and safety of ICE and TEE in patent foramen ovale (PFO) device closure. Materials and Methods: All 74 patients with a history of cryptogenic stroke undergoing PFO closure for secondary prophylaxis were selected from our registry. Intraprocedural TEE was performed by echocardiographer-cardiologists with the patient under general anesthesia. Conversely, ICE was performed with the patient under local anesthesia. Baseline characteristics, procedural details, and immediate outcomes were compared between the TEE and ICE groups (n = 49 and n = 25, respectively). Results: Although patients in the ICE group were older (47 ± 10 vs. 57 ± 7 years, p < 0.001), sex and comorbidity variables were similar between the two groups. The degree of inducible right-to-left shunt via the PFO, assessed using preprocedural TEE, was also comparable. Notably, fluoroscopy time (22 ± 18 vs. 16 ± 7 min, p = 0.030), radiation dose (498 ± 880 vs. 196 ± 111 mGy, p = 0.022), and total procedural time in the catheter laboratory (99 ± 30 vs. 67 ± 12 min, p < 0.001) were significantly lower in the ICE group than those in the TEE group. The entire hospital stay was similar between groups (3.8 ± 2.2 vs. 3.4 ± 1.3 days, p = 0.433). No procedural complications, such as device embolization, pericardial hemorrhage, major bleeding, mortality, or access-related vascular injury were reported in either group. Conclusions: ICE-guided PFO device closure is quicker and less hazardous in terms of radiation exposure than the TEE-guided procedure, with similar procedural outcomes and duration of hospital stay.

Post-operative left atrial volume index is a predictor of the occurrence of permanent atrial fibrillation after mitral valve surgery in patients who undergo mitral valve surgery.

BACKGROUND: Atrial fibrillation (AF) can occur even after the correction of mitral valve (MV) pathology in patients who have pre-operative sinus rhythm and undergo MV surgery. However, the factors associated with the occurrence of AF after MV surgery are still unclear. The aim of this retrospective study was to investigate the factors determining the occurrence of permanent AF after MV surgery in patients with preoperative sinus rhythm who underwent MV surgery. METHODS: Four hundred and forty-two patients (mean age 46 ± 12, 190 men) who underwent MV surgery and sinus rhythm were investigated retrospectively. Transthoracic echocardiography was performed before and after MV surgery at the time of dismissal. RESULTS: Permanent post-operative AF occurred in 81 (18%) patients even after successful MV surgery and preoperative sinus rhythm. It was more common in rheumatic etiology, a presence of mitral stenosis, lower pre- and post-operative left ventricular ejection fraction, higher post-operative mean diastolic pressure gradient across mitral prosthesis, larger post-operative left atrial volume index (LAVI) and lesser degrees of reduction in LAVI after surgery. In multiple regression analysis, post-operative LAVI was found to be an independent predictor for occurrence of AF. Post-operative LAVI > 39 ml/m2 was the cut-off value for best prediction of new onset permanent AF (sensitivity: 79%, AUC: 0.762, SE: 0.051, p < 0.001). CONCLUSION: New-onset permanent post-operative AF is not uncommon, even after successful MV surgery despite pre-operative sinus rhythm. Larger post-operative LAVI was an independent predictor for the occurrence of AF.

Improved early risk stratification of patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention using a combination of serum soluble ST2 and NT-proBNP.

BACKGROUND: Although soluble suppression of tumorigenicity 2 (sST2) in serum is known to be associated with ischemic heart disease and heart failure, data regarding its prognostic impact in ST-segment elevation myocardial infarction (STEMI) is limited. We evaluated the prognostic impacts of serum sST2 and other serum biomarkers in STEMI patients undergoing primary percutaneous coronary intervention (PCI). METHODS: Consecutive all 323 patients with STEMI that underwent primary PCI were enrolled. Blood tests and samples were obtained in an emergency room. The primary endpoint was 1-year major adverse cardiovascular and cerebrovascular events (MACCEs), defined as a composite of cardiovascular death, non-fatal MI, non-fatal stroke, and ischemia-driven revascularization. RESULTS: Mean age was 59.1±13.1 years (men 84%). MACCE (20 cardiovascular deaths, 7 non-fatal MI, 4 non-fatal stroke, 7 ischemia-driven revascularizations) occurred in 38 patients (12%). After adjusting for confounding factors, Cox regression analysis revealed that high serum sST2 (>75.8 ng/mL mean value, adjusted hazard ratio 2.098, 95% CI 1.008-4.367, p = 0.048) and high serum NT-proBNP level (>400 pg/mL, adjusted hazard ratio 2.606, 95% CI 1.086-6.257, p = 0.032) at the time of presentation independently predicted MACCE within a year of primary PCI. Furthermore, when high serum sST2 level was combined with high serum NT-proBNP level, the hazard ratio of MACCE was highest (adjusted hazard ratio 7.93, 95% CI 2.97-20.38, p<0.001). CONCLUSION: Elevated serum levels of sST2 or NT-proBNP at the time of presentation were found to predict 1-year MACCE independently and elevated serum levels of sST2 plus NT-proBNP were associated with even poorer prognosis in patients with STEMI undergoing primary PCI.

Cardiac Metastasis of Leiomyosarcoma Complicated with Complete Atrio-Ventricular Block and Ventricular Tachycardia.

We described a case of a 54-year-old male who presented with dizziness and dyspnea due to cardiac metastasis of leiomyosarcoma. Cardiac metastasis of leiomyosarcoma caused both bradyarrhythmia and tachyarrhythmia in the patient. He was treated with implantation of a permanent pacemaker for management of complete atrio-ventricular block and anti-arrhythmic drug that suppressed ventricular tachycardia successfully.

Normal range and regional heterogeneity of myocardial perfusion in healthy human myocardium: assessment on dynamic perfusion CT using 128-slice dual-source CT.

Information about myocardial perfusion in healthy hearts is essential for evaluating patients with ischemic heart disease. The purpose of this study was to determine the range and regional variability of myocardial perfusion in normal volunteers on dynamic perfusion computed tomography (CT). Myocardial perfusion was assessed in 19 healthy volunteers (age 33-60 years; 11 men) at rest and during adenosine-induced hyperemia using a 128-slice dual-source CT scanner. Data were quantified as cc/cc/min for the transmural myocardium based on a 17-segment American Heart Association model. Mean myocardial blood flows (MBF) were 1.73 ± 0.33 cc/cc/min during adenosine-induced hyperemia, 0.83 ± 0.21 cc/cc/min at rest, and perfusion reserve was 2.20 ± 0.53. Regional variability was 17 ± 5% for hyperemic perfusion, 18 ± 7% for resting, and 21 ± 6 % for perfusion reserve. Although statistically insignificant, perfusion in the septum was lower at rest and during hyperemia than in other regions. Women tended to have lower perfusion during hyperemia (1.65 ± 0.40 vs. 1.79 ± 0.28 cc/cc/min, P = 0.40), and higher perfusion at rest than men (0.91 ± 0.27 vs. 0.77 ± 0.15 cc/cc/min, P = 0.23), resulting in lower perfusion reserve (1.86 ± 0.31 vs. 2.45 ± 0.53, P = 0.11). This small cohort of healthy volunteers study reveals normal myocardial perfusion parameter on dynamic perfusion CT as follows: mean MBF is 1.73 ± 0.33 cc/cc/min during hyperemia, 0.83 ± 0.21 cc/cc/min at rest, and perfusion reserve is 2.20 ± 0.53. And the study also demonstrates considerable regional heterogeneity of the myocardial perfusion.

Echocardiographic predictor of acute heart failure after spine surgery: a novel tissue Doppler index associated with a potentially fatal complication of the operation.

BACKGROUND CONTEXT: Acute heart failure (HF) is a potentially fatal complication after spine surgery. PURPOSE: We sought to identify clinical and echocardiographic predictors of postoperative HF in spine surgery patients. STUDY DESIGN: Retrospective observational study. PATIENT SAMPLE: A total of 305 patients (128 men; age, 65 ± 9 years) who underwent spine surgery were consecutively enrolled. A transthoracic echocardiography was performed to all patients before the index operation. Patients with a history of HF or with left ventricular (LV) systolic dysfunction (LV ejection fraction <50%) were excluded. OUTCOME MEASURES: Heart failure was defined according to the Framingham criteria. The presence of postoperative dyspneic symptom and the sign of bilateral ankle edema were recorded by the physicians. Chest X-ray was mandatory for all patients and interpreted by the two physicians, including at least one radiologist. METHODS: Clinical, operative, and echocardiographic parameters were compared between patents with and without acute HF during the postoperative period (duration, 11 ± 9 days). This study was supported by Boryung Pharmaceutical Company (Seoul, Republic of Korea; 13,440 USD). RESULTS: Postoperative HF occurred in 31 patients (10%). Compared with those without postoperative HF, these patients were older (73 ± 7 vs. 64 ± 9 years), had longer anesthesia time (7.4 ± 4.2 vs. 3.6 ± 2.1 hours), and were treated with a greater volume of fluid replacement during the operation (3.8 ± 0.7 vs. 1.3 ± 0.1 L) (p<.05 for all). On echocardiographic evaluation, the ratio of early diastolic mitral inflow velocity to early diastolic mitral annular velocity (E/E') was higher (11 vs. 8) and left atrial volume index was larger (20 ± 6 vs. 17 ± 6 mL/m(2)) in patients with HF than in the control group (p<.05 for all), whereas the differences in LV ejection fraction and LV size were not significant. In multivariate analysis, E/E' (odds ratio, 1.399; 95% confidence interval, 1.169-1.674; p<.0001), age, and quantity of replaced volume during surgery were independent predictors of postoperative HF. CONCLUSIONS: Acute HF after spine surgery was rather common even in previously healthy patients. E/E' reflecting LV filling pressure predicted postoperative HF in patients who underwent spine surgery.

The Unusual Suspect: Anemia-induced Systolic Anterior Motion of the Mitral Valve and Intraventricular Dynamic Obstruction in a Hyperdynamic Heart as Unexpected Causes of Exertional Dyspnea after Cardiac Surgery.

Dynamic left ventricular (LV) outflow tract obstruction is a characteristic feature of hypertrophic cardiomyopathy; however, it can also occur in association with hyperdynamic LV contraction and/or changes in the cardiac loading condition, even in a structurally normal or near-normal heart. Here, we report a case of anemia-induced systolic anterior motion of the mitral valve and the resultant intraventricular obstruction in a patient who underwent coronary artery bypass grafting and suffered from anemia associated with recurrent gastrointestinal bleeding.

High prevalence of unrecognized chordae tendineae rupture in mitral valve prolapse patients undergoing valve replacement surgery.

BACKGROUND: Not infrequently, chordae tendineae rupture, which was not recognized preoperatively using echocardiography, was found during mitral valve (MV) surgery in patients with severe mitral regurgitation (MR) diagnosed with MV prolapse. We evaluated the incidence and predictors of echocardiographically-unrecognized chordae tendineae rupture in patients with severe MR because of MV prolapse. METHODS: We enrolled 124 patients undergoing MV surgery for severe MR because of nonrheumatic MV prolapse. Patients with MR because of infective endocarditis, ischemic heart disease, or echocardiographically-detected chordal rupture were excluded. The study sample was divided into 2 groups: surgically-proven chordae tendineae rupture (n = 51), and no chordae rupture (n = 73). RESULTS: Echocardiographically-unrecognized chordae tendineae rupture was found in 51 (41%) of 124 patients undergoing MV surgery because of MR. It was more common in patients with posterior or single-leaflet prolapse. Although the severity of MR was greater in patients with chordal rupture, left atrial volume index was smaller compared with those without. In a multivariate analysis, involvement of posterior leaflet (odds ratio [OR], 2.80; 95% confidence interval [CI], 1.15-6.84) or single leaflet (OR, 3.18; 95% CI, 1.07-9.45), MR severity (OR, 4.76; 95% CI, 1.96-11.59), and left atrial volume index (OR, 0.98; 95% CI, 0.96-0.99) were independently associated with chordal rupture (P < 0.05 for all). CONCLUSIONS: Unrecognized chordae tendineae rupture is a common unrecognized contributor to severe MR necessitating valve replacement in MV prolapse patients. Earlier recognition and more specific management might contribute to improved prognosis for such patients.

Small left atrial volume is an independent predictor for fainting during head-up tilt test: the impact of intracardiac volume reserve in vasovagal syncope.

BACKGROUND: Vigorous left ventricular (LV) contraction with progressive ventricular emptying during orthostatic stress may induce hyper-responsiveness of cardiac mechanoreceptor and vasovagal syncope (VVS). We hypothesized that intracardiac volume reserve estimated by the left atrial (LA) volume index (LAVI) plays an important role in the mechanism of VVS. METHODS: A total of 234 patients (115 male, 44 ± 18 years) who underwent head-up tilt test (HTT) and transthoracic echocardiography for unexplained syncope were consecutively enrolled. Patients with a positive HTT result (HTT+; n=152) were compared with those with negative HTT response (HTT-; n=82). RESULTS: 1. Compared to HTT- patients, HTT+ patients were younger (41 ± 17 vs. 48 ± 17 years, p=0.005), included a higher number of females (56% vs. 50%, p=0.009) and showed higher basal heart rate (67 ± 12 vs. 63 ± 11 bpm, p=0.047). 2. LAVI (20 ± 5 vs. 26 ± 13 ml/m(2), p<0.001), LV end-diastolic dimension (47.4 ± 3.7 vs. 49.0 ± 4.1mm, p=0.015), and the proportion of LV hypertrophy (13% vs. 24%, p=0.027) were smaller and early diastolic mitral annulus velocity was higher (9.7 ± 3.0 vs. 8.5 ± 2.6 cm/s, p=0.004) in HTT+ patients than those in HTT- group. 3. LAVI (OR 0.917 (0.860-0.977), p=0.007) was the only independent predictor of HTT induced VVS, and LAVI had a linear correlation with time to syncope during HTT (r=0.39, p=0.034). In addition, patients with LAVI ≥ 36 ml/m(2) did not faint during HTT. CONCLUSION: Small LA volume is an independent predictor of HTT-induced VVS. Limited intracardiac volume reserve might play an important role in the mechanism of VVS.

Newly developed aortic dissection after aorta cannulation during mitral valve surgery in a patient with marfan syndrome.

We report a case of newly developed aortic dissection after aorta cannulation during mitral valve surgery in a patient with Marfan syndrome. An unexpected fatal complication of cardiac surgery detected on postoperative imaging survey in Marfan syndrome patient and its surgical finding are described.

Comparison of inflammatory markers for the prediction of neointimal hyperplasia after drug-eluting stent implantation.

BACKGROUND: We compared the relationship between inflammatory markers and neointimal hyperplasia (NIH) after drug-eluting stent (DES) implantation. METHODS: We implanted a single DES in 42 consecutive patients with stable angina. The plasma high-sensitivity C-reactive protein (hs-CRP), interleukin-6 (IL-6), and matrix metalloproteinase-9 (MMP-9) levels were measured before, and 24 and 72 h after the procedure. Angiography and intravascular ultrasound were performed. RESULTS: No relationship was noted between the baseline hs-CRP level and NIH. A significant positive correlation was noted between NIH and the hs-CRP level obtained at 24 h (r=0.435, P=0.004), and 72 h (r=0.334, P=0.031) after the procedure. Interestingly, there was a positive correlation between the change (Δ) in the hs-CRP level and NIH at 24 h (r=0.414, P=0.006). The fourth quartile of the hs-CRP at 24 h after percutaneous coronary intervention (PCI) had significantly larger volume of NIH than the first quartile (20.1±25.1 vs. 2.7±6.4 mm, P<0.05). Moreover, NIH in the fourth quartile (20.9±26.4 mm) was higher than the first quartile (3.3±8.6 mm) of the Δ hs-CRP level at 24 h (P<0.05) after the procedure. Although the IL-6 level at the baseline and 72 h after the procedure were positively correlated with NIH (r=0.337, P=0.029 and r=0.435, P=0.004, respectively), the Δ IL-6 level at any stage was not correlated with NIH. Neither the MMP-9 level nor the Δ MMP-9 level at any stage was correlated with NIH. CONCLUSION: This prospective intravascular ultrasound study showed the inflammatory response after PCI, as measured by hs-CRP levels, but not the baseline hs-CRP level, predict NIH after DES implantation. Neither a change in the IL-6 nor MMP-9 levels at any stage after PCI reflected NIH.

Different clinical outcome of paravalvular leakage after aortic or mitral valve replacement.

Although aortic valve replacement (AVR) and mitral valve replacement (MVR) are the most commonly performed prosthetic valve replacement operations, it is unclear whether clinical outcomes of paravalvular leakage (PVL) after MVR or AVR are different. It was hypothesized that clinical outcomes of PVL after AVR would be more favorable than after MVR because the pressure gradient is much larger in PVL occurring at the mitral position, which happens at the systolic phase, than at the aortic valve. Over a 12-year period, 82 patients with PVL were identified. After excluding patients who required immediate surgical repair for severe symptoms, patients with Behçet disease or infective endocarditis, and those with PVL involving both valves, 54 remaining patients (21 women, mean age 56 ± 14 years, 23 AVRs) with mild to moderate leakage constituted the study population. The end points were cardiac death, all-cause mortality, repeat surgery, and urgent admission for heart failure. During a median follow-up period of 35 months, there were 27 events, including 23 repeated surgeries, 2 cardiac deaths, 1 noncardiac death, and 1 admission for heart failure. Cox regression analysis revealed that the valve location of PVL was the only independent clinical predictor of event-free survival. The estimated 8-year event-free survival rate was significantly higher in patients with PVL after AVR than those after MVR (70 ± 12% vs 16 ± 8%, p <0.0001). In conclusion, PVL after AVR demonstrated more favorable long-term clinical outcomes compared to that after MVR. In patients who develop PVL after AVR, repeat surgery may be deferred. However, in patients with PVL after MVR, more aggressive therapeutic approaches should be considered.

Left ventricular hypercontractility immediately after tilting triggers a disregulated cardioinhibitory reaction in vasovagal syncope: echocardiographic evaluation during the head-up tilt test.

OBJECTIVES: Vasovagal syncope (VVS) has been believed to occur when mechanoreceptors are discharged by vigorous ventricular contraction. However, previous investigators have reported divergent observations regarding the presence of left ventricular (LV) hypercontractility in VVS. Because the autonomic nervous system can be promptly activated after certain stimuli, we postulated that instantaneously increased LV contractility at the time of venous pooling may trigger the disregulated vasovagal reaction in VVS. METHODS: Forty-seven patients (31 males, mean age 41 ± 18 years) with unexplained syncope were enrolled. Echocardiography was performed during the head-up tilt test (HUTT) as follows: baseline, passive tilting (0 and 20 min), and tilting with isoproterenol administration (5 and 10 min). Patients were divided into 2 groups according to the results of the HUTT; group 1 (n = 12) had a positive result and group 2 had a negative response. RESULTS: LV ejection fraction (LVEF), determined immediately after tilting, increased in group 1, whereas LVEF decreased in group 2 (p = 0.032). Although left atrial and LV volumes decreased similarly during the test, group 1 showed a progressive reduction in LVEF, while LVEF progressively increased in group 2 (p = 0.007). CONCLUSION: Patients with HUTT-induced VVS presented LV hypercontractions immediately after tilting and a subsequent decrease in LV contractility. An instantaneous activation of the sympathetic nervous system at the time of venous pooling may trigger an early disregulated vasovagal reflex via an increase in LV contractility in VVS.

Central aortic pressure in aortic aneurysm and aortic dissection: a novel prognostic marker.

BACKGROUND: Some aortic aneurysm (AA) or aortic dissection (AD) patients can be observed to detect disease progression if optimal blood pressure is achieved. However, in another group of patients, disease progression occurs despite well-controlled blood pressure. The aim of this study was to determine the prognostic value of central aortic pressure in AA and AD. METHODS: Fifty-six newly diagnosed AA or AD patients (37 men, age: 60.3 +/- 12.9 years) who did not need urgent surgery or interventional treatment were enrolled. All patients achieved brachial SBP < or = 120 mm Hg with beta-blocker-based treatment within 1 month. Then, central aortic pressure parameters were noninvasively checked with radial tonometry (SphygmoCor Px Pulse Wave Analysis System, AtCor Medical, Sydney, Australia). All patients were monitored for at least 6 months and for up to 5 years. RESULTS: Thirty-three patients did well without disease progression. However, disease progression was noted despite well-controlled brachial blood pressure in 23 patients. In intergroup comparisons, central aortic systolic pressure (112.7 +/- 3.5 mm Hg vs. 104.3 +/- 7.5 mm Hg) and aortic augmentation index (AI: 33.4 +/- 13.5% vs. 23.4 +/- 8.7%) were significantly high in the disease progression group (P < 0.05). CONCLUSION: In some AA or AD patients, central aortic pressure and AI can be considered as surrogate prognostic markers.