Rosuvastatin Reduces Blood Viscosity in Patients with Acute Coronary Syndrome

BACKGROUND AND OBJECTIVES: Wall shear stress contributes to atherosclerosis progression and plaque rupture. There are limited studies for statin as a major contributing factor on whole blood viscosity (WBV) in patients with acute coronary syndrome (ACS). This study investigates the effect of statin on WBV in ACS patients. SUBJECTS AND METHODS: We prospectively enrolled 189 consecutive patients (mean age, 61.3±10.9 years; 132 males; ST-segment elevation myocardial infarction, n=52; non-ST-segment elevation myocardial infarction, n=84; unstable angina n=53). Patients were divided into two groups (group I: previous use of statins for at least 3 months, n=51; group II: statin-naïve patients, n=138). Blood viscosities at shear rates of 1 s-1 (diastolic blood viscosity; DBV) and 300 s-1 (systolic blood viscosity; SBV) were measured at baseline and one month after statin treatment. Rosuvastatin was administered to patients after enrollment (mean daily dose, 16.2±4.9 mg). RESULTS: Baseline WBV was significantly higher in group II ([SBV: group I vs group II, 40.8±5.9 mP vs. 44.2±7.4 mP, p=0.003], [DBV: 262.2±67.8 mP vs. 296.9±76.0 mP, p=0.002]). WBV in group II was significantly lower one month after statin treatment ([SBV: 42.0±4.7 mP, p=0.012, DBV: 281.4±52.6 mP, p=0.044]). However, low-density lipoprotein cholesterol level was not associated with WBV in both baseline (SBV: R2=0.074, p=0.326; DBV: R2=0.073, p=0.337) and after one month follow up (SBV: R2=0.104, p=0.265; DBV: R2=0.112, p=0.232). CONCLUSION: Previous statin medication is an important determinant in lowering WBV in patients with ACS. However, one month of rosuvastatin decreased WBV in statin-naïve ACS patients.

Different Characteristics between Patients with Apical and Non-Apical Subtypes of Stress-Induced Cardiomyopathy

BACKGROUND: Stress-induced cardiomyopathy (SCM) is characterized by apical ballooning on echocardiography, but some of SCM patients show non-apical involvement and their characteristics are not well defined. METHODS: We investigated 56 patients that were diagnosed as SCM and divided them into 2 groups: apical ballooning syndrome (ABS, n = 49, 87.5%) and non-apical ballooning syndrome (N-ABS, n = 7, 12.5%) groups. Patients with N-ABS were significantly younger than those of the ABS group (52 +/- 11 vs. 73 +/- 10 years, p < 0.001). RESULTS: Types of preceding stressors and clinical presentation including chest pain, pulmonary edema, cardiogenic shock and in-hospital mortality were comparable between the two groups. In the N-ABS group, wall motion score index was significantly lower than in the ABS group (1.61 +/- 0.35 vs. 1.93 +/- 0.31, p = 0.016). On electrocardiogram (ECG), T-wave inversion (57.1% vs. 95.8%, p < 0.001) were less frequent in the N-ABS than in the ABS group. Furthermore, maximum QT and corrected QT (QTc) intervals in the N-ABS patients were significantly shorter than the ABS patients (QT, 419.9 +/- 66.1 vs. 487.3 +/- 79.6 ms, p = 0.038; QTc, 479.0 +/- 61.9 vs. 568.0 +/- 50.5 ms, p < 0.001). CONCLUSION: Patients with the N-ABS showed not only atypical echocardiographic findings, but also atypical clinical and ECG manifestations. Integrated consideration is needed to reach a diagnosis of the non-apical subtype of SCM.

A Large, Free-Floating Right Atrial Thrombus Evoking Periodic Dizziness

No abstract available.

Prevalence of Significant Coronary Arterial Disease in Adult Patients who Underwent Valvular Surgery in Korea / 대한내과학회지

BACKGROUND/AIMS: The identification of significant coronary arterial disease (CAD) is important to reduce perioperative ischemic insult and the possibility of repeated open-chest surgery in patients scheduled to undergo valvular surgery. However, there are no published data on the incidence of significant CAD in these patients. Thus, we examined the prevalence of significant CAD in patients scheduled to undergo valvular surgery. METHODS: From January 2005 to June 2011, all consecutive adult patients diagnosed with significant valvular disease and scheduled for an elective open valvular operation were retrospectively investigated at Chungnam National University Hospital and Chonbuk National University Hospital. Patients who underwent emergent valvular operations due to acute aortic dissection or trauma and concomitant valvular operations at the time of coronary artery bypass graft (CABG) surgery were excluded. RESULTS: During the study period, a total of 431 patients (58 +/- 13 years old, 204 males) were included. The distributions of mitral (241 patients) and aortic valvular disease (230 patients) were similar. Coronary angiography was performed in 297 patients (68.9%). Of these, 36 (12.1%) showed significant CAD and 32 underwent concomitant CABG operations. Based on a multivariate analysis, the presence of CAD was significantly associated with old age (> or = 65 years old) [odds ratio (OR) = 3.081, 95% confidence interval (CI) = 1.372-6.921, p = 0.006], more cardiovascular risk factors (> or = 3) (OR = 3.002, 95% CI = 1.386-6.503, p = 0.005), and the presence of aortic stenosis (OR = 2.763, 95% CI = 1.269-6.013, p = 0.010). CONCLUSIONS: The incidence of significant CAD was 12.1% in adult patients who underwent valvular operations in Korea. CAD was more common in patients with old age, aortic stenosis, and multiple cardiovascular risk factors.

Infective Endocarditis due to Streptococcus Agalactiae in Young and Immunocompetent Woman: A Case of Structurally Normal Valve Endocarditis Presented with Major Stroke

We describe here a 26-year-old woman who presented confusion and right hemiparesis due to embolic obstruction of left internal carotid artery and middle cerebral artery. Transthoracic echocardiography showed structurally normal mitral valve with hypermobile echogenic material suggesting vegetation. The vegetation was disappeared after antimicrobial treatment without surgery.

Cardiovascular Behcet's Disease Presenting as a Subepicardial Hematoma: An Uneventful 2-Year Clinical Course

Cardiovascular involvement in Behcet's disease is not uncommon and could be life-threatening. We describe here a 28-year-old man, who developed sudden onset chest pain during warfarinization due to deep vein thrombosis. Echocardiography and computed tomography showed a 60x60 mm-sized hematoma in the pericardial space compressing the right heart. Coronary angiography showed totally occluded proximal right coronary artery. The hematoma was located at the subepicardial plane of the right atrium on surgical view and successfully evacuated. Follow-up echocardiography revealed complete resolution of the hematoma. He is doing well for 24 months after surgery.

A case of Defibrillator Twiddler's syndrome / 대한내과학회지

Here we describe a case of Twiddler's syndrome in a patient with an implanted cardioverter-defibrillator who tinkered with the device, shifting it to a vertical position and causing her skin to protrude in various locations. Fluoroscopy was used to determine what direction the device was rotating in during specific body postures and physical activities. Inappropriate shocks were delivered whenever the patient pushed the device down toward her sternum. The syndrome did not recur following training of the patient in a lead-revision procedure that involved shifting the device down vertically toward her lateral side with her hands.

Periprocedural Hemoglobin Drop and Contrast-Induced Nephropathy in Percutaneous Coronary Intervention Patients

BACKGROUND AND OBJECTIVES: The development of contrast-induced nephropathy (CIN) is associated with an increased risk of death and late cardiovascular events after percutaneous coronary intervention (PCI). The relationship between CIN and hemoglobin drop has been controversial. The aim of this study was to evaluate the clinical usefulness of periprocedural hemoglobin drop as a nontraditional risk factor for CIN. SUBJECTS AND METHODS: Five-hundred thirty-seven patients who underwent PCI were divided into 2 groups: Group I (486 patients: patients who did not develop CIN) and Group II (51 patients: patients who developed CIN). All patients were administered iodixanol as contrast media during coronary angiography. CIN is defined as a rise in serum creatinine of > or =25% or > or =0.5 mg/dL above the baseline value within 48 hours after contrast administration. RESULTS: Baseline clinical and cardiovascular risk factors were not significantly different between the two groups, except for low abdominal circumference (Group I : Group II=87.9+/-9.0 cm : 81.2+/-15.1 cm, p=0.024), body weight (Group I : Group II=63.5+/-10.6 kg : 59.7+/-9.2 kg, p=0.008), body mass index (BMI) (Group I : Group II=24.4+/-3.4 kg/m2 : 23.4+/-2.8 kg/m2, p=0.032), pre-PCI hemoglobin (Group I : Group II=13.2+/-2.0 g/dL : 12.3+/-2.0 g/dL, p=0.003), and post-PCI hemoglobin (Group I : Group II=12.4+/-1.9 g/dL : 11.5+/-1.8 g/dL, p=0.001). Multiple logistic regression analysis showed that a periprocedural drop in hemoglobin (>1 g/dL) was an independent predictor of CIN, like other known risk factors. CONCLUSION: A periprocedural drop in hemoglobin of more than 1 g/dL is another important independent predictor for CIN, even in patients administered the lowest nephrotoxic contrast agent, iodixanol, during PCI.

Simple Method of Counterclockwise Isthmus Conduction Block by Comparing Double Potentials and Flutter Cycle Length

BACKGROUND AND OBJECTIVES: Local wide split double potentials are used as a parameter to determine complete conduction block during cavotricuspid isthmus ablation in patients with isthmus dependent atrial flutter. However, delayed slow conduction in that region can sometimes be very difficult to differentiate from complete block. Flutter cycle length (FCL) can be used to confirm isthmus conduction block, because FCL is a measure of conduction time around the tricuspid annulus (TA). This study was designed to determine which degree of splitting of the local electrograms is adequate to confirm complete isthmus block, using FCL as a reference. SUBJECTS AND METHODS: Cavotricuspid isthmus (CTI) ablation was performed in fifty consecutive patients. The interval between the pacing stimulus on the lateral side of the CTI and the first component of the double potentials on the block line (SD1) corresponded to the counterclockwise conduction time. The interval between the pacing stimulus and second component (SD2) represented the clockwise conduction time to the contralateral side of the ablation line. SD1 and SD2 were measured before and after complete isthmus block. RESULTS: An SD1+SD2 reaching 90% of the FCL identified the counterclockwise isthmus conduction block with 94% sensitivity and 100% specificity. CONCLUSION: If the sum of SD1 and SD2 following isthmus ablation was close to the FCL, complete conduction block was predicted with high diagnostic accuracy and positive predictive value for at least counterclockwise conduction.

Cardiac Tamponade by Iatrogenic Pneumopericardium

Pneumopericardium is defined as the condition of presence of air in the pericardial space. It is associated with various etiologies such as chest trauma, infection or invasive procedures. We herein describe a case of cardiac tamponade associated with pneumopericardium. We diagnosed iatrogenic pneumopericardium by plain chest radiography and two-dimensional echocardiography. The patient was successfully treated by re-pericardiocentesis.

A fluttering worm-like thrombus-in-transit in the right atrium: A sign of disastrous embolism / 대한내과학회지

No abstract available.

Full Metal Jackets (> or =60 mm) of Drug-Eluting Stents: Short- and Long-term Clinical and Angiographic Outcomes

BACKGROUND AND OBJECTIVES: Drug-eluting stents (DES) are effective for the maintenance of patency in patients with various complex coronary artery diseases. We investigated the efficacy of full metal jackets (FMJs,> or =60 mm) using overlapping DES for very long coronary lesions. SUBJECTS AND METHODS: The medical records and angiographic data of ninety-nine patients, and 100 FMJs that were implanted at Chonbuk National University Hospital since March 2003, were analyzed. RESULTS: The mean age was 63+/-10 years and median follow-up period was 17.0 months. The mean lesion length was 57.7+/-10.8 mm, the mean number of implanted DES for FMJ was 2.2+/-0.5, and the mean length of the FMJ was 68.5+/-11.4 mm. Thirty percent of the lesions were the culprits of acute myocardial infarction and 22% were chronic total occlusive lesions. The procedural success rate was 98%. Triple antiplatelet agents were prescribed for 37.4% of the patients and the mean duration of clopidogrel use was 11.9+/-5.7 months. Overall major adverse cardiac events developed in 10% of patients. One patient died of probable stent thrombosis by the Academic Research Consortium definition. Follow-up coronary angiography was performed in 69% of cases. Binary restenosis was documented in 9 lesions (13.0%) and five FMJs (7.2%) were revascularized. Stent fractures were detected in four FMJs (5.8%). CONCLUSION: Although FMJs using DES may be regarded as a relatively safe and effective therapeutic approach for diffuse long coronary lesions, longer-term follow-up data with a larger population is needed to establish safety including special consideration for strategy of antiplatelet therapy.

Clinical Outcomes of Cobalt-Chromium Alloy ArthosPico Stent for Native Coronary Lesions

BACKGROUND AND OBJECTIVES: It has been reported that strut thickness is associated with the occurrence of in-stent restenosis. This prospective, multicenter, single-arm study was designed to evaluate the safety and efficacy of the ArthosPico stent manufactured with thin-strut cobalt-chromium alloy steel for simple de novo coronary lesions. SUBJECTS AND METHODS: A total of 150 coronary lesions that were > or =3.0 mm in diameter and < or =20 mm in length, which could be covered by a single stent, were enrolled. Clopidogrel was used for 1 month. RESULTS: Acute coronary syndrome was involved in 60.7% of patients. The right coronary artery (50.0%) was the most common target vessel. All stents were successfully deployed at the target lesions. Reference vessel diameter was 3.1+/-0.5 mm and lesion length was 13.6+/-4.6 mm. Minimal lumen diameter was increased from 1.03+/-0.48 to 3.04+/-0.49 mm after the procedure. Follow-up angiography was obtained in 117 lesions (78%). Binary restenosis was documented in 12.0% of stented segments and in 13.7% of analytic segments. Late luminal loss was found to be 0.78+/-0.75 mm in stented segments and 0.59+/-0.74 mm in analytic segments. During 7.0+/-2.8 months follow-up, cardiac death or non-fatal myocardial infarction occurred in 2 (1.3%) and 2 (1.3%) patients, respectively. Target lesion revascularization was performed in 11 (7.3%) patients. CONCLUSION: The cobalt-chromium alloy ArthosPico stent for relatively simple coronary lesions showed favorable acute and long-term outcomes in terms of very low incidence of death or myocardial infarction and a single digit rate of target lesion revascularization.

The Efficacy of Drug Eluting Stents on Restenosis Reduction in Small Coronary Arteries

BACKGROUND AND OBJECTIVES: The previous studies have demonstrated the superiority of implanting drug eluting stent (DES) for restenosis reduction compared with the implantation of uncoated stents in small coronary arteries. However, the arteries in those studies tended to have short lesions. So, we evaluated the efficacy of a drug eluting stent in small coronary lesions with a relatively long length. SUBJECTS AND METHODS: From July 2003 to March 2005, DESs (Cypher or Taxus) were implanted into 100 consecutive patients with 116 lesions that were less than 2.75 mm in diameter. All patients received aspirin indefinitely and clopidogrel for 6 months. The primary end point was 6 month angiographic in-segment restenosis, and the secondary end points were procedural success and any major adverse cardiac events (MACE: death, non fatal myocardial infarction and target lesion revascularization) at 9 months. RESULTS: The mean age of the patients was 63 years, 53% were male, 24% were diabetics, 34% were current smokers and 55% had hypertension. A total of 121 DESs were implanted into 116 lesions (mean number of DESs/lesion: 1.1/lesion). The mean proximal and distal reference diameters were 2.21+/-0.39 and 2.01+/-0.40 mm, respectively. The mean lesion length was 19.14+/-7.89 mm. The mean pre- and post-minimal lumen diameters were 0.73+/-0.42 mm and 2.26+/-0.41 mm, respectively. The mean size and length of the stents were 2.65+/-0.13 mm and 28.46+/-10.04 mm, respectively. The procedural success rate was 98.3%. The angiographic follow-up rate was 78.4%. The binary in-segment restenosis rate was 15.4% (14 lesions). The MACE at 9 months was 8.0%. CONCLUSION: DES implantation in small coronary lesions with a relatively long length demonstrated favorable results. However, a larger scale study is needed to clarify the efficacy of the DES in small coronary arteries.

Tachycardiomyopathy Induced by Ventricular Premature Complexes: Complete Recovery after Radiofrequency Catheter Ablation

Ventricular premature complexes (VPCs) are known to be one of the most benign cardiac arrhythmias when they occur in structurally normal hearts. We experienced a 32-year old man who presented with dyspnea, palpitations and very frequent VPCs (31% of the total heart beats). Echocardiography revealed a dilated left ventricle (LV 66 mm at end-diastole and 57 mm at end-systole) and a decreased ejection fraction (34%). Very frequent VPCs had been detected 10 years previously and he underwent a failed radiofrequency catheter ablation (RFCA) procedure at that time. The patient had been treated with heart failure medications including betablockers, ACE inhibitors and spironolactone for the two most recent years. Six months after we eliminated these VPCs with a second RFCA procedure, the heart returned to normal function and size. Long standing and very frequent VPCs could be the cause of left ventricular dysfunction in a subset of patients who suffer with dilated cardiomyopathy, and RFCA should be the choice of therapy for these patients.

Increased Aortic Stiffness is Associated with Increased Left Ventricular Mass and Diastolic Dysfunction

BACKGROUND AND OBJECTIVES: Stiffening of the aorta is a potential risk factor for increased cardiovascular morbidity and mortality. Increased aortic stiffness can be associated with an increased left ventricular (LV) mass and diastolic dysfunction. The aim of the study was to evaluate the relationship of the aortic stiffness to the LV hypertrophy (LVH) and diastolic dysfunction. SUBJECTS AND METHODS: A total of 188 consecutive patients, without overt cardiovascular disease or symptoms, were included. The LV mass and diastolic filling patterns were assessed. The aortic strain and distensibility were indirectly obtained from the aortic diameters, using echocardiography and blood pressure measurements. RESULTS: Of the 188 patients (92 males, 54+/-14 years old), hypertension was found in 57 and diabetes in 29, with both found in 32 patients. The aortic strain (3.77+/-2.42 vs. 5.13+/-4.27, p<0.001) and distensibility (0.11+/-0.09 vs. 0.22+/-0.21, p<0.001) were significantly lower, but the LV mass index (112.5+/-39.2 vs. 87.8+/-19.0 gm/m2, p<0.001) higher, in the hypertensive compared to normotensive patients. Also, the aortic strain (3.07+/-2.42 vs. 5.18+/-4.01, p<0.001) and distensibility (0.10+/-0.12 vs. 0.21+/-0.20, p<0.001) were lower in patients with LVH. The E/E' ratio was higher in the hypertensive patients (10.9+/-5.0 vs. 8.1+/-3.1, p<0.001) and in those with LVH (10.8+/-5.6 vs. 8.4+/-3.2, p<0.001). In a multivariate analysis, the parameters closely related with aortic strain were age (standardized coefficient beta=-0.240, p=0.001), LV mass index (beta=-0.158, p=0.025) and IVRT (beta=-0.155, p=0.035). The parameters significantly related with aortic distensibility were age (beta=-0.344, p<0.001) and LV mass index (beta=-0.224, p=0.001). CONCLUSION: Increased aortic stiffness is associated with an increased LV mass and diastolic abnormality.

A Case of Surgical Removal of a Hypermobile Left Ventricular Thrombus Complicated to Acute Myocarditis

Left ventricular mural thrombi can occur in setting of acute myocarditis. Major thromboembolism may occur according to the echocardiographic characteristics of the thrombi. Mobile, irregular and protruding thrombi are known to raise systemic embolism more easily than immobile laminar clot. We experienced a case of a hypermobile pedunculated left ventricular thrombus complicated to acute myocarditis in a 49-year-old woman. Mobility of it increased day by day in spite of the proper anticoagulation. Surgical removal of the thrombus was performed to prevent major thromboembolism.

Bioavailability of EVA-Coated Metallic Stents Implanted in the Rabbit Iliac Artery

BACKGROUND AND OBJECTIVES: Coronary artery stenting actually shows a high efficacy in the treatment of coronary heart disease, but has the major limitation of restenosis. The ethylene-vinyl acetate copolymer (EVA), a biocompatible nondegradable copolymer, has been employed as a rate-controlling membrane in several drug delivery systems. Herein, the feasibility of an EVA-coated coronary stent was evaluated as a possible route for localized drug delivery. MATERIALS AND METHODS: A total of 15 rabbits were employed in this study. An uncoated stent was implanted into the non-diseased iliac artery in six rabbits, and an EVA-coated stent into a further nine. On the 30th day following the stent implantations, stented segments of the iliac arteries were removed for histological processing and morphometric analysis. RESULTS: The mean neointimal area of the uncoated and coated groups were 1.009 and 1.011 mm2 (p=0.56), respectively. No inflammatory cells were found in coated group. There were no apparent differences between the two groups. CONCLUSION: The results from this study have demonstrated that an EVA-coated coronary stent might be an appropriate method for the controlled-release of a drug.

Association of Neutrophil Adhesion Molecules Expression and Change of sICAM-1 Concentration after Coronary Artery Stenting with Later Restenosis

BACKGROUND: Neointimal hyperplasia, as the most important mechanism of restenosis after intracoronary artery stenting, its severity is closely correlated with the degree of local inflammatory reaction initiated by vasular injury during stenting procedure. So, we proceeded this study to determine whether inflammatory markers such as CD11b/CD18 (Mac-1) adehsion molecules of neutrophils, sICAM-1 (soluble intercellular adhesion molecule-1), ESR, and CRP increase or not in the peripheral circulation after coronary artery stenting, and whether there is any association between these findings and the degree of later restenosis. METHOD: 32 patients (chronic stable angina 4, unstable angina 17, acute myocardial infarction 11) underwent single vessel coronary artery stenting were enrolled in our study. Blood samples were obtained from peripheral vein just before coronary artery stenting and 48 hours thereafter. The degrees of CD11b/CD18 expression on the surface of neutrophils were analyzed by flow cytometry with monoclonal antibodies, and sICAM-1 by ELISA method. At each times, ESR and CRP were also measured. Follow-up coronary artery angiography was performed with QCA analysis at least 6 months later. We compared the each 48 hours values with the baseline (just before procedure) values. Percentage increments (as a ratio 48 hours values to baseline) of CD11b/CD18 expression, sICAM-1, ESR, and CRP levels were also compared with the results of follow-up QCA analysis. RESULTS: Restenosis (diameter stenosis > or = 50%) occurred in 6 patients (19%) at follow up angiography. 48 hours values of CD11b/CD18 expression, sICAM-1, ESR, and CRP were significantly elevated from the baseline values (each p values, CD11b : < 0.0001, CD18 : 0.01, sICAM-1 : < 0.0001, ESR : 0.005, and CRP : 0.001). The percentage increments of CD11b/CD18 expression were more elevated in restenosis group than nonrestenosis group (CD11b : 341+/-215%/74+/-95%, CD18 : 84+/-60%/17+/-37%, each p < 0.001, 0.001). There was some positive correlation between the percentage increments in the expression of CD11b and the late loss index at the follow up angiography (r=.43, p<0.05). CONCLUSIONS: Through this study, we found that the activation of neutrophils was occurred, and that sICAM-1 level was increased after coronary artery stenting in the peripheral blood. There was some correlations between the degree of CD11b expression on the surface of neutrophils and the severity of late lumen loss of inserted stents. The measurements of increased neutrophil adhesion molecules of CD11b/CD18 levels at 48hrs after coronary stenting may have a value as the predictor of subsequent late restenosis.

A Case of Pheochromocytoma Presented with Life: Threatening Cardiogenic Shock

It is often possible to diagnose a pheochromocytoma only when a disastrous cardiac complication like a hypertensive crisis, episodes of unexpected left ventricular failure, myocarditis, arrhythmias, myocardial infarction and sudden death appears secondarily. We revealed that a patient who had been treated with a reversible left ventricular systolic dysfunction with cardiogenic indeed had a pheochromocytoma. Upon initial admission, a 35 years old man had upper respiratory tract infection and abdominal discomfort. Blood pressure was 140/90 mmHg and EKG showed transiently paroxysmal supraventricular tachycardia. Eight hours after admission, he appeared to be in cardiogenic shock. Echocardiography showed extensive global hypokinesia with severe left ventricular systolic dysfunction. Following conservative management he progressively recovered normal cardiac function although we did not discern the etiology of the left ventricular systolic dysfunction. He was readmitted six months later due to episodic headache and high blood pressure. Fortunately, due to the history of reversible left ventricular systolic dysfunction with cardiogenic shock, we were able to quickly assess him as having a pheochromocytoma. The laboratory data and radiological findings were compatible with this tumor, which was subsequently successfully removed through surgery. We suggest that the diagnosis of pheochromocytoma should be considered in young patients presenting with acute heart failure of non-specific origin.