Clinical profiles of patients with surgically resected pheochromocytoma and paraganglioma

Background/Aims@#Pheochromocytoma and paraganglioma (PPGL) are catecholamine-producing tumors that can cause blood pressure (BP) elevation and cardiovascular complications. Clinical presentation of these tumors may be changed through widespread use of imaging studies, which enables detection of PPGLs before onset of symptoms. We investigated clinical profiles of patients with surgically resected PPGLs. @*Methods@#From 2005 to 2017, 111 consecutive patients with surgically resected PPGLs in two tertiary hospitals in Korea were studied. @*Results@#Mean age was 52 ± 16 years, 57 patients (51.4%) were male and 54 (48.6%) were hypertensive. Twenty-nine PPGLs (26.1%) were extra-adrenal paragangliomas. Sixteen (14.4%) and seven patients (6.3%) (Group 1, n = 23) were diagnosed during work-up of hypertension and transient cardiomyopathy respectively, and the remainder (Group 2, n = 88) were incidentalomas detected during routine abdominal imaging. Patients in the Group 1 were younger and more frequently symptomatic, and had higher BPs, heart rates and levels of urinary catecholamines than those in the Group 2. Paragangliomas were less frequent and secretion of epinephrine and metanephrine was more predominant in the Group 1 than in Group 2. After the surgical resections, 18.2% of patients still needed antihypertensive medications. @*Conclusions@#Out of 111 patients with surgically resected PPGLs, 88 (79.3%) were diagnosed as incidentalomas. Seven patients presented with transient cardiomyopathy and 16 with hypertension. Tumor location and secretion of catecholamine may vary depending on the presence of symptoms.

Usefulness of Myocardial Longitudinal Strain in Prediction of Heart Failure in Patients with Successfully Reperfused Anterior Wall ST-segment Elevation Myocardial Infarction

BACKGROUND AND OBJECTIVES@#Acute myocardial infarction-related heart failure (HF) is associated with poor outcome. This study was designed to investigate the usefulness of global longitudinal strain (GLS), global circumferential strain (GCS) and mean longitudinal strain of left anterior descending artery territory (LSant) measured by 2-dimensional speckle tracking echocardiography (2D STE) in prediction of acute anterior wall ST-segment elevation myocardial infarction (ant-STEMI)-related HF.@*METHODS@#A total of 171 patients with ant-STEMI who underwent successful primary coronary intervention and had available 2D STE data were enrolled. Patients were divided into 3 groups: in-hospital HF, post-discharge HF, and no-HF groups.@*RESULTS@#In-hospital and post-discharge HF developed in 39 (22.8%) and 13 (7.6%) of patients, respectively and 113 patients (69.6%) remained without HF. Multivariate analysis showed that GLS was the only factor significantly associated with the development of in-hospital HF. For post-discharge HF, LSant was the only independent predictor. Other echocardiographic or laboratory parameters did not show independent association with the development of ant-STEMI-related HF.@*CONCLUSIONS@#GLS is a powerful echocardiographic parameter related to development of in-hospital HF and LSant was significantly associated with post-discharge HF in patients with successfully reperfused ant-STEMI.

Usefulness of Myocardial Longitudinal Strain in Prediction of Heart Failure in Patients with Successfully Reperfused Anterior Wall ST-segment Elevation Myocardial Infarction

BACKGROUND AND OBJECTIVES: Acute myocardial infarction-related heart failure (HF) is associated with poor outcome. This study was designed to investigate the usefulness of global longitudinal strain (GLS), global circumferential strain (GCS) and mean longitudinal strain of left anterior descending artery territory (LSant) measured by 2-dimensional speckle tracking echocardiography (2D STE) in prediction of acute anterior wall ST-segment elevation myocardial infarction (ant-STEMI)-related HF. METHODS: A total of 171 patients with ant-STEMI who underwent successful primary coronary intervention and had available 2D STE data were enrolled. Patients were divided into 3 groups: in-hospital HF, post-discharge HF, and no-HF groups. RESULTS: In-hospital and post-discharge HF developed in 39 (22.8%) and 13 (7.6%) of patients, respectively and 113 patients (69.6%) remained without HF. Multivariate analysis showed that GLS was the only factor significantly associated with the development of in-hospital HF. For post-discharge HF, LSant was the only independent predictor. Other echocardiographic or laboratory parameters did not show independent association with the development of ant-STEMI-related HF. CONCLUSIONS: GLS is a powerful echocardiographic parameter related to development of in-hospital HF and LSant was significantly associated with post-discharge HF in patients with successfully reperfused ant-STEMI.

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.

The Role of Antiarrhythmics in Atrial Fibrillation / 대한내과학회지

Atrial fibrillation (Afib) is the most common arrhythmia with clinical significance, and its incidence increases with advanced age. Afib is associated with a 3- to 5-fold increased risk of stroke, a 3-fold increase in the risk of heart failure, and higher mortality than without Afib. The treatment of Afib is multifold but revolves around one essential issue: whether to attempt to restore sinus rhythm or to simply control the ventricular rate. This decision depends on symptom severity, the age of the patient, underlying heart disease, and other comorbidities that may limit therapeutic options. The management of Afib with antiarrhythmic medications was reviewed.

Cervical Vagal Nerve Stimulation Activates the Stellate Ganglion in Ambulatory Dogs

BACKGROUND AND OBJECTIVES: Recent studies showed that, in addition to parasympathetic nerves, cervical vagal nerves contained significant sympathetic nerves. We hypothesized that cervical vagal nerve stimulation (VNS) may capture the sympathetic nerves within the vagal nerve and activate the stellate ganglion. MATERIALS AND METHODS: We recorded left stellate ganglion nerve activity (SGNA), left thoracic vagal nerve activity (VNA), and subcutaneous electrocardiogram in seven dogs during left cervical VNS with 30 seconds on-time and 30 seconds off time. We then compared the SGNA between VNS on and off times. RESULTS: Cervical VNS at moderate (0.75 mA) output induced large SGNA, elevated heart rate (HR), and reduced HR variability, suggesting sympathetic activation. Further increase of the VNS output to >1.5 mA increased SGNA but did not significantly increase the HR, suggesting simultaneous sympathetic and parasympathetic activation. The differences of integrated SGNA and integrated VNA between VNS on and off times (DeltaSGNA) increased progressively from 5.2 mV-s {95% confidence interval (CI): 1.25-9.06, p=0.018, n=7} at 1.0 mA to 13.7 mV-s (CI: 5.97-21.43, p=0.005, n=7) at 1.5 mA. The difference in HR (DeltaHR, bpm) between on and off times was 5.8 bpm (CI: 0.28-11.29, p=0.042, n=7) at 1.0 mA and 5.3 bpm (CI 1.92 to 12.61, p=0.122, n=7) at 1.5 mA. CONCLUSION: Intermittent cervical VNS may selectively capture the sympathetic components of the vagal nerve and excite the stellate ganglion at moderate output. Increasing the output may result in simultaneously sympathetic and parasympathetic capture.

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.

Effectiveness of head-up tilt test for the diagnosis of syncope in children and adolescents / 소아과

PURPOSE: We aimed to examine the effectiveness of the head-up tilt test (HUT) for the diagnosis of syncope or presyncope in children and adolescents. METHODS: HUT results and clinical features of 160 children and adolescents with syncope or presyncope were studied from May 2003 through March 2008 at the Chonbuk National University Hospital. The children and adolescents were subjected to 70degrees HUT for 45 minutes. The testees were divided into 2 groups: group I (children) comprising 39 children in the age range 7-12 years (mean, 10.59+/-1.60 years) and group II (adolescents) comprising 121 adolescents in the age range 13-20 years (mean, 15.93+/-2.28 years). Positive result rates of the HUT and types of hemodynamic response to the test in the 2 groups were compared. RESULTS: Of the 160 testees, 92 (57.5%) showed positive HUT results; they showed 3 patterns of response to tilting. Twelve patients showed a predominantly vasodepressor response; 10 patients showed a cardioinhibitory response; and 70 patients showed a mixed response. The positive result rates were 43.6% (17/39) and 62.0% (75/121) in groups I and II, respectively. Mixed response was the predominant positive hemodynamic response in both the groups. CONCLUSION: The HUT is a useful diagnostic tool for evaluating the condition of pediatric patients, including adolescents, with syncope. Further, it may be considered as the first step for evaluating the condition of such patients.

Experience With Using a Safe Landmark the Fossa Ovalis in Transseptal Procedures

BACKGROUND AND OBJECTIVES: Pressure monitoring and injection of contrast media after piercing the fossa ovalis are used to avoid life-threatening complications during transseptal procedures. However, when performing those maneuvers, the information provided can only be obtained after having pierced structures that may not have been the intended target. When we injected the contrast media through a Brockenbrough needle before piercing the fossa, the dye that had collected under the membranous septum tented by the transseptal equipment (tenting) was observed on the left anterior oblique (LAO) projection and this indicated the fossa ovalis. This study was performed to evaluate the usefulness and safety of tenting in order to identify the membranous septum during transseptal procedures. SUBJECTS AND METHODS: Contrast injections were performed on the fossa ovalis and the septal wall surrounding it during 64 transseptal procedures. The rates of dye staining and tenting in both the muscular and membranous septums were compared. RESULTS: No areas of the muscular septum exhibited any tenting. Various rates of dye staining of those areas were observed. However, the membrane of the fossa exhibited tenting without dye staining in all 64 cases. The sensitivity of the tenting without dye staining to identify the Fossa was 98%, and the specificity was 100%. CONCLUSION: Tenting without dye staining could differentiate the membranous septum from the muscular one with high diagnostic accuracy. This method could be used as a safe landmark for the fossa ovalis before piercing it during transseptal procedures.

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.

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.

Results of radiofrequency catheter ablation in children and adolescent with tachyarrhythmia / 소아과

PURPOSE: Radiofrequency catheter ablation (RFCA) has become an effective therapeutic modality for treating pediatric tachyarrhythmias. Using conventional RFCA catheters, ablation of parahisian accessory pathways may be difficult and have high risk for heart block. We reviewed the efficacy and complications of the RFCA in children and adolescent with arrhythmias including parahisian accessory pathways. METHODS: We studied 48 patients (aged 2 years to 20 years) who had undergone RFCA from August 2003 to March 2007. We reviewed clinical findings, electrophysiologic studies, RFCA data, complications, and follow-up results of the patients. RESULTS: Mean age of the patients was 13.1 years. Numbers and types of arrhythmias (age, acute success rate) were as follows: 19 WPW syndrome including 5 parahisian accessory pathways (13.74.6 yr, 18/19), 11 atrioventricular reentrant tachycardia with concealed bypass tract (12.35.0 yr, 10/11), 13 atrioventricular nodal reentrant tachycardia (12.64.4 yr, 13/13), 4 atrial flutter (13.07.4 yr, 3/4), and 1 ventricular tachycardia (20 yr, 1/1). Associated cardiac structural lesion was not detected in 48 patients. The recurrence rate was 6.5%, and the final success rate was 93.8%. CONCLUSION: These results suggest that RFCA is a highly effective treatment method in children and adolescent with tachyarrhythmia.

Results of radiofrequency catheter ablation in children and adolescent with tachyarrhythmia / 소아과

PURPOSE: Radiofrequency catheter ablation (RFCA) has become an effective therapeutic modality for treating pediatric tachyarrhythmias. Using conventional RFCA catheters, ablation of parahisian accessory pathways may be difficult and have high risk for heart block. We reviewed the efficacy and complications of the RFCA in children and adolescent with arrhythmias including parahisian accessory pathways. METHODS: We studied 48 patients (aged 2 years to 20 years) who had undergone RFCA from August 2003 to March 2007. We reviewed clinical findings, electrophysiologic studies, RFCA data, complications, and follow-up results of the patients. RESULTS: Mean age of the patients was 13.1 years. Numbers and types of arrhythmias (age, acute success rate) were as follows: 19 WPW syndrome including 5 parahisian accessory pathways (13.74.6 yr, 18/19), 11 atrioventricular reentrant tachycardia with concealed bypass tract (12.35.0 yr, 10/11), 13 atrioventricular nodal reentrant tachycardia (12.64.4 yr, 13/13), 4 atrial flutter (13.07.4 yr, 3/4), and 1 ventricular tachycardia (20 yr, 1/1). Associated cardiac structural lesion was not detected in 48 patients. The recurrence rate was 6.5%, and the final success rate was 93.8%. CONCLUSION: These results suggest that RFCA is a highly effective treatment method in children and adolescent with tachyarrhythmia.

A Case of Balloon Valvuloplasty using Three Balloon Catheters in a Child with Pulmonic Stenosis

Balloon dilatation of congenital stenotic lesion of the pulmonic valve has been used. Repeated balloon dilatation of restenosed lesion after previous balloon dilatation for the pulmonic stenosis is needed in some case. We treated a case of pulmonic restenosis with using three balloon catheters in a boy. The most critical problems related the valvuloplasty are severe systemic hypotension and bradycardia due to stasis of blood flow. The use of three balloon catheters instead of single or double balloons for the pulmonic stenosis could be a alternative interventional method to preserve the preexistent forward blood flow during inflation and to minimize vascular injury in children with large valve annulus.