Cardiac Arrest Related to Torsades de Pointes in a Patient Recovering from Diabetic Ketoacidosis / 대한내과학회지

Diabetic ketoacidosis (DKA) is an acute complication related to severe hyperglycemia. While the mortality rate for DKA is low with appropriate therapy, several complications may lead to deterioration of the clinical course. Here, we report a case of a 23-year-old patient with DKA who suffered from a rare but hemodynamically unstable cardiac arrhythmia, polymorphic ventricular tachycardia with prolonged QT interval, or Torsades de Pointes. During the recovery phase of DKA, three episodes of Torsades de Pointes suddenly occurred, and were recovered by immediate defibrillation. The patient did not have structural heart disease or a genetic predisposition. To the best of our knowledge, this is the first report of an adult with DKA complicated with QT prolongation related to Torsades de Points after correction of ketosis. To manage DKA, more attention may be needed on changes in the QT interval as well as risk factors for Torsades de Points.

Spontaneous Transition of Double Tachycardias with Atrial Fusion in a Patient with Wolff-Parkinson-White Syndrome

Among patients with Wolff-Parkinson-White syndrome, atrioventricular reciprocating tachycardia (AVRT) and atrioventricular nodal reentrant tachycardia (AVNRT) can coexist in a single patient. Direct transition of both tachycardias is rare; however, it can occur after premature atrial or ventricular activity if the cycle lengths of the two tachycardias are similar. Furthermore, persistent atrial activation by an accessory pathway (AP) located outside of the AV node during ongoing AVNRT is also rare. This article describes a case of uncommon atrial activation by an AP during AVNRT and gradual transition of the two supraventricular tachycardias without any preceding atrial or ventricular activity in a patient with preexcitation syndrome.

Application of New Oral Anticoagulants: Prevention of Stroke in Patients with Nonvalvular Atrial Fibrillation / 대한내과학회지

Only anticoagulation has been shown to reduce atrial fibrillation-related deaths. Vitamin K antagonists are difficult to use due to their narrow therapeutic range, unpredictable response, requirement for frequent coagulation monitoring, frequent dose adjustment, slow onset-offset, and numerous drug-drug and drug-food interactions. New oral anticoagulants (NOACs), such as dabigatran, rivaroxaban, and apixaban have been developed and are available in Korea, and edoxaban was shown to be effective and safe, also. NOACs showed better pharmacodynamics with predictable serum concentrations and effects, and no requirement for coagulation monitoring. These drugs have been shown to be more effective and safer than warfarin for prevention of stroke and systemic thromboembolism in patients with nonvalvular atrial fibrillation. Broad, appropriate, and aggressive use of NOACs would improve the results of treatment in patients with nonvalvular atrial fibrillation in Korea.

Intermittent, Non Cyclic Severe Mechanical Aortic Valve Regurgitation

Mechanical aortic prosthesis dysfunction can result from thrombosis or pannus formation. We describe an unusual case of intermittent, non cyclic mechanical aortic prosthesis dysfunction due to pannus formation with thrombus in the absence of systolic restriction of disk excursion, that presented with intermittent severe aortic regurgitation.

Relationship of Blood Pressure Variability and Heart Rate with Plasma hsCRP in Patients with Recently Diagnosed Hypertension / 대한내과학회지

BACKGROUND/AIMS: Blood pressure (BP) variability and heart rate (HR) are associated with target organ damage and cardiovascular complications; however, the exact mechanisms are uncertain. In this study, we examined the association of an inflammatory marker with BP variability and HR. METHODS: A total of 151 patients diagnosed recently with hypertension were subjected to 24-h ambulatory BP monitoring. BP variability was assessed as the standard deviation of the BP recordings. The average HR and HR variability were calculated from concomitantly recorded HR values. Plasma high-sensitivity C-reactive protein (hsCRP) was used as a marker of inflammation. RESULTS: The mean age of the study population was 44 +/- 11.3 years, and 74.2% of the patients were male. The plasma hsCRP level was higher in male patients (0.131 +/- 0.014 vs. 0.06 +/- 0.023, p = 0.001) and patients with a history of smoking (0.136 +/- 0.017 vs. 0.101 +/- 0.017, p = 0.003). A correlation analysis showed that the variability in diastolic BP during 24-h monitoring was associated with hsCRP (p = 0.002, r = 0.258). The 24-h (p = 0.004, r = 0.236), daytime (p = 0.003, r = 0.239), and nighttime (p = 0.020, r = 0.190) average HRs were related to the hsCRP level. The 24-h HR variability (p = 0.025, r = 0.182) was also associated with hsCRP. After adjusting for the effect of related variables, the 24-h diastolic BP variability (beta = 0.286, p = 0.011) and daytime average HR (beta = 0.169, p = 0.049) were positively related to hsCRP. CONCLUSIONS: Plasma hsCRP is related to diastolic BP variability in recently diagnosed hypertensive patients. Moreover, HR measured with BP is associated with hsCRP. These findings suggest that inflammation mediates adverse cardiovascular outcomes of BP variability and an elevated HR.

Management of a Remnant Electrode in a Patient With Cardioverter-Defibrillator Infection After Refusal of Intravascular Electrode Removal

Treatments of choice for cardiac implantable electronic device (CIED) infections are the removal of the entire CIED system, control of infection, and new device implantation. Occasionally, a complete CIED removal can not be performed for several reasons, such as very old age, severe comobidity, limited life expectancy, or refusal by a patient. We encountered a male patient who developed traumatic CIED infection five years after cardioverter-defibrillator implantation. An intravenous electrode could not be removed by a simple transvenous extraction procedure, and he refused surgical removal of the remnant electrode. After control of local infection, the tips of the electrode were separated and buried between muscles, and the wound was closed with a local flap. CIED infection did not recur for 12 months even without relying on long-term antimicrobial treatment.

Early Detection Of Asymptomatic Coronary Artery Disease In Patients With Type 2 Diabetes Mellitus

BACKGROUND/AIMS: In type 2 diabetic patients, coronary artery disease (CAD) is usually detected at an advanced stage due to a lack of symptoms. The aim of this study was to define which clinical parameters or non-invasive tests predict CAD in asymptomatic type 2 diabetic patients. METHODS: One hundred fourteen asymptomatic type 2 diabetic patients were divided into two groups based on the number of cardiovascular disease (CVD) risk factors (group A > or =2, group B or =10 years (OR=3.28; 95% CI, 1.29-8.84) were independent CAD risk factors in asymptomatic patients. CONCLUSIONS: We recommend a routine screening for CAD in type 2 diabetic patients who have a longer (> or =10 years) diabetic duration or a family history of CAD, even if they are asymptomatic for CAD.

A Case of Dual-Chamber Pacing Treatment in a Patient with Hypertrophic Cardiomyopathy with Left Ventricular Outflow Tract Obstruction

The management of symptomatic patients with hypertrophic Cardiomyopathy has generally included the use of beta-blockers and calcium channel blockers. Surgical treatment has been attempted for operable patients who have become refractory to medical therapy. However, associated complications, high mortality rate, and high recurrence of symptoms have shifted the treatment focus toward alternative therapy modalities. Recently, a DDD type pacemaker has been introduced as an alternative treatment option. We report a case of a patient with hypertrophic cardiomyopathy treated with dual-chamber pacing.

Endomyocardial Fibrosis: A Case Report / 대한흉부외과학회지

Endomyocardial fibrosis(EMF) is an unusual type of cardiomyopathy characterized by a restriction to the ventricular filling and an obliteration of the inflow portion in the ventricular cavity by a fibrosis and often by a thrombus formation. The atrioventricular valve may be involved, resulting in an atrioventricular valvular regurgitation. The only known effective treatments are endomyocardiectomy and replacement of regurgitant AV valves. We report the experience of a case of EMF which required surgical management.

A Case of Cerebral Infarction Caused by Tumor Emboli from the Site of

Multiple cerebral infarction developed in a 36-year-old woman with adenocarcinoma of the right lung with direct cardiac invasion. Neurological examination and brain MRI showed findings of ordinary infarction. Transesophageal echocardiography showed left atrial pedunculated mass which was the potential source of embolism. We report a rare case who had such multiple spontaneous tumor emboli large enough to result in clinically detectable cerebral infarction.

Mesothelial/Monocytic Incidental Cardiac Excrescences, So-called "Cardiac MICE": A case report

A rare case of mesothelial/monocytic incidental cardiac excrescences (cardiac MICE) is described in the aspect of pathological interest. This cardiac lesion is pathologically characterized by exuberant proliferation of mixed mesothelia and monocytes and might be misdiagnosed as metastatic carcinoma, rhabdomyosarcoma, and histiocytoid hemangioma, if the disease is not in the minds of pathologists. The reactive nodular hyperplasia due to irritation to mesothelia by various causes is a most prevailing pathogenetic mechanism. About 20 cases have been reported in the worldwide literature. A 67-year-old female patient presented with cough and dyspnea for 2 months, without any history of previous cardiac operation. 2D echocardiography of the heart revealed moderate amount of pericardial effusion with posterior wall thickening. Under the impression of metastatic malignancy, pericardiostomy was performed. Grossly, the tissue was dark hemorrhagic and friable and the histologic sections revealed the solid tumor-like proliferation of round to polygonal histiocytic cells admixed with small cuboidal mesothelial cells which formed strips and tubular arrays. They were found within the fibrinous network and there were scattered empty vacuolar spaces. Immunohistochemical staining confirmed their biphasic nature with the CD68 positivity of the histiocytes and the cytokeratin positivity of the cuboidal cells. Factor VIII positivity was not detected in any cell components. The lesion was considered the monocytic and mesothelial proliferation of reactive nature, so-called cardiac MICE in the pericardial cavity. We report a typical case of so-called MICE first in the Korean literature.

An Experience of Cox-maze III Procedure for Chronic Atrial Fibrillation / 대한흉부외과학회지

During the past several years, the maze operation has become the most effective method of treatment for chronic atrial fibrillation. When the maze procedure is done concomittantly with other cardiac operations, surgeons, in their initial experiences, may be concerned about the additional operative risks and uncertainty of the results. We performed the Cox-maze III procedure in six cases of chronic atrial fibrillation associated with mitral, mitral & aortic, or coronary arterial disease. Maze III procedure was done with open mitral commissurotomy (3 cases), mitral valve replacement (1 case), aortic and mitral valve replacement (1 case), and two-vessel coronary bypass graft (1 case). In spite of rather prolonged aortic cross clamp time, cardiac recovery was uneventful in all cases. No cases required reexploration for postoperative bleeding. All patients showed regular sinus rhythms immediate or between 2 and 20 days postoperateratively. Transient postoperative supraventricular arrhythmarias were easily controlled by various antiarrhythmic agents. In follow up evaluations, all cases showed regular sinus rhythm on ECG and the right and left atrial transport function was confirmed by Doppler echocardiography in all except one. Though our experience was limited in case number, the Cox-maze III procedure was effective in controlling the chronic atrial fibrillation without serious additional operative risks.

Long-term Follow-up of the Patients with Permanent Antibradycardia Pacemaker

BACKGROUND: Antibradycardia pacemaker is one of the treatment modalities for bradyarrhythmia. We present the clinical results of 440 implantations of permanent pacemaker between August 1984 and December 1997 at Department of Internal Medicine in Seoul National University Hospital. METHOD: We investigated the indication of permanent pacing, the pacing modes, the complications of permanent pacing, and the chronic pacing threshold. RESULT: The study was comprised of 440 patients (M/F : 179/261, mean age : 59+/-12 years, 58+/-14 years, respectively). Indications of the primary pacemaker implantations were sinus node dysfun-ction in 53% and atrioventricular conduction disorders in 47%. Twelve percent of total pacemaker procedures were pulse-generator replacements. Pacing modes were VVI in 59.1%, VVIR in 10.2%, DDD in 30.2%, and others in 0.5%. Complications developed in 21 cases (4.8%) during long-term follow-up. They included 8 cases of pacing failure due to increased pacing threshold, 2 cases of early power depletion, 2 cases of lead dislodgement, 6 cases of lead fracture, 3 cases of skin erosion, 3 cases of hematoma, 3 cases of infection, and 1 case of skeletal muscle stimulation. Chronic pacing thresholds at pacing width of 0.5 msec were 1.9+/-0.4 V for the epicardial ventricular leads (n=11), 1.3+/-0.5 V for the endocardial ventricular leads (n=36), and 1.1+/-0.2 V for the atrial leads (n=4) after 7 to 10 years of implantation. CONCLUSION: Sinus node dysfunction was the more common indication than atrioventricular block for the antibradycardia pacemaker implantation. Long-term follow-up of the pacemaker patients would be very useful to detect the pacing system abnormalities and to maximize the battery longevity by adjustment of pacing output according to the level of chronic pacing threshold.

Long-term Follow-up of the Patients with Permanent Antibradycardia Pacemaker

BACKGROUND: Antibradycardia pacemaker is one of the treatment modalities for bradyarrhythmia. We present the clinical results of 440 implantations of permanent pacemaker between August 1984 and December 1997 at Department of Internal Medicine in Seoul National University Hospital. METHOD: We investigated the indication of permanent pacing, the pacing modes, the complications of permanent pacing, and the chronic pacing threshold. RESULT: The study was comprised of 440 patients (M/F : 179/261, mean age : 59+/-12 years, 58+/-14 years, respectively). Indications of the primary pacemaker implantations were sinus node dysfun-ction in 53% and atrioventricular conduction disorders in 47%. Twelve percent of total pacemaker procedures were pulse-generator replacements. Pacing modes were VVI in 59.1%, VVIR in 10.2%, DDD in 30.2%, and others in 0.5%. Complications developed in 21 cases (4.8%) during long-term follow-up. They included 8 cases of pacing failure due to increased pacing threshold, 2 cases of early power depletion, 2 cases of lead dislodgement, 6 cases of lead fracture, 3 cases of skin erosion, 3 cases of hematoma, 3 cases of infection, and 1 case of skeletal muscle stimulation. Chronic pacing thresholds at pacing width of 0.5 msec were 1.9+/-0.4 V for the epicardial ventricular leads (n=11), 1.3+/-0.5 V for the endocardial ventricular leads (n=36), and 1.1+/-0.2 V for the atrial leads (n=4) after 7 to 10 years of implantation. CONCLUSION: Sinus node dysfunction was the more common indication than atrioventricular block for the antibradycardia pacemaker implantation. Long-term follow-up of the pacemaker patients would be very useful to detect the pacing system abnormalities and to maximize the battery longevity by adjustment of pacing output according to the level of chronic pacing threshold.

Permanent pacemaker implantation via coronary sinus

We report a case of successful ventricular pacing via the coronary sinus in a 34 year-old female patient admitted because of repetitive dizziness and syncope. She had rheumatic valvular disease with mitral valve replacement 14 years earlyer. and the mitral, aortic and tricuspid valves were subsequently replaced with prosthetic mechanical valves 4 years ago. Two years after the triple valve replacement, complete AV block developed with the symptoms of dizziness and syncope. A permanent pacemaker was implanted epicardially. Six months later the epicardial lead was replaced because of increased pacing threshold. A year later the epicardial lead had to be replaced because of increased threshold and capture failure to pace. To avoid further thoracotomy, a 'Medtronic 2188' electrode was implanted in the posterior left ventricular vein via the coronary sinus. Pacing threshold was 1.2 volt/0.4 msec. Five days later, the pacing threshold increased to 3.0 volt/0.4 msec. Prednisolone had been given for 10 months. The new system has been functioning well and the pacing threshold was 1.0 volt/0.4 msec at 11 months after implantation. Ventricular pacing via the coronary sinus can be an alternative to the epicardial pacemaker system in patient whose tricuspid valve have been replaced with mechanical prosthetic valve.

Permanent pacemaker implantation via coronary sinus

We report a case of successful ventricular pacing via the coronary sinus in a 34 year-old female patient admitted because of repetitive dizziness and syncope. She had rheumatic valvular disease with mitral valve replacement 14 years earlyer. and the mitral, aortic and tricuspid valves were subsequently replaced with prosthetic mechanical valves 4 years ago. Two years after the triple valve replacement, complete AV block developed with the symptoms of dizziness and syncope. A permanent pacemaker was implanted epicardially. Six months later the epicardial lead was replaced because of increased pacing threshold. A year later the epicardial lead had to be replaced because of increased threshold and capture failure to pace. To avoid further thoracotomy, a 'Medtronic 2188' electrode was implanted in the posterior left ventricular vein via the coronary sinus. Pacing threshold was 1.2 volt/0.4 msec. Five days later, the pacing threshold increased to 3.0 volt/0.4 msec. Prednisolone had been given for 10 months. The new system has been functioning well and the pacing threshold was 1.0 volt/0.4 msec at 11 months after implantation. Ventricular pacing via the coronary sinus can be an alternative to the epicardial pacemaker system in patient whose tricuspid valve have been replaced with mechanical prosthetic valve.

Changes of Cardiac Function by the Arteriovenous Fistula in End Stage Renal Failure Patients

A hemodialysis arteriovenous fistula may cause high output cardiac state by volume overload and decreased systemic vascular resistance. Arteriovenous fistulas for hemodialysis consist usually of either a radiocephalic fistula at the wrist or a more proximal brachiocephalic fistula at the antecubital fossa. In this study the contribution of arteriovenous fistula to cardiac function has been evaluated by comparing cardiac performance before and after the point occlusion of the anastomotic site. The results suggest that the occlusion of arteriovenous fistula may decrease end-diastolic left ventricular volume (VOLd), increase end-systolic left ventricular volume (VOLs), decrease stroke volume (SV), decrease ejection fraction (EF) and decrease cardiac output (CO). This study shows that arteriovenous fistula influences directly to cardiac performance, so careful determination of dialysis option is required for the end stage renal failure patients with marginal heart function.

Radiofrequency Catheter Ablation of a Mahaim Fiber at Lateral Tricuspid Annulus

A 20 year-old male with recurrent syncope and wide QRS tachycardea with LBBB type underwent radopfreqiemcu catjeter ab;atopn. Symptoms were present for 8 years. Electrophysiologic study revealed an antidromic atrioventricular reentrant tachycardia using an atrioventricular Mahaim fiber which conducted only anterogradely and resulted in LBBB QRS morphology on preexcitation. ecremental conduction was also noticed during single atrial extrastimulation and rapid atrial pacing. The ateial insertion of thd Mahaim fiber was at the lateral tricuspid annulus and the venteicular insertion was at the lateral right ventricle near the tricuspid annulus. iscrete Mahaim fiber potential was recorded during atrial pacing and during tachycardia. ahaim fiber was successfully ablated at the atrial side of lateral tricuapid annulus where the discrete Mahaim fiber potential was recorded. No complications occurred. Tachycardiadid not recur during a follow-up of 6 months.

Radiofrequency Catheter Ablation of Idiopathic Left Ventricular Tachycardia

BACKGROUND: Idiopathic left ventricular tachycardia(ILVT) with no structural heart disease is not an uncommon disease and characterized by the ECG feature of right bundle branch block. This study was performed to evaluate the effectiveness of radiofrequency catheter ablation (RFCA) for the treatment of ILVT and the usefulness of Purkinje potential(P-potential) in determining the site of successful ablation and to compare the biophysical parameter according to the modes of energy application. METHOD: From January 1993 to July 1996, 18 patients with symptomatic ILVT underwent RFCA. The ablation site were guided by pace mapping, ventricular activation mapping or P-potential. RESULTS: Of the 18 patients, there were 14 male and 4 female patients with a mean age of 34.1 years-old. RFCA eliminated VT successfully in 14 of total 18 patients(78%), 11 of 12 in leftaxis VT, 2 of 3 in right axis VT and 1 of 3 in northwest axis VT. Successful sites of wall in 3 patients with right axis deviation or northwest axis. Ablations in 5 of the 9 patients, guided by pace mapping or ventricular activation mapping, were successful and in 9 all patients, guided by P-potential, were successful. In 9 patients guided by the P-potential, the earliest P-potential appeared 22.7+/-7.7msec earlier than the QRS complex during sinus rhythm and 32.0+/-11.5msec earlier during VT. Pace mapping with similar QRS was not necessarily essential for a successful ablation. In comparing the biophysical parameters according to energy delivery modes, more energy was delivered safety during successful ablation in temperature mode(mean 1148.3J) than constant power mode(520.9J). No acute and late complication was developed during ablation and for a mean of 25 months follow-up. One case of VT with right axis deviation relapsed 2 months after successful ablation. CONCLUSION: RFCA is useful for the effective and safe treatment of ILVT. The earliest P-potential might be a better guide than mapping or earliest ventriclar activation for the determination of ablation sites in ILVT with left axis deviation. More energy was delivered safety during successful ablation in temperature mode than constant power mode.

Apoptosis in Ischemia-Reperfused Myocardium of Rabbit

BACKGROUND: Apoptosis, as opposed to necrosis, is a active and regulated mode of cell death. Persistent myocardial ischemia results in necrosis. The most effective method to limit ischemic myocardial injury is reperfusion, however, reperfusion itself may be associated with tissue injury. The pathophysiologic findings of myocardial ischemia-reperfusion are well known. However, involvement of apoptosis, as a form of tissue damage, has not neen well defined. Recently apoptosis has been suggested as a specific feature of myocardial reperfusion injury leading to late cell death. This study was performed to investigate whether reperfusion induces apoptosis irrespective of reperfusion time, and the pattern of distribution and the extent of apoptosis in rabbit myocardium. METHOD: New Zealand white rabbits weighing 1.8-2.9kg underwent 20 or 30 minutes left anterior descending(LAD) or left circumflex coronary artery occlusion followed by reperfusion for 30 minutes(n=1), 1 hour(n=1), 3 hours (n=2), and 4 hours (n=3). Ventricles were excised immediately after intervention. Tissues were fixed in 10% buffered formalin and embedded in paraffin. Apoptosis was examined by hematoxylin and eoisin(H & E) staining, in situ nick end labeling, and transmission electron microscopy. Number of apoptotic cells was evaluated semiquantitatively on H & E stained section. Myocardial tissues of ischemia only(LAD occlusion for 30 minutes, n=2) and normal rabbits(n=2) were also examined. RESULTS: Evidence of apoptosis was detected in every ischemia-reperfused myocardium irrespective of reperfusion time of 30 minutes to 4 hours. Apoptotic cells were found in the non-necrotic myocardium near necrotic areas and in islets of the non-necrotic myocarium inside necrotic areas. In the areas where apoptotic cells were distributed, the average number of apoptotic cells ranged from 1.0(30 minutes and 1 hour reperfused myocardium) to 1.1(3 hours and 4 hours reperfused myocardium) per high power field(X400)(the proportion ; less than 1% of cardiomyocytes at specific time point of reperfusion). Apoptotic cells were not detected in ischemia only and normal myocardium. CONCLUSION: These fingings suggest that apoptosis is involved as a form of cell death and it may contribute to cardiomyocyte loss not to a large extent in ischemia-reperfusion injury of rabbit myocardium.