Valsartan 160 mg/Amlodipine 5 mg Combination Therapy versus Amlodipine 10 mg in Hypertensive Patients with Inadequate Response to Amlodipine 5 mg Monotherapy

BACKGROUND AND OBJECTIVES: When monotherapy is inadequate for blood pressure control, the next step is either to continue monotherapy in increased doses or to add another antihypertensive agent. However, direct comparison of double-dose monotherapy versus combination therapy has rarely been done. The objective of this study is to compare 10 mg of amlodipine with an amlodipine/valsartan 5/160 mg combination in patients whose blood pressure control is inadequate with amlodipine 5 mg. SUBJECTS AND METHODS: This study was conducted as a multicenter, open-label, randomized controlled trial. Men and women aged 20-80 who were diagnosed as having hypertension, who had been on amlodipine 5 mg monotherapy for at least 4 weeks, and whose daytime mean systolic blood pressure (SBP) ≥135 mmHg or diastolic blood pressure (DBP) ≥85 mmHg on 24-hour ambulatory blood pressure monitoring (ABPM) were randomized to amlodipine (A) 10 mg or amlodipine/valsartan (AV) 5/160 mg group. Follow-up 24-hour ABPM was done at 8 weeks after randomization. RESULTS: Baseline clinical characteristics did not differ between the 2 groups. Ambulatory blood pressure reduction was significantly greater in the AV group compared with the A group (daytime mean SBP change: -14±11 vs. -9±9 mmHg, p<0.001, 24-hour mean SBP change: -13±10 vs. -8±8 mmHg, p<0.0001). Drug-related adverse events also did not differ significantly (A:AV, 6.5 vs. 4.5%, p=0.56). CONCLUSION: Amlodipine/valsartan 5/160 mg combination was more efficacious than amlodipine 10 mg in hypertensive patients in whom monotherapy of amlodipine 5 mg had failed.

The Role of Large Animal Studies in Cardiac Regenerative Therapy Concise Review of Translational Stem Cell Research

Animal models have long been developed for cardiovascular research. These animal models have been helpful in understanding disease, discovering potential therapeutics, and predicting efficacy. Despite many efforts, however, translational study has been underestimated. Recently, investigations have identified stem cell treatment as a potentially promising cell therapy for regenerative medicine, largely because of the stem cell's ability to differentiate into many functional cell types. Stem cells promise a new era of cell-based therapy for salvaging the heart. However, stem cells have the potential risk of tumor formation. These properties of stem cells are considered a major concern over the efficacy of cell therapy. The translational/preclinical study of stem cells is essential but only at the beginning stages. What types of heart disease are indicated for stem cell therapy, what type of stem cell, what type of animal model, how do we deliver stem cells, and how do we improve heart function? These may be the key issues that the settlement of which would facilitate the transition of stem cell research from bench to bedside. In this review article, we discuss state-of-the-art technology in stem cell therapies for cardiovascular diseases.

Familial Occurrence of Atrioventricular Nodal Reentrant Tachycardia in a Mother and Her Son

Atrioventricular nodal reentrant tachycardia (AVNRT), caused by a reentry circuit involving fast and slow atrioventricular nodal pathways, is one of the most common types of paroxysmal supraventricular tachycardias. While familial Wolff-Parkinson-White syndrome has been well recognized, familial AVNRT has been rarely reported. We report a familial occurrence of AVNRT in a mother and her son, who were symptomatic and successfully treated with radiofrequency catheter ablation of slow pathway.

A Rare Case of Aortic Valve Myxoma: Easy to Confuse With Papillary Fibroelastoma

Myxoma of the aortic valve is an exceedingly uncommon condition. In this article, we report the case of a 72-year-old man with myxoma arising from the aortic valve. We extirpated the mass and repaired the aortic valve with the patient under cardiopulmonary bypass. The postoperative course was uneventful. Histological examination confirmed that the mass was a myxoma.

Late-Onset Postpneumonectomy Empyema Presenting as Right-Sided Heart Failure: Extrinsic Right Atrial Compression

Although it is rare, the right atrium can be encroached on by abnormal mediastinal structures, including aortic aneurysms, carcinomas, hepatic cysts and diaphragmatic paralysis. Extrinsic compression of the right atrium causes significant hemodynamic compromise and can lead to fatal outcomes. We describe the case of a 66-year old man with a past history of pulmonary tuberculosis that had undergone right pneumonectomy 40 years previously. He then presented with signs and symptoms of right-sided heart failure. These new signs and symptoms were recognized to be secondary to extrinsic compression of the right atrium, which was due to late-onset postpneumonectomy empyema, and the signs and symptoms were successfully relieved by performing open drainage of the empyema.

Stenting of the Left Main Coronary Artery in a Patient With Takayasu's Arteritis

Management of Takayasu's arteritis of the left main coronary artery (LMCA) is difficult because of the possibility of restenosis. Clinically significant stenotic lesions must be considered anatomical correlation. Many studies have reported that the management of stenotic lesions of the LMCA with endoluminal stenting and balloon angioplasty and de-novo stenting is safe and effective for patients with Takayasu's arteritis. We report the case of a patient with Takayasu's arteritis of the LMCA. The patient had undergone two consecutive percutaneous coronary interventions because of recurrent restenosis of in-stent lesions, and eventually underwent coronary artery bypass graft (CABG) surgery for myocardial infarction in the same lesion. We suggested treatment with CABG because the pathophysiology of Takayasu's arteritis is different from that of atherosclerotic stenosis.

Tricuspid Valvular Myxoma: Unusual Case of Tricuspid Valve Myxoma Mimicking Thrombus after Pulmonary Artery Embolectomy and Tricuspid Annuloplasty in Pulmonary Thromboembolism Patient

A 55-year-old man with massive pulmonary thromboembolism underwent thrombolysis, pulmonary artery embolectomy and tricuspid annuloplasty. Nine months later, a mobile echogenic intra-cardiac mass was found in the tricuspid valve. Because the patient had undergone annuloplasty, thrombosis was suspected as the most likely diagnosis and thrombolytic therapy was instituted. However, the size of the cardiac mass did not change and after surgical excision the mass was found to be a myxoma. Cardiac valvular tumors are uncommon and when they occur they are usually slow growing fibroelastomas. In this case, the rapid growing cardiac myxoma on the tricuspid valve was found after the occurrence of pulmonary thromboembolism. To our knowledge, this is first reported case of tricuspid valve myxoma in Korea.

The Management of Cardiovascular Abnormalities in Patient With LEOPARD Syndrome

LEOPARD syndrome (LS) is a rare hereditary disorder in Asian countries. This syndrome consists of multiple systemic abnormalities. In particular, characteristic cardiovascular effects in LS may include variable clinical manifestations from benign to life-threatening courses. The cardiac effects of this syndrome consist of left ventricular hypertrophy (LVH), pulmonary stenosis (PS), coronary artery dilatation and electrocardiogram(ECG) abnormalities. Since there are few LS patients who have undergone a complete cardiovascular evaluation, the nature and clinical prognosis of cardiovascular abnormalities in this syndrome remain uncertain. Also, there have been few reports on therapeutic strategies for cardiovascular abnormalities in LS. Here we describe a case of LS who presented with multiple cardiovascular problems and underwent successful surgical and medical treatment.

The Pulmonary Embolism Severity Index in Predicting the Prognosis of Patients With Pulmonary Embolism

BACKGROUND/AIMS: Many prognostic models have been developed to help physicians make medical decisions on treating patients with pulmonary embolism. Among these models, the Pulmonary Embolism Severity Index (PESI) has been shown to be a successful risk stratification tool for patients with acute pulmonary embolism. The PESI, however, had not been applied to patients with pulmonary embolism in Korea. METHODS: The patients included in this study were diagnosed by computed tomography at Inje University's Ilsan Paik Hospital between December 1999 and March 2007. Risk stratification for the patients was performed using the PESI. The mortality rate was calculated according to each PESI risk class. RESULTS: Of the 90 patients enrolled in this study, ten were assigned to PESI class I, 29 to PESI class II, 22 to PESI class III, eight to PESI class IV, and ten to PESI class V. The mortality rate after 30 days in each class was 0, 10.3, 9.1, 0, and 50% (p=0.0016), respectively, whereas the respective hospital mortality rate was 4.8, 13.8, 13.6, 12.5, and 50% (p=0.0065). The overall mortality was 9.5, 27.6, 31.8, 50.0, and 60%, respectively (p=0.0019). The mortality rate was significantly associated with the PESI class. CONCLUSIONS: The PESI class was found to be significantly correlated with the 30-day mortality rate, hospital mortality, and overall mortality. Our data indicate that the PESI can be used to predict the prognosis of patients with pulmonary embolism and in making medical decisions regarding the treatment of patients with pulmonary embolism.

A case of metastatic mycotic pseudoaneurysms that developed after aortic surgery / 대한내과학회지

Multiple mycotic pseudoaneurysms that develop after aortic surgery are a rare infectious complication. The clinical course of this disease is severe and associated with a high mortality. Few published cases have described mycotic pseudoaneurysms that are localized mainly in the brain, heart, and aorta. In this case, a 33-year-old woman was admitted with abdominal pain and mild fever after graft surgery for a ruptured thoracic aorta that occurred following a vehicle accident. Thoracoabdominal computed tomography (CT), angiography, and transesophageal echocardiography (TEE) demonstrated multiple pseudoaneurysms and thromboembolic obstructions in the thoracic aorta and its branches. She was treated with anticoagulation, coil embolization, and surgical resection. Microscopically, a resected pseudoaneurysm showed the characteristic features of fungal colonies with thrombi. This patient has been well for 2 months after removing the pseudoaneurysms and treatment with systemic antifungal agents.

Preoperative and Postoperative Evaluation of Multiple Giant Coronary Aneurysms by the Use of Coronary CT Angiography with 64-MDCT: A Case of Multiple Giant Coronary Aneurysms Treated with Aneurysmectomy and Coronary Artery Bypass Surgery

A coronary artery aneurysm is an uncommon disorder and is seen as a characteristic dilatation of a localized portion of the coronary artery. Clinical manifestation of a coronary artery aneurysm varies from an asymptomatic presentation to sudden death of a patient. Although coronary aneurysms are typically diagnosed by the use of coronary angiography, a new generation of coronary 64-slice multidetector computed tomography (64-MDCT) scanners have successfully been used for evaluating this abnormality in a noninvasive manner. In the present case, we performed coronary 64-MDCT scanning preoperatively and postoperatively on a patient with multiple giant coronary aneurysms. The use of coronary 64-MDCT may provide an evaluation technique not only for diagnosis but also for follow-up after surgery for this condition.

Two Cases of Successful Primary Percutaneous Coronary Intervention in Patients With an Anomalous Right Coronary Artery Arising From the Left Coronary Cusp

An anomalous origin of the right coronary artery (RCA) from the left coronary cusp is a rare congenital anomaly. Because of the unusual location and the noncircular luminal orifice of this anomaly, cannulation of this artery during coronary angiography and percutaneous coronary intervention (PCI) poses significant technical difficulties when using the currently available guiding catheters. Primary PCI should be performed as quickly as possible when a patient displays this condition. When we face the situation of an anomalous artery during primary PCI, it takes a much longer time to open the occluded artery. We report here on two cases of successful primary PCI with using manually manipulated catheters and Ikari type guiding catheters in 2 patients who both had an anomalous RCA arising from the left coronary cusp.

Diagnostic accuracy of 64-slice multidetector CT coronary angiography for the evaluation of coronary artery disease / 대한내과학회지

BACKGROUND/AIMS: Invasive coronary angiography remains the gold standard in the diagnosis of coronary artery disease. However, multidetector CT (MDCT) coronary angiography is an emerging technique that is available for the non-invasive detection of coronary artery stenoses. While the diagnostic accuracy of first generation MDCT is limited, recently released 64-slice MDCT has yielded promising results due to increased temporal and spatial resolution. The objective of this study was to investigate the diagnostic accuracy of non-invasive 64-slice MDCT for coronary artery disease. METHODS: One hundred one patients (63 males and 38 females; mean age, 63.7+/-10.5 years) undergoing conventional coronary angiography were included in this study. All coronary arteries, including the distal segments and side branches, were analyzed for the presence of significant stenosis (> or =50% diameter stenosis) and compared with of the quantitative coronary angiographic findings. RESULTS: Of the 1,440 coronary artery segments studied, 1,348 segments were assessed quantitatively by both MDCT and conventional coronary angiography (94%). Two hundred nine significant stenoses were detected by conventional coronary angiography. On a segment-based analysis, the senisitivity, specificity, and positive and negative predictive values of 64-slice MDCT were 96, 97, 85, and 99%, respectively. On a vessel-based analysis, the sensitivity, specificity, and positive and negative predictive values of 64-slice MDCT were 96, 97, 85, and 99%, respectively. The corresponding values obtained on a patient-based analysis were 100, 94, 97, and 100%, respectively. Coronary calcification was the major cause of false-positive findings. CONCLUSIONS: This study demonstrated that 64-slice MDCT coronary angiography is of similar accuracy as conventional coronary angiography for the detection of coronary artery disease. In selected groups of patients, 64-slice MDCT may replace the more invasive coronary angiography.

Three Cases of Arterial Occlusion That Occurred After the Use of Angioseal(R)

Femoral arterial closure devices are now commonly used after both diagnostic and therapeutic coronary procedures. They have been shown to reduce the time to ambulation and to decrease the length of the hospital stay. Angioseal is a commercially available femoral artery closure device that has been approved by the Food and Drug Administration (FDA). The device sandwiches an intra-arterial absorbable anchor on the luminal side of the vessel and a thrombin plug on the surface of the vessel with using a self-cinching stitch. We report here on three patients who presented with acute and delayed arterial occlusive complications that were found to be due to an Angioseal anchor that was not appropriately reabsorbed.

Successful Resuscitation of Cardiac Arrest with Acute Massive Pulmonary Embolism during Operation Using Percutaneous Cardiopulmonary Support (PCPS): A case report / 대한흉부외과학회지

Since the introduction of extracorporeal cardiopulmonary support of cardiac arrest in 1983, emergent cardiopulmonary support has been used to treat cardiac arrest. Acute massive pulmonary embolism is associated with a high mortality rate and it poses a challenge for both the anesthesiologist and the surgeons especially during operations. This report describes the use of the emergent bypass system in the effective management of an intraoperative massive pulmonary embolism and cardiac arrest in a 56-year-old woman. The patient was discharged on warfarin and there was no recurrence of the pulmonary embolism at the follow-up visit.

A Case of Abciximab Induced Acute Profound Thrombocytopenia Resulting in Compartment Syndrome of the Forearm from Massive Bleeding at the Brachial Artery Access Site

Abciximab is one of the glycoprotein IIb/IIIa receptor inhibitors, and it is known to be effective for preventing and treating the thrombotic complications of percutaneous coronary intervention (PCI). On the other hand, there is an increasing risk of hemorrhagic complications when using abciximab, especially in the case of abciximab-induced thrombocytopenia. Acute profound thrombocytopenia is a rare, but life threatening adverse reaction to abciximab, and it can even occur within a few hours of the first exposure. We report here on a case of 56 year-old woman who experienced massive bleeding of her brachial artery access site. This was caused by abciximab-induced acute profound thrombocytopenia after performing PCI concomitant with using abciximab.

Spontaneous Closure of Iatrogenic Coronary Artery Fistula to Left Ventricle After Septal Myectomy for Hypertrophic Obstructive Cardiomyopathy

Cases of iatrogenic coronary artery fistulas draining into the left ventricle after surgical myectomy for hypertrophic obstructive cardiomyopathy have been published as sporadic reports. However, its management scheme and prognosis are not clear because of the low incidence. A 46-yr-old woman was hospitalized for evaluation of chest pain and shortness of breath for 3 months. Transthoracic echocardiographic examination showed typical hypertrophic obstructive cardiomyopathy with a peak pressure gradient of 71 mmHg across the left ventricular outflow tract. The patient underwent surgical septal myectomy. Postoperative color Doppler imaging revealed a diastolic blood flow from the interventricular septal myocardium to the left ventricular cavity, i.e. iatrogenic coronary artery fistula to the left ventricle. Ten days later, the fistula closed spontaneously which was diagnosed by transthoracic echocardiography and confirmed by coronary angiography.

Thrombolysis in the Obstructed Prosthetic Tricuspid Valve: Importance of the Site of Prosthetic Valve and the Patient's Adherence with Anticoagulation Therapy

A prosthetic valve thrombus that occludes the blood flow or interferes with the valvular function is a rare, but life-threatening complication after prosthetic valve replacement. The patient's adherence with taking his anticoagulant medication is most critical. However, as seen in this presentation, the location of the prosthetic valve at the supra coronary sinus site may also be important. For the patient in this study, the blood flow and the speed of the flow through the valve were significantly reduced because the flow from the coronary sinus bypassed the prosthetic valve. This particular location of the prosthetic valve may be one of the risk factors that caused the thrombus. The right-sided prosthetic valve thrombus was successfully treated by thrombolysis with using urokinase, and there was no evidence of pulmonary embolism.

A Case of Spontaneous Left Atrial Intramural Hematoma Causing Vaso-occlusive Cardiogenic Shock

Intramural hematoma of the cardiac muscle is a rare clinical condition. Only a few cases have been reported in the medicosurgical conditions related to post cardiac surgery, chest trauma and dissecting aneurysms of the aorta. Moreover, there are few cases of spontaneous left atrial intramural hematoma and they may occur in the medical conditions related to calcified mitral annulus dissection or amyloidosis. We experienced a case of spontaneous intramural left atrial hematoma in a 29 year-old male resulting in vaso-occlusive cardiogenic shock. We report the clinical manifestation and treatment of this case with a review of literatures.

Balloon-Based Distal Protection Device Improves the Recovery of Left Ventricular Function after Primary Coronary Angioplasty

BACKGROUND AND OBJECTIVES: Despite the high success rate of primary angioplasty in cases of acute myocardial infarction (AMI), myocardial reperfusion can frequently be compromised, mainly due to distal embolization, which can be effectively prevented with the use of distal protection devices. The goal of this study was to see whether PercuSurge(r), a balloon-based distal protection device, could improve myocardial reperfusion and late clinical outcomes after primary coronary angioplasty. SUBJECTS AND METHODS: Between April 2002 and July 2003, 29 patients with AMI, within 12 hours of the onset of symptoms, were scheduled to undergo primary angioplasty using PercuSurge(r) (PS group). Thirty patients were selected as a control group by matching the 5 clinical and angiographic variables; the clinical status and coronary angiograms were also prospectively reviewed and analyzed. RESULTS: There were no significant differences in the baseline clinical and angiographic characteristics, including the left ventricular ejection fraction (LVEF) between two groups. The procedures were successful, without complications, in all patients from both groups. However, the PS group was associated with a significantly higher incidence of myocardial blush score of 3 (PS 58%, control 30%, p=0.001) and early ST-segment elevation resolution (PS 76%, control 47%, p=0.02) compared to the control group. The PS group also showed a greater LVEF at 60 days after the procedure (PS 51+/-5%, control 46+/-8%, p=0.007). There was no significant difference in the incidences of death or myocardial infarction between the two groups during the follow-up period. CONCLUSION: The use of the PercuSurge(r) was found to be safe and feasible during primary angioplasty, and this system also improved the recovery of the left ventricular function as well as myocardial reperfusion following primary coronary angioplasty.