Pulmonary tumor thrombotic microangiopathy in a patient with breast cancer / 대한내과학회지

Pulmonary tumor thrombotic microangiopathy (PTTM) is a rare malignancy-related complication causing severe pulmonary hypertension, right heart failure, and death. PTTM is characterized by diffuse fibrocellular intimal proliferation and multiple thrombi formation in the pulmonary arteries and arterioles, which result from invasion of the pulmonary blood vessels by tumor cells. Establishing the diagnosis of PTTM is very difficult and few cases are diagnosed ante mortem. We report the case of a 48-year-old woman diagnosed with PTTM before death who developed breast cancer and presented with persistent dyspnea on exertion.

A Case of Coronary Artery Aneurysm after Sirolimus-Eluting Stent Implantation

This report describes the case of a 26-year-old male diagnosed with angina on exertion. A diagnostic coronary angiography revealed significant luminal narrowing at the middle third of the left anterior descending artery and proximal circumflex artery. The patient underwent implantation of sirolimus-eluting stents. Eight months after implantation of the stents, a follow-up coronary angiography showed intrastent coronary artery aneurysms. We suggest that the implantation of the sirolimus-eluting stent caused late formation of a coronary artery aneurysm.

Intracoronary Radiation Therapy (IRT) for In-Stent Restenosis

The efficacy of beta and gamma emitters in reducing clinical and angiographic restenosis in patients with in-stent restenosis has been confirmed by a number of studies. This review is intended to give an overview of the individual trials, summarize pertinent lessons that have been learned and give insight into the future of intracoronary radiation. The encouraging results from the clinical trials have established vascular brachytherapy as a standard of care for patients with in-stent restenosis.

Cutting Balloon Angioplasty versus Conventional Balloon Angioplasty for In-Stent Restenosis Treated by Intracoronary Radiation Therapy

BACKGROUND: Cutting Balloon angioplasty (CBA) may be a useful treatment modality for in-stent restenosis (ISR) as it maintains a stable position during dilatation and results in potentially less injury than plain old balloon angioplasty (POBA). The purpose of this study was to compare CBA and POBA with intracoronary radiation therapy (IRT) for in-stent restenosis (ISR). METHODS: We selected 157 consecutive patients from the WRIST (Washington Radiation for In-stent restenosis Trial) series of gamma radiation trials using both gamma and beta emitters for ISR of native coronaries or saphenous vein grafts, who were treated with CBA or POBA as the only treatment strategy before intracoronary radiation therapy. Patients in the CBA (N=64) and POBA (N=93) groups were matched for baseline demographic and procedural characteristics. Radiation was delivered successfully in all cases. RESULTS: At angiographic follow up, acute gain was higher in the CBA group than the POBA group (1.7+/-.7 mm vs. 1.4+/-.9 mm, p=0.03). The angiographic restenosis rate (17.1% vs. 23.5%, p=NS) and edge restenosis rate (6.3% vs. 12.2%, p=NS) were not significantly lower in the cutting balloon cohort. At a 6 month clinical follow up, the CBA group showed a statistically decreased rate of clinically driven target vessel revascularization compared to the POBA group (5.7% vs.18.3%, p=0.038). CONCLUSION: Cutting balloon angioplasty is a reasonable treatment strategy for in-stent restenosis prior to intracoronary radiation therapy.

A Case of IgA Nephropathy Associated with LV Thrombus and Cerebral Infarction / 대한신장학회잡지

Thrombosis is one of the important complications in nephrotic syndrome and related to the hypercoagulable state of the nephrotic syndrome, although the exact mechanism is under the debate. While venous trombosis is frequently encountered, arterial thrombosis is rare. Renal vein thrombosis occurs frequently in the patients with nephrotic syndrome due to membranous glomerulonephritis (MGN), membranoproliferative glomerulonephritis (MPGN). It, however, rarely happens in IgA nephropathy. Intracardiac thrombus in the nephrotic syndrome have been described few in the earlier literatures. We reported a case of IgA nephropathy with LV thrombus and cerebral infarction that has been treated successfully with thrombolytic theraphy. So far, the patient on the outpatient clinics have reported no specific complaints.

The Usefulness of B-type Natriuretic Peptide test in Critically Ill, Noncardiac Patients / 결핵

BACKGROUND: Previous studies have suggested that a B-type natriuretic peptide(BNP) test can provide important information on diagnosis, as well as predicting the severity and prognosis of heart failure. Myocardial dysfunction is often observed in critically ill noncardiac patients admitted to the Intensive Care Unit, and the prognosis of the myocardial dysfunction needs to be determined. This study evaluated the predictability of BNP on the prognosis of critically ill noncardiac patients. METHODS: 32 ICU patients, who were hospitalized from June to October 2002 and in whom the BNP test was evaluated, were enrolled in this study. The exclusion criteria included the conditions that could increase the BNP levels irrespective of the severity, such as congestive heart failure, atrial fibrillation, ischemic heart disease, and renal insufficiencies. A triage B-Type Natriuretic Peptide test with a RIA-kit was used for the fluorescence immunoassay of BNP test. In addition, the acute physiology and the chronic health evaluation (APACHE)IIscore and mortality were recorded. RESULTS: There were 16 males and 16 females enrolled in this study. The mean age was 59 years old. The mean BNP levels between the ICU patients and control were significantly different (186.7+/-274.1pg/mL vs. 19.9+/-21.3 pg/mL, p=0.033). Among the ICU patients, there were 14(44%) patients with BNPlevels above 100 pg/mL. The APACHEIIscore was 16.5+/-7.6. In addition, there were 11 mortalities reported. The correlation between the BNP and APACHEIIscore, between the BNP and mortality were significant (r=0.443, p=0.011 & r=0.530, p=0.002). The mean BNP levels between the dead and alive groups were significantly different (384.1+/-401.7 pg/mL vs. 83.2+/-55.8 pg/mL p=0.033). However, the PaO2/FiO2 did not significantly correlate with the BNP level. CONCLUSION: This study evaluated the BNP level was elevated in critically ill, noncardiac patients. The BNP level could be a useful, noninvasive tool for predicting the prognosis of the critically ill, noncardiac patients.

The Application of B-Type Natriuretic Peptide Level of the Dyspneic Patients: Differentiation Between Cor Pulmonale and Left Ventricular Dysfunction / 결핵

BACKGROUND: The serum B-type natriuretic peptide (BNP) is released from the ventricles as a response to volume or pressure overload of the ventricles. A few studies have reported that the BNP measurements are useful in differentiating between heart failure and pulmonary causes in patients who visited the emergency department with dyspnea as the chief complaint. It is difficult to differentiate a right heart failure from a left heart failure in the emergency room. However, there is no report on the application of a BNP assay to differentiate in right heart failure from left heart failure. In this study, the BNP levels were measured from dyspneic patients in the emergency department to determine whether or not the BNP level would be useful in differentiating the cause of the dyspnea from right ventricular failure and left ventricular failure. METHOD: 89 patients who visited emergency department of the Bundang Cha Hospital with dyspnea from June 2002 to March 2003 were selected. The 29 patients from the outpatient clinics and inpatients were randomly selected as the control. RESULTS: The BNP levels of patients in the left heart failure group were significantly different from that of the patients in the right heart failure group (682+/-314 pg/mL vs. 149+/-94 pg/mL, p=0.000). When the BNP cut-off level was designated as 219 pg/mL using the receiver operating characteristic curve, the sensitivity was 94.3%, and specificity was 92.9%. In addition, the positive predictive value was 97% and the negative predictive value was 86.7% in differentiating right heart failure from left heart failure. CONCLUSION: Measurements of the serum BNP levels is an accurate and rapid method that can aid in distinguishing between right heart failure and left heart failure.

A Case of Primary Pulmonary Hypertension Diagnosed in Puerperium

Primary pulmonary hypertension is a condition characterized by sustained elevations of pulmonary artery pressure without demonstrable cause. It is incurable and progressive clinical entity. The incidence has been estimated at approximately 1 to 2 cases per million people in the general population. The maternal mortality of primary pulonary hypertension in pregnancy was said to be 30% and the first month after delivery represents the period of highest risk. We experienced a 27-year-old women with primary pulmonary hypertension diagnosed in postpartum period. She was transferred from the department of obstetrics to internal medicine due to dyspnea on the first day of postpartum. She was diagnosed by perfusion lung scan, chest CT and confirmed by echocardiography. This diagnosis were supported by findings of pulmonary angiogram and cardiac catheterization. Initially she was treated with diuretics, aspirin and anticoagulant therapy, and as a result of the treatment, her symptoms improved. However after 8months has elapsed, exertional dyspnea was worsening. Thus she was treated with calcium channel blocker, aspirin and diuretics and was followed at 1 month interval on the outpatient clinics.

A Case of Aortic Dissection with Compromised Superior Mesenteric Artery Treated with Stents Insertion at Origin of the Artery

The treatment of a thoracic aortic dissection is guided by prognostic and anatomical information. Stanford type A aortic dissection requires surgery, but the appropriate treatment of a Stanford type B aortic dissection has not been determined, especially in patients with visceral artery compromise associated with the aortic dissection due to the failure of surgery to improve the prognosis.We report a case of a 35-year-old man, with a Stanford type B aortic dissection, where the superior mesenteric artery was obstructed. This condition was successfully treated with stents inserted at the origin of the artery.

Impairment of diastolic function in newly diagnosed non-insulin-dependent diabetes mellitus / 대한내과학회지

BACKGROUND: Heart failure is one of the major cause of premature mortality and morbidity in diabetes mellitus. It has been well recognized that left ventricular diastolic dysfunction caused by autonomic neuropathy, hyperinsulinemia, hyperlipidemia might be a preceding underlying mechanism of heart failure in diabetes. Also, an impairment of diastolic function in early diabetic patients has been reported in some literature. So, we evaluated the diastolic function in newly diagnosed diabetics with echocardiography. METHODS: All patients with newly diagnosed NIDDM in Pundang Cha general hospital from December 1996 to June 1998 were enrolled (n=20). The 20 healthy volunteers comparable for age, sex, body surface area were enrolled as a control group. The echocardiography was performed in all patients before any treatment. Blood pressure, pulse rate, fasting and postprandial sugar and insulin level, serum total cholesterol, triglyceride, HDL-cholesterol, LDL-cholesterol were also checked in all patients. RESULTS: There were no significant difference in blood pressure, pulse rate, total cholesterol, triglyceride, HDL-cholesterol and LDL-cholesterol level between both groups. E and A ratio of mitral inflow and peak diastolic velocity of pulmonary vein flow were significantly decreased in NIDDM group compared with control group (p<0.01). But there were no significant difference in left ventricular mass index, isovolumic relaxation time, deceleration time and peak atrial reversal velocity. CONCLUSION: This study demonstrates that an impairment of left ventricular diastolic function occurs early in the NIDDM and investigation of diastolic function should be performed in the clinical evaluation of early diabetic patients.

A Serial Echocardiograhic Obesrvation of Acute Myocardial Injury Associated with Pheoechromocytoma Crisis

Pheochromocytoma may cause anatomic and functional cardiac abnormalities. Various echocardiographic abnormalities have been observed, including systolic anterior movement, global hypokinesis as well as hypokinesis of the base and the apex of LV. There are no previous reports of serial echocardiographic finding in patients with pheochromocytoma. We experienced a 38-year-old woman with pheochromocytoma who suffered from acute myocardial injury. Echocardiography revealed that the acute myocardial injury started in the base in the early phase and subsequently extended to the mid-portion of left ventricule. The injury persisted longer in the base than the mid-portion. than 1.5 times the adjacent normal coronary artery.

A Case of Vasospastic Angina Pectoris Occurring Following Administration of Oral Imigran(R) for Migraine

Imigran(R) (sumatriptan), a 5-hydroxytryptamine (HT) derivative, is highly effective in aborting attacks of migraine and cluster headache. The drug is generally well tolerated. However tolerated, although up to 8% of patients consistently have demonstrate chest symptoms, including chest pressure, tightness, and pain, often mimicking angina pectoris. It has been suggested that these chest symptoms are caused by coronary vasoconstriction, and that this effect may be mediated by endothelial dysfunction. This can be reversed by the administration of glyceryl trinitrate. We report a case of vasospastic angina pectoris occurring after the administration of oral sumatriptan in a patient with migraine.

A Case of Cerebral Thromboembolism Occurred after Restoration to Sinus Rhythm of Paroxysmal Atrial Flutter in Apical Hypertropic Cardiomyopathy with Spontaneous Echo Contrast(SEC)

Atrial flutter occurs most often in patients with organic heart disease. It appears that chronic atrial flutter is associated with a remarkably high risk of clinically apparent thromboembolism and effective anticoagulation appears to reduce this risk, but acute or recent onset, postoperative atrial flutter may have a lower risk of thromboembolism than those with chronic atrial flutter. In chronic atrial flutter or fibrillation with organic heart disease, anticoagulation is generally justified but there is some debate about anticoagulation in paroxysmal atrial flutter. The spontaneous echo contrast is generally accepted one of the major risk factor of thromboembolism and usually occurred in mitral stenosis, dilated cardiomyopathy, and enlarged left atrium, but rarely observed in apical hypertrophic cardiomyopathy. We experienced a patient with apical hypertrophic cardiomyopathy, who visited to emergency medical center due to dizziness and suffered from cerebral thromboembolism after restoration of sinus rhythm. In transesophageal echocardiography, there was moderate to severe spontaneous echo contrast in left atrium. This patient showed that transesophageal echocardiography evaluation of left atrium might be mandatory in patients with paroxysmal atrial flutter and organic heart disease.

A Case of Left Ventricular Thrombophilia after Anterior Wall Acute Myocardial Infarction

In acute myocardial infarction, mural thrombi occur in approximately 20 per cent of patients who do not receive anticoagulant therapy and about 10 percent of thrombi result in systemic embolization. Threrfore, in acute phase of myocardial infarction, heparinization is considered as essential therapeutic regimen which afterwards acute phase, might have no clinical significance. We experienced a patient with recurrent LV apical thrombi inspite of an sufficient anticoagulation. This patient was treated with primary balloon PTCA and optimal duration of anticoa-gulation with IV heparin was maintained. At predischarge follow-up, TTE revealed huge LV apical thrombi and warfarinization was started. Three episodes of appearance and disappearance of thrombi have been noted and we report this patient as thrombophilia associated with acute myocardial infarction.

A Case of Congenital Pericardial Defect Diagnosed by Computed Tomography

Pericardial defect is a rare congenital cardiac disorder. Most patients were asymptomatic but some patients with partial pericardial defect occasionally complain acute symptoms such as angina, syncope, rarely sudden cardiac death. So, differential diagnosis with other ischemic or structural heart disease is crucial in the management of such patients. But there is no consistently successful diagnostic method. In the past, artificial diagnostic pneumothorax was used to document the absence of pericardium. However, it is not easily accepted due to excess morbidity and failure rate. Recently, echocardiography and more often, computed tomography, magnetic resonance imaging are used to confirm the diagnosis. We experienced a 52 years old male patient with atypical chest pain, who was diagnosed as complete left pericardial defect with computed tomography.

Three Cases of Peripartum Cardiomyopathy

Peripartum cardiomyopathy(PPCM) is a rare form of cardiomyopathy of unclear cause that can have life-threatening consequences. Cardiac dilatation and congestive heart failure of unexplained cause may develop during the last month of pregnancy or within the first few months after delivery. It is rare, but it varies among geographic regions. Recent estimates of incidence range from 1: 15,000 in the United States, 1: 6000 in Japan, and 1: 1000 in South Africa. The cause of this disorder is unknown but in some patients endomyocardial biopsy has shown evidence of myocarditis, Necropsy shows cardiac enlargement, often with mural thrombi, endocardial thickening and pericardial effusion, along with histologic evidence of myocardial degeneration, fibrosis and lymphocyte infiltration. However, based on recent data, it seems that endocardial biopsies are currently of minor diagnostic and therapeutic benifit in patients with PPCM. The symptoms, signs, and treatment are similar to those in patients with idiopathic dilated cardiomyopathy, but thromboembolic complications are particularly common. The mortality rate is quite variable but may be as high as 25 to 50 percent. We experienced three case of peripartum cardiomyopathy after delivery. The patients were treated with digitalis, vasodilator and diuretic, which induced improvement of the clinical and echocardiographic finding.

Effect of Low Molecular Weight Heparin on Plasma Thrombin-Antithrombin Complex and Tissue Factor Pathway Inhibitor in Patients with Coronary Artery Disease / 대한혈액학회지

BACKGROUND: The anticoagulant efficacy of low molecular weight heparin (LMWH) as an alternative substitute for standard heparin (SH) was evaluated by measuring thrombin-antithrombin complex (TAT) and tissue factor pathway inhibitor (TFPI). METHODS: Twenty-two patients with coronary artery disease (CAD) were divided into three groups and plasma heparin concentration, platelet count, aPTT, TAT and TFPI before and after injection of SH and LMWH were measured. RESULTS: Plasma heparin concentrations were well correlated after the injection of heparin in group B (LMWH 200 U/kg) and C (LMWH 240 U/kg), but not in group A (SH). Platelet counts were not decreased in most patients and life-threatened bleeding was not observed in any patients. APTT prolongations were observed in all patients of SH group, but not in any patients of B and C. TAT levels were not significantly different between groups. TFPI levels were not significantly different between groups. Heparin levels were well correlated with TFPI levels, but not with TAT levels. CONCLUSION: The anticoagulant effect of LMWH up to 240 U/kg/D was not superior over SH in CAD patients, although it has several merits such as no requirement of aPTT monitoring or better predictability.

A Case of Percutaneous Transluminal Coronary Angioplasty with Stent in a Patient of Acute Myocardial Infarction with Situs Inversus Totalis

Situs inversus totalis with dextrocardia is a rare congenital anomaly and its incidence is approximately 1: 6,000-35,000 in general population. Such patients usually have structurally normal hearts and are expected to have normal life span. Coronary angioplasty in such patients have previously been reported, but reported cases in literature are scanty. This report describes our experience of successful percutaneous transluminal coronary angioplasty with stent in acute myocardial infarction patient with situs inversus totalis and dextrocardia who exhibited total occlusion of the mid left anterior descending coronary artery.

Comparison of left ventricular hypertrophy between hypertensives and chronic renal disease patients: Echocardiographic Study / 대한내과학회지

OBJECTIVES: Left ventricular hypertrophy (LVH) is one of the most common echocardiographic findings and an important prognostic factor for cardiovascular mortality in hypertensives and chronic renal failure patients. To evaluate the prevalence and the types of LVH, and left ventricular systolic and diastolic functions as worsening of renal function, and to elucidate the risk factors for LVH, we performed this study retrospectively in normal populations, hypertensives, and renal failure with or without hemodialysis. METHODS AND SUBJECTS: We recruited the study population among the patients who had taken echocardiography at Pun-Dang CHA Hospital from July, 1995 to June, 1997. They are consisted of 54 patients for normal control, 53 patients of hypertensives, 31 patients of mild renal failure with less than 4.5 mg/dl of serum creatinine (Group I), 29 patients of moderate renal failure with more than 4.5 mg/dl of serum creatinine (Group II), and 47 patients of end stage renal disease with hemodialysis (Group III). The echocardiography was performed with all standard strategies including 2 dimension, M mode, and Doppler signals. RESULTS: 1) Among the baseline characteristics, the body mass index only significantly increased in hypertensives compared with group II and III.2) The prevalences of LVH in each groups were 5.6% in control group, 49.1% in hypertensives, 83.8% in group I, 89.7% in group II, and 100% in group III respectively. And the pevalences of concentric LVH were 5.6%, 43.3%, 41.9%, 34.5%, and 25.5% and those of the eccentric hypertrophy were 0.0%, 5.7%, 41.9%, 55.2%, and 74.5% respectively. The prevalence of eccentric hypertrophy increased according to deterioration of renal function.3) The left ventricular mass index was significantly higher in hypertensives, Group I, Group II, and Group III than normal control and the left ventricular volume index was greater in all renal failure patients compared with controls and hypertensives.4) In pre-hemodialysis renal failure patients, the types of LVH were consisted of 8 of normal heart (Group A), 23 of concentric LVH (Group B), and 29 of eccentric LVH (Group C). The systolic blood pressure and mean arterial pressure were significantly higher in group C than group A but there was no significant difference between group C and B. The RBC volume was significantly decreased in group B and C compared with group A. The echocardiographic end diastolic interventricular septal thickness and posterior wall thickness were significantly thicker in group B than others but end diastolic LV dimension, LV mass index, and LV volume index were significantly increased in group C than group B and A. The LV ejection fraction and fractional shortening as markers of LV systolic function in group C revealed the lowest level among three groups. The E velocity among the Doppler study profiles was significantly higher in group C than others.5) In hemodialysis group, all the patients had any types of LV hypertrophic changes. The concentric LVH group (group B) had significantly higher systolic blood pressure and mean arterial pressure than eccentric LVH (group C) but there was no difference in diastolic blood pressure between two groups. The echocardiographic interventricular septum and posterior wall were thicker in group B than group C but end diastolic LV dimension and LV volume were significantly higher in group C than group B.6) The LV mass index in pre-hemodialysis group had positive relationship with blood pressure and serum urea nitrogen level and the LV volume index was positively correlated with systolic blood pressure and mean blood pressure.7) The LV mass index in hemodialysis group had positive relationship with age and systolic blood pressure and LV volume index was positively correlated with serum urea nitrogen level but negatively correlated with blood pressure. CONCLUSION: The prevalence of LVH was much higher in renal failure group than hypertenssives and the proportion of eccentric LVH was increased with worsening of renal function. Although the arterial hypertension is the most important risk factor for LVH, this finding suggested existence of other contributing risk factors for LVH in chronic renal failure, which included uremia, anemia, and age.

Clinical Study of the Intravenous Amiodarone in Acute Myocardial Infarction with Life-Threatening Refractory Ventricular Tachyarrhythmias

BACKGROUND: Recently, the amiodarone has emerged as a promising antiarrhythmic agent and its efficacy and safety has been widely accepted with many literatures. But there was no general agreement regarding the dosage and indication of intravenous (IV) amiodarone in acute myocardial infarction with life-threatening refractory ventricular tachyarrhythmias. METHOD: From October 1995 through October 1997, we recruited retrospectively 9 patients of acute myocardial infarction who had received IV amiodarone for life-threatening refractory ventricular tachyarrhythmias and analyzed the initial response, adverse effect, and loading dose. RESULTS: 1) Acute efficacy:Eight of 9 patients promptly restored normal sinus rhythm immediately after intravenous amiodarone administration. 2) In-Hospital Mortality:One patients died due to ventricular tachyarrhythmias refractory to aggressive management and 5 in 8 patients who had responded promptly with IV amiodarone discharged alive and other 3 patients died due to cardiogenic shock with normal sinus rhythm. 3) Immediate adverse effects:Five patients experienced immediate adverse effects after IV amiodarone; 3 patients of hypotension, 1 patient of first degree AV block, and the other of Morbitz type 2 AV block. 4) Long term follow-up:Among 5 patients discharged alive, one died as unexpected consequence. Other 4 patients have been still alive without maintenance medication. CONCLUSION: The IV amiodarone for suppression of life-threatening ventricular tachyarrhythmias in patients with acute myocardial infarction seemed to be an effective second-line therapeutic drug and have acceptable adverse effects. In the future, the large scale study regarding the dosage and indication might be warrented.