Comparison of Outcomes after Device Closure with Transseptal Puncture and Standard Technique in Patients with Patent Foramen Ovale and Ischemic Events.

OBJECTIVES: The purpose of this study was to compare the effectiveness of device closure with the transseptal puncture and standard technique in patients with patent foramen ovale (PFO) and ischemic events. METHODS: Eighty-two consecutive patients (men: 60 patients, mean age: 45.2 years) who underwent PFO closure with the Amplatzer PFO Occluder were enrolled. PFO closure with the transseptal puncture was performed in 22 patients (transseptal puncture technique, group I). In the remaining patients (n = 60), PFO closure was performed with the standard technique (group II). The co-primary end points were the incidence of significant residual shunt on follow-up transesophageal echocardiography (TEE) and a composite of death, stroke, transient ischemic attack (TIA), and peripheral embolism. RESULTS: Baseline characteristics were similar between the two groups. On TEE, despite similar grade of interatrial right-to-left shunt, shunt at rest/septal hypermobility was less common in group I than in group II (40.9% vs. 72.9%, P < 0.010). The device was successfully implanted in all patients. On follow-up TEE, significant residual shunt was more common in group I than in group II (28.6% vs. 4.3%, P = 0.021). In addition, composite of death, stroke, TIA, or peripheral embolism was more common in group I than in group II (13.6% vs. 0%, P = 0.017) during the follow-up period (mean 25.4 months). CONCLUSION: Compared to the standard technique, PFO closure with the transseptal puncture technique showed higher incidence of residual shunt and ischemic events. Therefore, this technique might be considered in only highly selected patients as the last option.

Clinical Significance of Dynamic Left Ventricular Outflow Tract Obstruction During Dobutamine Stress Echocardiography in Women With Suspected Coronary Artery Disease.

BACKGROUND: Although dobutamine stress echocardiography (DSE) is frequently associated with dynamic left ventricular outflow tract obstruction (DLVOTO), little is known about its clinical significance in women with suspected coronary artery disease (CAD). METHODS AND RESULTS: One hundred and two female patients (57±10 years) who underwent DSE as part of the Korean women's chest pain registry study were included. Doppler echocardiography was performed during DSE to assess the presence of DLVOTO. Patients with DLVOTO (n=52) were older than those without DLVOTO (n=50; P=0.001). Hypertension was more prevalent in patients with DLVOTO (P=0.02). Patients with DLVOTO had smaller LV diameter, but higher LV mass index and relative wall thickness (P<0.05 for all). LV diastolic function (as reflected by late diastolic velocity, deceleration time of early diastolic velocity [E], and ratio of E velocity to early diastolic mitral annular velocity), was worse in patients with DLVOTO (P<0.05 for all). Patients with DLVOTO had shorter exercise time (P=0.02) and lower amount of work (P=0.04) than patients without DLVOTO. DSE-provoked DLVOTO was not related to the presence of CAD in these patients. CONCLUSIONS: In Korean women with suspected CAD, DSE-provoked DLVOTO is correlated with LV concentric remodeling and LV diastolic dysfunction, and may be associated with limited exercise tolerance and symptoms of chest pain.

Anti-Anginal and Metabolic Effects of Carvedilol and Atenolol in Patients with Stable Angina Pectoris: A Prospective, Randomized, Parallel, Open-Label Study.

BACKGROUND: While recent guidelines have suggested the potential for beta-blockers as first-line agents in chronic stable angina, few data regarding comparative anti-anginal and metabolic effects between beta-blockers with and without vasodilating properties have been reported, particularly in patients with angina pectoris. OBJECTIVE: Our objective was to compare the anti-anginal and metabolic effects of carvedilol and atenolol in patients with stable angina pectoris. METHODS: A total of 89 patients (mean age 54.9 ± 9.3 years; male 53.9 %) with stable angina pectoris were randomly assigned to carvedilol (n = 43) or atenolol (n = 46). The subjects undertook an exercise treadmill test and completed the Seattle Angina Questionnaire (SAQ); metabolic parameters were measured at baseline and 6 months after treatment. RESULTS: The baseline characteristics of both groups were well balanced. Both carvedilol and atenolol significantly reduced heart rate from baseline (76 ± 11 to 66 ± 9 beat/min, p < 0.001; 74 ± 9 to 64 ± 9 beat/min, p < 0.001, respectively) with no significant changes in systolic and diastolic blood pressure. Improvement of time to ST-segment depression during the treadmill exercise and the SAQ scores for angina stability and frequency after 6 months of treatment were similar between groups. There was no significant change from baseline in the level of fasting glucose, insulin, or glycated hemoglobin in either group. However, total cholesterol and low-density lipoprotein cholesterol levels significantly reduced to a greater extent with carvedilol than with atenolol (-23 vs. -10 and -38 vs. -24 %, respectively, p < 0.05 for both), although the rate of statin use was comparable. No changes were seen in high-density lipoprotein cholesterol and triglyceride levels after 6 months of treatment in both groups compared with baseline. CONCLUSIONS: Both carvedilol and atenolol had a similar anti-anginal effect. Compared with atenolol, carvedilol might have more beneficial effects on lipid metabolism in patients with stable angina pectoris [ClinicalTrials.gov identifier: NCT02547597].

Erratum: Obesity and Hypertension in Association with Diastolic Dysfunction Could Reduce Exercise Capacity.

[This corrects the article on p. 394 in vol. 46, PMID: 27275176.].

The role of abnormal metabolic conditions on arterial stiffness in healthy subjects with no drug treatment.

BACKGROUND: Subjects with abnormal metabolic conditions had increased risk for cardiovascular disease. We investigated the role of abnormal metabolic conditions on arterial stiffness in healthy subjects with no drug treatment. METHODS: A total 601 subjects (age 48.7 ± 11.8 years, male 46.2 %, hypertension 19.1 %) were enrolled. Major cardiovascular risk factors, metabolic conditions and parameters (pre-diabetes, diabetes mellitus, metabolic syndrome, fasting blood sugar (FBS), glycated hemoglobin), lipid profiles, hsCRP, and brachial ankle pulse wave velocity (baPWV) were measured. RESULTS: Subjects with metabolic syndrome (n = 200) had higher baPWV than in subjects without metabolic syndrome (n = 401) even after adjustments for age, sex and presence of hypertension (1435.9 ± 212.2 vs. 1336.5 ± 225.0 cm/sec, p < 0.001). The differences of baPWV among normal FBS, prediabetes and diabetes mellitus groups are significant (P for trend = 0.036) by multivariate analysis (adjustments for age, sex, office systolic blood pressure). Subjects with diabetes mellitus (n = 30) had higher baPWV than in subjects with normal FBS (n = 384, 1525 ± 267.1 vs. 1341.5 ± 224.1 cm/sec, P = 0.016 adjustments for age, sex, office systolic blood pressure). BaPWV in subjects with prediabetes (n = 187) was slightly higher, but not statistically significant than in subjects with normal FBS (P = 0.377). Of interest, FBS was one of the independent predictors for increased baPWV (ß = 0.809, 95 % CI 0.222-1.397, p = 0.007) by multivariate analysis. CONCLUSIONS: Subjects with abnormal metabolic conditions have increased arterial stiffness independent of age and BP which may contribute to the development of cardiovascular disease.

Obesity and Hypertension in Association with Diastolic Dysfunction Could Reduce Exercise Capacity.

BACKGROUND AND OBJECTIVES: Empirical evidence is lacking on the cumulative disease burden of obesity and hypertension and its impact on cardiac function and exercise capacity. The purpose of this study was to determine whether the presence of obesity and hypertension together was associated with cardiac dysfunction and exercise capacity. SUBJECTS AND METHODS: Using a retrospective study design, medical records were reviewed for echocardiographic and treadmill exercise stress test data. Subjects were grouped according to four categories: normal control, obese, hypertensive, or obese and hypertensive. RESULTS: Obese, hypertensive persons showed significantly lower Ea and E/A ratio and greater E/Ea ratio, deceleration time, left ventricular (LV) mass, and LV mass index compared to their counter parts (normal control, obese and/or hypertensive) (all p<0.05), after controlling for age and sex. After controlling for age and sex, significant differences in exercise capacity indices were found, with the obese group having shorter exercise time, lower metabolic equivalents, and lower maximal oxygen uptake than the normal control, hypertensive, or both groups (all p<0.05). The hypertensive or obese and hypertensive group had greater maximal blood pressure compared with the normal control group (all p<0.001). Obese and hypertensive persons were approximately three times more likely to have diastolic dysfunction (odd ratio=2.96, p=0.001), when compared to the reference group (normotensive, non-obese, or hypertensive only persons). CONCLUSION: Diastolic dysfunction was associated with obesity and/or hypertension. The cumulative risk of obesity and hypertension and their impact on diastolic dysfunction which could be modifiable could reduce exercise capacity.

Thrombotic Occlusion of Stent Graft Limbs due to Severe Angulation of Aortic Neck in Endovascular Repair of Abdominal Aortic Aneurysm.

Endovascular aneurysm repair (EVAR) is a safe alternative to open surgical repair for an abdominal aortic aneurysm. However, unfavorable aortic anatomy of the aneurysm has restricted the widespread use of EVAR. Anatomic limitation is most often related to characteristics of the proximal neck anatomy. In this report, we described a patient with a severely angulated proximal neck who underwent EVAR, but required repeat intervention because of thrombotic occlusion of stent graft limbs.

Protective effect of angulated aorta for saving coronary artery during endovascular repair for ascending aortic pseudoaneurysm.

Ascending aortic pseudoaneurysm is a rare complication after cardiothoracic surgery and the open surgical repair for this complication is challenging. We report on a patient who developed an ascending aortic pseudoaneurysm after aortic valve replacement (AVR), which was treated successfully with endovascular therapy. Our case showed that angulation of the ascending aorta is one of factors for consideration in application of endovascular therapy and endovascular therapy might be an option for management of ascending aortic pathology in patients with high surgical risk, particularly patients with a severely angulated proximal ascending aorta.

A case of Cowden syndrome diagnosed from multiple gastric polyposis.

Cowden syndrome is a rare autosomal dominant disorder that is characterized by multiple hamartomas in a variety of tissues and this is associated with germline mutations in the phosphatase and tensin homologue (PTEN) gene, which is the tumor suppressor gene located on chromosome 10q23.3. It is characterized by multiple hamartomatous neoplasms of the skin, oral mucosa, gastrointestinal (GI) tract, bones, central nervous system, eyes, and genitourinary tract. Cowden syndrome does not have increased risk of GI malignancy; however, it has an increased risk of breast, thyroid and endometrial cancer development. Here the authors report a rare case of Cowden syndrome incidentally diagnosed from multiple gastric polyposis. A 29-year-old woman presented with multiple gastric polyps. The laboratory results were normal except for mild anemia, with a hemoglobin level of 11.9 g/dL. Esophagogastroduodenoscopy revealed multiple gastric, duodenal polyps and esophageal acanthosis. Colonoscopy revealed possible hamartomatous polyps in the rectum. Under the suspicion of Cowden syndrome, sonography of the thyroid and breasts was carried out, which revealed multiple thyroid masses. Subsequent fine-needle aspiration biopsy revealed the presence of clusters of follicular epithelial cells, and due to the possibility of malignancy, the patient underwent total thyroidectomy. The pathology was reported as invasive follicular carcinoma. A gene study by direct sequencing showed the presence of a PTEN mutation (c.633C > A /p.Cys211*).

A comparison of two brands of clopidogrel in patients with drug-eluting stent implantation.

BACKGROUND AND OBJECTIVES: Although generic clopidogrel is widely used, clinical efficacy and safety between generic and original clopidogrel had not been well evaluated. The aim of this study was to evaluate the clinical outcomes of 2 oral formulations of clopidogrel 75 mg tablets in patients with coronary artery disease (CAD) undergoing drug-eluting stent (DES) implantation. SUBJECTS AND METHODS: Between July 2006 and February 2009, 428 patients that underwent implantation with DES for CAD and completed >1 year of clinical follow-up were enrolled in this study. Patients were divided into the following 2 groups based on treatment formulation, Platless® (test formulation, n=211) or Plavix® (reference formulation, n=217). The incidence of 1-year major adverse cardiovascular and cerebrovascular event (MACCE) and stent thrombosis (ST) were retrospectively reviewed. RESULTS: The baseline demographic and procedural characteristics were not significantly different between two treatment groups. The incidence of 1-year MACCEs was 8.5% {19/211, 2 deaths, 4 myocardial infarctions (MIs), 2 strokes, and 11 target vessel revascularizations (TVRs)} in Platless® group vs. 7.4% (16/217, 4 deaths, 1 MI, 2 strokes, and 9 TVRs) in Plavix® group (p=0.66). The incidence of 1-year ST was 0.5% (1 definite and subacute ST) in Platless® group vs. 0% in Plavix® group (p=0.49). CONCLUSION: In this study, the 2 tablet preparations of clopidogrel showed similar rates of MACCEs, but additional prospective randomized studies with pharmacodynamics and platelet reactivity are needed to conclude whether generic clopidgrel may replace original clopidogrel.

Right coronary cusp prolapse resembling subpulmonic stenosis in an old adult patient with ventricular septal defect.

Ventricular septal defect (VSD) can be associated with various complications such as aortic regurgitation (AR). AR in VSD come from a deficiency or hypoplasia of the conal septum which leads to abnormal apposition in diastole and prolapse of the poorly supported noncoronary or right coronary cusp through the VSD into the right ventricle resembling subpulmonic stenosis and subsequently results in distortion of the aortic valve and progressive AR. AR often increases in severity with age and it indicates a worse prognosis. Therefore, appropriate timing of surgical repair in progressive AR in VSD might be important. Until now, many earlier experiences about surgical repair of AR complicating VSD were on adolescents or young adults. We reported a case of AR in 48-year-old male patient with right coronary cusp prolapse complicating the subarterial type of VSD which was properly assessed by echocardiography and was successfully treated with surgical repair. Right coronary cusp or noncoronary cusp prolapse should be suspected in AR complicating VSD through proper echocardiographic assessment and the surgical repair on VSD and distorted aortic valve should be considered in the old patient, as well as the young.

Successful management of portopulmonary hypertension with beraprost.

Portopulmonary hypertension is a complication of chronic liver disease, which has significant effects on survival and prognosis. Although the pathogenesis of pulmonary arterial hypertension has been well known, portopulmonary hypertension is often underestimated in patients with chronic liver disease. Every clinician who manages patients with chronic liver disease complaining of dyspnea should consider portopulmonary hypertension because this disorder requires special treatment. Herein, a 40-year-old woman with liver cirrhosis who complained of dyspnea on exercise is presented. She was diagnosed with portopulmonary hypertension by echocardiography and right-heart catheterization. Beraprost was used to reduce the pulmonary arterial pressure and improve the symptoms. Her symptoms were improved after 2 weeks, and improved symptoms and reduced pulmonary arterial pressure were sustained for 18 months.