Antithrombotic or Anti-Platelet Agents in Patients Undergoing Permanent Pacemaker Implantation

BACKGROUND AND OBJECTIVES: The growing implantations of electrophysiological devices in the context of increasing rates of chronic antithrombotic therapy in cardiovascular disease patients underscore the importance of an effective periprocedural prophylactic strategy for prevention of bleeding complications. We assessed the risk of significant bleeding complications in patients receiving anti-platelet agents or anticoagulants at the time of permanent pacemaker (PPM) implantation. SUBJECTS AND METHODS: We reviewed bleeding complications in patients undergoing PPM implantation. The use of aspirin or clopidogrel was defined as having taking drugs within 5 days of the procedure and warfarin was changed to heparin before the procedure. A significant bleeding complication was defined as a bleeding incident requiring pocket exploration or blood transfusion. RESULTS: Permanent pacemaker implantations were performed in 164 men and 96 women. The mean patient age was 73+/-11 years old. Among the 260 patients, 14 patients took warfarin (in all of them, warfarin was changed to heparin at least 3 days before procedure), 54 patients took aspirin, 4 patients took clopidogrel, and 25 patients took both. Significant bleeding complications occurred in 8 patients (3.1%), all of them were patients with heparin bridging (p<0.0001). Heparin bridging markedly increased the length of required hospital stay when compare with other groups and the 4 patients (1.5%) that underwent the pocket revision for treatment of hematoma. CONCLUSION: This study suggests that hematoma formation after PPM implantation was rare, even among those who had taken the anti-platelet agents. The significant bleeding complications frequently occurred in patients with heparin bridging therapy. Therefore, heparin bridging therapy was deemed as high risk for significant bleeding complication in PPM implantation.

Progressive Familial Heart Block Type I in a Korean Patient

A 29-year-old man was referred to the emergency department with a complaint of abdominal pain and dizziness. He had experienced two previous syncopal episodes. His family history revealed that his mother and his two uncles had received permanent pacemaker implantation. His initial heart rate was 49 beats per minute. The electrocardiography (ECG) showed atrial flutter and right bundle branch block (RBBB) with left anterior fascicular block (LAFB). On admission, 24-hour Holter showed ventricular pause up to 16 seconds during syncope. Radio frequency catheter ablation (RFCA) of atrial flutter was performed. The ECG revealed bifascicular block (RBBB and LAFB) and first-degree atrioventricular block. He received a permanent pacemaker implantation. His brother's and his sister's ECGs also showed trifascicular block and the pedigree showed autosomal dominant inheritance. This patient was diagnosed with a progressive familial heart block (PFHB) type I. This would be the first report of a PFHB type I case documented in Korea.

Assessment of Left Ventricular Function by Analysis of Volume-Time Curves of 16 Segments with Real-Time Three Dimensional Echocardiography : Left Ventricular Asynchrony as a Clinical Parameter for Patients with Heart Failure

BACKGROUND AND OBJECTIVES : Recent technical developments with high-resolution real-time 3-dimensional echocardiography (RT3DE) have facilitated the acquisition of high quality images and the analysis of segmental volume-time curves (VTCs). The purposes of this study were to assess left ventricular (LV) asynchrony with using the VTCs of 16 segments by RT3DE and to compare this with tissue Doppler imaging (TDI) as a clinical parameter. SUBJECTS AND METHODS : Twenty-three heart failure (HF) patients (LVEF: 25+/-6%, age: 60+/-13 years) and 16 normal controls underwent TDI and RT3DE at baseline and 1-year. The standard deviation (SD3) of the end systolic time to reach the minimal systolic volume for the 16 segments on VTCs was obtained by RT3DE. The standard deviation (SD2) of the electromechanical coupling time for the 8 segments was measured using TDI. RESULTS : SD3 was markedly higher in the HF patients than that in the controls (7.7+/-2.5 vs 1.5+/-1.0%, respectively, p<0.01) and it increased as the LVEF decreased (r=-0.85, p<0.01). SD2 was also significantly higher in the HF patients (27.0+/-8.6 vs 12.6+/-5.0 msec, respectively, p<0.01) and it had good negative correlation with the LVEF (r=-0.72, p<0.01). SD3 was well correlated with SD2 (r=0.66, p<0.01). At 1-year, the HF patients with an increased LVEF showed a decreased SD3 (7/13). In contrast, the patients with a decreased LVEF had an increased SD3 (3/13). CONCLUSION : The analysis of VTCs for the 16 LV segments with using RT3DE from a single acoustic window may be a useful clinical parameter for evaluating the LV function, including LV asynchrony, the LV volume and the LVEF.

Comparison Study between Dobutamine Stress Echocardiography Using Real-Time Three Dimensional and Two Dimensional Echocardiography for Diagnosis of Coronary Artery Disease : Dobutamine Stress Echocardiography Using Real-Time Three Dimensional Echocardiogr

BACKGROUND AND OBJECTIVES: Dobutamine stress echocardiography (DSE) with 2D echocardiography (2DE) is one of the time-consuming procedures in the diagnosis of coronary artery disease (CAD). Moreover, the accuracy of DSE with 2DE depends on the operator's skill or bias during the image acquisition. This study was conducted to determine the feasibility and accuracy of DSE with real-time 3D echocardiography (RT3DE) for the diagnosis of CAD. SUBJECT AND METHODS: 62 patients (RT3DE: 36, 2DE: 26), suspected of angina pectoris and post-revascularization ischemia, underwent DSE and coronary angiography (CAG). Image acquisition was performed at the baseline, and at 4 times during the dobutamine infusion and recovery stages. The procedure time (from the baseline to the end of the peak dose stage) was recorded. Off-line analyses of the volumetric images acquired with RT3DE were performed using 3D computer software (TomTec, Co.). Digitized quad-screen images acquired with 2DE were analyzed using the 2DE review system (ProSolv 4.0). >50% luminal diameter stenosis of any coronary artery on CAG was defined as significant coronary artery stenosis. RESULTS: The procedure time of DSE with RT3DE was significantly shorter than that of DSE with 2DE (25+/-4 vs. 37+/-4 mins, p0.05) or specificity (p>0.05) between the two procedures. CONCLUSION: DSE with RT3DE seems to be a feasible and less time consuming diagnostic procedure, probably providing comparable sensitivity and specificity for the detection of coronary artery stenosis, than DSE with 2DE.

The Role of P Wave from Surface Electrocardiography for the Prediction of Atrial Fibrillation after Coronary Artery Bypass Graft Surgery

BACKGROUND AND OBJECTIVES: Atrial fibrillation (AF) is a common arrhythmia that develops after coronary artery bypass graft surgery (CABG), and contributes to the morbidity and prolonged length of hospital day associated with the procedure. The purpose of this study was to determine predictors of AF after CABG. SUBJECTS AND METHODS: One hundred and twelve (112) patients (mean age 59+/-10, male 64, female 48), who underwent isolated CABG at one institution, were enrolled. The patients' clinical characteristics, medications, electrocardiogram (ECG), echocardiogram and coronary angiogram were reviewed retrospectively. We measured the P wave duration and dispersion, and the PR interval from 12-lead surface ECG in each patient. Documentation of AF after the CABG was obtained from ECG monitoring in the coronary care unit and those taken after the CABG. Logistic regression analysis was performed, and the discriminatory values of the parameters compared by receiver operating characteristic (ROC) curves. RESULTS: AF developed in thirty-three patients (29.5%) after the CABG. Multivariable predictors were dichotomized on the basis of their variable distribution. A maximal P wave duration > or =110 msec (p or =58 years (p=0.023, sensitivity 94%, specificity 54%) were considered significant predictors of AF after CABG. CONCLUSION: This study has demonstrated that AF after CABG can be predicted preoperatively from a prolonged maximal P wave duration on preoperative ECG and a patient's old age.

A Case of Extensive Ventricular Wall Rupture from the Posterior Wall to the Ventricular Septum after Acute Myocardial Infarction Demonstrated by Real-Time 3D Echocardiography

2D echocardiography (2DE) is a well established tool for the diagnosis of the mechanical complications after acute myocardial infarction (AMI) such as free wall and ventricular septal rupture. However, the extension of the rupture and the relationship with contiguous anatomic structures may not be clearly defined by 2DE. Real-time 3D echocardiography (RT3DE) is known to provide surgical enface view allowing complete visualization of the cardiac structures and comprehension of their spatial orientations to other anatomic structures. Obtaining such information with RT3DE before operation in AMI patient with mechanical complication may be essential for the optimal surgical treatment. We report a case of extensive ventricular wall rupture from the posterior wall to the ventricular septum after AMI demonstrated by RT3DE.

A case of coronary artery true aneurysm developed after stent implantation / 대한내과학회지

Coronary aneurysm is a rare disorder, defined as a abnormal dilatation that exceeds 1.5 times the diameter of the adjacent segment of artery. Percutaneous transluminal coronary angioplasty is often associated with a coronary aneurysm and mechanical injury of vessel wall during the procedure is suspected as the cause. The reported incidence of coronary aneurysms in Caucasians was 4.9%, but the incidence in Asian population was 0.25%. Morphologically, aneurysms can be divided into true versus pseudo aneurysms. These differentiation by intravascular (interventional) ultrasound is important to predict prognosis of the coronary aneurysm. We experienced a case of coronary artery true aneurysm, that developed after coronary balloon angioplasty and stent implantation. So we report the case.

A Case of Left Atrial Myxoma Presenting with Myocardial Infarction

Coronary artery embolization is an extremely rare and potentially lethal complication of atrial myxomas. We observed of a case of left atrial myxoma associated with acute anteroseptal and inferior myocardial infarction. A transthoracic echocardiographic study revealed the presence of an echogenic, mobile mass, compatible with myxoma in the left atrium. Coronary angiography disclosed abrupt occlusions of the distal left anterior descending artery and the right coronary artery. The tumor was successfully removed surgically after medical treatment and the patient was doing well post operatively at 6-month follow-up.

Usefulness of Endoscopic Mucosal Resection for Curative Treatment of Early Gastric Cancer / 대한소화기학회지

BACKGROUND/AIMS: Endoscopic mucosal resection (EMR) has been widely accepted as a curative treatment of early gastric cancer (EGC). The aim of this study was to determine the usefulness and limitations of EMR for treatment of EGC by analyzing our own experience. METHODS: We retrospectively evaluated 51 EGC lesions (45 mucosal and 6 submucosal cancers) from 49 patients who had undergone EMR between Oct. 1997 and Aug. 2002 at Inha Universtiy Hospital. RESULTS: Among 45 lesions of mucosal cancer, enbloc resection was performed in 13 lesions and piecemeal resection in 32 lesions. Complete resection rates of enbloc and piecemeal resection were 84.6% and 43.8%, respectively (p=0.012). Complete resection rate of the lesions smaller than 1 cm in size was 71.4%, 1 to 2 cm in size 52%, and greazter than 2 cm in size 37.5%. Complete resection rates of well, moderately, and poorly differentiated EGC were 59.4%, 71.4%, and 16.7%, respectively (p=0.048). Thirty-three patients underwent a follow-up endoscopy at I month after EMR and two were found to have residual cancers. One patient who had a piecemeal EMR showed cerical and abdominal lymph node metastasis 10 months after EMR. CONCLUSIONS: In selected patients with EGC, EMR can be a curative treatment modality. However, complete resection rate is low in large sized and poorly differentiated EGCs and when piecemeal resection is performed.

Relation of the Lesion Length and Eccentricity to the Fractional Flow Reserve

BACKGROUND AND OBJECTIVE: Fractional flow reserve (FFR) has emerged as an easily obtainable, and accurate, lesion-specific parameters for the physiological evaluation of coronary artery stenosis. However, the effects of the lesion length and eccentricity on the FFR remain unclear. Therefore, the relationship between the lesion length and eccentricity to the FFR, and the lesion length to the degree of stenosis were studied to see if there was any significant influence on the trans-stenotic pressure gradients and the FFR. SUBJECTS AND METHODS: Intravascular ultrasound (IVUS) was performed and the FFR measured in 19 lesions, ranging from 80 to 90% in area stenosis (AST), using a pressure wire. The eccentric index at the most stenotic site, and the length of the coronary stenosis lesion, above 50 and 70% of the AST, at the most stenotic site were obtained using IVUS. The FFR was defined by the ratio of distal mean coronary pressure (Pd) to that of the aortic mean pressure (Pa) under hyperemia. RESULTS: The FFR showed no correlation with the eccentricity or the length of the stenosis lesions when they were more than 50% of the AST (p>0.05). However, the FFR showed a significant correlation with the length of the most stenotic lesions (r=-0.79, p<0.001) and the lesions with an AST of more than 70% (r=-0.47, p<0.05). The hyperemic pressure gradient across the lesion showed a significant correlation with the length of the lesion, but only to those with the most severe portion of stenosis (r=0.64, p=0.003). CONCLUSION: In the functional evaluation of coronary stenosis, the length of the most stenotic lesions, as well as the cross sectional area and minimal lumen area at the most stenotic lesion, should be considered, as this study has shown that the length of the most severe stenotic lesion could influence the FFR and trans-stenotic pressure gradients.

A Case of Massive Bleeding in Jejunal Tuberculosis Treated by Transcatheter Embolization / 대한소화기내시경학회지

Common complications of the intestinal tuberculosis are perforation, obstruction, fistulas, and malabsorption. Massive gastrointestinal bleeding is an extremely rare complication of intestinal tuberculosis. Moreover, this may be the first report in the world on transcatheter arterial embolization against the massive bleeding from intestinal tuberculosis patient. We experienced a case of lower gastrointestinal bleeding due to extensive intestinal tuberculosis as massive as vital sign was unstable. Colonoscopy and esophagogastroduodenoscopy did not reveal bleeding focus. Active jejunal bleeding was suspected by technetium99m labelled RBC scintigraphy. Emergency superior mesenteric artery angiography showed active bleeding focus from jejunal branch of artery and transcatheter arterial embolization was tried with microcoil. After embolization, he had no more hematochezia and vital sign became stabilized. On third hospital day, upper endoscopy was done using pediatric colonoscopy and there were multiple circular ulcers on the proximal jejunum but no evidence of mesenteric ischemia. Small bowel tuberculosis should be suspected as a cause of lower gastrointestinal bleeding in case of negative colonoscopy and upper endoscopy. We suggest that the transcatheter embolization could be taken into consideration as a first-line method of treatment for massive bleeding from intestinal tuberculosis before surgical resection.

A Case of Bacterial Aortitis with Splenic Abscess by E.coli

Bacterial aortitis is a rare, but fatal, infectious disease underlying an atherosclerotic aorta or normal aortic wall in an immunocompromised host. The commonly identified organisms responsible for the condition are Salmonella, Staphylococcus and Streptococcus, and on rare occasions, E.coli. We report a case of a 57-year-old man with bacterial aortitis and a splenic abscess caused by E.coli, which was successfully treated by periaortic debridement, prosthetic graft replacement, splenectomy and antibiotic therapy.