Extension of catheter ablation and outcome for ventricular tachycardia or premature ventricular contractions from the right ventricular outflow tract.

Objective We aimed to determine whether the extension of ablation could influence the ablation outcome for ventricular tachycardia (VT)/premature ventricular contractions (PVCs) from the right ventricular outflow tract (RVOT). Methods and results The radiofrequency catheter ablation results of 33 VT/6 frequent PVCs from the RVOT were analysed. The ablation extension was divided into 3 categories from the final successful ablation point with the earliest activation: (I) focal ablation (15 cases); ablation at 1 or 2 points; (II) focal with extended ablation (12 cases); focal and surrounding area ablation (maximum ≤1 cm) after elimination of clinical VT/PVCs; and (III) broad ablation (12 cases); continued broad ablation (maximum >1 cm) after elimination of clinical VT/PVCs. Acute termination was defined as the complete elimination and non-inducibility of clinical VT/PVCs during the procedure. For the mean follow-up of 12.8 months, the recurrence rate was not significantly different among the groups (P = 0.49). The mean procedure time was longer in group II, but ablation times and complication rates were not different among the groups. When acute termination was achieved, the overall recurrence rate was 7.6%. However, when confirming absence of the clinical VT/PVCs using 24-hour Holter monitoring immediately after the procedure, the recurrence rate was 2.7%. Conclusions Ablation extension did not affect ablation outcome of VT/PVCs from the RVOT. Confirmation of absence of clinical VT/PVCs using 24-hour Holter monitoring immediately after the procedure could guarantee long-term success.

ECG features and proarrhythmic potentials of therapeutic hypothermia.

OBJECTIVE: Hypothermia can induce ECG J waves. Recent studies suggest that J waves may be associated with ventricular fibrillation (VF) in patients with structurally normal hearts. However, little is known about the ECG features, clinical significance or arrhythmogenic potentials of therapeutic hypothermia (TH)-induced J waves. METHODS: We analysed ECGs from 240 patients who underwent TH at six major university hospitals in Korea between August 2010 and December 2013. The prevalence, amplitudes and distributions of the J waves and the development of malignant arrhythmia were analysed. RESULTS: The average patient body temperature was 33.5±1.0°C during TH. J waves were observed in 98 patients (40.8%). They were newly developed in 91 cases, and pre-existing J waves were augmented in seven patients. J waves during TH were primarily observed in leads II, III, aVF and V4-6. The average amplitude of the J waves was 0.239±0.152 mV. There were four VF events during TH. These events occurred in three patients who were finally diagnosed with Brugada syndrome, idiopathic VF or early repolarisation syndrome, respectively, and in one patient with non-cardiac aetiology (asphyxia). CONCLUSIONS: J waves were recorded in about 40% of the patients who received TH. They were most frequently observed in the inferior limb leads or lateral precordial leads. Life-threatening VF occurred only rarely (1.7%) during TH and were mainly observed in patients with primary arrhythmic disorder. Although a causal relationship between TH-induced J waves and VF remains unknown, administering TH to this potentially susceptible, high-risk population may require careful attention.

Impact of Carvedilol versus ß1-selective ß blockers (bisoprolol, metoprolol, and nebivolol) in patients with acute myocardial infarction undergoing percutaneous coronary intervention.

Although ß blocker (BB) has constituted one of the mainstays of evidence-based therapy for patients with acute myocardial infarction (AMI), the comparative efficacy of different BBs remains uncertain. We sought to determine the comparative effectiveness of nonselective BB carvedilol and the most frequently prescribed ß1-selective BBs (bisoprolol, metoprolol, and nebivolol) in patients with AMI undergoing percutaneous coronary intervention (PCI). A total of 7,863 patients were selected from the prospective national AMI registry, and patients were divided into carvedilol group (n = 6,231) and ß1-selective BB group (n = 1,632) at hospital discharge. The primary end point was all-cause death or MI during follow-up. During a mean follow-up of 243 ± 144 days, all-cause death or MI occurred in 94 patients (1.5%) in the carvedilol group versus 31 patients (1.9%) in the ß1-selective BB group (adjusted hazard ratio 0.81, 95% confidence interval 0.54 to 1.22, p = 0.32). This result was consistent across various risk subgroups. The risks of all-cause death, cardiac death, and MI were also similar between the groups. After propensity-score matching, no difference was observed in the rate of all-cause death or MI (1.7% in the carvedilol vs 1.9% in the ß1-selective BB group, adjusted hazard ratio 0.84, 95% confidence interval 0.49 to 1.46, p = 0.55). In conclusion, no differences in the risk of all-cause death or MI were observed between the carvedilol and ß1-selective BB groups in contemporary practice of the treatment for AMI.

Benign Mature Teratoma in Anterior Mediastinum.

Teratoma of mediastinum is rare germ cell tumor. Anterior mediastinum is the most common extragonadal site. Benign mediastinal teratoma accounts for 60% of all mediastinal germ cell tumors. Benign mature teratoma has excellent prognosis after surgical excision. We present a case of 20-year-old woman diagnosed as benign mature teratoma which compressed main pulmonary trunk. The patient underwent surgical excision.

Comparative Effectiveness of Angiotensin II Receptor Blockers Versus Angiotensin-Converting Enzyme Inhibitors Following Contemporary Treatments in Patients with Acute Myocardial Infarction: Results from the Korean Working Group in Myocardial Infarction (KorMI) Registry.

BACKGROUND: There are few data on the comparative effectiveness of angiotensin II receptor blockers (ARBs) and angiotensin-converting enzyme inhibitors (ACEIs) in a broad spectrum of patients with acute myocardial infarction (AMI), undergoing percutaneous coronary intervention (PCI). METHODS: A total of 8574 patients were selected from the prospective AMI registry, the Korean Working Group in Myocardial Infarction (KorMI) Registry, and divided into two groups on the basis of discharge prescription: ARB (n = 2281) or ACEI (n = 6293). The study was also designed using propensity-score matching (1171 patients in the ARB vs. 2752 patients in the ACEI group). The primary outcome was a composite of cardiac death or myocardial infarction (MI) during 1-year follow-up. RESULTS: The Cox model showed both the ARB and ACEI groups had similar risk of cardiac death or MI [adjusted hazard ratio (HR) for ARB 0.69, 95% confidence interval (CI) 0.38-1.25, p = 0.22]. This result was consistent across various risk subgroups, including patients with preserved left ventricular systolic function, or according to the Global Registry of Acute Coronary Events (GRACE) risk scoring system. After propensity-score matching, there was no significant difference in the incidence of cardiac death or MI between the groups (1.3% in the ARB group vs. 1.7% in the ACEI group, adjusted HR for ARB 0.68, 95% CI 0.38-1.23, p = 0.21). The risks of all-cause death, cardiac death, or MI were also similar between groups. CONCLUSIONS: In a broad spectrum of AMI patients with interventional and pharmacologic treatments, the short-term risk of cardiac death or MI was similar between ARB and ACEI groups.

Acquired Large Calcified Unruptured Sinus of Valsalva Aneurysm.

Acquired aneurysms of the sinus of Valsalva are rare. They are caused by infections such as tuberculosis, syphilis and endocarditis, as well as atherosclerosis and traumatic injury. They may be asymptomatic and incidentally discovered. We present a rare case of a large acquired calcified unruptured aneurysm of the right coronary sinus of Valsalva that was compressing the right ventricular outflow tract.

Mechanical extraction of a massive intracoronary thrombus from the super-dominant right coronary artery in thrombogenic lung cancer patient.

The congenital absence of the left circumflex artery and a compensatory super-dominant right coronary artery (RCA) is a very rare benign coronary anomaly in the clinic. The presence of a massive thrombus in the super-dominant RCA can lead to fatal results in cases of acute myocardial infarction, unless the thrombus is mechanically removed. Aspiration of the thrombus using a 6 Fr right Judkins guide catheter is useful to extract a massive thrombus and is both safe and effective. We report a case of complete revascularization of the super-dominant RCA after thrombus aspiration using a 6 Fr Judkins right catheter in a patient with acute inferior and inferolateral wall myocardial infarction.

Veno-veno-arterial ECMO support for acute myocarditis combined with ARDS: a case report.

BACKGROUND: In patients who developed a combined situation of severe acute respiratory distress syndrome with refractory hypoxemia and acute cardiac failure with circulatory collapse, traditional veno-venous or veno-arterial extracorporeal membrane oxygenation approach alone may not be sufficient enough to maintain both an acceptable range of gas exchange and a hemodynamic stability. CASE REPORT: A 27-year-old male patient was suffering from severe acute respiratory distress syndrome caused by community-acquired pneumonia and acute myocarditis with circulatory shock. After mechanical ventilation for respiratory support, he was in a persistently refractory shock state. Veno-veno-arterial mode of extracorporeal membrane oxygenation was thus applied to provide both respiratory and circulatory support simultaneously, with good success. DISCUSSION: Modifying to a veno-veno-arterial mode can be another alternative strategy in a combined situation of refractory respiratory and cardiac failure, thus providing not only respiratory support but also circulatory support. In veno-veno-arterial mode, the returning circuit from the pump was divided with a Y connector into 2 reinfusion circuits; each reinfusion circuit was connected to the contralateral side femoral vein and artery, respectively. The distribution of reinfusion flow was adjusted depending on the patient's cardiopulmonary status. CONCLUSIONS: Although there is no consensus about the veno-veno-arterial mode of extracorporeal membrane oxygenation, this combined mode can be helpful in patients with acute refractory respiratory and cardiac failure, as shown in the present case. We need further experience and improvements in the circuit system used in the veno-veno-arterial mode of ECMO.

Right ventricle inflow obstructing mass proven to be a synovial sarcoma.

Soft tissue sarcoma is the most common malignant cardiac tumor. The chief modes of presentation are embolization, obstruction, and arrhythmogenesis. We describe an unusual case of a 27-year-old man who presented with nausea and dyspnea on exertion. Transthoracic echocardiography and computed tomography revealed a huge mass in the right heart that extended through the inferior vena cava and right renal vein to the right kidney. The cardiac mass was resected, and an immunohistochemical analysis revealed it to be a TLE1-positive synovial sarcoma. After surgery, the patient received serial adjuvant chemotherapy. We herein describe the case with a brief review.

Spironolactone lowers the rate of repeat revascularization in acute myocardial infarction patients treated with percutaneous coronary intervention.

BACKGROUND: We sought to assess the effect of the aldosterone receptor blocker, spironolactone, on 1-year clinical outcomes in all-comers with acute myocardial infarction (AMI) undergoing percutaneous coronary intervention. METHODS: A total of 10,309 AMI patients were recruited between November 2005 and April 2008 from a nationwide AMI registry in Korea. Patients were divided into 2 groups: those treated with spironolactone (n = 720; 7.0%) and those who had not been treated at discharge. The primary end point was major adverse cardiac events (MACEs), defined as the composite of death from any cause, recurrent AMI, or repeat revascularization at 1 year after admission. RESULTS: The spironolactone group had a greater number of comorbidities than the nonspironolactone group. There was no significant association between the spironolactone treatment and MACE at 1 year (adjusted hazard ratio [HR] 0.95, 95% confidence interval 0.72-1.24, P = .69) in the overall population. The risks of death from any cause, cardiac death, and recurrent AMI were also similar between the groups. However, patients who received spironolactone had a lower risk of repeat revascularization than did those who did not receive spironolactone (adjusted HR 0.58, 95% CI 0.39-0.86, P = .007). Of guideline-eligible patients (n = 821/10,309; 8.0%), 170 (20.7%) of 821 patients received a spironolactone at hospital discharge. When limited to the guideline-eligible patients' population, a statistical trend toward lower MACE was observed in patients treated with spironolactone (14.3% vs 13.7%, adjusted HR 0.63, 95% CI 0.37-1.10, P = .10). CONCLUSIONS: All-comer AMI patients undergoing percutaneous coronary intervention who received spironolactone had a lower risk of repeat revascularization. Randomized trials are needed.

Congenital partial defect of the left pericardium presenting as chest pain.

Congenital pericardial defect is a rare cardiac defect with variable clinical presentations. It is usually an unexpected finding during cardiac surgery or autopsy. The clinical detection of congenital absence of pericardium is important because of its life-threatening complications such as fatal myocardial strangulation, myocardial ischaemia and sudden death. We present a patient with the incidental finding of left-sided partial defect of the pericardium during evaluation of chest pain.

A large pericardial cyst compressing the left atrium presenting as a pericardiopleural efussion.

Pericardial cysts are rare congenital abnormalities with a reported incidence rate of 1:100,000, accounting for about 7.6% of all mediastinal masses. These cysts frequently occur in the right cardiophrenic angle and their diagnosis is usually suspected after an abnormal chest X-ray is obtained. Herein, we present a case of pericardial cyst compressing the left atrium complicated by a pericardial effusion and pleural effusion in a 62 year-old man with chest discomfort and dyspnoea. After the pericardial cyst was surgically removed, the histopathological examination revealed an inflamed pericardial cyst lined with mesothelial cells.

Acute myocardial infarction caused by coronary embolism from Aspergillus endocarditis.

Although the primary cause of acute coronary syndrome is atherosclerotic disease, it is important to include other causes of acute myocardial infarction. This report describes the case of a 53-year-old man with acute myeloid leukemia, who was referred to our cardiology department for treatment of acute myocardial infarction with ST segment elevation on an electrocardiogram. Portable echocardiography showed large areas of vegetation on the anterior mitral leaflet, while coronary angiography demonstrated the total occlusion of the left anterior descending artery. A histologic examination of the embolectomy specimen confirmed the presence of Aspergillus fungal thrombi. This report highlights a rare case of fatal Aspergillus endocarditis with myocardial infarction due to embolism in an immunosuppressed patient.

Multiple papillary fibroelastomas and thrombus in the left heart.

Cardiac papillary fibroelastomas (CPF) are benign cardiac tumors and usually discovered incidentally during echocardiography. This report describes the case of a 68-year-old man, referred to cardiology for multiple masses of the left ventricle and left atrium. The transthoracic echocardiography revealed multiple oscillating masses in the left ventricle and aortic valve, non-mobile mass in the left atrium with severe mitral stenosis and moderate aortic regurgitation. The patient underwent surgical resection of the masses with valve replacements. Histopathologic examination confirmed the diagnosis of CPF in the left ventricle and aortic valve, thrombus in the left atrium.

Comparison of the axillary venous approach and subclavian venous approach for efficacy of permanent pacemaker implantation. 8-Year follow-up results.

BACKGROUND: Long-term data on lead complication rates are limited for both the axillary and subclavian venous approaches for permanent pacemaker implantation. METHODS AND RESULTS: We conducted a single-center, retrospective, nonrandomized comparison. We reviewed the patients who had consented to receiving a permanent pacemaker implant. A superficial landmark or radiographic contrast guiding was used for the axillary venous approach, whereas conventional landmarks were used for the subclavian venous approach. From January 1992 to December 2005, we analyzed 1,161 permanent pacemaker leads in 655 patients [subclavian venous approach (group I: 338 patients, 542 leads) and axillary venous approach (group II: 317 patients, 619 leads)]. Baseline characteristics of the patients did not differ. However, DDD-pacemakers and atrial leads were used more often in group II than in group I (94% vs. 62% and 49% vs. 40%, P<0.01). During the 8-year follow-up, lead complication rates were lower in group II (17 leads, 3%) than in group I (31 leads, 6%) (P=0.03), and group II had a better complication-free survival curve than group I with a 49% relative risk reduction in lead complication rates (hazard ratio =0.51; 95% confidence interval, 0.27-0.94; P=0.03). CONCLUSIONS: The axillary venous approach for permanent pacemaker implantation has better long-term efficacy and lower lead complication rates than the subclavian venous approach.

Coronary-pulmonary artery fistula-multiple diagnostic imaging modalities.

Coronary artery fistula is rare anomalies. Most adult patients are usually asymptomatic. A fistula is incidentally identified in the adult using echocardiography. Coronary angiography is considered the standard tool to confirm a coronary artery fistula. However, multidetector computed tomography (MDCT) angiography is considered a good alternative to coronary angiography.

Low pressure pulmonary artery aneurysm with atrial septal defect.

Pulmonary artery (PA) aneurysm is a rare finding in the thoracic cavity, accompanied by pulmonary hypertension. Clinical presentation of PA aneurysms is usually asymptomatic. The guideline for PA aneurysm treatment is unclear. We report an unusual case of low pressure PA aneurysm associated with atrial septal defect in a 69-year-old man.

Multiple feeding vessels from left circumflex artery and right coronary artery to myxoma in left atrium.

A 62-year-old woman with six months history of dizziness was admitted to our hospital. A large mass in the left atrium was detected by transthoracic echocardiography. Coronary angiography showed two feeding arteries from the right coronary artery and left circumflex artery to the left atrium. Chest computed tomography, coronary computed tomographic angiography and contrast echocardiography were performed. Those showed multiple intratumoral neovascularities from surface of the mass. After those examinations, the mass was completely resected. Histopathologic examination confirmed the diagnosis of cardiac myxoma. There was no abnormal remnant mass, based on a follow-up transthoracic echocardiography.