Cilostazol Protects Endothelial Cells Against Lipopolysaccharide-Induced Apoptosis Through ERK1/2- and P38 MAPK-Dependent Pathways

BACKGROUND/AIMS: We examined the effects of cilostazol on mitogen-activated protein kinase (MAPK) activity and its relationship with cilostazol-mediated protection against apoptosis in lipopolysaccharide (LPS)-treated endothelial cells. METHODS: Human umbilical vein endothelial cells (HUVECs) were exposed to LPS and cilostazol with and without specific inhibitors of MAPKs; changes in MAPK activity in association with cell viability and apoptotic signaling were investigated. RESULTS: Cilostazol protected HUVECs against LPS-induced apoptosis by suppressing the mitochondrial permeability transition, cytosolic release of cytochrome c, and subsequent activation of caspases, stimulating extracellullar signal-regulated kinase (ERK1/2) and p38 MAPK signaling, and increasing phosphorylated cAMPresponsive element-binding protein (CREB) and Bcl-2 expression, while suppressing Bax expression. These cilostazol-mediated cellular events were effectively blocked by MAPK/ERK kinase (MEK1/2) and p38 MAPK inhibitors. CONCLUSIONS: Cilostazol protects HUVECs against LPS-induced apoptosis by suppressing mitochondriadependent apoptotic signaling. Activation of ERK1/2 and p38 MAPKs, and subsequent stimulation of CREB phosphorylation and Bcl-2 expression, may be responsible for the cellular signaling mechanism of cilostazolmediated protection.

Losartan/Hydrochlorothiazide Fixed Combination Versus Amlodipine Monotherapy in Korean Patients With Mild to Moderate Hypertension

BACKGROUND AND OBJECTIVES: The antihypertensive efficacy and tolerability of losartan (LST) in fixed combination with hydrochlorothiazide (HCTZ) has not been compared to those of amlodipine monotherapy in Asians. This is an important comparison to draw, because Asians have been suggested to respond more favorably to calcium channel blockers and less favorably to angiotensin-converting enzyme inhibitors in comparison to Westerners. We sought to compare these two regimens in Korean patients with mild to moderate hypertension. SUBJECTS AND METHODS: 174 patients were randomized to receive LST 50 mg once daily, which could be titrated to LST/HCTZ 50/12.5 mg at 4 weeks, followed by 100/25 mg at 8 weeks; or to receive amlodipine besylate 2.5 mg once daily, which could be titrated to 5 mg at 4 weeks, followed by 10 mg at 8 weeks to achieve diastolic blood pressure <90 mmHg. RESULTS: At 12 weeks, the differences between the LST/HCTZ and amlodipine groups with regard to diastolic and systolic blood pressure were 1.2 mmHg (95% confidence interval: -1.1 to 3.4) and -0.5 mmHg (95% confidence interval: -4.3 to 3.4), respectively. The rates of achieving systolic blood pressure <140 mmHg were 66.7% in the LST/HCTZ group and 75.9% in the amlodipine group (p=0.20). The rates of drug-related adverse events were 15.6% in the LST/HCTZ group and 11.9% in the amlodipine group (p=0.49). CONCLUSION: The two regimens, with a relatively higher dose of LST/HCTZ compared to that required in Westerners, produced equivalent blood pressure reduction and were comparably well tolerated in Korean patients with mild to moderate hypertension.

Two cases of acute fulminant myocarditis supported by extracorporeal membrane oxygenation / 대한내과학회지

Myocarditis is defined as inflammation of the myocardium caused by viral, richettsial, bacterial, or protozoal infection, or drug toxicity. The clinical course of patients with myocarditis varies from subclinical disease to fulminant myocarditis (FM). FM occurs rapidly and causes heart failure or lethal arrhythmia, often leading to death by cardiogenic shock due to severe left ventricular dysfunction. For some critical patients who have difficulty maintaining hemodynamic status, percutaneous cardiopulmonary support, extracorporeal membrane oxygenation (ECMO), and/or a mechanical ventricular assist device are available alternative choices. Here we report cases of patients with FM who were treated using ECMO during the acute stages of the illness.

Orthodromic Atrioventricular Reentrant Tachycardia Masquerading as Atrial Fibrillation

No abstract available.

Q waves in congenitally corrected transposition of the great arteries / 대한내과학회지

No abstract available.

Coronary Artery-Right Ventricular Fistulae After an Acute ST Segment Elevation Myocardial Infarction

No abstract available.

Marked QT prolongation and T inversion in a patient with acute pulmonary thromboembolism / 대한내과학회지

No abstract available.

Severe Stenosis of the Left Main Coronary Artery Detected on Electrophysiologic Study

A cardiac electrophysiologic study (EPS) is a safe procedure with a low complication rate. We report here a case of severe stenosis of the left main coronary artery (LMCA) that was incidentally detected during an EPS; this was successfully managed by stenting the LMCA. The patient was a 75-year-old man with recurrent chest fluttering and no previous angina underwent EPS and he developed acute ischemic chest pain due to induced atrial fibrillation. The coronary angiography showed a critical stenosis in the distal LMCA. The patient underwent percutaneous coronary intervention with a sirolimus-eluting stent in the LMCA. The patient has remained asymptomatic during a 1-year follow-up period. To prevent potentially catastrophic complications, performing a stress myocardial imaging test should be strongly considered before conducting EPS in elderly patients.

A Case of Late Recurrent Vasospasm After Sirolimus-Eluting Stent Implantation

A 67-year-old male with stable angina was admitted to our cardiovascular center. He had neither any history of smoking, diabetes mellitus, hypertension, cerebrovascular accident nor family history of coronary artery disease. Coronary angiography showed a 90% tubular eccentric luminal narrowing at the mid left anterior descending artery (m-LAD). A sirolimus-eluting stent (SES) was implanted in the m-LAD. Coronary angiography performed after 9 months did not reveal restenosis or recurrent coronary artery disease. However, the patient returned to the emergency room with severe chest pain after 17 months. Coronary angiography showed severe diffuse vasospasm distal to the m-LAD stent site. After 20 days, vasospastic myocardial infarction developed. A zotarolimus-eluting stent with a phosphorylcholine polymer was implanted distal to the m-LAD stent. The zotarolimus-eluting stent was used because the polymer in the SES or sirolimus was considered a possible cause for the recurrent vasospasm. The patient had no further chest pain during the 9 months after zotarolimus-eluting stent implantation. We suspect that the polymer in the SES or sirolimus might have caused endothelial dysfunction and provoked the late vasospasm. Here, we describe this case of late recurrent vasospasm after SES implantation.

Electrical Storm Late after Surgery for a Double-Chambered Right Ventricle, Aortic Regurgitation and a Ventricular Septal Defect: A Case of Successful Catheter Ablation

An electrical storm is defined as multiple occurrences of ventricular tachycardia/fibrillation (VT/VF) within a single day; this is a medical emergency and a poor prognostic marker in patients with an implantable cardioverter-defibrillator (ICD). We report here on the occurrence of electrical storms in a 35-year-old man with a repaired DCRV and ICD. He had recurrent VT and electrical storms that were refractory to amiodarone and beta-blocker. A cardiac electrophysiologic study was performed 11 months after the ICD was implanted and two forms of VT were induced. After the catheter ablation of the VTs, the monomorphic VT became non-inducible. The frequency of the VT decreased from 35 per month before the catheter ablation to 1.1 times per month after the procedure. Catheter ablation of VT could be an effective treatment for patients with electrical storms refractory to antiarrhythmic drugs.

Simultaneous acute myocardial infarction in two coronary arteries / 대한내과학회지

The simultaneous presentation of acute myocardial infarction (AMI) in the right and left coronary arteriesis rare. Diabetes mellitus (DM), thrombus due to multivessel spasm, AMI with hypercoagulation,and hypoperfusion of other coronary arteries after an AMI may cause the simultaneous occurrence of right and left coronary artery infarctions. If emergency coronary revascularization (percutaneous coronary intervention, thrombolysis, and coronary artery bypass surgery) is not performed immediately, the mortality rate is very high due to the development of cardiogenic shock and ventricular arrhythmia. Here, we report a number of cases involving the simultaneous development of AMIin two coronary arteries and discuss the importance of rapid revascularization.

Synergistic Efficacy of Concurrent Treatment with Cilostazol and Probucol on the Suppression of Reactive Oxygen Species and Inflammatory Markers in Cultured Human Coronary Artery Endothelial Cells

In the present study, we aimed to identify the synergistic effects of concurrent treatment of low concentrations of cilostazol and probucol to inhibit the oxidative stress with suppression of inflammatory markers in the cultured human coronary artery endothelial cells (HCAECs). Combination of cilostazol (0.3~3micrometer) with probucol (0.03~0.3micrometer) significantly suppressed TNF-alpha-stimulated NAD(P)H-dependent superoxide, lipopolysaccharide (LPS)-induced intracellular reactive oxygen species (ROS) production and TNF-alpha release in comparison with probucol or cilostazol alone. The combination of cilostazol (0.3~3micrometer) with probucol (0.1~0.3micrometer) inhibited the expression of vascular cell adhesion molecule-1 (VCAM-1) and monocyte chemoattractant protein-1 (MCP-1) more significantly than did the monotherapy with either probucol or cilostazol. In line with these results, combination therapy significantly suppressed monocyte adhesion to endothelial cells. Taken together, it is suggested that the synergistic effectiveness of the combination therapy with cilostazol and probucol may provide a beneficial therapeutic window in preventing atherosclerosis and protecting from cerebral ischemic injury.

Two Cases of an Implantation of a Permanent Pacemaker Using a Transaxillary Incision

In surgeries that require the implantation of a pacemaker, the endocardial pacemaker leads are introduced into the cardiac chambers through subclavian or axillary venous catheterization or cephalic vein cutdown. The drawback of this type of surgery is scarring of the pectoral area, which can be a serious cosmetic problem especially for young women. In this study, we report on 2 cases where a permanent pacemaker in two young women with symptomatic bradycardia was implanted using a transaxillary incision. Both patients successfully recovered with no complications and were asymptomatic for more than 17 months after the procedure. Therefore, we found that implantation of a pacemaker via transaxillary incision provided excellent cosmetic results and should be considered in young women that require this type of surgery.

The Effect of Intra-coronary Nicorandil Prior to Reperfusion in Acute ST Segment Elevation Myocardial Infarction

BACKGROUND AND OBJECTIVES: Intravenous nicorandil infusion with percutaneous coronary intervention (PCI) has been reported to reduce reperfusion injury events and to improve cardiac function in patients with an acute myocardial infarction. However, there is limited information on the use of intra-coronary nicorandil. A prospective randomized single center study was designed to evaluate the efficacy of the use of intra-coronary nicorandil. SUBJECTS AND METHODS: Seventy-three patients with an acute ST segment elevation myocardial infarction were randomly assigned to the nicorandil group (n=37) or a control group (n=36); all patients received a PCI. In the nicorandil group of patients, 4 mg of intra-coronary nicorandil was infused directly into the infarct area prior to reperfusion (2 mg before ballooning, 2 mg before stenting). The composite endpoint was the incidence of ventricular arrhythmia, no-reflow and slow flow. We estimated the post thrombolysis in myocardial infarction (TIMI) grade, the myocardial perfusion grade after PCI and the short-term clinical outcome. RESULTS: The baseline characteristics were similar in both groups of patients. A significant difference was observed in the composite endpoint in the nicorandil group of patients as compared to the control group of patients (p=0.037). The achievement rate of post TIMI grade 3 was significantly higher in the nicorandil group of patients (p=0.019). The myocardial perfusion grade 1 was not observed in the nicorandil group of patients; however, it was observed in five patients in the control group (p=0.019). Major adverse cardiac events in hospital and in 30 days were similar between the two groups. CONCLUSION: Intra-coronary nicorandil infusion reduced the occurrence of no-reflow, slow reflow, reperfusion arrhythmia and improved the myocardial perfusion grade and TIMI flow during PCI. The results of this study showed that the use of intracoronary nicorandil improved the clinical outcome in patients with an acute myocardial infarction.

A Safety and Effectiveness of High Pressure Balloon Dilatation for Sirolimus-Eluting Stent Implantation in the Ischemic Heart Disease

BACKGROUND: We have no information about the safety and effectiveness when we perform overdilating a sirolimuseluting stent(SES) with high pressure. In some specific animal model, the study reported overdilatation of SES with high pressure resulted in increase of restenosis. The aim of this study was to evaluate the safety and effectiveness of overdilatation of SES with high pressure. METHODS: 97 patients underwent PCI using SES between August 2003 and July 2005 were divided into two group(high pressure group, low pressure group), stents were implanted with high pressure(>18 atm) and low pressure(<12 atm). We compared between the two group of safety of stents, major adverse cardiac events(MACE), rate of restenosis, late loss. RESULTS: In high pressure group, there are more type C lesion(51% vs 38%, p<0.01). There were no significant differences between the two groups regarding MACE(12.8% vs 17.2%, p=0.78), in-stent restenosis rate(2.6 % vs 5.2%, p=0.65). There are small increasing of late loss in high pressure group, but no statistically significant difference(0.30 vs 0.15, p=0.05). CONCLUSION: Implantation of SES overdilated with high pressure is able to be performed safely to obtain wider inner lumen of stents.

Angioplasty for Difficult Complex Lesions With Using the Venture(TM) Catheter for Wire Placement

We report here on the use of the Venture(TM) catheter to facilitate successful advancement of a guidewire across difficult, complex lesions after the prior attempts at guide wire passage were unsuccessful with using standard wires. This Venture(TM) catheter may increase the success rate and reduce the procedural time for such a challenging interventional procedure.

Prognosis According to the Timing of Percutaneous Coronary Intervention in an Acute Non-ST Segment Elevation Myocardial Infarction

BACKGROUND AND OBJECTIVES: An early invasive strategy with coronary angiography and revascularization is currently the recommended treatment for patients at high risk with an acute non-ST-segment elevation myocardial infarction (NSTEMI). In this early invasive strategy, percutaneous coronary intervention (PCI) is generally recommended within 48 hours, but there is little data on earlier intervention in intermediate risk patients. SUBJECTS AND METHODS: We studied retrospectively the past medical records of 118 patients at intermediate risk that were admitted at Pusan National University Hospital and were stratified by the time interval from chest pain onset to PCI (Group I: 48 h). Clinical outcomes were evaluated in terms of in-hospital and 12 months follow-up of a major adverse cardiac event (MACE). RESULTS: Baseline characteristics were not different statistically among the three groups, except for the use of tirofiban. There were no in-hospital deaths or myocardial infarctions (MI) in Group I and Group II patients, but there were three cases of in-hospital deaths in Group III patients. The incidence of a 12-month MACE was 0% in Group I patients, 6.7% (one revascularization) in Group II patients and 17.1% (3 deaths, 3 MIs, 7 revascularizations) in Group III patients (p=0.043). CONCLUSION: In acute NSTEMI, the incidence of a 12-month MACE was lower in the intermediate risk group when PCI was performed in the early period. Early PCI could be recommended in acute NSTEMI on the basis of the status of individual patients.

Impact of Drug-Eluting Stents on Clinical Outcomes in Patients With Diffuse Coronary Lesions

BACKGROUND AND OBJECTIVES: In the era of stents, lesion length remains an important predictor of restenosis. Drug-eluting stents (DESs) have significantly reduced in-stent restenosis (ISR), but results in long lesions are still lacking. Therefore, we investigated the impact of DESs on clinical outcomes in patients with diffuse coronary lesions. SUBJECTS AND METHODS: Between January 2004 and January 2005, 80 patients (94 lesions) with lesions >20 mm in length were treated with one or more DESs and underwent follow-up coronary angiography. The patients were divided into three groups: Group 1 was composed of those with lesions 21 to 35 mm in length, Group 2 was composed of those with lesions 36 to 50 mm in length, and Group 3 was composed of those with lesions > or =51 mm in length. RESULTS: The mean clinical follow-up duration was 9 months. On the 6-month follow-up angiogram, 6.4% of the lesions had binary ISR (5.0% in group 1, 8.7% in group 2, and 9.1% in group 3). The percent diameter stenosis was 6.0+/-18.15% in Group 1, 12.61+/-21.99% in Group 2, and 19.81+/-31.26% in Group 3(p< 0.05). Late lumen loss was 0.17+/-0.50 mm in Group 1, 0.39+/-0.66 mm in Group 2, and 0.59+/-0.93 mm in Group 3 (p<0.05). Lesion length was associated with an increase in percent diameter stenosis and late lumen loss (of 6.9% and 0.21 mm per 15 mm). CONCLUSION: DES implantation is considered safe and effective in the treatment of diffuse lesions. However, lesion length may be associated with an increase in percent diameter stenosis and late lumen loss at 6-month follow-up.

Association between Arterial Stiffness and Coronary Atherosclerosis in the Elderly

BACKGROUND: While increased arterial stiffness is known to be related to atherosclerosis, the association between arterial stiffness and atherosclerotic coronary artery disease(CAD) has not been fully evaluated. The purposes of this study was to determine the relationship of pulse wave velocity(PWV) reflecting arterial stiffness and atherosclerotic CAD in the elderly. METHODS: PWV were assessed in three hundred and nineteen consecutive elderly patients(167men, 152 women) who underwent coronary angiography because of suspected CAD. We examined the association between PWV and coronary angiographic findings. RESULTS: Increased heart-femoral PWV was associated with high incidence of atherosclerotic CAD(p=0.001) and severity of CAD(p=0.023). Heart-femoral PWV was only a significant factor among all of PWV in determination of atherosclerotic CAD(p=0.016). The incidence of coronary artery disease was higher in the highest quartile of PWV than in the lowest one(odds ratio 3.6). The receiver operator characteristic curve demonstrated that heart-femoral PWV of 1,200cm/s was useful to discriminate atherosclerotic CAD in the elderly(sensitivity 30%, specificity 82%). CONCLUSION: Herat-femoral PWV is a useful noninvasive test to discriminate CAD and evaluate the severity of CAD in the elderly.

Catheter Ablation of a Left Free-Wall Accessory Pathway via the Radial Artery Approach

Catheter ablation of the left free-wall accessory pathways (APs) is normally performed by the retrograde transaortic approach via a femoral artery or the transseptal approach. Here we report a case of an overt left free-wall AP, which was successfully ablated with a retrograde transaortic approach via the radial artery without any vascular complications. The patient has remained free of any symptoms or pre-excitation observed on the ECG during a 10-month post- ablation follow-up.