Search

This study aimed to determine prevalence, differentiate underlying causes, and identify the benign group in subjects with asymptomatic T-wave inversion (TWI). We retrospectively read 12-lead electrocardiograms from 3,929 consecutive asymptomatic men in the air force (3,929 participants, mean age 39.3 ± 8.7 years) who underwent medical screening at the Aerospace Medical Center, Korea, from September 2010 to August 2012. TWIs other than in right precordial leads (V 1 and V 2 ) were present in 23 men (0.6%). All subjects with persistent TWI for 1 year (n = 18) underwent additional study, with the exception of 1 patient who refused further evaluation. Of 17 subjects with investigated persistent TWI, 8 (47.1%) had an apically displaced papillary muscle, 5 (29.4%) exhibited idiopathic TWI, 3 (17.6%) had apical hypertrophic cardiomyopathy, and 1 (5.9%) had Maron type 2 hypertrophic cardiomyopathy with dynamic left ventricular outflow obstruction. The depth of TWI was significantly shallow in the benign group (idiopathic TWI, 1.6 ± 0.5 mm) compared with potentially nonbenign group (the others; 5.5 ± 3.3 mm, p = 0.021). Lateral lead TWI was significantly correlated with potentially nonbenign group (46% vs 0%, p = 0.049). In conclusion, asymptomatic TWI is not rare (0.6%), even in a healthy population such as Korean Air Force society, and at least 29.4% of subjects with TWI are considered to belong to the benign group that does not require aggressive evaluation and criteria of TWI ≤2 mm other than lateral leads without co-morbidity could help to distinguish the benign group from the potentially nonbenign group.

Atrioventricular nodal reentrant tachycardia (AVNRT), caused by a reentry circuit involving fast and slow atrioventricular nodal pathways, is one of the most common types of paroxysmal supraventricular tachycardias. While familial Wolff-Parkinson-White syndrome has been well recognized, familial AVNRT has been rarely reported. We report a familial occurrence of AVNRT in a mother and her son, who were symptomatic and successfully treated with radiofrequency catheter ablation of slow pathway.

Although it is rare, the right atrium can be encroached on by abnormal mediastinal structures, including aortic aneurysms, carcinomas, hepatic cysts and diaphragmatic paralysis. Extrinsic compression of the right atrium causes significant hemodynamic compromise and can lead to fatal outcomes. We describe the case of a 66-year old man with a past history of pulmonary tuberculosis that had undergone right pneumonectomy 40 years previously. He then presented with signs and symptoms of right-sided heart failure. These new signs and symptoms were recognized to be secondary to extrinsic compression of the right atrium, which was due to late-onset postpneumonectomy empyema, and the signs and symptoms were successfully relieved by performing open drainage of the empyema.

A stent fracture (SF) is one of the responsible factors for in-stent restenosis after a percutaneous coronary intervention. Factors that have an important role for a SF are vessel tortuosity, the presence of a right coronary artery lesion, overlapping stents, and the use of a drugeluting stent (DES) such as a sirolimus-eluting stent. Unlike with the use of bare metal stents, most SFs have occurred with the use of DES, and a DES may be a possible factor for a SF. A SF can cause clinical problems that range from stable angina to acute coronary syndrome. We experienced a case of acute myocardial infarction that was combined with a SF. We describe here the coronary angiography findings and the 64-multidetector computed tomography images before and after the SF.

The prognostic value of poststent fractional flow reserve (FFR) has not been clearly defined in patients with drug-eluting stent (DES) implantation. This study sought to evaluate the association between FFR and clinical outcomes after DES implantation with intravascular ultrasound (IVUS) assistance.A total of 115 lesions (107 patients) with FFR measurement after IVUS-assisted DES implantation were enrolled. Poststent angiographic and IVUS parameters were compared with FFR values. Clinical outcomes were assessed by target vessel failure (TVF), defined as a composite of target vessel revascularization, death, or non-fatal myocardial infarction attributed to the target vessel.Mean poststent FFR was 0.92 ± 0.04. Minimal stent area by IVUS had a positive correlation with poststent FFR (r = 0.36; P.01). Poststent FFR ≥0.89 was a physiologic cut-off value for 1-year TVF-free survival. The best cut-off value of minimal stent area to define poststent FFR ≥0.89 was5.4 mm² (sensitivity, 63.2%; specificity, 90.0%). At 3-year follow-up, lesions with poststent FFR ≥0.89 had a better TVF-free survival rate than those with poststent FFR0.89 (89.3% vs 61.1%, P =.03).Poststent FFR can be a useful predictor for long-term clinical outcomes after DES implantation and relevant to IVUS minimal stent area.

Microstructural evolution during the hot-pressing of TiH 2 and TiC powder mixtures was investigated. It was observed that TiH 2 was completely transformed to Ti and that carbon atoms diffused from TiC particles into the matrix during the process. It is suggested that this was responsible for the formation of α-Ti in the matrix in preference to the α ′ -Ti.

Neurocardiogenic syncope is the most common cause of syncope in patients who present in outpatient clinics. Head-up tilt test (HUT) has been widely used to diagnose neurocardiogenic syncope. However, the HUT does not always produce a positive response in patients with suspected neurocardiogenic syncope. The aim of the present study was to assess the clinical history and characteristics of patients with suspected neurocardiogenic syncope or presyncope who undertook HUT, and to identify prognostic factors of a positive HUT response. During the first phase of HUT, patients were tilted to a 70-degree angle for 30 minutes. If the first phase produced a negative response, the second phase was subsequently performed involving intravenous isoproterenol administration. Of 711 patients, 423 (59.5%) patients showed a positive HUT response. In contrast to previous studies, this study showed that the vasodepressive type (76.6%) was the most common pattern of positive response, and that the rate of positive response during the first phase was low (7.1%). By multivariate analysis, the occurrence of junctional rhythm was found to be a predictor of an impending positive response in HUT (P < 0.001). The shorter time interval between the last episode and HUT was also a predictor of positive response (P = 0.0015). Younger age (P = 0.0003) and a history of physical injury during a syncopal episode (P = 0.019) were found to be associated with a positive response in the first phase of HUT.

Aims The anatomical criteria for the diagnosis of ischaemia referenced by fractional flow reserve (FFR) from non-invasive coronary computed tomographic angiography (CCTA), invasive coronary angiography (ICA), and intravascular ultrasound (IVUS) have not been evaluated contemporarily in a large-scale study. The aim of this study was to assess the diagnostic value of CCTA compared with ICA and IVUS in patients with intermediate coronary stenosis. Methods and results CCTA, ICA, IVUS, and FFR were performed in 181 coronary lesions with intermediate severity. Minimal lumen diameter (MLD) and per cent diameter stenosis (%DS) were determined by CCTA and ICA, whereas minimal lumen area (MLA) was determined by CCTA and IVUS. Inducible ischaemia was defined by FFR ≤0.80. Diagnostic performances from non-invasive and invasive methods were compared. FFR ≤0.80 was observed in 49 (27.1%) lesions. CCTA MLD was smaller than ICA MLD (1.3 ± 0.5 vs. 1.5 ± 0.4 mm, P < 0.001), CCTA %DS was higher than ICA %DS (54.0 ± 14.0 vs. 50.3 ± 12.8%, P < 0.001), and CCTA MLA was smaller than IVUS MLA (2.2 ± 1.2 vs. 3.2 ± 1.2 mm2, P < 0.001). This trend was consistent irrespective of lesion location, lesion severity, and plaque characteristics. For the determination of ischaemia, diagnostic performance of CCTA %DS was lower than ICA %DS [area under the curve (AUC) 0.657 vs. 0.765, P = 0.04], and that of CCTA MLA was lower than IVUS MLA (AUC 0.712 vs. 0.801, P = 0.03). Conclusion Anatomical criteria for the diagnosis of ischaemia-producing coronary stenosis differ by non-invasive and invasive methods. Compared with invasive methods, CCTA presents overestimation in assessing lesion severity and lower diagnostic performance in assessing ischaemia.

Because dipyridamole is used to assess heart rate (HR) variability, we investigated whether a low HR response during dipyridamole single photon emission computed tomography (SPECT) in patients with diabetes indicates the presence of cardiac autonomic neuropathy (CAN).Subjects were 61 non-insulin-dependent diabetes patients without perfusion defects, myocardial infarction, or arrhythmia who underwent thallium 201 SPECT imaging. The control group comprised 28 subjects without diabetes. HR was measured during infusion of dipyridamole at a rate of 0.14 mg/kg/min, and peak-baseline ratios of 1.20 or less were defined as low. CAN severity was classified by standard autonomic function tests as severe (n = 22), mild (n = 19), or none (n = 20). HR ratios were significantly attenuated in patients with diabetes compared with those in control subjects (1.22 +/- 0.12 vs 1.32 +/- 0.12, P.001). Among the patients with diabetes, HR ratios decreased as CAN severity increased from none (1.32 +/- 0.10) to mild (1.23 +/- 0.12, P.05) to severe (1.13 +/- 0.08, P.005). There was good correlation between HR ratio and R-R interval ratio to deep breathing and to Valsalva, and patients with low HR ratios showed an attenuated response to both tests (all P.001). The sensitivity and specificity of HR ratios in the detection of CAN were 77% and 74% for severe CAN and 63% and 90% for mild-to-severe CAN, respectively.In patients with diabetes who have normal dipyridamole SPECT results, an attenuated HR response observed during stress indicates a high likelihood of CAN. Further work that assesses these results in diabetes patients with coronary artery disease is warranted.

We examined whether cardiac sympathetic imaging with iodine-123 metaiodobenzylguanidine (MIBG) would predict improvement of left ventricular (LV) function and exercise capacity in patients with heart failure after treatment with carvedilol.Eighteen patients with heart failure and 5 control subjects underwent I-123 MIBG imaging. Heart-to-mediastinum ratios at 20 minutes and 3 hours and myocardial washout rates (WR) were measured. Of the 18 patients, 11 were randomized to receive carvedilol medication, whereas the remaining 7 received a placebo. Only the carvedilol group demonstrated a significant improvement in both heart failure functional class and LV ejection fraction (EF) 1 year after the start of medication. Within the carvedilol group, MIBG WR showed a significant inverse correlation with improvement in LVEF (rho = -0.74, P =.02). The diagnostic accuracy of WR for predicting EF response to carvedilol was 91%. WR also appeared to be inversely related to the peak oxygen consumption rate (rho = -0.65, P =.08), although this did not reach statistical significance.I-123 MIBG imaging appears useful in predicting which patients with heart failure are likely to show the most improvement in LV function and exercise capacity after carvedilol treatment. Further studies in this area appear to be warranted.

Objectives The aging process affects responsiveness and other functions of endothelium and vascular smooth muscle cells, predisposing the old vessels to the development of atherosclerotic lesions. Endothelial nitric oxide synthase (ecNOS) gene polymorphisms were shown to affect the occurrence of acute myocardial infarction (AMI). We hypothesized that aging may affect the association between the ecNOS gene polymorphism and AMI. Methods We investigated the age-related distribution of the ecNOS gene a/b polymorphism in 121 male AMI patients and 206 age-matched healthy male controls. Results The aa, ab and bb genotypes were found in 1, 49 and 156 cases among the control subjects and 5, 23 and 93 cases among the AMI patients, respectively. There was a significant correlation between the ecNOS polymorphism and AMI (p = 0.045). When the correlation was analyzed by age, the significance remained only in the group below the age of 51 (p = 0.009). The proportion of smokers was increased in the young patients when compared to the old patients (p = 0.033), indicating that smoking also has greater effect on the younger population. The incidences of hypertension and diabetes mellitus, however, were similar in both populations. Conclusion Our work provides the first evidence that links ecNOS polymorphism to the risk of AMI in relation to age. Young persons who smoke or have ecNOSaa genotype may have an increased risk of developing AMI. The functional as well as structural changes associated with aging in the vascular endothelium may mask the effect of the ecNOS polymorphism in the development of AMI in old persons.

Background Efficient and stable transfer of therapeutic DNA into injured myocardium would be an initial step towards a genetic treatment aimed at myocardial repair after myocardial infarction. Proliferating cardiac fibroblasts in the healing myocardium could be a compelling target for retroviral infection. We evaluated the feasibility of direct in vivo gene transfer into injured myocardium using a high-titer, stable retroviral vector. Methods Using the TE-FLY-A-based MFG retroviral vector harboring nlsLacZ reporter, the gene transfer efficiency was assessed first in vitro in rat cardiac fibroblasts, followed by in vivo evaluation in healing rat myocardium after local freeze–thaw injury. A total of 2.5×107 infectious units of retrovirus were injected into the injured region of a beating rat heart. The transduced cells were identified by X-gal staining and immunohistochemistry. Results Highly efficient transduction of cardiac fibroblasts was observed in vitro with 98% of the cells transduced with single infection. The cell proliferation index in the cardiac granulation tissue appeared maximal 3 days after cryoinjury. Retroviral injection into the injured beating heart induced gene expression localized to the wound repair region. One week after retrovirus injection, 14% of the cells in the reparative tissue were β-gal-positive, while 4% were β-gal-positive after 4 weeks. The transduced cells were mostly myofibroblasts. Conclusions Local gene transfer to the healing rat heart is feasible by retrovirus in vivo. This observation may serve as a useful guide for the development of gene therapy aimed at myocardial repair after myocardial infarction. Copyright © 2000 John Wiley & Sons, Ltd.

Conventional angiography has been used for diagnosis of Takayasu arteritis (TA). In early stage of TA, subtle inflammatory wall thickening of the aorta and its branches without significant stenosis may be the only morphologic change of TA. Magnetic resonance (MR) imaging appears to be useful in the diagnosis of early stage TA by visualizing concentric wall thickening of the vessels. T2-weighted images may show bright signal of edema in and around the inflamed vessel. Contrast media-enhanced MR shows enhanced wall of vessels even in chronic stage, which may indicate the activity of TA at the tissue level. MR angiography allows us noninvasive assessment of the vascular tree and it may replace conventional angiography.

Background Because equivocal fixed perfusion defects on single photon emission computed tomography (SPECT) often cause a diagnostic dilemma in patients with suspected coronary artery disease (CAD), we used receiver-operating characteristic (ROC) curve analysis to evaluate the degree of increased accuracy provided by adding gated images for interpretation of such cases.

To evaluate 64-section multidetector coronary computed tomographic (CT) angiography for the depiction of coronary stent fracture in patients and in vitro.This retrospective study was approved by the institutional review board, and informed patient consent was waived. The coronary CT angiograms obtained in 371 consecutive patients (268 men, 103 women; mean age, 62.9 years) with 545 stents were reviewed. All patients with stent fractures underwent conventional coronary angiography and/or fluoroscopy as part of their medical care. In phantom studies, magnified radiographs of three types of drug-eluting stents in their fully expanded, maximally bent, and unrolled states were obtained. CT angiography and fluoroscopy of a water phantom that contained two drug-eluting stents--Cypher and Taxus devices--with four fractures each were performed, and two radiologists blinded to the fracture information evaluated the images.Twenty-four stents with fractures were identified. Eighteen fractured stents (13 Cypher, four Taxus, one S670) in 14 patients were detected with CT angiography; six (33%; two Cypher, four Taxus) of these 18 stents in five (36%) patients were not detected on conventional angiograms at the initial readings. Six fractured stents showed significant (50%) recurrent in-stent stenosis. Of 58 arteries with overlapping stent placements, eight (14%) had fractures involving 11 stents. In the in vitro studies, 57 stent fractures (31 Cypher, 26 Taxus) were detected with CT angiography and 38 (18 Cypher, 20 Taxus) were detected with fluoroscopy.Coronary CT angiography depicts stent fractures in patients and phantoms, even those fractures that are not clearly depicted by conventional angiography.http://radiology.rsnajnls.org/cgi/content/full/249/3/810/DC1.

Objective: The aim of this study was to evaluate the incidence of coronary-to-bronchial artery fistula (CBF) and clinical significance in 1300 patients examined with 64-multidetector computed tomography (MDCT) coronary angiography. Methods: One thousand three hundred ten patients underwent coronary MDCT for atypical chest pain or screening. Volume-rendering and multiplanar reconstruction images were reviewed, and subsequent cineangiographies were compared. Results: Eight cases of CBF were detected-6 originated from the left circumflex artery, and 2 originated from the right coronary artery. A hypertrophied anomalous branch of left circumflex artery was observed in 1 case, and underlying bronchiectasis was noted. Seven cases had a thin-wall communicating vessel. Subsequent cine-angiography revealed identical appearance with MDCT reconstruction images. Conclusions: The incidence of CBF (0.61%) in this study is similar to those of a few cineangiographic studies in the literature. Our study showed that 64-MDCT coronary angiography is an accurate and noninvasive tool for detection of CBF.

The objective of our study was to evaluate whether the SD of CT attenuation values obtained from unenhanced scans of the left atrium is a reliable parameter for the individual modulation of tube current to achieve uniform image quality in coronary CT angiography (CTA).One hundred patients (59 men and 41 women) who were suspected to have coronary artery disease underwent coronary CTA using a 64-MDCT scanner. In addition to clinical studies, we also performed measurements on water phantoms. Tube current was modulated by the SD of the CT attenuation values measured from the left atrium on unenhanced images scanned at 300 mA. A modulation table was created from data obtained from the studies of water phantoms scanned at various tube currents. Other scanning parameters were identical to those used to obtain unenhanced and contrast-enhanced studies of the 100 patients. The SD values were measured from images scanned at an adjusted tube current, and the images of normal coronary and internal mammary arteries were graded. Radiation doses measured using the volume CT dose index (CTDI(vol)) were compared between the SD of the CT attenuation values and the modulation parameters suggested by the manufacturer of the scanner.Image quality was rated as grade 3 (low mottle) on a 4-grade scale by four observers for 92-94 of the 100 patients (average, 92.5%). The mean SD value at an adjusted tube current was 12.1 H with an SD of 0.758 H (target SD = 12 H). A radiation dose reduction of 9-45% was achieved in patients grouped by weight who weighed less than 70 kg, and a reduction of up to 71% was seen in individual cases.Modulating tube current using the SD of CT attenuation values from the left atrium is a highly reliable method of achieving uniform image quality in coronary CTA.

Coronary artery injury after blunt chest trauma is very rare, but this can result in a serious acute myocardial infarction. Coronary artery dissection is an uncommon complication of thoracic injuries. We report a case of a 17-year-old male who was presented with an anterior myocardial infarction following blunt chest trauma after a bicycle accident. His coronary angiography revealed aneurysmal dilatation with dissection of the distal left main stem coronary artery. Intravascular ultrasound showed a dissecting flap at the left main stem coronary artery. The patient was treated conservatively and discharged without serious sequelae. When symptoms and electrocardiographic findings are compatible with acute myocardial infarction, careful evaluation is important in patients with thoracic injuries for proper management. If the patient is stable, medical therapy may be appropriate. But early intervention should be considered in the presence of ongoing myocardial ischemia.

Aim: Aggressive surgical therapy is mostly recommended in patients with both anorectal and primary sacrococygeal cancers. Pelvic floor defects secondary to major surgery as abdominoperineal amputation, sacrectomy and multivisceral resections are really surgical challenge. Hereby, we present the early results of patients with graft reconstruction of both anterior and posterior pelvic floor defects. Patients & Results: Four male and one female oncologic patients with pelvic floor reconstruction between 2011-2013 were enrolled. The mean age and follow-up of the patients were 63 years and 15 month. Pelvic exenteration was performed for advanced rectal cancer (n1⁄42), anal cancer (n1⁄41), sacral chordoma (n1⁄42). Pelvic floor reconstruction was performed via prosthetic grafts and advanced skin flaps. Morbidity rate was 20% (n1⁄41, wound infection) and no mortality was seen. While two patients with rectal cancer had undergone neo-adjuvant therapy, the others received adjuvant therapy. Both sacrococygeal and intraabdominal recurrences were seen in one patient with sacral chordoma and debulking surgery was performed. Conclusion: Aggressive pelvic floor surgery is the mainstay in the treatment of locally advanced tumors of this origin. Pelvic gerniation due to exentration may be challenge to the surgeon and therefore wait for solution. Pelvic reconstruction with prosthetics is a good alternative with encouraging results. No conflict of interest.

Entropy measures of RR interval variability during daily activity over a 24h period were compared in 30 patients with a positive head-up tilt (HUT) test and 30 patients with a negative HUT test who had a history of alleged neurocardiogenic syncope. Two different entropies, approximate entropy (ApEn) and entropy of symbolic dynamics (SymEn), were employed. In patients showing a positive HUT test, the entropies were significantly decreased when compared with the patients with a negative HUT test. In addition, SymEn in the patients with a negative HUT test was significantly lower than in the normal controls. Discriminant analysis using SymEn could correctly identify 89.3% (520/582) of the 1 h RR interval data of the patients with a positive HUT test regardless of the time of day. Baseline entropies of heart rate dynamics during daily activity were found to be significantly lower in patients with alleged neurocardiogenic syncope and a positive HUT test than in those with the same history but with a negative HUT test. The decreased entropy of symbolic heart rate dynamics may be of predictive value of a positive HUT test in patients with alleged neurocardiogenic syncope.

The purpose of this study was to evaluate the role of contrast-enhanced MR imaging in the determination of disease activity in patients with Takayasu's arteritis.High-resolution contrast-enhanced T1-weighted spinecho MR imaging using small fields of view (14-20 cm) and thin slices (4-5 mm) was performed in 26 patients with Takayasu's arteritis and 16 healthy subjects. The degree of aortic mural enhancement was assessed by measuring signal intensity and by visually estimating it in comparison with that of the myocardium.Contrast-enhanced MR imaging showed more enhancement of thickened aortic wall compared with myocardium, thus suggesting active Takayasu's arteritis on MR imaging in 16 patients. Determination of disease activity using contrast-enhanced MR imaging was concordant with clinical findings in 23 patients (88.5%). Contrast-enhanced MR findings were concordant with laboratory findings in most patients (erythrocyte sedimentation rate in 92.3% [24/26] and C-reactive protein in 84.6% [22/26]). The measured signal intensity of the aortic wall relative to that of myocardium during the early phase of contrast-enhanced MR imaging correlated well with the erythrocyte sedimentation rate (r = 0.78, p0.005) and with the C-reactive protein level (r = 0.63, p0.005).Contrast-enhanced MR imaging provides information about disease activity of Takayasu's arteritis, which may be useful in the diagnosis and treatment of Takayasu's arteritis.

A21-year-old woman presented with left ocular pain and severe pulsatile headache. She had suffered from easy bruisability since she was young. On physical examination, ecchymoses and bruises were noticed on trauma sites (Figure 1A⇓). The skin was so thin that subcutaneous blood vessels were visible (Figure 1B⇓). Huge hematomas and ecchymoses occurred at the puncture sites after angiography (Figure 1C⇓). There was no significant hyperelasticity of the skin. …

To examine whether moderate hyperhomocyst(e)inemia is associated with coronary artery disease and the number of diseased coronary vessels in Koreans, we investigated 201 patients with angiographically documented coronary artery disease and 187 healthy subjects without evidence of stroke and coronary artery disease. The mean plasma total homocysteine in patients was higher than in controls (10.3 μmol/L; 95% confidence interval, 7.0–13.6 vs. 8.9 μmol/L; 6.0–11.8) ( p =0.005). The prevalence of moderate hyperhomocyst(e)inemia, defined as the top 90th percentile in controls (13.2 μmol/L), was higher in patients than in controls (23.9% vs. 10.2%, p =0.001). Plasma homocyst(e)ine levels were not correlated to age, body mass index, levels of serum cholesterol, creatinine, and uric acid. Based on multiple logistic regression analyses with adjustment for total cholesterol, hypertension, smoking status, diabetes, age, and body mass index, the adjusted odds ratio of moderate hyperhomocyst(e)inemia for coronary artery disease was 1.53 (95% confidence interval: 1.39–1.65, p =0.0001). Moderate hyperhomocyst(e)inemia, diabetes mellitus, and old age were more prevalent in patients with triple-vessel disease than in single- or double-vessel disease ( p =0.02). Multiple logistic regression analysis revealed that moderate hyperhomocyst(e)inemia was a significant predictor of triple-vessel disease with odds ratio of 2.78 (95% confidence interval: 1.08–7.10, p =0.02). We conclude that moderate hyperhomocyst(e)inemia is an independent risk factor for coronary artery disease, and also related significantly to the presence of triple-vessel disease.

Pheochromocytoma in pregnancy is very rare but it is associated with very high maternal and fetal mortality. Therefore, it is important to include pheochromocytoma in the differential diagnosis of hypertension associated with pregnancy. It is difficult to make a diagnosis of pheochromocytoma in pregnancy before delivery. The characteristic symptoms of pheochromocytoma could be initiated during delivery because the process of delivery, general anesthesia, fetal movement, induce acute surge of catecholamine release, which could also induce cardiomyopathy. Early diagnosis and intensive care can affect the prognosis of cardiomyopathy induced by pheochromocytoma. Proper management with alpha-blockade, beta-blockade and angiotension converting enzyme inhibitor could acutely reverse the course of cardiomyopathy.

Abstract The deletion (D) allele of the insertion/deletion (I/D) polymorphism of the angiotensin converting enzyme (ACE) gene is strongly associated with an increased level of circulating ACE. The ACE gene polymorphism may influence the production of angiotensin II (Ang II). It has been shown that Ang II modulates fibrinolysis, that is, Ang II increases plasminogen activator inhibitor-1 (PAI-1) mRNA and plasma PAI-1 levels in vitro and in vivo. Considered together, we tested the hypothesis that the deletion allele of the ACE gene might be associated with increased levels of PAI-1. We related the ACE genotype to PAI-1 antigen levels in 603 men and 221 women attending a routine health screening. As a whole, the plasma PAI-1 level was not strongly associated with ACE genotype. Since the PAI-1 level was significantly influenced by well-known risk factors for coronary artery disease (CAD), we further analyzed the data after excluding subjects with major cardiovascular risk factors. In low-risk male subjects, the DD genotype had significantly higher levels of plasma PAI-1 (DD: 20.3±2.2; DI: 13.9±1.1; II: 13.6±1.3 ng/mL, P =.010 by ANOVA). In low-risk female subjects, the DD genotype showed a tendency to a high level of plasma PAI-1 without statistical significance. When analysis was restricted to postmenopausal women (age≥55 or FSH≥35 ng/mL), the DD genotype showed a significantly higher level of PAI-1 than subjects with the DI and II genotypes (27.7±6.2 versus 15.6±1.8 ng/mL, P =.028). The DD polymorphism of the ACE gene is associated with high PAI-1 levels in male and possibly in postmenopausal female subjects who have lower conventional cardiovascular risk factors. These results suggest that the increased ACE activity caused by DD polymorphism may play an important role in elevating the level of plasma PAI-1. Our data support the notion that the genetic variation of ACE contributes to the balance of the fibrinolytic pathway.

We experienced an unusual case of cardiac tamponde caused by a rupture of the coronary arteriovenous aneurysm in a 54-year-old woman. The patient was suffered from sudden chest pain and syncope, and was initially managed by pericardiocentesis following an echocardiogram which revealed a massive pericardial effusion with signs of cardiac tamponade. She was referred to our hospital under the impression of aortic dissection with cardiac tamponade. She underwent an emergency operation and was found to have a 2 x 2 cm sized bleeding cystic mass protruding from the proximal anterior descending coronary artery. The aneurysm was excised and the openings connected with the coronary artery and right ventricular outflow tract were closed with sutures from the inside of aneurysm. Subsequent coronary arteriography supported the diagnosis.

Management of Takayasu's arteritis of the left main coronary artery (LMCA) is difficult because of the possibility of restenosis. Clinically significant stenotic lesions must be considered anatomical correlation. Many studies have reported that the management of stenotic lesions of the LMCA with endoluminal stenting and balloon angioplasty and de-novo stenting is safe and effective for patients with Takayasu's arteritis. We report the case of a patient with Takayasu's arteritis of the LMCA. The patient had undergone two consecutive percutaneous coronary interventions because of recurrent restenosis of in-stent lesions, and eventually underwent coronary artery bypass graft (CABG) surgery for myocardial infarction in the same lesion. We suggested treatment with CABG because the pathophysiology of Takayasu's arteritis is different from that of atherosclerotic stenosis.

Aims: We investigated whether the new contact mapping system, EnSite velocity system, is safe and effective for ablation of non-sustained ventricular tachycardia (VT) originating from the right ventricular outflow tract (RVOT). Methods: A 42 year-old women who was old handball player presented with palpitation and dyspnea. Holter and treadmill test showed non-sustained VT with left bundle branch block pattern. Results: In electrophysiology study, non-sustained VT was easily induced by isoproterenol infusion at more than 140 beat per min of heart rate. Voltage and activation mapping were performed with EnSite velocity system. After the ablation at anterior septum of RVOT, non-sustained VT was not induced. Conclusion: The new contact mapping system, EnSite velocity system, is effective and helpful for mapping and ablation of RVOT VT.

LEOPARD syndrome (LS) is a rare hereditary disorder in Asian countries. This syndrome consists of multiple systemic abnormalities. In particular, characteristic cardiovascular effects in LS may include variable clinical manifestations from benign to life-threatening courses. The cardiac effects of this syndrome consist of left ventricular hypertrophy (LVH), pulmonary stenosis (PS), coronary artery dilatation and electrocardiogram(ECG) abnormalities. Since there are few LS patients who have undergone a complete cardiovascular evaluation, the nature and clinical prognosis of cardiovascular abnormalities in this syndrome remain uncertain. Also, there have been few reports on therapeutic strategies for cardiovascular abnormalities in LS. Here we describe a case of LS who presented with multiple cardiovascular problems and underwent successful surgical and medical treatment.

Background/Aims: Many prognostic models have been developed to help physicians make medical decisions on treating patients with pulmonary embolism. Among these models, the Pulmonary Embolism Severity Index (PESI) has been shown to be a successful risk stratification tool for patients with acute pulmonary embolism. The PESI, however, had not been applied to patients with pulmonary embolism in Korea. Methods: The patients included in this study were diagnosed by computed tomography at Inje University's Ilsan Paik Hospital between December 1999 and March 2007. Risk stratification for the patients was performed using the PESI. The mortality rate was calculated according to each PESI risk class. Results: Of the 90 patients enrolled in this study, ten were assigned to PESI class I, 29 to PESI class II, 22 to PESI class III, eight to PESI class IV, and ten to PESI class V. The mortality rate after 30 days in each class was 0, 10.3, 9.1, 0, and 50% (p=0.0016), respectively, whereas the respective hospital mortality rate was 4.8, 13.8, 13.6, 12.5, and 50% (p=0.0065). The overall mortality was 9.5, 27.6, 31.8, 50.0, and 60%, respectively (p=0.0019). The mortality rate was significantly associated with the PESI class. Conclusions: The PESI class was found to be significantly correlated with the 30-day mortality rate, hospital mortality, and overall mortality. Our data indicate that the PESI can be used to predict the prognosis of patients with pulmonary embolism and in making medical decisions regarding the treatment of patients with pulmonary embolism. (Korean J Intern Med 2009;24:123-127)

Femoral arterial closure devices are now commonly used after both diagnostic and therapeutic coronary procedures. They have been shown to reduce the time to ambulation and to decrease the length of the hospital stay. Angioseal is a commercially available femoral artery closure device that has been approved by the Food and Drug Administration (FDA). The device sandwiches an intra-arterial absorbable anchor on the luminal side of the vessel and a thrombin plug on the surface of the vessel with using a self-cinching stitch. We report here on three patients who presented with acute and delayed arterial occlusive complications that were found to be due to an Angioseal anchor that was not appropriately reabsorbed. (Korean Circ J 2008;38:339-342)

An anomalous origin of the right coronary artery (RCA) from the left coronary cusp is a rare congenital anomaly. Because of the unusual location and the noncircular luminal orifice of this anomaly, cannulation of this artery during coronary angiography and percutaneous coronary intervention (PCI) poses significant technical difficulties when using the currently available guiding catheters. Primary PCI should be performed as quickly as possible when a patient displays this condition. When we face the situation of an anomalous artery during primary PCI, it takes a much longer time to open the occluded artery. We report here on two cases of successful primary PCI with using manually manipulated catheters and Ikari type guiding catheters in 2 patients who both had an anomalous RCA arising from the left coronary cusp. (Korean Circ J 2008;38:179-183)

Abciximab is one of the glycoprotein IIb/IIIa receptor inhibitors, and it is known to be effective for preventing and treating the thrombotic complications of percutaneous coronary intervention (PCI). On the other hand, there is an increasing risk of hemorrhagic complications when using abciximab, especially in the case of abciximab-induced thrombocytopenia. Acute profound thrombocytopenia is a rare, but life threatening adverse reaction to abciximab, and it can even occur within a few hours of the first exposure. We report here on a case of 56 yearold woman who experienced massive bleeding of her brachial artery access site. This was caused by abciximab-induced acute profound thrombocytopenia after performing PCI concomitant with using abciximab. (Korean Circ J 2007;37:594-598)

Background and Objectives:Arterial stiffness and wave reflections increase with advancing age, and the systolic and pulse pressures are elevated. These changes in aortic stiffness and pulse wave velocity with aging may change the cardiac function. The diastolic function of the left ventricle declines with aging even in normal healthy subjects too. This investigation was designed to assess the correlations between the left ventricular diastolic function and arterial stiffness with using echocardiography including doppler tissue imaging (DTI) and an applanation tonometer. Subjects and Methods:The subjects were 100 healthy volunteers who had normal left ventricular systolic function and no major cardiovascular risk factors such as hypertension, hypercholesterolemia, diabetes, obesity and smoking. The left ventricular diastolic function was assessed with the mitral inflow indexes and DTI, and the pulmonary venous return was measured by echocardiography. The central aorta blood pressure, the augmentation index (AIx) and the pulse wave velocity (PWV) were evaluated by using an applanation tonometer (SphygmoCoR system). Results:With advancing age, the left mitral E/A ratio decreased (r=-.738, p

Chest radiographs (A and B) from a 63-year-old asymptomatic woman with a loud continuous cardiac murmur over the mid–left parasternal area demonstrate two anteriorly located, round, calcified paracardiac masses (arrows) along the courses of the coronary arteries, measuring 52 mm …

Background and Objectives:Contrast-induced nephropathy (CIN) is associated with increased morbidity and mortality in coronary angiography. Although the mechanism is unclear, N-acetylcysteine (NAC) is known to protect against CIN. Preliminary studies with NAC have found conflicting results for the prevention of CIN in patients undergoing coronary angiography. This study was designed to evaluate the efficacy and safety of NAC for the prevention of CIN in patients undergoing coronary angiography. Subjects and Methods:48 patients with chronic renal insufficiency (mean (±SD) serum creatinine concentration, 2.06±0.56 mg/dL), who were undergoing coronary angiography with a nonionic, low-osmolar contrast agent, were prospectively studied. Pa- tients were randomly assigned to receive either the antioxidant, NAC (600 mg orally twice daily), and 0.45% saline intravenously (n=25), before and after administration of contrast agents, or saline only (n=23). The renal function parameters were assessed 48 hour before and after radiocontrast media administration. Results:14 of the 48 patients (29%) showed an increase in the 0.5 mg/dL serum creatinine concentration after 48 hours of contrast media administration: 4 of the 25 patients in the NAC group (16%) and 10 of the 23 in the control group (43%; p=0.036; relative risk, 0.37; 95% confidence interval, 1.04 to 7.79). In the NAC group, the mean serum creatinine concentration insignificantly increased (p=0.54), from 2.2±0.8 to 2.3±0.9 mg/dL, after 48 hours of contrast media administration; whereas, in the control group, the mean serum creatinine concentration significantly increased (p=0.011), from 1.9±0.4 to 2.2±0.8 mg/dL. The absolute change in serum creatinine concentration was significantly greater in the control than the NAC group (p=0.044). Conclusion:Prophylac- tic oral administration of the antioxidant NAC, along with hydration, prevents the decrease in the renal func- tion induced by a nonionic, low-osmolality contrast agent in patients with chronic renal insufficiency. (Korean Circulation J 2005;35:696-701)

� , This study was designed to assess the relative merits of percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in multivessel coro- nary artery disease (MVCAD), particularly for Korean diabetics. Among 3,279 patients with MVCAD who were recommended for revascularization were enrolled from nine centers in Korea, 2,154 were selected after statistical adjustments for the disparities between two groups. Survival rates were not significantly different for three years between two groups. Among diabetic patients, the three-year mortality rate in PCI group was 1.9-fold higher than that of CABG group, although it was not statistically significant (PCI 19.8%, CABG 11.4%, p=0.14). The three-year mortality rate was similar between the two groups in non-diabetics (PCI 8.3%, CABG 10.0%, p=0.50). The 30-day rate of cerebrovascular event was higher in CABG group, for both dia- betic (CABG 3.6%, PCI 0.0%, p

Background and Objectives:The impact on long-term adverse cardiac events of troponin T (TnT or creatine kinase-MB (CK-MB release after percutaneous transluminal coronary angioplasty (PTCA is not well defined. The purpose of the study is to evaluate the effect of elevated TnT or CK-MB on the late major adverse cardiac events (MACE;Q wave myocardial infarction (MI, revascularization, or cardiac death). Subjects and Methods:Study population were 207 consecutive patients (M:F=148:59, mean 60.8± 9.2 years who underwent PTCA. Patients with acute MI, unstable angina with abnormal levels of TnT or CK- MB, or newly developed Q MI after PTCA were excluded. Cardiac enzyme levels were measured before and 8, 24 hours after PTCA for CK-MB, and before and 16 hours after PTCA for TnT. Group I (n=181, 87.4% had normal levels of both after PTCA. Group II (n=26, 12.6% had abnormal levels of CK-MB (≥16 U/L and/or TnT (≥0.2 ng/mL. 1-year follow-up was available in 201 (97.1% patients. Results:Incidence of non-Q MI after PTCA was 26/207 (12.6%. Major complications such as acute coronary occlusion, side branch occlusion, and major dissection were significantly associated with elevation of TnT or CK-MB after PTCA (p=0.01. However, elevation of CK-MB or TnT was not significantly associated with late MACE by Kaplan-Meier survival curve (p=0.46. During 1-year follow-up, event free rate of group I and II were 76.6% and 69.2%, respectively. Conclusion:Acute coronary occlusion, side branch occlusion, or major dissection can increase the level of TnT or CK-MB after PTCA. But, elevation of CK-MB or TnT after PTCA dose not

Background and Objectives:The diagnosis of paroxysmal atrial fibrillation (PAF) and the prediction of its recurrence are sometimes difficult. There have been several recent studies attempting to detect patients at risk for PAF while in sinus rhythm by using the P wave signal-averaged ECG. We undertook to define an appropriate technique of P wave signal-averaged ECG and to estimate the reproducibility of the test. Additionally, we estimated the usefulness of P wave signal-averaged ECG in patients at risk for PAF. Subjects and Methods: Forty-five patients with PAF were included in the study undertaken between March 1997 and June 1998. Twelve-lead surface ECG and P wave signal-averaged ECG were performed in the patients. The total P wave duration was measured by the P wave signal-averaged ECG using P wave template and least-square fit filter. The same process was followed in forty sexand age-matched controls. Results:The measurement of P wave duration with P wave signal-averaged ECG was highly reproducible. The measured P wave duration showed significant prolongation in the patient group at cutoff frequencies of 20 Hz and 30 Hz (123.6±15.3 vs. 114.8±14.5 msec, p=0.009 at 20 Hz, 120.1±17.8 vs. 107.5±18.8 msec, p=0.002 at 30 Hz). An abnormal P wave duration defined as over 120 msec in duration by P wave signal-averaged ECG was able to detect PAF with a sensitivity of 60%, specificity of 73%, positive predictive value of 71%, and a negative predictive value of 62%. Conclusion:A prolonged P wave duration as measured by P wave signal-averaging technique may be a simple noninvasive marker of risk for the development of atrial fibrillation. (Korean Circulation J 2002; 32(2):146-154)

Background and Objectives:The causes of vasospastic angina are not well known. We attempted to elucidate the risk profiles of Korean patients with vasospastic angina. Subjects and Methods:The risk profiles were analyzed in 181 patients with vasospastic angina (VA), 1533 patients with obstructive coronary artery disease (CAD) who underwent coronary angiography at Samsung Seoul Hospital, and 455 normal control subjects, sex and age matched to the VA group and selected from the Health Promotion Center of Samsung Seoul Hospital. Results:The male to female ratio was significantly higher in the VA group (4.6:1) than the obstructive CAD group (2.7:1). The mean age of the VA group (52.2±10.7 years) was significantly younger than the mean age of the obstructive CAD group (59.0±10.6 years) (p

Background and Objectives:Heart rate variability (HRV) reflects the autonomic integration of the heart. There have been many reports asserting that HRV in patients with myocardial infarction or heart failure is an independent prognostic factor to predict fatal arrhythmia and sudden cardiac death. However, the role of HRV is still controversial in stable angina patients without a history of myocardial infarction. In this study, we tried to compare HRV indices between stable angina patients and normal subjects. Materials and Methods:Twentyone stable anginal patients without a history of myocardial infarction (mean age:57±2 years) and twenty-one relatively healthy persons without a history of coronary heart disease (mean age:53±2 years) were included in the study and underwent 24-hour ambulatory ECG monitoring. In the patients group, all underwent coronary angiography following 24-hour ambulatory ECG monitoring. HRV was analyzed over the whole 24 hours, using time and frequency domain parameters, according to time phases and coronary angiographic severity. Results: There were no significant differences in age, sex or cardiovascular risk factors, with the exception of hypertension (p=0.001) between the two groups. HRV indices such as rMSSD, pNN50, LF, HF, LFnorm and HFnorm were significantly decreased (p

Neurocardiogenic syncope is a relatively common cause of syncope and is diagnosed by a head-up tilt test. A wide variety of medical treatments has been proposed, such as beta-blocker, vasoconstrictor, fludrocortisone, and serotonin re-uptake inhibitors. However, there are some cases in which these therapies have failed to prevent syncope. A recent report has shown that tilt training is a very effective therapy for recurrent neurocardiogenic syncope. Therefore, in order to determine whether tilt training could prevent symptoms in the patients with recurrent neurocardiogenic syncope, this study was undertaken. Five patients diagnosed with neurocardiogenic syncope by head-up tilt test were included. During hospital admission, they were tilted daily until a negative response occurred. Negative responses were noted in four patients. However, tilt training was discontinued in one patient due to lack of response. Following discharge, the four patients performed tilt training at home by leaning against a wall. They were interviewed on the phone eight to eleven months later and they have not experienced any symptoms during the follow-up period. This is the first domestic report of tilt training in patients with neurocardiogenic syncope.( ( ( (Korean Circulation J 2001;31(8 :801-808