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Background The influence of β-blockers on heart rate recovery (HRR) and rating of perceived exertion (RPE) during Phase I cardiac rehabilitation (CR) for patients with a recent episode of acute myocardial infarction (AMI) is not clear. Methods From October 2009 to July 2011, 105 patients with a recent episode of AMI who received a successful percutaneous coronary intervention were recruited into this study. Before entering Phase II CR, each patient underwent a cardiopulmonary exercise test (CPET), where RPE was assessed every minute and related parameters were recorded. Results The participants entering CR had relatively low mean peak oxygen consumption (VO 2max ). However, the peak heart rate and VO 2max were lower in those taking β-blockers. The RPE value at the ventilatory threshold (VT) was significantly higher (12.7 ± 1.7) in participants who were taking β-blockers relative to those who were not (11.5 ± 1.4). The HRR value was lower (12.5 ± 8.8) in participants who were taking β-blockers relative to those who were not (17.0 ± 9.1). Conclusion These findings suggest that use of β-blockers increased the RPE value at the VT. In addition, HRR was attenuated by β-blockers. In patients who do not undergo CPET, the use of β-blockers should be taken into consideration when using RPE for the initial exercise prescription to determine training intensity. [ABSTRACT FROM AUTHOR]

Abstract: Background: The glutathione thymidine repeats [(GT)n] of the heme oxygenase (HO)-1 gene promoter have been shown to be correlated with the incidence of coronary artery disease (CAD), patients with shorter repeats being less likely to have CAD. In this study, we investigated whether (GT)n repeats in the HO-1 promoter were related to a quantitative angiographic severity of CAD. Methods: The allele frequency of the HO-1 gene promoter (GT)n repeats was examined in CAD patients with de novo lesions (n = 328). Patients' baseline coronary severity was quantified using the Jeopardy scoring system. Results: The allele frequency of GT repeats in the HO-1 gene promoter had bimodal peaks at (GT)23 and (GT)30. Therefore, we defined allele classes as follows: S allele (<23 repeats), M allele (23–29 repeats), and L allele (≥30 repeats). The group with severe CAD (Jeopardy score ≥8) had a significantly lower frequency of the S allele (3.7% vs. 8.9%; p = 0.042) than the group with moderate CAD (Jeopardy score <8). None of the patient with the highest score of 12 (n = 17) carried the class S allele. In a multivariate binary logistic analysis, being a carrier of shorter GT repeats was a significant negative predictor (odds ratio 0.393; p = 0.024) of a higher Jeopardy score grade of CAD. Conclusion: Our study showed that shorter (GT)n repeat in the HO-1 gene promoter were associated with a lower Jeopardy severity score in patients with significant CAD. [Copyright &y& Elsevier]

Abstract: Background: Rotational atherectomy (RA) has been advocated in the bare metal stent (BMS) era but is underused now due to technique demands and nonsuperior outcomes. The aim of this study was to evaluate the procedural and clinical outcomes of patients with very complex, severely calcified coronary lesions treated by RA and drug-eluting stents (DESs) in our current percutaneous coronary intervention (PCI) practice in a region where RA use has been limited by lack of insurance reimbursement. Methods: From March 2004 to November 2010, all consecutive patients who required RA treatment for severely calcified de novo lesions of native coronary arteries followed by DES implantation were queried from the cath lab database and recruited. Their clinical and angiographic characteristics at the index PCI were analyzed and completed by a thorough review of the medical charts. Results: A total of 67 consecutive patients with 71 very complex, heavily calcified coronary lesions treated with RA plus DES were recruited. Of these patients, 64% presented with acute coronary syndrome, 9.0% with cardiogenic shock, 43.3% with chronic renal failure, and 50.7% with diabetes. Multiple-vessel diseases were found in 92.5% of our patients, and the average coronary artery calcification (CAC) score was 3.6±1.4. Of the coronary lesions, 26.7% were either balloon-uncrossable or balloon-undilatable. The angiographic success rate was 100% with one non-Q myocardial infarction. Five patients (7.5%) died in hospital, all initially presenting with extensive myocardial infarction and/or cardiogenic shock. The out-of-hospital major adverse cardiac event was 17.9% at the mean follow-up of 23.2 months (range: 5–86), primarily due to high target-lesion revascularization and target-vessel revascularization rates of 10.4% and 10.4%, respectively. Only one (1.5%) probable subacute stent thrombosis was observed in the follow-up. Conclusion: RA with DES implantation in very complex, heavily calcified coronary lesions can achieve very low complication and low out-of-hospital major adverse cardiac event rates even in high-risk patients despite use limited by lack of insurance reimbursement. The study results convince us to sustain and even broaden the use of this novel, but underused, device in the DES era. [Copyright &y& Elsevier]

Abstract: Mycotic subclavian artery pseudoaneurysms are rare. There are controversies over the surgical or endovascular approach as the treatment of choice for these lesions. The standard surgical debridement might not be a choice for poorly surgically reachable lesions or for patients with multiple comorbidities. Endovascular aneurysm repair may be an effective alternative in selected cases. This treatment was rarely reported previously. Herein, we present a high-surgical-risk case with a highly suspected left subclavian arterial mycotic pseudoaneurysm, which, although difficult to approach surgically, was successfully managed with stent grafting and a complete antibiotic treatment course. An 89-year-old male was admitted due to intermittent fever and hemoptysis for 2 months. Salmonella group B was cultured from his sputum, and a 3.5 cm pseudoaneurysm was identified by chest multidetector-row computed tomography (MDCT) angiogram. Endovascular treatment with a graft stent was chosen due to high surgical risk and difficult surgical access to the lesion. The intervention was well planned ad hoc, based on MDCT images and meticulously performed by dual endovascular approaches. Antibiotics were continued after the procedure, and the patient was discharged from the hospital. As MDCT disclosed near-complete regression of the pseudoaneurysms 2 months later and the patient was in healthy status, antibiotics were continued for 6 months. He was readmitted 11 months later due to lacunar infarction with minor pneumonia over the left lower lung in which Salmonella enteritis was also diagnosed. After this acute event, he was again hospitalized 14 days later due to sepsis with adult respiratory distress syndrome and shortly expired despite all emergent treatment measures. No evidence of local subclavian infection recurrence was noted throughout or related to subsequent events. In conclusion, endovascular treatment of an infected subclavian artery pseudoaneurysm could be a choice in selected patients, but treatment of underlying infection determines the clinical outcome. [Copyright &y& Elsevier]

Abstract: A 41-year-old man received an electrophysiological study (EPS) and radiofrequency catheter ablation (RFCA) for atrioventricular reentrant tachycardia (AVRT) in our hospital. Massive pulmonary embolism (PE) with hypotension developed 9 hours after these procedures. After emergent pulmonary angiography and catheter-directed intrathrombus urokinase infusion and clot breaking, the patient recovered well. This case suggests that life-threatening PE may occur in patients who receive EPS, RFCA, or both. An adequate observation time after RFCA and clinical alertness are necessary for immediate diagnosis and treatment. Emergent catheter-directed therapy may be of benefit in some patients with acute massive PE. [Copyright &y& Elsevier]

Abstract: A 63-year-old male with Wolff-Parkinson-White syndrome was admitted for ablation of accessory pathway. Intracardiac electrogram revealed a left-side accessory pathway during tachycardia, which was successfully ablated from the right posterior tricuspid annulus because of a long slanted transseptal accessory pathway (2.2 cm). [Copyright &y& Elsevier]

Abstract: The worldwide outbreak of pandemic influenza A (H1N1 influenza) infection in 2009 caused numerous hospitalizations and deaths resulting from severe complications such as pneumonia, sepsis, and acute respiratory distress syndrome. Fulminant myocarditis caused by H1N1 infection has been reported in children but rarely in adults. We present an adult who contracted H1N1 infection followed by fulminant myocarditis. Early implementation of extra-corporeal membrane oxygenation support in conjunction with a specific anti-influenza viral medication (Oseltamivir) led to the patient’s complete recovery from cardiogenic shock in 2 weeks. [Copyright &y& Elsevier]

Anomalous origin of the left coronary artery arising from the pulmonary artery (ALCAPA) is a rare congenital heart defect that affects approximately 1 in 300,000 live births and accounts for 0.5% of all congenital heart disease. Without surgical intervention, most patients with this anomaly die in infancy. The diagnosis of ALCAPA syndrome is sometimes difficult, especially in children, because it often presents with atypical symptoms and signs. Echocardiography can yield some findings that are highly indicative of this syndrome. Cardiac catheterization usually establishes the diagnosis, but it is invasive and painful. Multidetector-row computed tomography (MDCT) is a valuable alternative tool to confirm the diagnosis of ALCAPA syndrome. In this report, we describe a 24-year-old woman with a dilated right coronary artery detected by transthoracic echocardiography, showing an interventricular abnormal flow over the diastolic phase of the cardiac cycle and the left main coronary artery not merging with the ascending aorta. The diagnosis of ALCAPA syndrome was confirmed by MDCT. [ABSTRACT FROM AUTHOR]

Background: Percutaneous transvenous mitral commissurotomy (PTMC) is an effective treatment for mitral stenosis, but transseptal puncture carries a certain risk of complications. Our previous report has shown the effectiveness of phase-array intracardiac echocardiography (ICE)-guided transseptal puncture in patients with dilated left atrium undergoing PTMC. However, there are few reports comparing the new-generation mechanical versus phase-array ICE-guided transseptal puncture in PTMC. Methods: Between March 2007 and March 2008, 6 consecutive patients with symptomatic mitral stenosis with dilated left atrium (range, 4.1–6.1 cm) underwent transseptal puncture by mechanical ICE guidance in PTMC by the same experienced operator. The procedural, echocardiographic and clinical results were retrospectively retrieved and analyzed. In addition, phase-array ICE-guided transseptal cases (n = 7), which included consecutive cases from May to December 2008, were compared. Results: All 6 patients could have fossa ovalis visualized by ICE, and none of them had false transseptal puncture. Mechanical ICE provided a panoramic wider view of the interatrium septum, and offered better knowledge of the needle''s geographic contact to the fossa ovalis than did the phase-array system. The fluoroscopic time of PTMC in the mechanical ICE-guided group (37 ± 9 minutes, n = 6) was similar (p = 0.465) to that of phase-array guidance (31 ± 15 minutes, n = 7). Conclusion: Mechanical ICE is effective in guiding transseptal puncture in PTMC. [Copyright &y& Elsevier]

We report on a patient who was referred for percutaneous transvenous mitral commissurotomy for symptomatic mitral stenosis. However, transthoracic and transesophageal echocardiography both revealed a large mobile left atrial thrombus, occupying almost half of the left atrial body. Because the patient strongly declined surgical mitral treatment, he was administered warfarin for 2 years. Complete resolution of left atrial thrombus was confirmed by follow-up transesophageal echocardiography. Successful percutaneous transvenous mitral commissurotomy was undertaken without complications. [Copyright &y& Elsevier]

Coronary embolism with acute myocardial infarction (MI) following direct-current (DC) cardioversion of atrial fibrillation (AF) has rarely been reported. We present the case of a 34-year-old female with severe aortic regurgitation and highly symptomatic paroxysmal AF. Acute embolic MI occurred 4 days after DC cardioversion of AF, although there was no left atrial thrombus detected before this procedure. Insufficient anticoagulation therapy during the post-cardioversion period was the cause, leading to embolic MI. [Copyright &y& Elsevier]

Background: Premature coronary artery disease (CAD) is a special entity with a strong link to familial hypercholesterolemia, family history of premature CAD, or multiple coexistent atherosclerotic risk factors. Drug-eluting stenting (DES), including paclitaxel-eluting stenting (PES) and sirolimus-eluting stenting (SES), has been proven to have a lower restenotic rate. However, to date, few studies have investigated the clinical and angiographic results of DES in premature CAD patients. Methods: Between February 2004 and October 2005, premature CAD patients, defined as those younger than 50 years ofage, who were treated with DES in our medical center were all retrospectively enrolled. Their baseline clinical characteristics, clinical outcome and angiographic follow-up results were analyzed. Results: A total of 26 patients (M/F: 23/3) were enrolled, with a mean age of 44 ±6 years (range, 24–50 years). Conventional atherosclerotic risk factors were prevalent in this study group, including diabetes mellitus (35%), hypertension (35%), hyperlipidemia (54%) and smoking (73%). Moreover, there was 1 homozygous and 1 heterozygous familial hypercholesterolemia case in our study group. In terms of angiographic results, there were 40 target lesions in 34 target vessels. Forty DES (39 PES, 1 SES) were implanted with a median stent diameter of 3 mm and median length of 24 mm. The clinical follow-up was counted up to May 2006, with a mean follow-up duration of 540 ±168 days; 11 (42%) patients had a second angiogram during the follow-up period (200 ±98 days after DES). None of the patients had target lesion revascularization (TLR). In addition, there was no difference in TLR or stent thrombosis between patients with or without acute coronary syndrome. Conclusion: Based on our single-center experience, DES had good short-term follow-up results for a premature CAD group with diverse and multiple atherosclerotic risk factors. [Copyright &y& Elsevier]

Abstract: Eosinophilic myocarditis is recognized by severe heart failure and marked eosinophilia infiltration resulting from different etiologies. Acute necrotizing eosinophilic myocarditis, the initial presentation of the disease, is rare and often fatal, with unique echocardiographic pictures, and followed by endocardial thrombosis and chronic endomyocardial fibrosis. We report a young female with acute lymphoblastic leukemia who presented fever and acute heart failure syndrome. The echocardiography showed severe left ventricle diastolic dysfunction with preserved ejection fraction. Systemic eosinophilia and the unique echocardiographic images made the diagnosis of acute necrotizing eosinophilic myocarditis. The patient survived after intensive cytotoxic chemotherapy including high-dose steroid. [Copyright &y& Elsevier]