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A 17-yr-old young woman was referred to our hospital with a 2-yr history of claudi- cation of the lower extremities and severe arterial hypertension. Physical examina- tion revealed significantly different blood pressures between both arms (160/92 and 180/95 mmHg) and legs (92/61 and 82/57 mmHg). The hematological and biochemical values were within their normal ranges, except for the increased ery- throcyte sedimentation rate (83 mm/hr) and C-reactive protein (6.19 mg/L). On 3- dimensional computed tomographic angiography, the ascending aorta, the aortic arch and its branches, and the thoracic and, descending aorta, but not the renal artery, were shown to be stenotic. The diagnosis of type IIb Takayasu's arteritis was made according to the new angiographic classification of Takayasu's arteritis, Takyasu conference 1994. Percutaneous transluminal angioplasty with stenting was performed on the thoracic and abdominal aorta. After the interventional proce- dures, the upper extremity blood pressure improved from 162/101 mmHg to 132/85 mmHg, respectively. She has been free of claudication and there have been no cardiac events during 2-yr of clinical follow-up.

The link between coronary flow reserve (CFR) and Duke treadmill score (DTS) in patients with microvascular angina remains elusive.We studied 108 subjects (M/F=48:60, mean age 54+/-9 years) with chest pain and normal coronary angiogram. ETT was performed by Bruce's protocol and the equation for calculating DTS was DTS=exercise duration-(5x ST deviation)-(4x exercise angina), with 0=none, 1=nonlimiting, 2=exercise limiting. The coronary flow velocity at diastole (PDV) using transesophageal Doppler echocardiography (TEE) was obtained from the proximal left anterior descending coronary artery and CFR was calculated as the ratio of hyperemic PDV after the intravenous infusion of dipyridamole (0.56 mg/kg) to baseline PDV.CFR was 3.04+/-0.45 in group with negative ETT and 2.19+/-0.62 in group with positive ETT (P0.001) and was 1.51+/-0.31 in high risk group with a score ofor = -11, 2.39+/-0.63 in moderate risk group with scores between -11 and + 5, and 3.04+/-0.43 in low risk group with a score ofor = +5 on DTS (P0.001 versus low risk group, respectively). DTS has significant correlation with CFR (r=0.704, P0.001).DTS is a composite index that reflects CFR and helps clinicians determine the severity of ischemia in patients with microvascular angina.

Background Coronary flow reserve (CFR) capacity of penetrating intramyocardial coronary artery (PICA) in apical hypertrophic (AH) cardiomyopathy has not been studied yet. Methods We studies 65 patients with normal coronary angiogram results (mean age 56 ± 10 years; 33 men, 32 women). Of these, 30 were normotensive without any left ventricular hypertrophy (control group), 24 had hypertension (HTN) without any left ventricular hypertrophy (HTN group), and 11 had AH cardiomyopathy (AH group). PICA-CFR and PICA-width ratio were calculated after the intravenous infusion of adenosine (140 μg/kg/min) just beneath the apical impulse window at a depth of 3 to 5 cm by using high-frequency transthoracic Doppler echocardiography. Results PICA-CFR was successfully measured in 59 (90.8%) of 65 patients. PICA-CFR was 1.65 ± 0.49 in AH group, 2.50 ± 0.77 in HTN group, and 2.42 ± 0.73 in control group ( P P = .025 vs HTN and control). PICA-CFR was closely related to width-ratio of PICA ( r = 0.448, P = .002). Conclusion PICA in AH has higher resting diastolic velocity, wider diameter, and impaired CFR compared with nonhypertrophied myocardium.

Clinical, echocardiographic, and carotid ultrasound parameters were compared according to the level of cardiac tropopin T (cTnT) (cTnT0.04 vsor =0.04 microg/L; cTnT0.1 vsor =0.1 microg/L) in patients with end-stage renal disease without acute coronary syndrome. Left atrial size, left ventricular mass index, the ratio of transmitral early left ventricular filling velocity to early diastolic Doppler tissue imaging velocity of the mitral annulus, and the prevalence of left ventricular dysfunction and diabetes mellitus were higher in the groups with cTnTor =0.04 andor =0.1 microg/L. Diabetes was an independent correlate of cTnT elevation ofor =0.04 andor =0.1 microg/L. Left ventricular mass index and left atrial size were independent predictors of cTnT elevations ofor =0.04 andor =0.1 microg/L, respectively.

Background Coronary spasm seems to be associated with coronary nitric oxide deficiency. Objectives We investigated whether the Glu298Asp polymorphism in the endothelial nitric oxide synthase (eNOS) gene is a definite risk factor for coronary spasm and whether diffuse spasm involving normal-looking coronary artery correlates significantly with the Glu298Asp polymorphism, in contrast with focal spasm superimposed on an atherosclerotic plaque. Methods A polymerase chain reaction followed by restriction fragment length polymorphism analysis was performed in 118 control participants and in 102 patients with variant angina and a similar degree of atherosclerotic burden. Patients with coronary spasm were divided into diffuse spasm and focal spasm subgroups according to morphological criteria. Results There was a significantly higher incidence of the Glu298Asp polymorphism in the coronary spasm group than in the control group (21.5% compared with 8.5%,P=0.006). Multiple logistic regression analysis using risk factors and the Glu298Asp polymorphism showed that the most important predictive factor for coronary spasm was the Glu298Asp polymorphism (odds ratio 2.83, 95% confidence interval 1.25-6.41,P= 0.009). The diffuse spasm subgroup had a significantly higher frequency of the Glu298Asp polymorphism than the control group (25.9% compared with 8.5%,P= 0.002). However, the focal spasm subgroup did not differ from the control group in the frequency of Glu298Asp polymorphism. Conclusion The Glu298Asp polymorphism in the eNOS gene is a definite risk factor for coronary spasm, especially for diffuse coronary spasm. This result supports the notion that diffuse coronary spasm is significantly associated with endothelial dysfunction, in contrast to focal spasm.Coron Artery Dis14:293-299 © 2003 Lippincott Williams & Wilkins.

OBJECTIVE: Previous pathologic and roentgenographic studies have suggested a relation between aortic plaque and coronary artery disease but have lacked clinical utility. The study was undertaken to elucidate whether atherosclerotic aortic plaque detected by transesophageal echocardiography can be a clinically useful marker for significant obstructive coronary artery disease. METHODS: Clinical and angiographic features and intraoperative transesophageal echocardiographic findings were prospectively analyzed in 131 consecutive patients (58 women and 73 men, aged 17 to 75 years [mean 54 +/- 12]) undergoing open heart surgery. Significant obstructive coronary artery disease was defined as > or = 50% stenosis of > or = 1 major branch. RESULTS: Seventy-six (58%) of 131 patients were found to have obstructive coronary artery disease. In 76 patients with significant coronary artery disease, 71 had thoracic aortic plaque. In contrast, aortic plaque existed in only 10 of the remaining 55 patients with normal or minimally abnormal coronary arteries. The presence of aortic plaque on transesophageal echocardiographic studies had a sensitivity of 93%, a specificity of 82% and positive and negative predictive values of 88% and 90%, respectively, for significant coronary artery disease. There was a significant relationship between the degree of aortic intimal changes and the severity of coronary artery disease (r = 0.74, P < 0.0001). Multivariate logistic regression analysis of patient age, sex, risk factors of cardiovascular disease and transesophageal, echocardiographic findings revealed that atherosclerotic aortic plaque was the most significant independent predictor of coronary artery disease. CONCLUSION: This study indicates that transesophageal echocardiographic detection of atherosclerotic plaque in the thoracic aorta is useful in the noninvasive prediction of the presence and severity of coronary artery disease.

To evaluate the relation between peripheral vascular endothelial function and coronary flow reserve (CFR), we assessed flow mediated dilation (FMD) of brachial artery and the intima-media thickness (IMT) of the carotid artery in 32 subjects (mean age 58+/-9 years, M/F=9:23 ) with chest pain and normal coronary angiogram. The subjects were divided into 2 groups according to CFRor=2.1 or2.1 measured with transthoracic echocardiography in distal left anterior descending coronary artery. We found % FMD was decreased in the group with CFR2.1 than those of CFRor=2.1 and CFR was correlated with peripheral FMD. However, IMT was not different between two groups. These results suggest that microvascular dysfunction is primarily related to endothelial dysfunction rather than advanced atherosclerosis and because it is a generalized process that involves the whole arteries, the measurement of brachial FMD can be a useful diagnostic tool to evaluate microvascular dysfunction in patients with chest pain and normal coronary angiogram.

To document the correlation between renal damage and circadian blood pressure variation, urinary microalbumin excretion rate (UAER) and 24-hour ambulatory blood pressure monitoring (24-hr ABPM) were performed in 16 normotensives and 29 stage I–III essential hypertensive subjects (whole-day mean BP; 120.13/79.06 mmHg vs 152.59/94.31 mmHg, p0.05). 10 subjects (2/16 in normal vs 8/29 subjects in hypertensives) revealed over 16 μg/min of UAER. All of the awaking BP variables and whole-day mean BP were correlated with the UAER in whole subjects and hypertensives, but almost sleep BP variables except maximum DBP and mean DBP were not. On the contrary, only daytime minimum DBP and SBP were correlated with UAER in normotensives. The common best correlated BP variable in awaking time was minimum BP (DBP and SBP; r=0.49, r=0.44 in whole, r=0.51, r=0.58 in hypertensives, r=0.54, 0.56 in normotensives, all p

Noninvasive measurement of coronary vasomotion is important for the evaluation of patients with coronary artery disease (CAD). We tested the possibility of the assessment of epicardial coronary artery vasodilating capacity using freehand 3-dimensional (3D) echocardiography.In 45 individuals (29 control subjects [age 51 +/- 12 years, male:female = 14:15; control group] with normal coronary angiogram and 16 patients with multivessel CAD ([age 60 +/- 12 years, male:female = 9:7; CAD group]), using a 3D echocardiography unit with magnetic tracking system linked to the conventional 2-dimensional ultrasound system, 3D echocardiography image acquisition and reconstruction of the distal left anterior descending coronary artery (LAD) flow were performed before and after sublingual nitroglycerin administration (0.6 mg). Quantitative analysis of coronary vasodilation was performed on cross-sectional 3D images and was compared with the mean diameter of the distal LAD by quantitative coronary angiography.The distal LAD diameter on coronary 3D increased from 2.28 +/- 0.79 to 3.32 +/- 1.07 mm (52.3 +/- 28.5%) in control group and from 2.36 +/- 0.65 to 2.89 +/- 0.81 mm (23.7 +/- 23.9%) in CAD group after nitroglycerin administration (P.005 vs control group). The cut surface diameter of the 3D LAD flow was 2.17 +/- 0.34 mm and the mean diameter using quantitative coronary angiography was 1.99 +/- 0.28 mm. There was a good correlation between baseline diameter of 3D image and mean quantitative coronary angiography data (R = 0.673, P.005).The vasodilation after nitroglycerin administration is reduced in advanced atherosclerosis and can be noninvasively measured. The 3D reconstruction of the distal LAD flow is a promising noninvasive technique to study coronary vasomotor function.

The purpose of this study was to compare coronary flow reserve (CFR) capacity of penetrating intramyocardial coronary artery (PICA) using transthoracic Doppler echocardiography and biochemical marker of myocardial fibrosis in hypertension (HTN).In 58 patients (male:female ratio = 31:27; mean age 47 +/- 9 years) with chest pain and normal coronary angiogram findings, the width of color Doppler signal and peak diastolic velocity of PICA flow were measured in the myocardium just beneath the apical impulse window using transthoracic Doppler echocardiography. PICA-CFR and PICA-width ratio were calculated as the ratio of hyperemic to baseline peak diastolic velocity and as the ratio of hyperemic to baseline width after the adenosine infusion (140 mug/kg/min), respectively. Serum carboxy-terminal propeptide of procollagen type I, as a biochemical marker, was measured and patients were divided into 3 groups: 19 with HTN and PICA-CFR less than 2.0 (group A); 23 with HTN and PICA-CFR of 2.0 or more (group B); and 16 who were normotensive with PICA-CFR of 2.0 or more (group C).Baseline peak diastolic velocity for group A was higher than the other two groups (P.005 vs groups B and C). PICA-width ratio was higher than the other two groups (P.005 vs groups B and C). Serum propeptide of type I was 137.1 +/- 16.6 ng/mL in group A, 96.2 +/- 13.7 ng/mL in group B, and 78.8 +/- 11.2 ng/mL in group C (P.0001 vs group B and group C). PICA-CFR was closely related to serum propeptide of type I (P.001, r = -0.723).The impaired PICA-CFR is related to myocardial fibrosis in patients with HTN, chest pain, and normal coronary angiogram results.

This study was performed to evaluate the influence of left bundle branch block (LBBB) on left anterior descending coronary artery (LAD) flow.We divided 89 subjects (34 males and 55 females, mean age 64 +/- 14 years) into an LBBB group (n = 40), a right ventricular (RV) pacing group (n = 26), and a control group (n = 23). All of the patients were examined with surface electrocardiography (ECG) and underwent transthoracic Doppler echocardiography (TTE) to measure QRS duration on the ECG, left ventricular ejection fraction (LVEF), left ventricular end-diastolic volume (LVEDV), and left ventricular end-systolic volume (LVESV). Coronary flow velocity was measured in the distal LAD with TTE, and the percentage of diastolic flow duration (%DD) was expressed as the percentage of diastolic duration of coronary artery flow divided by the R-R interval.The %DD of the LAD was significantly shorter in the LBBB group (40.4% +/- 12.4%) with LVEF50% than in the RV pacing group (60.3% +/- 7.3%) and the control group (59.3% +/- 7.6%) (P.01 vs the control and RV pacing groups), and it was also significantly shorter in the LBBB group (49.3% +/- 10.5%) with LVEFor = 50% than in the control and RV pacing groups (P.01 vs the control and RV pacing groups). In the LBBB group, the %DD of the LAD had a positive correlation with LVEF (P.05; r = .50), a negative correlation with LVEDV (P.05; r = -.57), and a negative correlation with QRS duration (P.05; r = -.41).Unlike RV pacing, LBBB itself can disturb the coronary perfusion of the LAD through shortening of the diastolic flow duration. Furthermore, systolic dysfunction potentiates the shortening effect of diastolic flow duration by LBBB. Whether left ventricular systolic dysfunction is the result of the coronary flow disturbance by LBBB or vice versa merits further investigation.

Infective endocarditis (IE) of the aortic valve is most commonly associated with perivalvular invasion and intracardiac fistula formation, which sometimes give rise to unpredictable clinical events. Massive pericardial effusion and aorticocardiac fistula are very rare complications of IE. We present a case in which IE of the aortic valve was initially associated with massive pericardial effusion requiring drainage and later complicated by rupture of a sinus of Valsalva with a fistula into the right atrium without formation of aneurysm. To our knowledge, the concurrent occurrence of these two events in a patient with IE has not been previously reported.

To evaluate the usefulness of exercise treadmill test in determining the true microvasculature-induced ischemia, we compared the pattern of ST depression with coronary flow reserve (CFR) using transthoracic Doppler echocardiography (TTE) in patients with chest pain and normal coronary angiogram.Fifty-nine subjects (M/F=21:38, mean age 55+/-9 years) with chest pain and normal coronary angiogram underwent maximal symptom-limited exercise treadmill test (ETT). CFR was estimated with TTE and dipyridamole. Patients with a history of acute myocardial infarction, regional wall motion abnormalities, hypertrophic cardiomyopathy, ejection fraction less than 50%, or primary valvular heart disease were excluded from this study.No ST change was observed in 20 of 59 (34%) patients, up slope depression was observed in 20 (34%), flat depression in 13 (22%), and down slope depression in 6 (10%). Eleven of thirty nine (28%) exercise positive patients had decreased CFR2.1. CFR was 3.1+/-0.6 in group with no ST change, 3.1+/-0.6 in group with up slope depression, 2.1+/-0.6 in group with flat depression (p0.05 versus group with no change and group with upslope depression, respectively), and 2.0+/-0.4 in group with down slope depression (p0.05 versus group with no change and group with up slope depression, respectively). Flat to down slope depression of ST change during ETT had sensitivity of 58% and specificity of 95% for predicting CFR2.1.Flat and down slope depression of ST segment during ETT might increase the sensitivity and specificity to detect the true microvasculature-induced ischemia that is defined as CFR less than 2.1 in patients with chest pain and normal coronary angiogram.

Pacemaker lead infection is a rare but a dangerous complication. Diagnosis can usually be established by the clinical picture and blood cultures. Transesophageal two dimensional echocardiography might be crucial in the diagnosis by visualizing pacing lead vegetations. Medical treatment alone is rarely successful, and several studies have suggested the infected pacemaker systems should be removed quickly for optimal management. We describe a case of Aspergillus infection in a permanent ventricular pacing lead, which appears to be the first reported case in Korea. A 30-yr-old man was evaluated for the symptoms and signs of congestive heart failure 3 yr after DDD pacemaker implantation. The transthoracic and transesophageal echocardiogram showed a large movable round shaggy mass attached to a ventricular lead in the right atrium. The atrial and ventricular leads were removed during cardiopulmonary bypass, and a new epicardial pacing system was implanted. The functional ventricular pacemaker lead was encased in a large organized thrombus. Histological findings were consistent with Aspergillus infection in a large thrombus attached to a pacemaker lead.

A 68 year old woman was referred for evaluation of chest pain. The patient had a six month history of typical angina occurring with moderate exertion. She had a 10 year history of hypertension. Her blood pressure was …

Few cases of pulmonary embolism detected by transthoracic echocardiography (TTE) have been reported. We present a case of a patient affected by pulmonary embolism caused by protein C deficiency. Transthoracic echocardiography showed a thrombus in transit (ie, visualization of a thrombus within the pulmonary artery). A hypercoagulable state caused by deficiency of protein C is a rare cause of pulmonary thromboembolism. Our experience demonstrates a massive pulmonary thrombus resulting from such a deficiency. Transthoracic echocardiography should be considered as the first diagnostic method for patients with suspected pulmonary embolism. (J Am Soc Echocardiogr 2000;13:682-4.)

BACKGROUND AND OBJECTIVES: It is known that angiotensin converting enzyme inhibitors and angiotensin II type 1 receptor blockers (ACEIs and ARBs, respectively) are effective in preventing atrial fibrillation (AF) in high-risk patients. However, it is not known whether ACEIs and ARBs are effective in preventing the recurrence of AF after catheter ablation. SUBJECTS AND METHODS: One hundred fifty-two patients (mean age, 57+/-10 years; M : F=94 : 58) who underwent catheter ablation due to drug-refractory paroxysmal (mean age, 57+/-10 years; M : F=58 : 43) or persistent AF (mean age, 56+/-10 years; M : F=36 : 15) were enrolled. We compared the recurrence rates between the groups with and without ACEIs or ARBs use in paroxysmal and persistent AF. The mean duration of follow-up was 18+/-14 months. RESULTS: The overall recurrence rate after ablation therapy was 26% (n=39). The recurrence rate was significantly decreased in the patients with persistent AF with the use of ACEIs or ARBs (12.1% vs. 61.1%, p

Background and Objectives: Cardiomyopathy is a common cause of heart failure, yet it is sometimes difficult to determine its exact etiology. Endomyocardial biopsy (EMBx) has been considered to be one of the important diagnostic modalities for unexplained cardiomyopathy. The aim of this study was to analyze the diagnostic value of EMBx. Subjects and Methods: 30 patients (M : F=26 : 4, mean age: 41±11 yrs) who underwent EMBx since 1992 at St. Mary’s hospital were enrolled. The patients were classified into 4 groups by their clinical manifestations as follows: Group I: 11 patients with left ventricular hypertrophy (LVH) of an unknown etiology and suspicious of having infiltrative disease on their non-invasive tests, Group II: 15 patients with heart failure of an unknown etiology and rapid progression, Group III: 2 patients with heart failure and peripheral eosinophilia, Group IV: 2 patients with suspicious arrhythmogenic right ventricular dysplasia and cardiac mass. Results: EMBx confirmed the diagnosis in 8 of 30 cases (26.7%). In Group I, 3 patients were confirmed to have amyloidosis (27.3%). In Group II, 2 patients were diagnosed as having lymphocytic myocarditis (13.3%). In Group III, all of 2 patients (100%) were diagnosed as eosinophilic myocarditis. In Group IV, 1 patient was confirmed to have cardiac metastasis from esophageal cancer. The diagnostic rate was higher for Group III than for Group II (p=0.007). There were no complications related with EMBx. Conclusion: EMBx may be a useful tool to confirm the causes of cardiomyopathy in selected patients. (Korean Circ J 2008;38:374-378)

Background and Objectives：In patients with aplastic anemia, chronic iron overload due to multiple blood transfusions, leads to secondary hemochromatosis. Cardiac involvement in hemochromatosis is the leading cause of death. The goal of this study was to find the echocardiographic characteristics of patients with aplastic anemia and chronic iron overload. Subjects and Methods：Echocardiography was performed on 33 patients with aplastic anemia (age 33±10, M：F=14：19) and 15 controls (age 34±8, M：F=6：9). The regions of interest on digitalized 2-D images of the papillary muscle (PM) in the parasternal short-axis view and the interventricular septum (IVS) in the apical 4-chamber view were analyzed using histograms, which quantified the echoreflectiveness (256 gray scales; black=0, white=255) of the myocardium. The echocardiographic parameters of each group were compared, including wall thickness, chamber dimensions, systolic, diastolic function indexes and echoreflectiveness. The aplastic anemic patients were divided into two groups (22 with serum ferritin level≥2,000 μg/L vs. 11 with

Background and Objectives：The intima-media thickness (IMT) of the common carotid artery has been widely used as a good index of atherosclerosis. The aim of this study was to test the correlation between the thickness of the high echogenicity intimal area (HELIT) on carotid ultrasound and the plaque burden of the culprit lesion on coronary intravascular ultrasound (IVUS). Subjects and Methods：In 33 patients (M：F=20：13, mean age 63±8 yrs) that underwent coronary angiogram, the HELIT and IMT from carotid ultrasound were compared with the plaque burden of the culprit vessel on IVUS. The high echogenic layer of the intimal area (HELIA) on carotid ultrasound was defined as a thickened echogenic superficial layer at the far wall of the common carotid artery using 15 MHz linear array transducer. The plaque burden was defined as the maximal percent plaque area of the culprit lesion on IVUS. The HELIT and IMT ration was defined as the percent ratio of HELIT on IMT. Results：The mean HELIT, carotid IMT, ratio of HELIT/IMT and maximal percent plaque area of the culprit lesion were 0.27± 0.03 mm, 0.85±0.22 mm, 0.33±0.07 and 68.43±11%, respectively. The HELIT was closely related to the maximal percent plaque area on IVUS (r=0.34, p

환 자 : 오○경, 24세, 여자 주 소 : 고열, 오한, 우상복부동통, 요통 병 력 : 2005년 8월 7일내원 5일전고열, 오한, 호흡곤란 및우상복동통과요통이발생하여지역병원에서급성담낭염과 이에 동반된 패혈증으로 진단하고 항생제 (cefotaxime, icepamicin, metronidazole)를 3일간 투여하였으나 증세의 호 전이없어본원에입원하였다. 기왕력 : 특이사항없음. 가족력 : 아버지는결핵의기왕력으로치료받음. 사회력 : 직업은학생이었으며그외특이사항없음. 이학적 소견 : 입원 당시 혈압은 125/70mmHg, 맥박수는 분당 82회, 호흡수는 분당 20회, 체온은 37.8°C 였다. 환자는 급성병색을보였고, 의식은명료하였다. 결막은약간창백하였 고, 황달은 없었으며, 안저 소견은 정상이었다. 경정맥은 팽대 되지않았고, 호흡음은우측이감소되었다. 심장박동은규칙적 이었으나, 2도의 연속성 심잡음이 흉골좌연을 따라 청진되었 다. 간과 비장은 촉지되지 않았다. 우상복부 압통은 있었으나 반동압통은없었고피부에발진및출혈반은없었다. 동맥관 개존증과 합병된 폐동맥판막 심내막염의 치험 1예

Background and Objectives：Currently, the drug-eluting stent (DES) has been widely used because of its excellent clinical outcome. We compared the utilization patterns and clinical outcomes between the DES and the bare metal stent (BMS) in the real world. Subjects and Methods：We retrospectively reviewed the stent registry at the Catholic Medical Center between January 2002 and October 2004. There were 1120 patients treated with DES (n=1837) who were compared to 910 patients who received BMS implantation (n=1238). Results：Patients with de novo lesions in the DES group more frequently had multivessel disease and received a greater number of stents than those in BMS group (p

s S81 601 Effects of hypertension on adriamycin-induced cardiomyopathy of rats H.-J. Youn, S.-H. Ihm, C.-S. Park, E.-J. Cho, H-O. Jung, H.-K. Jeon, J.-H. Kim, S.-J. Hong, Y.-S. Choi. Catholic University of Korea, Internal Medicine, College of Medicine, Seoul, Korea, Republic of Aim: We intended to elucidate the eflects ol hypertension on adriamycin-induced cardiomyopathy. Methods: Normotensive Wislar-Kyolo rats (WKY) and spontaneously hypertensive rats (SHR) were randomly divided into adriamycin-lrealed groups or salinetreated groups. Adriamycin with the dosage ol 2.5 mg/kg was administrated intraperitoneally ol 6 equal injections lor 3 weeks for adriamycin-lrealed groups, and normal saline with same volume was administrated lor saline-treated groups. Translhoracic echocardiography with a 15 MHz linear array transducer was performed at baseline and at sixth week to measure lractional shortening ol the lell ventricle. Histologic analyses used picrosirius red stain were performed for quantifying fibrosis. Results: (1) Adriamycin4reated WKY group, the lelt ventricular systolic lunction was decreased significantly (P=0.002), and fibrosis ol perivascular and interstitial area ol the myocardium was increased significantly (P=0.001, P=0.002), compared with saline4realed WKY group. (2) Saline-treated SHR group, fibrosis ol perivascular and interstitial area ol the myocardium was increased significantly, compared with saline4reated WKY group (P=0.002, P=0.002). (3) Adriamycin4realed SHR group, the fibrosis on perivascular area ol the myocardium was increased significantly, compared with saline4realed SHR group and adriamycin-lrealed WKY (P=0.001, P=0.001). Conclusion: These results suggest the hypertension increases the perivascular and interstitial fibrosis, resulting in aggravation ol adriamycin-induced cardiomy

Acute myocardial infarction is generally caused by the rupture or erosion of an atheromatous plaque and thrombosis. Acute myocardial infarction associated with a myocardial bridge or slow coronary flow is rare. We experienced a case of acute myocardial infarction, caused by a coronary thrombus in association with a myocardial bridge and slow coronary flow. A 33-year-old man presented with the sudden onset of chest pain. A diagnostic coronary angiography revealed an intraluminal contrast-filling defect, proximal to the myocardial bridge in the left anterior descending artery, with TIMI-2 flow. After an intracoronary injection of 150,000 units of urokinase and an intravenous injection of abciximab, the patient’s chest pain subsided, with the follow-up coronary angiography showing the disappearance of the coronary thrombus. (Korean Circulation J 2005;35:639-642)

Background Hypertension is an important risk factor for sudden cardiac death, of which the incidence increases with increases in blood pressure. Prolonged QT dispersion has been identified to indicate increased risk of life-threatening ventricular arrhythmia and sudden cardiac death. In this study, QT dispersion was investigated in hypertensive patients during the strain phase of the Valsalva maneuver. Methods The study population included 75 subjects: 25 with normal blood pressure (Control), 25 with stage I hypertension (Group A), and 25 with stage II hypertension (Group B). Electrocardiography for QT dispersion was recorded at 25 mm/sec paper speeds before and during the Valsalva maneuver. Results The patients in Group B were significantly older than the controls (p

Background and Objectives:Glucose-insulin-potassium (GIK) fluid infusion may improve the myocardial energy metabolism in the ischemic condition. A prospective randomized clinical trial was designed to determine whether a GIK fluid infusion can reduce the ventricular remodeling in acute myocardial infarction. Subjects and Methods:For the patients with acute myocardial infarction, during thrombolytic therapy with urokinase, GIK fluid (26% glucose 1000 mL, 50 IU insulin, and 80 mmol KCl) was administered for 24 hours. The ventricular volumes and function were evaluated by echocardiography during the admission period, at 6 months and at 12 months following discharge. Results:This trial was done prospectively for 2 years in 73 patients; the GIK group included 41 patients and the control group included 32 patients. The median value of "the pain to door time" was 195 minutes in the GIK group and it was 120 minutes in the control group (p=NS). The wall motion score was 1.52±0.39 in the GIK group and it was 1.39±0.35 in the control group. The left ventricular volumes, ejection fractions, cardiac indices and the globular indices showed no significant difference between the two groups. The side effects of the GIK fluid were mild phlebitis in 6 patients (14.6%) and congestive heart failure in 5 patients (12.2%). Conclusion:This trial could not verify the beneficial effects of administering GIK fluid on the ventricular remodeling after acute myocardial infarction. The limitations of this trial were as follows: "the pain to door time" was too long and the severity of the myocardial infarction was mild. Low rates for the echo- cardiogrphy follow-up and the randomization failure in a few patients were also noted. (Korean Circulation J 2005;35:779-786)

Background and Objectives：As a predictor of atherosclerosis, the intima-media thickness (IMT) of the common carotid artery (CCA) shows only a weak correlation with the extent of coronary artery disease (CAD). The purpose of this study was to evaluate the hand measured IMT value of the CCA as reliable and strong predictors of the severity of coronary artery atherosclerosis. Subjects and Methods：We performed an ultrasonographic examination of the right CCA by using a 15 MHz linear array transducer in 268 patients (M: F=160: 108, mean age 61.2±10.2) who underwent coronary angiography to evaluate ischemic heart disease. The internal dimension, maximal IMT, irrespective of location and morphology (focal or diffuse), and the IMT of 6 more randomly selected points in the CCA were measured. We classified the plaques as type A (low or equal echo density compared with adventitia) or type B (higher echo density than adventitia). Modified Gensini scores were calculated, as a marker of the extent of CAD, and compared with the results of the IMT examination. Results：Carotid plaques were detected in 156/268 (58%) patients. 119 and 37 patients were types A and B, respectively. The Gensini score was significantly higher in patients with type B (40.6±23.5) than type A plaques (29.3±21.7) (p=0.01). Modified Gensini score was correlated with age (r=0.22 p

Background and Objectives:Matrix metalloproteinase-9 (MMP-9) plays an important role in the genesis of atherosclerotic plaque rupture and acute coronary syndrome (ACS), including an acute myocardial infarction (AMI). A single nucleotide polymorphism (SNP) in the MMP-9 promoter (-1562C>T) has recently been identified. This study investigated whether the SNP of the MMP-9 promoter is a significant risk factor for an AMI due to plaque rupture and if SNPs affect the transcription of the gene that elevates the MMP-9 expression level. Subjects and Methods:A polymerase chain reaction, followed by a restriction fragment length polymorphism analysis, was performed in 173 control participants and 206 AMI patients. The serum levels of MMP-9 in the groups with or without the SNP were measured, using ELISA, and compared. Results:There was a significantly higher incidence of the -1562C>T MMP-9 polymorphism in the AMI compared to the control group (27.6% vs. 17.9%, p=0.04). A multiple logistic regression analysis of the risk factors for coronary artery disease and the MMP-9 polymorphism showed the MMP-9 polymorphism to be an important factor in the prediction of an AMI (odds ratio 1.67, 95% confidence interval 1.02-2.67, p=0.04). Conclusion: The -1562C>T polymorphism in the MMP-9 promoter is a definite risk factor for an AMI, and is associated with elevated MMP-9 expression. These results suggest that a SNP in the MMP-9 promoter is strongly associated with an Acute Myocardial Infarction. (Korean Circulation J 2005;35:192-196)

Background and Objectives:This study was designed to investigate whether the serum concentration of the carboxy-terminal propeptide of procollagen type I PIP, a marker of myocardial fibrosis, was related to the change of the ventricular filling dynamics in patients with early type 2 diabetes mellitus (DM). Subjects and Methods:Echocardiography was performed in 28 patients with type 2 DM and 32 age-matched healthy controls, ranging from 31-69 years of age, with normal left ventricular (LV) systolic function and ECG at rest. Subjects with diabetic complications, including microalbuminuria, nephropathy (Cr>1.3 mg/dL), severe obesity (BMI≥30 kg/m), LV hypertrophy (LV septal thickness and/or posterior wall thickness 12 mm on M-mode) and hypertension, were excluded. The serum concentrations of PIP and Transforming growth factor TGF-β1 were measured by enzyme immunoassay methods. Results:The type 2 DM group had lower mitral (Type 2 DM vs. Control: 0.88±0.28 vs. 1.17±0.34, p

Background and Objectives：The characterization of penetrating intramyocardial coronary artery (PICA) flow in diseased myocardium may offer insight into the spectrum of coronary physiology. However, the Coronary flow reserve (CFR) of PICA in apical hypertrophic cardiomyopathy (AH) has not yet been studied. This study tested the feasibility of CFR measurements of PICA by using high-frequency transthoracic Doppler echocardiography (TTE) and evaluated the hemodynamic and morphologic differences of PICA between patients with AH and patients without hypertrophy. Subjects and Methods：In 65 subjects with normal coronary angiograms [mean age 56±10 yrs；M：F=33：32；30 normotensive subjects without hypertrophy (Control group)；24 hypertension subjects without hypertrophy (HTN group)；11 subjects with apical hypertrophic cardiomyopathy (AH group)], we examined the myocardium just beneath the apical impulse window at a depth of 3 to 5 cm using TTE (7-MHz broadband transducer). After obtaining linear color signals using a special preset coronary program with a low Nyquist limit (12 to 20 cm), the width, peak (PDV) and mean (MDV) diastolic pulsed Doppler velocities, and diastolic velocity time integrals (VTI) were measured. PICA-CFR was calculated as the ratio of hyperemic PDV after the intravenous infusion of adenosine (140 μg/kg/min) to baseline PDV. The PICA-width ratio was calculated as the ratio of hyperemic to baseline width of color Doppler signals of PICA. Results：PICA-CFR was successfully measured in 59 (90.8%) of the 65 subjects. Baseline PDV of PICA was 39.6±21.0 cm/s in the AH group, 18.5±5.8 cm/s in the HTN group, and 17.5±6.8 cm/s in the control group (p

Background and Objectives:Diastolic heart failure (DHF) is defined as clinical evidences of heart failure, with a normal ejection fraction (EF) and abnormal diastolic function. However, the distinction between DHF and SHF is often difficult. Strain (S) and strain rate (SR) echocardiography can measure the regional myocardial function as a magnitude and rate of deformation. The hypothesis“myocardial velocity (Vel), S & SR can provide additional information for differentiation DHF from SHF”was assessed. Subjects and Methods: 30 patients with symptomatic HF and low EF (SHF group) and 27 with symptomatic HF, and normal EF and diastolic dysfunction (DHF group) were enrolled. 37 age-and sex-matched control subjects were recruited. Conventional echo and regional indices (Vel, S and SR), measured at the mid septum and posterior wall, were obtained. Results:Almost all clinical and echo indices of control were different between the two HF groups. The EF, LV mass, S’ and DT in DHF were greater than those with SHF. The LA size, diastolic dysfunction grades; E, A, E/A, E’, A’ and E/E’, were not different between the two HF groups. In the regional indices, the peak S (long axis: 12.0±5.4 vs. 17.6±5.9%, radial axis: 26.4±12.7 vs. 46.0±16.7%) and systolic Vel (long axis: 2.6±0.8 vs. 3.6±0.9 cm/s, radial axis: 2.1 (1.2 vs. 3.7±1.4 cm/s) with SHF were significantly lower than those with DHF. However, the SR of the two groups was not different. The best cutoff values of peak S were 13.7% (long axis) and 32.9% (radial axis), and the systolic Vel were 3.0 cm/s (long axis) and 2.8 cm/s (radial axis). Conclusion:The peak S and systolic Vel may be useful indices for differentiating DHF from SHF. A similarly decreased SR in the two HF groups suggests that DHF has decreased myocardial contractility, despite the normal EF. (Korean Circulation J 2004; 34(11):1090-1098)

Sporadic calcification of the left atrium is frequently observed in patients with long standing rheumatic valvular heart disease. However, massive calcification involving the entire left atrium, the so-called porcelain or coconut atrium, is extremely rare. A case of recurrent thrombosis in the left atrium was experienced due to massive calcification of the left atrial wall, despite the therapeutic anticoagulant level of the patient follow

Bilateral coronary arteriovenous fistula (CAVF), arising from both the right and left coronary arteries, are rare. We experienced a 44 years old male patient with bilateral CAVF, and coronary atherosclerosis, whose diagnosis was confirmed by coronary angiography. The hemodynamic result revealed minimal left-to-right shunt. Therefore, only percutaneous coronary artery intervention of the coronary artery stenosis was performed. Here, this rare case is reported, with a review of the literature. (Korean Circulation J 2004;34(9):909-912)

Background and Objectives:Fibrinolytic therapy or percutaneous coronary intervention are different forms of reperfusion therapy for an acute myocardial infarction. The aim of this study was to assess the differences in the early managements, including reperfusion therapy and inhospital outcomes, of patients with acute myocardial infarction (MI) between hospitals with and without coronary revascularization facilities. Subjects and Methods:The clinical characteristics, reperfusion therapy, initial medical treatments, frequency of invasive and non-invasive studies and inhospital mortalities of 962 and 433 acute myocardial infarction patients in hospitals with and without coronary revascularization facilities, respectively, between 1995 and 2000, were retrospectively compared. Results:There were no differences in the clinical characteristics between two groups. There was also no difference in the rate of reperfusion therapy between two groups (57.9 vs. 58.0 %, p=NS). Patients in hospitals with coronary revascularization facilities more often underwent coronary angiography (18.9 vs. 61.4%, p

Coronary pseudo-lesion is an artificial lesion that occurs during percutaneous transluminal coronary angioplasty by an angioplasty guide wire and/or a balloon as a result of a straightening of the vessel curvature. A specific treatment is not required and the condition is completely resolved after removing the angioplasty wire. There are few reports about a pseudo-lesion, particularly in the left circumflex artery. We report two cases of a coronary pseudo-lesion induced by an angioplasty guide wire; one case affecting the left circumflex artery and the other affecting the right coronary artery. (Korean Circulation J 2004;34(8):799-803)

Background：Previous studies showed that increased QT dispersion has been observed during episodes of myocardial ischemia or infarction and identified the patients at risk of arrhythmia or sudden death. The aim of this study was to investigate the relation between QT dispersion and left ventricular (LV function (systolic and diastolic, dimension and mass as well as to analyze the differences of this relationship according to the extent of angiographic coronary stenosis in patients with coronary artery disease. Methods：The study population included 262 patients (male 129, female 133；average age 60 years. Echocardiography was done for the measurement of left ventricular function, dimension and mass on admission. Electrocardiography for QT and QTc (corrected QT dispersion were recorded 25 mm/sec paper speeds before the coronary angiography. Patients were divided into two groups； Group A where angiographic coronary stenosis

Background and Objectives:This study was designed to formulate a method for the qualitative and quantitative measurements of aortic valve sclerosis (AVS) and to assess the relationship between this method and the degree of the carotid intima-media thickness (IMT) in neurologically asymptomatic patients. Subjects and Methods:One hundred and seventeen patients (Male 43%, 57.9±13.1 years of age) were retrospectively studied. Only the rightand non-coronary cusps were analyzed. AVS (cusp thickness of ≥2.0 mm) severities were classified into two groups according to the thickness and presence of the restricted motion of the cusp: mild AVS:AVS of

Background and Objectives:The eventual goal of reperfusion therapy, for an acute myocardial infarction (MI), is rapid and complete reperfusion into the myocardium beyond the epicardial artery. The recently designed TIMI frame count (TFC) and myocardial perfusion grade (TMPG) can be used to define the myocardial tissue perfusion. This study was undertaken to compare the TFC and TMPG for the assessment of myocardial reperfusion following primary angioplasty in patients with an acute anterior wall infarction. Subjects and Methods:33 patients, who admitted for acute myocardial infarction, between January 1998 and March 2001, were the subjects of this study. The subjects all underwent successful primary angioplasty on the LAD, with TIMI III flow. The ECGs, performed on admission and 1 hr after the angioplasty, were compared, the extent of the resolution of the ST elevation assessed. The TFC and TMPG were analyzed by 2 different observers using the coronary angiograms performed immediately and 7 days after the angioplasty. A retrospective analysis of the clinical events at the hospital, and the major coronary events during a follow-up of more than 6 months after discharge were performed. Results:The subjects were divided into 3 groups, completely recovered (n=11) and incompletely recovered (n=12) and not recovered (n=10), according to extent of the resolution of the ST elevation. There were no differences between the groups in their baseline characteristics. The TFC in the completely recovered group was significant lower (p=0.02, p=0.01) than the other patient groups immediately after the angioplasty, but there was no significant difference (p=0.28, p=0.32) in the TFC between the 3 patients groups 7 day after the angioplasty. The TMPG in the completely recovered group was consistently higher than in the other patient groups, both immediately and 7 days after the angioplasty. Five patients, who developed major coronary events during 16 month follow-up, tended to show no, or an incomplete resolution, of their ST elevation. They also showed significantly lower TMPG compared with the others, both immediately, and 7 days, after PTCA, but no significant difference at all in the TFC. Conclusion:The TMPG was closely associated with the rate of the ST elevation resolution in both the early and late periods after the primary angioplasty in acute MI, indicating that the TMPG is a better marker for the evaluation of myocardial reperfusion after primary angioplasty than the TFC. The low TMPG was observed to be related with a higher major coronary event rate, suggesting its usefulness as a predictor of long-term prognosis. (Korean Circulation J 2003;33 (10):864-870)

Background and Objectives:The purpose of this study was to analyze the patterns of coronary artery flow, using transthoracic Doppler echocardiography (TTE), in subjects with chest pains and normal coronary angiograms. Subjects and Methods:93 patients (M:F = 34:59, mean age:57±11 years) with chest pains and normal coronary angiograms were included in this study. After obtaining baseline clinical data, an exercise treadmill test (ETT) was performed, according to the Bruce protocol. The peak diastolic coronary artery flow velocity (PDV), at rest, and the coronary flow reserve (CFR), in the distal left anterior descending coronary artery (LAD), were estimated, using dipyridamole, with TTE. After the administration of angiotensin II receptor (AT II) blockers to 12 patients with a CFR