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Objective: Rotational atherectomy (RA) and newly developed second-generation drug-eluting stent (DES) support the strategy of longer stent deployment in comparison to short stent implantations in the past. However, studies analyzing the outcome of patients who received long stent implantation following RA are few in number. The present study compared the clinical outcomes of patients with the coronary arterial disease (CAD) who underwent RA with long stent implantation using first- and second-generation DES.Methods: A retrospective cohort study was performed at the single center from March 2003 to October 2019. Eighty-seven patients with CAD who underwent RA with ≥32 mm long stent implantation were enrolled in the study and divided into two groups according to the type of DES. As a primary endpoint, the cumulative 2-year incidence of major adverse cardiac events (MACE) including death, myocardial infarction (MI), target vessel revascularization, and stent thrombosis (ST) was compared by DES type. Adjusted interaction between the type of stent and clinical variables was estimated to determine the predictor variables of MACE.Results: The second-generation DES group was associated with a shorter procedure duration and more common usage of intravascular ultrasound in procedural characteristics. In the second-generation DES group, a trend toward a lower rate of MI and ST existed. All-cause mortality and cardiovascular mortality were not significantly different. When combined with MACE, we could identify a significant reduction in the second-generation DES group.Conclusion: In comparison to the first-generation DES group, the second-generation DES group was associated with a lower rate of MACE for 2 years in patients who underwent RA with long stent implantation.

Background: Apelin-13 (A13) regulates cardiac homeostasis. However, the effects and mechanism of A13 infusion after an acute myocardial injury (AMI) have not been elucidated. This study assesses the restorative effects and mechanism of A13 on the peri-infarct region in murine AMI model. Methods: 51 FVB/N mice (12 weeks, 30 g) underwent AMI. A week following injury, continuous micro-pump infusion of A13 (0.5 μg/g/day) and saline was initiated for 4-week duration. Dual contrast MRI was conducted on weeks 1, 2, 3, and 5, consisting of delayed-enhanced and manganese-enhanced MRI. Four mice in each group were followed for an extended period of 4 weeks without further infusion and underwent MRI scans on weeks 7 and 9. Results: A13 infusion demonstrated preserved LVEF compared to saline from weeks 1 to 4 (21.9 ± 3.2% to 23.1 ± 1.7%* vs. 23.5 ± 1.7% to 16.9 ± 2.8%, * p = 0.02), which persisted up to 9 weeks post-MI (+ 1.4%* vs. − 9.4%, * p = 0.03). Mechanistically, dual contrast MRI demonstrated significant decrease in the peri-infarct and scar % volume in A13 group from weeks 1 to 4 (15.1 to 7.4% and 34.3 to 25.1%, p = 0.02, respectively). This was corroborated by significant increase in 5-ethynyl-2′-deoxyuridine (EdU +) cells by A13 vs. saline groups in the peri-infarct region (16.5 ± 3.1% vs. 8.1 ± 1.6%; p = 0.04), suggesting active cell mitosis. Finally, significantly enhanced mobilization of CD34 + cells in the peripheral blood and up-regulation of APJ, fibrotic, and apoptotic genes in the peri-infarct region were found. Conclusions: A13 preserves cardiac performance by salvaging the peri-infarct region and may contribute to permanent restoration of the severely injured myocardium.

BackgroundPulmonary arterial hypertension (PAH) is a progressive chronic disease with poor outcomes. One reason for poor prognosis is the lack of understanding regarding individual variability in response to treatment. Idiopathic PAH (IPAH) patients with bone morphogenetic protein receptor type 2 (BMPR2) mutations have distinct phenotypes that are crucial for individualized therapy but evidence regarding their prevalence and clinical features in the Korean population is lacking. Therefore, the present study aimed to screen Korean IPAH patients for BMPR2 mutations and analyze their clinical phenotypes.MethodsWe enrolled 73 unrelated IPAH patients for BMPR2 mutation screening between March 2010 to November 2015 from 11 hospitals in Korea. Thirty-three lineal family members from 6 families of BMPR2 mutation carriers were also screened.ResultsAmong 73 patients, 16 (22%) had BMPR2 mutations. Mutation carriers were younger (27 vs. 47 years; p = 0.02) and had a higher mean pulmonary arterial pressure (mPAP) than non-carriers (64 vs. 51 mmHg; pConclusionThe prevalence of BMPR2 mutations in Korean IPAH patients was 22%. Mutation carriers were younger and had a poorer hemodynamic profile compared with the non-carriers.Clinical trial registrationClinicaltrials.gov NCT01054105.

Pulmonary hypertension (PH) is defined as resting mean pulmonary artery pressure ≥ 25 mmHg and is caused by multiple etiologies including heart, lung or other systemic diseases. Evaluation of right ventricular (RV) function in PH is very important to plan treatment and determine prognosis. However, quantification of volume and function of the RV remains difficult due to complicated RV geometry. A number of imaging tools has been utilized to diagnose PH and assess RV function. Each imaging technique including conventional echocardiography, three-dimensional echocardiography, strain echocardiography, computed tomography and cardiac magnetic resonance imaging has-advantages and limitations and can provide unique information. In this article, we provide a comprehensive review of the utility, advantages and shortcomings of the multimodality imaging used to evaluate patients with PH.

The development of various techniques and equipments for percutaneous coronary artery intervention (PCI) has led to an increase in age of the PCI population, and an increase in complexity of cases such as chronic total occlusion and calcified lesion. However, on the other hand, these subsets can increase the rate of balloon failure (inability to cross or dilate a coronary stenosis with a balloon) [1]. Among the many devices for PCI, rotational atherectomy (RA) has shown high procedural success rates with non-crossable calcified stenosis [2]. It is well known that RA for this frustrating subset is limited by the required size of guiding catheters and the ability to cross the lesion with a dedicated RotaWire [3], and 1.25 mm burr passage failure after successful RotaWire delivery is uncommon situation. In this report, we present a case in which 1.25 mm rotational burr non-crossable heavily calcified lesion was successfully treated by the RA through 6 in 8Fr inner guiding system.

BACKGROUND Impaired exercise tolerance with dyspnea is common in hypertensive patients and this may be due to the exaggeration of nonuniform ventricular activation during exercise. So we want to evaluate the effect of left ventricular hypertrophy (LVH) on systolic intraventricular dyssynchrony during exercise. METHODS A total of 85 patients with hypertension who having exertional dyspnea and 30 control individuals were enrolled. Exercise stress echocardiography was performed using a symptom limited, multistage supine bicycle test. To evaluate the dyssynchrony of left ventricular (LV), we calculated the standard deviation (SD) of the averaged time-to-peak systolic velocity (TPs-SD, ms) of 12 middle and basal LV segments obtained from the three standard apical views at rest and peak exercise. RESULTS There was no significant difference in systolic blood pressure (BP) and heart rate between the two groups. TPs-SD was significantly higher in patients with LVH at rest (31.5 ± 12.1 vs. 22.0 ± 12.6 ms, p = 0.002) with exaggeration of the degree at peak exercise (39.0 ± 11.9 vs. 24.6 ± 13.3 ms, p < 0.001). Multiple regression analysis showed LV mass index was independently associated with LV dyssynchrony at peak exercise (β = 0.515, p = 0.001) when controlled for age, sex, and systolic BP at peak exercise. CONCLUSION Intraventricular systolic dyssynchrony during exercise is significantly associated with the degree of LVH in hypertensive patients.

Aim: Cardiovascular disease is the most common cause of death in patients undergoing dialysis. The accuracy of multidetector computed tomography (MDCT) for detecting coronary disease has not been determined, and little information is available regarding the performance of MDCT in patients undergoing dialysis. Methods: Twenty-nine patients undergoing dialysis were analyzed and MDCT and coronary angiography (CAng) were performed consecutively. The coronary arteries were divided into four segments for analysis. We compared the significant stenosis lesions (≥50% luminal narrowing) identified by MDCT with those found by CAng. The total coronary artery calcium (CAC) score was determined by summing the individual lesion scores from each of the coronary branches. Results: One hundred and sixteen coronary artery branches in 29 patients were analyzed. The sensitivity, specificity, and positive and negative predictive values of MDCT for detecting significant coronary artery stenosis (≥50% stenosis) were 68%, 94%, 71% and 93%, respectively. The CAC scores were significantly higher in subjects with coronary artery disease (CAD) (514.0 ± 493.6 vs 254.3 ± 375.3, P = 0.05). The severe CAC score (>500) was related to the presence of significant CAD (P = 0.05) and the sensitivity and specificity for detecting significant CAD were 50% and 80%, respectively. Conclusion: MDCT is a useful and non-invasive approach for detecting or excluding CAD in patients undergoing dialysis.

Background Retrograde approach through collateral channels was recently proposed to increase the success rate of percutaneous coronary intervention (PCI) for coronary chronic total occlusion (CTO), but this approach is still an incompletely described technique. Methods We analyzed 24 cases of retrograde PCI for CTO, which were done from July 2006 to April 2008. Results Septal collaterals were more frequently used than epicardial collaterals (75% vs. 25%), without showing statistical differences in wire passage rate according to the size or location of the collaterals. Once the retrograde wire successfully crossed collateral (18/24 cases), CTO lesion was successfully crossed in all cases by using 4 different kinds of techniques: retrograde wire crossing (44%), kissing wire (22%), controlled antegrade and retrograde subintimal tracking (22%), and reverse controlled antegrade and retrograde subintimal tracking (11%). Among them, successful recanalization was achieved in 17 cases, yielding 71% retrograde PCI success rate. In failed cases with retrograde approach, 4 cases were recanalized by switching to antegrade approach. Thus, total PCI success rate was 88% (21/24 cases). There were several cases of unexpected complications mainly related to collateral-donor artery without in-hospital major adverse cardiac events (MACE). During clinical follow-up (median 10.3 months), overall MACE rate was 18% in the successful retrograde PCI group. Conclusions The retrograde approach can improve the success rate with PCI for CTO. However, strict case selection with systemized approach is essential due to the technical complexities accompanied by the potential risk of unexpected complications.

Induced pluripotent stem cells (iPSCs) produce exosomes, which underlie the restorative effects in the injured myocardium. These nanoscale vesicles attenuate the innate immune response in the post-injury myocardium. The secretome of the human amniotic mesenchymal stem cells (hAMSCs) are known to

A 38-year-old woman who had undergone pelvic lymphangioma resection two months previously presented with cough and dyspnea. Transthoracic echocardiography and CT demonstrated the presence of a mixed cystic/solid component tumor involving the inferior vena cava, heart and pulmonary artery. Complete resection of the cardiac tumor was performed and lymphangioma was confirmed based on histopathologic examination. To the best of our knowledge, this is the first report of lymphangiomatosis with cardiac and pelvic involvement in the published clinical literature.

Although normal or exaggerated early diastolic mitral annular velocity (E') provides an excellent specificity for differentiating constrictive pericarditis (CP) from restrictive cardiomyopathy (RCM), its sensitivity has been shown to be lower, especially in patients with CP who had underlying myocardial abnormality. This study sought to evaluate the incremental value of systolic mitral annular velocity (S') and time difference between onset of mitral inflow and onset of E' (T(E'-E)) for differentiation between CP and RCM. This study included 44 participants (28 male, 16 female; mean age 47 years, range 10-76): 17 patients with CP, 12 with RCM, and 15 control subjects. Standard mitral inflow Doppler and tissue Doppler echocardiography were performed. E' (9.5 +/- 1.7 vs 4.7 +/- 1.6 cm/s, P.001) and S' (7.7 +/- 1.3 vs 4.6 +/- 1.9 cm/s, P.001) were significantly higher, whereas T(E'-E) (21.0 +/- 32.0 vs 53.1 +/- 30.4 milliseconds, P = .02) was significantly shorter in patients with CP than with RCM. Diagnostic accuracy of E' for differentiation of CP from RCM was higher than S' or T(E'-E) (area under curve 0.99 vs 0.87 vs 0.74, respectively). E' of 8 cm/s had excellent specificity (100%) for differentiation of CP from RCM but sensitivity (70%) was relatively low. However, when combining E' with S' and T(E'-E), the sensitivity could be increased when compared with E' alone (70% with E', 88% with E' + S', and 94% with E' + S' + T(E'-E)), P = .001). In conclusion, the measurement of S' and T(E'-E) can be helpful for differentiating between CP and RCM by providing incremental diagnostic information to E'.

Autologous mesenchymal stem cell (MSC) transplantation therapy for repair of myocardial injury has inherent limitations due to the poor viability of the stem cells after cell transplantation. Adhesion is a prerequisite for cell survival and also a key factor for the differentiation of MSCs. As a novel prosurvival modification strategy, we genetically engineered MSCs to overexpress tissue transglutaminase (tTG), with intention to enhance adhesion and ultimately cell survival after implantation. tTG-transfected MSCs (tTG-MSCs) showed a 2.7-fold and greater than a twofold increase of tTG expression and surface tTG activity, respectively, leading to a 20% increased adhesion of MSCs on fibronectin (Fn). Spreading and migration of tTG-MSCs were increased 4.75% and 2.52%, respectively. Adhesion of tTG-MSCs on cardiogel, a cardiac fibroblast-derived three-dimensional matrix, showed a 33.1% increase. Downregulation of tTG by transfection of small interfering RNA specific to the tTG resulted in markedly decreased adhesion and spread of MSCs on Fn or cardiogel. tTG-MSCs on Fn significantly increased phosphorylation of focal adhesion related kinases FAK, Src, and PI3K. tTG-MSCs showed significant retention in infarcted myocardium by forming a focal adhesion complex and developed into cardiac myocyte-like cells by the expression of cardiac-specific proteins. Transplantation of 1 × 106 MSCs transduced with tTG into the ischemic rat myocardium restored normalized systolic and diastolic cardiac function. tTG-MSCs further restored cardiac function of infarcted myocardium as compared with MSC transplantation alone. These findings suggested that tTG may play an important role in integrin-mediated adhesion of MSCs in implanted tissues.Disclosure of potential conflicts of interest is found at the end of this article.

BACKGROUND Function of right ventricle (RV) influences on symptoms and prognosis in various diseases. However the regional RV function analyzed with 2-dimensional (2D) strain echocardiography before and just after treadmill test has not been evaluated. The aim of this study was to show the change of regional RV function just after treadmill exercise with strain analysis. METHODS A total of thirty eight patients who visited hospital for hypertension, chest pain or dyspnea between January 2007 and December 2010 were retrospectively analyzed (men, 47.4%; mean age, 54.9 ± 7.2 years). Treadmill exercise test and pre and post echocardiography were performed. 2D strain echocardiography was analyzed off line in RV free wall and septum. RESULTS Mean exercise duration was 737 ± 132 sec. Tissue velocity in lateral tricuspid annulus is significantly increased in post exercise (initial, 10.5 ± 2.4 cm/sec vs. post exercise, 12.2 ± 1.8 cm/sec, p = 0.006). Systolic strain of RV free wall apex and mid portion were significantly changed in post exercise stage (free wall apex, -18.2 ± 7.6% vs. -22.3 ± 5.8%, p = 0.010; free wall mid, -14.1 ± 6.7% vs. -22.6 ± 6.8%, p = 0.022). CONCLUSION 2D strain imaging provides a precise tool to quantify regional RV function and reveals a characteristic regional pattern of RV after treadmill exercise.

A 64-year-old woman was admitted due to exertional dyspnoea (New York Heart Association functional class III) and pitting oedema. She had a past medical history of hypertension 4 years ago and hypercholesterolaemia 3 years ago. Her electrocardiogram showed normal sinus rhythm with enlargement of left atrium (LA). The echocardiogram showed …

Contrast-enhanced multi-detector row spiral computed tomography (MDCT) was introduced as a promising noninvasive method for vascular imaging. This study examined the accuracy of this technique for detecting significant coronary artery stenoses. Both MDCT(Sensation 16, Siemens, Germany, 12 × 0.75 mm collimation and 0.42 sec rotation speed, 120 kV, 500 effective mA, and 2.7 mm/rotation table-feed) and invasive coronary angiography (CAG) were performed on 61 patients (mean age 59.2 ± 10, 44 men) who were suspected of having coronary artery disease. All patients were treated with atenolol (25 - 50 mg) prior to imaging and the heart rate was maintained below 65 beats per minutes during image acquisition. The images were reconstructed in the diastole around TI - 400 ms with a 0.5 mm increment and a 1.0 mm thickness. All coronary arteries with a diameter of 2.0 mm or more were assessed for the presence of a stenosis (> 50% luminal narrowing). Two independent radiologists who were unaware of the results of the invasive CAG evaluated the MDCT data, and the results were compared with those from the invasive CAG (interval 1- 27, mean 11 days). An evaluation of the CT coronary angiogram (CTCA) was possible in 58 of the 61 patients (95%). Image acquisition of the major coronary arteries including the left main trunk was available in 229 out of 244 arteries. Invasive CAG showed that 35 out of 58 patients had significant coronary artery stenoses by. patient analysis of those who could be evaluated showed that CT coronary angiography correctly classified 30 out of 35 patients as having at least 1 coronary stenosis (sensitivity 85.7%, specificity 91.3%, positive predictive value 93.8%, negative predictive value 80.8%). By analyzing each coronary artery, CAG found 62 stenotic coronary arteries in the 229 coronary arteries that could be evaluated. MDCT correctly detected 50 out of 62 stenotic coronary arteries and an absence of stenosis was correctly identified in 156 out of 167 normal coronary arteries (sensitivity 80.6%, specificity 93.4%, positive predictive value 81.9%, negative predictive value 92.8%). The non-invasive technique of MDCT for examining the coronary artery appears to be a useful method for detecting coronary artery stenoses with a high accuracy particularly with the proximal portion and large arteries.

We sought to determine whether insulin resistance (IR) is related to arterial stiffness in nondiabetic hypertensive patients, independent of metabolic status and gender. IR has been associated with increased arterial stiffness in patients with diabetes. In nondiabetic hypertensive patients, the correlation between IR and arterial stiffness has yet to be investigated. We enrolled 284 nondiabetic patients who were being treated for hypertension. At the time of enrollment, the patients underwent a baseline laboratory assessment including homeostatic model assessment (HOMA) IR index and pulse wave velocity (PWV). The HOMA IR index is used as a marker of IR, and brachial to ankle PWV (baPWV) was used as a marker of arterial stiffness. Of the 284 study subjects, 121 were classified as having metabolic syndrome. The patients with metabolic syndrome were older than the non-metabolic syndrome patients (55.4+/-10.7 vs. 52.1+/-11.6 years, p=0.013), but there was no gender difference between the two groups. The average baPWV was significantly higher in the patients with metabolic syndrome (1,506+/-235 vs. 1,435+/-211 cm/s, p=0.009). The HOMA index was independently associated with an increase in arterial stiffness (r=0.548, p

Renal artery stenosis is an important cause of secondary hypertension as well as ischemic nephropathy. The purpose of this study was to determine the clinical predictors in patients with renal artery stenosis in a population referred for coronary angiography. From March 1998 to July 1999, 1459 patients undergoing coronary angiography for various indications were routinely screened for renal artery stenosis by undergoing abdominal aortography. Coronary angiography, carotid angiography, and abdominal aortography was performed via either the radial or the femoral approach. The data were analyzed retrospectively. Out of 1459 patients undergoing abdominal aortography, 158 (10.8%) were found to have significant renal artery stenosis with 24 of the patients having bilateral stenosis. Significant coronary artery diseases were found in 994 of the 1459 study population (68.1%), with 134 (13.5%) of these patients having concomitant renal artery stenosis. Multivariate logistic regression showed that extracranial carotid artery stenosis odds ratio [(OR) 4.89 (95% confidence interval 2.57-9.33), P0.001], peripheral artery disease [OR 4.64 (2.65-9.33), P0.001], renal insufficiency [OR 2.68 (1.43-5.02), P = 0.002], significant coronary artery disease [OR 2.01 (1.12-3.59), P = 0.019], hypercholesterolemia [OR 1.92 (1.07-3.43), P = 0.028], hypertension [OR 1.85 (1.16-2.95), P = 0.010], and old age (60 years) [OR 1.64 (1.01-2.64), P = 0.044] were significant clinical predictors of renovascular disease. The prevalence of indolent atherosclerotic renal artery stenosis is relatively high in selected groups of patients with high clincial risk factors for this underdiagnosed disease. Renal artery stenosis should be highly suspected in patients who have these risk factors because early detection of this disease may reverse the progression to chronic renal failure and end-stage renal disease.

REFER TO THE PAGE 135-143 By American Heart Association statistics updated at 2013, more than one in three female adults has some form of cardiovascular disease (CVD). Since 1984, the number of CVD deaths for females has exceeded those for males.1) Twenty-six percent of women age 45 and older who have an initial recognized myocardial infarction (MI) die within a year compared with 19% of men. In addition, 64% of women who died suddenly of coronary heart disease (CHD) had no previous symptoms.1) Compared with men, women have a 10-to-20-year lag in the initial presentation of CHD. Additionally, women do not always present with the "characteristic" pattern of chest pain. Other typical symptoms for women during their initial presentation include shortness of breath, diaphoresis, nausea, epigastric pain, and fatigue.2) Therefore, early diagnosis of CHD is very important to women to reduce the incidence of disease and prevent sudden cardiac death. However it is not easy. Electrocardiograms and exercise electrocardiograms are less sensitive to changes in women, making it more difficult for providers to diagnose CHD.3) What was worse, as seen on angiography, plaque in women tends to be distributed diffusely, rather than in clumps, causing women's angiographic studies to be misinterpreted as "normal".4) We also should consider the risk factors that affect women specifically. For example, men tend to develop hypertension at younger ages than women; women's low-density lipoprotein cholesterol levels tend to be lower than men's at younger ages but exceed those of men in advanced age; and while triglyceride levels decline in men of middle and older age, they rise in women of comparable ages.5) Therefore, the addition of the measurement of C-reactive protein to screening based on lipid levels may provide an improved method of identifying women at risk for cardiovascular events.6) The wide spread use of echocardiography has contributed to the early recognition of several distinct cardiac diseases in women as well as management of women-specific cardiac diseases.7) Dobutamine stress echocardiography (DSE) is being used for the diagnosis of CHD especially patients with chest pain who cannot exercise adequately. And this test showed sensitivity for detecting coronary artery disease of 78% and a specificity of 93%.8) DSE is especially useful in women with chest pain because as we commented above, electrocardiograms and exercise electrocardiograms are less sensitive to changes in women and this test has been relatively high sensitivity and specificity. In this issue, DSE and execise electrocardiography for the detection of CHD in women with chest discomfort was compared.9) About two hundred consecutive female patients who presented with chest pain in outpatient clinic, and who underwent treadmill exercise test (TET), DSE and coronary angiography were included for the study. The results showed that the sensitivity and specificity were higher with DSE (70.4, 94.6%) than TET (53.7, 73.6%) for detection of > 50% CHD. And DSE also showed greater diagnostic accuracy than TET by > 75% CHD criteria, and in subsets of patient with intermediate pretest probability. This manuscript is meaningful to compare TET and DSE in Korean women with chest pain. And as a result, demonstrated that DSE had a higher diagnostic value than TET in Korean female patients and as the disease severity of CHD worse, DSE had greater diagnostic accuracy than TET. However, the sensitivity of both tests to diagnose CHD in this study appeared lower than previously reported values.10),11) The reason may be lower prevalence of CHD, and much more patients with only single vessel disease in this study compared to previous study. One thing we should know is that, enrolled all patients came to outpatient clinic with vague chest pain, so the possibility of severe CHD was somewhat low. If they had more severe CHD such as unstable angina or MI, the test results might be different from those of this manuscript. Recently, multimodality imaging such as CT, MRI and strain analysis also showed very high sensitivity and specificity for detection of CHD. And the prevalence of women's CVD had been increased gradually. Therefore, much more studies regarding best diagnostic accurate modality in women's heart field, management and prognosis should be performed continuously.

Background Fundamental echocardiography has some drawbacks in patients with difficult-to-image echocardiograms. The aim of this study is to evaluate impact of contrast echocardiography (CE) on ventricular function assessment and clinical diagnosis in routine clinical echocardiography. Methods Two hundred sixty patients were prospectively enrolled over 3 years in 12 medical centers in Korea. General image quality, the number of distinguishable segments, ability to assess regional wall motion, left ventricular (LV) apex and right ventricle (RV) visualization, LV ejection fraction, changes in diagnostic or treatment plan were documented after echocardiography with and without ultrasound contrast agent. Results Poor or uninterpretable general image was 31% before contrast use, and decreased to 2% (p

Cardiovascular disease is the most common cause of death in patients undergoing dialysis. The accuracy of multidetector computed tomography (MDCT) for detecting coronary disease has not been determined, and little information is available regarding the performance of MDCT in patients undergoing dialysis.Twenty-nine patients undergoing dialysis were analyzed and MDCT and coronary angiography (CAng) were performed consecutively. The coronary arteries were divided into four segments for analysis. We compared the significant stenosis lesions (≥50% luminal narrowing) identified by MDCT with those found by CAng. The total coronary artery calcium (CAC) score was determined by summing the individual lesion scores from each of the coronary branches.One hundred and sixteen coronary artery branches in 29 patients were analyzed. The sensitivity, specificity, and positive and negative predictive values of MDCT for detecting significant coronary artery stenosis (≥50% stenosis) were 68%, 94%, 71% and 93%, respectively. The CAC scores were significantly higher in subjects with coronary artery disease (CAD) (514.0 ± 493.6 vs 254.3 ± 375.3, P = 0.05). The severe CAC score (500) was related to the presence of significant CAD (P = 0.05) and the sensitivity and specificity for detecting significant CAD were 50% and 80%, respectively.MDCT is a useful and non-invasive approach for detecting or excluding CAD in patients undergoing dialysis.

Background: A large number of studies have demonstrated that left ventricular hypertrophy (LVH) detected with standard electroand echocardiography is an independent predictor of future cardiovascular complications in various subsets of patients. Due its low cost and wide availability electrocardiography represents the first line test for the assessment of cardiac organ damage in hypertensive patients. However a significant limitation is represented by its low sensitivity in detecting LVH. Aim of this study was to evaluate the prevalence of LVH detected by electroor echocardiography and the relationship between these two measures in a general population sample(Vobarno study). Methods: A total of 385 subjects (mean age 57 10years,44%males,64% hypertensives,44% overweight and 16%obese)underwent clinical examination with blood pressure measurement,standard laboratory examinations,a 12 leads electrocardiogram standard and standard echocardiography.EKGLVH was defined as the presence of a Sokolow-Lyon voltage 38 mm and/ or a Cornell voltage QRS duration product>2440 mm*msec and/or R in aVL;Echo-LVH was defined as LVM>50 g/m2.7 in men and 47g/m2.7 in women. Results: LVH prevalence was 5.1% and 16.3% with EKG and Echo,respectively.LVH was detected by both methods only in 2.0% of patients.The prevalence of EKG-LVH was 1.7% with Sokolow-Lyon voltage,4.2% with Cornell product and 5.1% with both EKG criteria.In hypertensives the prevalence of LVH was significantly greater than normotensives(6.8% vs 2.2% with EKG-LVH and 22.7% vs 9.6% with Echo).The concordance of the two techniques in identifying patients with LVH was only partial,and in particular,among patients with EKG-LVH a significant proportion(39%) did not have echo-LVH.However,patients with EKG-LVH but without Echo-LVH had greater LV mass index(39.9 vs 34.4 gr/m2.7,p

Intravascular ultrasonography (IVUS) imaging is a user-friendly technique widely used during coronary interventions. An 80-year-old man was admitted with chest pain, and successful percutaneous coronary intervention was performed with stent implantation. One week later, the patient complained of further chest pain. Urgent coronary angiography showed total occlusion of the middle left anterior descending artery and the aspiration of thrombi was high. IVUS imaging showed inadequate stent strut apposition and distal dissection. We attempted another stent implantation but the IVUS catheter was stuck on the 0.014 inch wire. Therefore, we tried to pass the wire across the lateral side. After the wire was successfully passaged, the sprinter balloon was passed through the crushed stent to expand it. After 4 days later, the patient was discharged with no symptoms or electrocardiographic change.

A retrograde approach through the collateral channels is considered to improve the success rate of percutaneous coronary intervention for coronary chronic total occlusion (CTO). Various kinds of strategies and techniques are required to improve the success rate of this novel approach. We describe a case in which a CTO was successfully recanalized by the retrograde approach, using a new anchoring balloon technique (double anchoring balloon technique) which enabled the successful balloon passage through the hard CTO lesion.

Background Because the ratio of mitral inflow and annular velocity to stroke volume has been reported as an index of diastolic elastance (Ed), the hypothesis tested in the present study was that Ed during exercise would be more abnormal in female than in male patients with type 2 diabetes. Methods and Results Ed was measured at rest and during graded supine bicycle exercise (25W, 3-min increments) in 53 patients (27 males, mean age 53±14 years) with type 2 diabetes and 53 age- and gender-matched controls. The patients with diabetes were divided into 2 groups by gender. Ed was not significantly different at rest between men and women, but was significantly higher during exercise in women than in men (25 W, 0.15±0.04 vs 0.20±0.07, p=0.009; 50 W, 0.16±0.05 vs 0.21±0.08, p=0.0175). Conclusion Left ventricular (LV) diastolic elastance is abnormal during exercise, but not at rest, in patients with diabetes without overt heart disease. Female gender was associated with increased LV stiffness during exercise among patients with type 2 diabetes. (Circ J 2008; 72: 1443 - 1448)

Background Secondary tricuspid regurgitation (TR) as a result of pulmonary hypertension and/or left-sided heart disease is caused by tricuspid valve (TV) annular dilatation and tethering of the tricuspid leaflet after right ventricular (RV) dilatation. However, the mechanism of isolated TR without significant pulmonary hypertension remains unknown. The present study investigated the RV function and TV deformations in patients with isolated TR to find out the mechanism and etiology of the disease. Methods and Results Twelve patients with isolated, severe TR were included. RV area, volume, ejection fraction (EF), tenting distance and tenting area were measured. These parameters were compared with 12 age-and gender-matched controls and 12 patients with secondary TR. The cause of isolated TR was incomplete coaptation associated with annular dilatation without other problems. Compared with the controls, RV end-diastolic volumes and annular diameters were significantly larger and RVEF was significantly lower in patients with isolated TR. Tenting area and tenting distance were also significantly higher. However, there were no significant differences in these parameters between patients with isolated and secondary TR. Conclusions Isolated TR was associated with RV remodeling, systolic dysfunction and resultant annular dilatation and tethering of tricuspid leaflets. (Circ J 2008; 72: 1645 - 1649)

Percutaneous coronary intervention (PCI) of a chronic total occlusion (CTO) caused by in-stent restenosis (ISR) is sometimes very difficult due to the presence of hard occlusive components that prevent wire passage. We report a case of CTO caused by ISR (ISR-CTO) in which the occlusion was crossed with the wire subintimally along the outside of the stent and was successfully re-stented. Subintimal tracking along the outside of the stent can be considered as another approach for PCI of ISR-CTO in cases where conventional approaches fail.

Left ventricular hypertrophy (LVH) is associated with a reduction of subendocardial coronary flow reserve, which may be associated with abnormal myocardial longitudinal function during exercise. To test this hypothesis, 182 hypertensive patients underwent multistage supine bicycle exercise testing. Patients were classified as follows: patients with normal geometry (group 1, n = 116), concentric remodeling (group 2, n = 31), or LVH (group 3, n = 31). The results showed that the ratio of E/E', an index of left ventricular (LV) filling pressure, was significantly elevated in the LVH group at rest and during exercise. At rest, the mitral annular systolic velocity (S') was similar between the three groups at rest, whereas S' during exercise was significantly lower in the LVH group. The magnitude of change in S' during exercise was also significantly lower in the LVH group. Multiple linear regression analysis showed that peak double product (beta = 0.208, P = .006) and LV mass index (beta = -0.158, P = .028) were independently associated with LV longitudinal contractile reserve. Also, multiple linear regression analysis showed that changes in S' from baseline to peak were independently associated with exercise duration (beta = 0.123, P = .041) when controlled for age, male gender, baseline E', peak systolic blood pressure, and LV mass index. The results from this study demonstrate that LVH was significantly associated with abnormal LV longitudinal contractile reserve in hypertensive patients.

Relative aldosterone excess is associated with endothelial dysfunction and higher incidence of end organ damage. We sought to investigate whether plasma aldosterone-to-renin ratio (ARR) is associated with left ventricular (LV) longitudinal function reserve to exercise in patients with controlled hypertension. In the patients with controlled and uncomplicated hypertension without overt LV hypertrophy, plasma aldosterone concentrations (ng/dL) and renin activities (ng/mL/h) were measured. Then 28 consecutive patients with higher ARR (group II, ARR > or = 30, 55 +/- 10 years) and 56 age- and sex-matched patients with lower ARR (group I, ARR < 30) underwent supine bicycle exercise echocardiography. Despite similar 24-hour blood pressure, LV mass index was significantly higher in group II (91.1 +/- 16.4 vs 101.7 +/- 18.2 g/m(2), P = .008). Early diastolic and systolic mitral annular velocity (E' and S', cm/s) at 50-W exercise was significantly lower in group II compared with group I (9.91 +/- 1.66 vs 8.67 +/- 1.65 cm/s, P = .002; 9.52 +/- 1.71 vs 8.46 +/- 1.79, P = .010, respectively) despite similar resting values. Longitudinal diastolic functional reserve at 25-W and 50-W exercise, defined as DeltaE' (change from resting E', cm/s) of group II was significantly lower than that of group I (2.60 +/- 1.42 vs 1.85 +/- 1.44 cm/s, P = .016; 3.40 +/- 1.48 vs 2.36 +/- 1.43 cm/s, P = .003, respectively). In conclusion, in patients with hypertension without overt LV hypertrophy, increased ARR is associated with increased LV mass, and impaired LV longitudinal functional reserve during exercise.

Background and Objectives: We assessed the ability of portable echocardiography (with contrasts) to clearly delineate the cardiac structure, and evaluated the impact of its use on the diagnosis and management of critically ill patients in Korea. Subjects and Methods: We prospectively enrolled 123 patients (mean age 66±16 years), who underwent portable transthoracic echocardiography (with contrast) for image enhancement at 12 medical centers. The quality of the global left ventricular (LV) images, the number of the regional LV segments visualized, the ability to visualize the LV apex and the right ventricle (RV), and any changes in the diagnostic procedure and treatment strategy were compared before and after the contrast. Results: Of the 123 patients, 52 (42%) were using mechanical ventilators. The amount of poor or uninterpretable images decreased from 48% to 5% (p

We sought to determine the accuracy of myocardial contrast echocardiography (MCE)-derived index of myocardial blood flow and myocardial blood volume fraction (MBVF) in predicting transmural extent of infarction and wall-motion recovery.Low and high mechanical index MCE and contrast-enhanced magnetic resonance imaging were performed 5 to 7 days after successful percutaneous revascularization in 30 patients with acute myocardial infarction and regional wall-motion change was assessed 3 months later. The index of myocardial blood flow was calculated as A x beta (dB/s) using the equation y = A (1 - e(-beta t)), which fits the replenishment curve of low mechanical index MCE. The MBVF (mL/100 g myocardium) was calculated as 100 x 10(relative contrast intensity [CI]/10), using the relative CI by subtracting the cavity CI from the adjacent transmural CI using high mechanical index MCE. The contrast-enhanced magnetic resonance imaging-derived transmural extent of delayed hyperenhancement (DE) in 16 segments were measured and compared with corresponding MCE data.Among 480 segments, 382 measurable segments were subdivided into 5 groups as follows: no DE, 1% to 25% DE, 26% to 50% DE, 51% to 75% DE, and 76% to 100% DE. An increment of the extent of DE was significantly related to a decrement of A x beta (P.001) and MBVF (P.001). The optimal cut-off MBVF for predicting greater than 50% DE was 1.92 mL (sensitivity 82%, specificity 73%, P.01), and persistently dysfunctional motion was 1.81 mL (sensitivity 74%, specificity 75%, P.01).The MCE-derived A x beta and MBVF can be effective predictors of transmural extent of infarction and wall-motion recovery in the reperfused acute myocardial infarction.

C-reactive protein (CRP) has been known to be associated with vascular inflammation and hypertension. Pulse wave velocity (PWV) increases according to the degree of the arterial stiffness in hypertension patients. Therefore, PWV may be correlated with CRP levels in treated hypertensive patients, irrespective of medication. We sought to determine whether there is a correlation between hsCRP and arterial stiffness in non-diabetic treated hypertensive patients, independent of cardiovascular risk factor. This study consisted of 424 non-diabetic patients at least 45-years-old who were being treated for hypertension. At the time of enrollment, the patients underwent a baseline laboratory assessment of C-reactive protein levels and pulse wave velocity (PWV). Heart to femoral PWV (hfPWV) and brachial to ankle PWV (baPWV) were used as a marker of arterial stiffness. Subjects were categorized according to tertiles of hsCRP level [Group 1: first tertile (0.20-0.46 mg/L), Group 2: second tertile (0.47-1.15 mg/L), Group 3: third tertile (1.17-9.71 mg/L)]. Group 1 consisted of 141 patients (mean age 58+/-8 years), Group 2 had 142 patients (mean age 60+/-9 years) and Group 3 had 141 patients (mean age 61+/-8 years). The hfPWV and baPWV increased significantly along with the hsCRP level. Group 1, Group 2 and Group 3 demonstrated hfPWV and baPWV of 965+/-199 and 1438+/-246, 975+/-174 and 1487+/-258 and 1043+/-215 and 1566+/-252 cm/s, respectively (p

Background Non-dippers are known to carry a high risk of cardiovascular complications due to higher cumulative 24-h pressure load over time. In this study, we hypothesized that non-dippers would be associated with adverse cardiac remodeling and left ventricular (LV) dysfunction in treated hypertensive patients. Materials and methods A total of 150 outpatients treated with antihypertensive drugs for at least 1 year were enrolled. The patients were classified as non-dippers if their daytime ambulatory systolic and diastolic BP did not decrease by at least 10% during the night. LV diastolic function was assessed by measuring mitral inflow velocity ( E ), early diastolic mitral annulus tissue velocity ( E ′) and LV systolic function was assessed by measuring systolic tissue velocity ( S ′), longitudinal systolic strain and strain rate. Results The Cornell voltage product, LA volume index and LV mass index was significantly higher in non-dippers. Early diastolic mitral annulus tissue velocity ( E ′) was lower and E / E ′ was higher in non-dippers suggestive of diastolic dysfunction. Systolic tissue velocity ( S ′), systolic strain and strain rate were significantly lower in non-dippers suggestive of systolic dysfunction. The non-dipper status, controlled for age, sex and LV mass index showed significant correlation with E ′ ( β =−0.203, P =0.002), E / E ′ ( β =0.354, P S ′ ( β =−0.231, P =0.002), strain ( β =−0.162, P =0.040) and strain rate ( β =−0.186, P =0.015). Conclusions This study showed the non-dippers in treated hypertensive patients were associated with adverse cardiac remodeling and early LV dysfunction. Further studies to demonstrate the long term prognostic significance of this finding is warranted.

Noncompaction of the ventricular myocardium (NVM) is a rare cardiac abnormality of unknown etiology. The condition is characterized by prominent and excessive trabeculations in a ventricular wall segment, with deep intertrabecular spaces perfused from the ventricular cavity. Polycystic kidney diseases are characterized by the formation of multiple cysts in the kidneys and liver and, less frequently, in the pancreas. Cardiovascular abnormalities including hypertension, mitral valve prolapse, and intracranial aneurysms are also frequently recognized. However, polycystic kidney disease and isolated ventricular noncompaction have not previously been correlated. Here, we describe one case of isolated noncompaction of ventricular myocardium with polycystic kidney disease, coupled with a progressive worsening of heart failure. We confirmed these abnormalities using contrast echocardiography, abdominopelvic computed tomography, and cardiac magnetic resonance imaging.

Purposes: We assessed the association between arterial stiffness, as determined by brachial ankle pulse wave velocity (baPWV), and the extent of coronary artery disease (CAD) by conventional coronary angiography (CAG) in patients who visited outpatient clinic for angina without any previous history of heart disease. Method: We retrospectively analyzed the data of 583 consecutive patients who had undergone baPWVand elective CAG for suspected CAD between January 2012 and November 2013 in single cardiovascular center. Results: The baPWV was one of the statistically meaningful predictors of significant CAD (diameter of stenosis >50%) in addition to male gender, age, the level of HDL-cholesterol and HbA1c in multivariate analysis. However, baPWV was not the significant predictor of revascularization. When the extent of CAD was classified into following 4 groups; no significant CAD, 1-, 2and 3-vessel disease, there was significant difference of baPWV between the significant and non significant CAD group, but there was no difference of baPWV among the three significant CAD groups, although there was trend toward the positive correlation. Conclusion: Although baPWV was an independent predictor of significant CAD, it was not significantly associated with the extent of CAD.

Are left ventricular hypertrophy (LVH) in electrocardiography (EKG) an accurate increased lv mass and a surrogate marker for cardiovascular events in hypertensive patients? Hye-Sun Seo, Mi-Jeong Kim, In Hyun Jung. Incheon St.Marys Hospital, the Catholic University of Korea, Incheon, Korea, Republic of; Sejong General Hospital, Bucheon, Korea, Republic of; Soonchunhyang Universtiy Hospital, Bucheon, Korea, Republic of

One of the major limitations of transradial coronary intervention is the inability to use large guiding system, which leads to the development of dedicated sheathless guide catheter system. However, these devices are not available in the Republic of Korea. We present a case in which conventional guiding catheter was used for sheathless transradial coronary intervention in the treatment of complex coronary anatomy.