Search

Because of paucity of published data, we evaluated the 2-year major clinical outcomes between early invasive (EI) and delayed invasive (DI) strategies according to the stage of chronic kidney disease (CKD) in patients with non-ST-segment elevation myocardial infarction (NSTEMI), who underwent a successful newer-generation drug-eluting stent (DES) implantation.A total of 8241 NSTEMI patients were recruited from the Korea Acute Myocardial Infarction Registry (KAMIR). Based on baseline estimated glomerular filtration rate (eGFR; ≥90, 60-89, 30-59, and30 mL/min/1.73 mAfter multivariable-adjusted and propensity score-adjusted analyses, the cumulative incidence of MACE (group A, p = 0.139 and p = 0.103, respectively; group B, p = 0.968 and p = 0.608, respectively; group C, p = 0.111 and p = 0.196, respectively; group D, p = 0.882 and p = 0.571, respectively), all-cause death, re-MI, and any repeat revascularization was similar between the EI and DI groups in the 4 different renal function groups.In the era of newer-generation DES, EI and DI strategies showed comparable major clinical outcomes in patients with NSTEMI and CKD during a 2-year follow-up period. However, to confirm these results, further randomized, large-scale, long-term follow-up studies are needed.

Background: There is limited data comparing the Xience everolimus-eluting stent (EES) and the Resolute zotarolimus-eluting stent (ZES) with the BioMatrix biolimus-eluting stent (BES). Methods: This open-label, randomized, noninferiority trial enrolled all-comer patients to be randomly treated with either BES, EES, or ZES in a 1:1:1 ratio in 15 centers across South Korea. The primary end point was a device-oriented composite outcome consisting of cardiac death, target-vessel myocardial infarction, and clinically indicated target lesion revascularization at 24 months. The BES was compared with the EES and the ZES by intention-to-treat analyses with a noninferiority margin of 3.8%, respectively. Results: Because of slow recruitment and low event rates, this trial was prematurely terminated after enrollment of 1935 (75%) of the intended 2580 patients. Of the 1911 patients randomized to either EES (n=638), BES (n=634), or ZES (n =639), the rate of device-oriented composite outcome was 3.6%, 2.2%, and 3.9%, respectively, at 24 months (BES versus EES: absolute risk difference −1.4% [upper limit of 1-sided 95% CI: −3.2%]; P for noninferiority P for noninferiority Conclusions: The BES was noninferior to either the EES or the ZES in all-comer patients for device-oriented composite outcome at the 24-month follow-up. However, caution is advised regarding interpretation of these results due to the premature termination of this study. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT01397175.

Background Successful percutaneous coronary intervention (PCI) of the occluded infarct-related artery (IRA) in latecomers may improve long-term survival mainly by reducing left ventricular remodeling. It is not clear whether inhibition of renin–angiotensin system (RAS) brings additional better clinical outcomes in this specific population subset. Methods Between January 2008 and June 2013, 669 latecomer patients with acute ST-segment elevation myocardial infarction (STEMI) (66.2 ± 12.1 years, 71.0% males) in Korea Acute Myocardial Infarction Registry (KAMIR) who underwent a successful PCI were enrolled. The study population underwent a successful PCI for a totally occluded IRA. They were divided into two groups according to whether they were prescribed RAS inhibitors at the time of discharge: group I (RAS inhibition, n = 556), and group II (no RAS inhibition, n = 113). Results During the one-year follow-up, major adverse cardiac events (MACE), which consist of cardiac death and myocardial infarction, occurred in 71 patients (10.6%). There were significantly reduced incidences of MACE in the group I (hazard ratio = 0.34, 95% confidence interval 0.199–0.588, p = 0.001). In subgroup analyses, RAS inhibition was beneficial in patients with male gender, history of hypertension or diabetes mellitus, and even in patients with left ventricular ejection fraction (LVEF) ≥40%. In the baseline and follow-up echocardiographic data, benefit in changes of LVEF and left ventricular end-systolic volume was noted in group I. Conclusions In latecomers with STEMI, RAS inhibition improved long-term clinical outcomes after a successful PCI, even in patients with low risk who had relatively preserved LVEF.

Bariatric surgery is being considered as a therapeutic option for morbidly obese patients. Data are accumulating showing that this surgical intervention may improve in major cardiovascular morbidity and mortality. We evaluated the effects of bariatric surgery on left ventricular (LV) structure and function including LV mechanics in obese patients. Thirty-seven patients (age = 36 ± 10 years; male:female = 11:26) undergoing bariatric surgery were enrolled. Echocardiography was performed before and after at least 1 year of bariatric surgery. Conventional echocardiographic parameters, including tissue Doppler measurements, were measured. LV global longitudinal, circumferential, and radial deformations were assessed utilizing 2D speckle tracking software. Patients decreased body mass index by 11.8 ± 4.7 over 15.6 ± 5.5 months. Bariatric surgery led to significant decreases in left ventricular (LV) size and mass (51.0 ± 3.3 to 49.1 ± 3.4 mm, p

A 56 -year-old female with long-standing resistant hypertension to treatment with a combination of seven different drugs, referred for catheter-based radiofrequency renal denervation (RDN). A radial access was chosen because the patient was very obese and of short stature. This described renal denervation through the radial artery might represent an alternative for patients in whom femoral access is a higher-risk option, such as very obese patients and patients with peripheral artery disease or with a higher bleeding risk. Nevertheless, with the current available system, this approach is difficult and cannot be widely used, not only because of the length but also because of the stiffness of the catheter.

Objectives A pathophysiological mechanism of microvascular dysfunction in ST-segment elevation myocardial infarction (STEMI) is multifactorial; thus, multiple modalities were needed to precisely evaluate a microcirculation. Methods We complementarily assessed microcirculation in STEMI by the index of microcirculatory resistance (IMR) and coronary flow reserve (CFR) immediately after a primary percutaneous intervention in 89 STEMI patients. Cardiovascular and cerebrovascular events (MACCE) including cardiovascular death, target vessel failure, heart failure, and stroke were assessed during a mean follow-up period of 3.0 years. Results The microcirculation of enrolled patients was classified into four groups using cutoff CFR and IMR values (CFR>2 and mean IMR): group-1 (n=23, CFR>2 and IMR≤27); group-2 (n=31, CFR≤2 and IMR≤27); group-3 (n=9, CFR>2 and IMR>27); and group-4 (n=26, CFR27). On echocardiography 3 months later, improvement in the wall motion score index was shown in group-1 (P

Background Despite common use of second-generation drug-eluting stents in treating patients with coronary artery disease, there is lack of data comparing these stents exclusively in patients with acute myocardial infarction (AMI), especially with metabolic syndrome (MetS), which is highly prevalent in AMI and potential to worsen clinical outcomes. The aim of this study was to compare clinical outcomes of everolimus-eluting stent (EES) and Resolute-zotarolimus-eluting stent (R-ZES) in AMI patients with MetS, in terms of stent-related and patient-related outcomes. Methods A total of 3942 AMI patients in the KAMIR (Korea Acute Myocardial Infarction Registry) were grouped according to the presence of MetS and stent type: EES (N=1582) and R-ZES (N=255) in MetS (1837). Target lesion failure (TLF) and patient-oriented composite events (POCE) at 1 year were evaluated. Results In MetS patients, TLF (3.7% vs. 2.7%, p=0.592) and POCE (7.9% vs. 6.7%, p=0.764) were similar between EES and R-ZES. Also in Non-MetS patients, TLF (3.9% vs. 3.1%, p=0.307) and POCE (6.4% vs. 7.3%, p=0.866) were similar between 2 groups. TLF was similar between MetS and Non-MetS patients (3.6% vs. 3.8%), while POCEs (7.7% vs. 6.6%) were higher in MetS. Propensity-score matching analysis showed similar results between stent groups in MetS and Non-MetS. In multivariate analysis, left ventricular ejection fraction and symptom-to-door time were independent predictors of TLF and POCE in MetS patients with AMI. Conclusions In MetS patients with AMI, EES and R-ZES showed excellent performance and safety. However, patient-oriented composite events were relatively high, suggesting more efforts to improve them.

BACKGROUND: Atrial fibrillation (AF) can be a risk factor for development of significant tricuspid regurgitation (TR). We investigated which clinical and echocardiographic parameters were related to severity of functional TR in patients with lone AF. METHODS: A total of 89 patients with lone AF were enrolled (75 ± 11 years; 48% male): 13 patients with severe TR, 36 patients with moderate TR, and 40 consecutive patients with less than mild TR. Clinical parameters and echocardiographic measurements including right ventricular (RV) remodeling and function were evaluated. RESULTS: Patients with more severe TR were older and had more frequently persistent AF (each p < 0.001). TR severity was related to right atrial area and tricuspid annular systolic diameter (all p < 0.001). The patients with moderate or severe TR had larger left atrial (LA) volume and increased systolic pulmonary artery pressure (SPAP) than the patients with mild TR (p = 0.04 for LA volume; p < 0.001 for SPAP). RV remodeling represented by enlarged RV area and increased tenting height was more prominent in severe TR than mild or moderate TR (all p < 0.001). Multivariate analysis showed type of AF, LA volume, tricuspid annular diameter and tenting height remained as a significant determinants of severe TR. In addition, tenting height was independently associated with the presence of severe TR (p = 0.04). CONCLUSION: In patients with lone AF, TR was related to type of AF, LA volume, tricuspid annular diameter and RV remodeling. Especially, tricuspid valvular tethering seemed to be independently associated with development of severe functional TR.

A 27-year old male presented with acute inferior wall myocardial infarction. Coronary angiogram revealed normal left coronary arteries and a giant coronary aneurysm in Right coronary artery (RCA). Primary angioplasty of RCA was performed. Large thrombus burden was retrieved with aspiration device and coronary flow restored. However, despite best efforts some thrombus remained and decision to stent was deferred to a later date. Dimensions of aneurysm on quantitative coronary angiogram were 16 mm in width and 43 mm in length. Two weeks later coronary angiogram revealed normal flow in RCA without any angiographically visible thrombus. PCI was performed with two 3.0 × 28 mm covered stents, graft master (JoStent) deployed across the aneurysm, overlapping each other. This completely sealed the aneurysm and intravascular ultrasound confirmed no leakage through the covered stents. Patient remains asymptomatic 2 months post procedure on triple antiplatelet therapy.

There are limited data about characteristics of hypertension subtypes in Asian hypertensive patients and their impacts on treatment of hypertension. This prospective, multi-center, observational study evaluated 2439 hypertensive patients. (≥60 years) Inadequately controlled and drug-naive patients were categorized into three hypertension subtypes (isolated systolic hypertension [ISH], combined systolic/diastolic hypertension [SDH], and isolated diastolic hypertension [IDH]), and proportions of each hypertension subtype were evaluated. After 6-month strict treatments, we compared the characteristics of patients who did not achieve target BP with those who did. In overall population, ISH was the most common subtype (53.2%; 1297/2439). However, in drug-naive patients, SDH was the predominant hypertension subtype (59.6%; 260/436). Notably, the proportion of ISH was substantially lower than previously known data. Predictors associated with failure of reaching target BP were old age (>70 years), hypertension awareness, and baseline systolic blood pressure (≥160 mm Hg) for total patients. In drug naive patients, hypertension awareness, ISH, and microalbuminuria were associated with treatment failure. These findings might have an impact on the evaluations and antihypertensive treatments of elderly Korean patients.

Purpose Functional mitral regurgitation (FMR) and myocardial dyssynchrony commonly occur in patients with dilated cardiomyopathy (DCM). The aim of this study was to elucidate changes in FMR in relation to those in left ventricular (LV) dyssynchrony as well as geometric parameters of the mitral valve (MV) in DCM patients during dobutamine infusion. Materials and methods Twenty-nine DCM patients (M:F=15:14; age: 62±15 yrs) with FMR underwent echocardiography at baseline and during peak dose (30 or 40 ug/min) of dobutamine infusion. Using 2D echocardiography, LV end-diastolic volume, end-systolic volume (LVESV), ejection fraction (EF), and effective regurgitant orifice area (ERO) were estimated. Dyssynchrony indices (DIs), defined as the standard deviation of time interval-to-peak myocardial systolic contraction of eight LV segments, were measured. Using the multi-planar reconstructive mode from commercially available 3D image analysis software, MV tenting area (MVTa) was measured. All geometrical measurements were corrected (c) by the height of each patient. Results During dobutamine infusion, EF (28±8% vs. 39±11%, p=0.001) improved along with significant decrease in cLVESV (80.1±35.2 mm³/m vs. 60.4±31.1 mm³/m, p=0.001); cMVTa (1.28±0.48 cm²/m vs. 0.79±0.33 cm²/m, p=0.001) was significantly reduced; and DI (1.31±0.51 vs. 1.58±0.68, p=0.025) showed significant increase. Despite significant deterioration of LV dyssynchrony during dobutamine infusion, ERO (0.16±0.09 cm² vs. 0.09±0.08 cm², p=0.001) significantly improved. On multivariate analysis, ΔcMVTa and ΔEF were found to be the strongest independent determinants of ΔERO (R²=0.443, p=0.001). Conclusion Rather than LV dyssynchrony, MV geometry determined by LV geometry and systolic pressure, which represents the MV closing force, may be the primary determinant of MR severity.

We herein report the case of a 23-year-old man who presented with recurrent pancreatitis and was diagnosed with primary pancreatic extranodal natural killer/T-cell lymphoma, nasal type, involving the right ventricle. The cardiac involvement was screened and confirmed by transthoracic echocardiography (TTE), cardiac magnetic resonance imaging and fluorodeoxyglucose positron emission tomography. Although the patient did not have any cardiac symptoms or evidence of arrhythmia before chemotherapy, he presented with fatal newly developed ventricular tachycardia during the early stages of chemotherapy. The follow-up TTE after his chemotherapy demonstrated markedly decreased thickness of the invaded myocardium, thus suggesting that the myocardium infiltrated by lymphoma cells might become vulnerable to fatal arrhythmia with tumor regression.

Background The second-generation drug-eluting stents (DES) have shown superiority in many studies relating to safety and efficacy when compared with the first-generation DES. However, it is unclear whether there are differences in efficacy and safety among the second-generation DES after long-term follow-up. Methods This multicenter, prospective, randomized, open-labeled trial will directly compare the efficacy and safety among the patients treated with either everolimus-eluting stent (EES), zotarolimus-eluting stent with biolinx polymer (ZES-R), or biolimus-eluting stent (BES) with minimal exclusion criteria. The primary end point is a patient-oriented composite consisted of cardiac death, myocardial infarction not clearly attributable to a nontarget vessel and clinically indicated target lesion revascularization at 24-month clinical follow-up post-index procedure. With the hypothesis that “BES is non-inferior to EES” or “BES is non-inferior to ZES-R” in primary end point, approximately 2,600 patients will be assigned to one of the types of stents using a web-based randomization system. Conclusions The CHOICE trial will directly compare the efficacy and safety of EES, ZES-R, and BES in everyday clinical practice for long-term follow-up.

Background Three-dimensional (3D) speckle tracking echocardiography (STE) has been developed to overcome the limitations of two-dimensional (2D) STE and has been applied in the several clinical settings. However, no data exist about the prognostic value of 3DSTE-based strain on clinical outcome after myocardial infarction (MI). This study was designed to investigate the prognostic value of area strain (AS) by 3D speckle tracking in predicting clinical outcome after acute MI. Methods We assessed 96 patients (62±14 years, 72% male) with acute MI and who had undergone a coronary angiography. Clinical parameters and conventional echocardiographic measurements including the left atrial (LA) size and tissue Doppler measurements were evaluated. The global left ventricular (LV) AS was measured using 3D speckle tracking software. The relationship between the AS and clinical outcome of death or hospitalization for heart failure (HF) was assessed. Results During a median follow-up of 33±10 months, primary endpoint of death or HF occurred in 12 patients (12.5%). AS was predictive of death or HF after adjustment for age, gender, peak CK-MB, LA volume, LV end-systolic volume, LV mass, the ratio of early mitral inflow velocity to early mitral annular velocity, and LV ejection fraction in a multivariate Cox model (HR 1.23, 95% CI 1.02–1.47, P=.03). In addition, AS added incremental value in predicting death or heart failure on a model based on clinical and standard echocardiographic measures (P=.008). Conclusion AS is independently associated with increased risk of death or HF after acute MI, suggesting that it can be a useful prognostic parameter in the patients following MI.

We investigated the prognostic value of newly developed T-wave inversion after primary percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction. New T-wave inversion was defined as new onset of T-wave inversion after the primary PCI, without negative T waves on the presenting electrocardiogram. The primary end point was the occurrence of major adverse cardiac events (MACE), which consisted of cardiovascular mortality, nonfatal myocardial infarction, and rehospitalization for heart failure. A total of 271 patients were analyzed and followed up for 24 months in this study. New T-wave inversion was observed in 194 patients (72%), whereas the remaining 77 patients (28%) did not show T-wave inversion after the index PCI. Post-PCI Thrombolysis In Myocardial Infarction flow grade 2 or 3 was observed more frequently in patients with new T-wave inversion (97% vs 90%; p = 0.011). The cumulative MACE rate was significantly lower in patients with new T-wave inversion than in those without new T-wave inversion (8% vs 30%; odds ratio 0.197, 95% confidential interval 0.096 to 0.403; p

The neutrophil-to-lymphocyte ratio (NLR) has been proved as a reliable inflammatory marker for the atherosclerotic process and as a predictor for clinical outcomes in patients with various cardiovascular diseases. A recent study reported that elevated NLR is associated with impaired myocardial perfusion in patients with ST-segment elevation myocardial infarction (STEMI). We investigated whether NLR is associated with coronary microcirculation as assessed by the index of microcirculatory resistance (IMR) in patients with STEMI who had undergone primary percutaneous coronary intervention (PCI). A total of 123 patients with STEMI who underwent successful primary PCI were enrolled in this study. NLR was obtained on admission, and patients were divided into 3 groups by NLR tertile. IMR was measured using an intracoronary thermodilution-derived method immediately after index PCI. Symptom onset-to-balloon time was significantly longer (p = 0.005), and IMR was significantly higher in the high NLR group than that in the low and intermediate groups (21.94 ± 12.87 vs 23.22 ± 12.73 vs 32.95 ± 20.60, p = 0.003). Furthermore, in multiple linear regression analysis, NLR showed an independent positive correlation with IMR (r = 0.205, p = 0.009). In conclusion, NLR has shown positive correlation with IMR, whereas negative association with infarct-related artery patency in patients with STEMI who underwent primary PCI. Therefore, NLR at admission could reflect myocardial damage and the status of coronary microcirculation in patients with STEMI (ClinicalTrials.gov number, NCT02828137).

Objective Differences in microvascular integrity can diversely influence the functional assessment of epicardial coronary artery disease in each patient. We investigated the relevance of the index of microcirculatory resistance (IMR) and fractional flow reserve (FFR) of intermediate coronary lesions. Methods The IMR and FFR were measured in 67 intermediate coronary lesions of the left anterior descending artery of 67 patients, by using a pressure sensor/thermistor-tipped guidewire. Results To assess the differences in FFR in relationship to the IMR value, patients were divided into tertile IMR groups as follows: Low-IMR (n=22, IMR 14±3), Mid-IMR (n=23, IMR 21±2), and High-IMR (n=22, IMR 36±10). An analysis of variance showed that the High-IMR group had significantly higher FFR values (0.87±0.07) than the Low-IMR group (0.81±0.08) (p=0.03). Functionally significant lesions with FFR ≤0.8 accounted for 9% of lesions in the High-IMR group, 36% in the Low-IMR group and 22% in the Mid-IMR group (p=0.02). In the multivariate logistic analysis, the IMR value was an independent determinant of FFR ≤0.8 (p=0.03). Conclusion In patients with a high IMR, intermediate lesions as identified with visual estimation were more frequently functionally insignificant. The IMR can provide additional information in understanding the mismatch between the anatomical and functional severity of intermediate coronary stenosis.

Anemia is an independent predictor of bleeding complications and poor clinical outcomes after percutaneous coronary intervention. Percutaneous coronary transradial intervention (TRI) is better than percutaneous coronary transfemoral intervention (TFI) in terms of reducing bleeding complications that can affect the prognosis. This study aims to investigate the clinical outcomes between TRI and TFI for patients with anemia. We analyzed periprocedure complications, in-hospital mortality, and major adverse cardiac events for one year in the Korean TRI registry from January 2013 to April 2014. Patients with chronic kidney disease for whom TFI is preferred were excluded. Anemia was defined as hemoglobin13 g/dl for men and12 g/dl for women. A total of 1,279 patients were finally enrolled. Of these, 348 patients had anemia. Among them, 253 patients (72.7%) underwent TRI and 95 patients (27.3%) underwent TFI. There were no significant differences of baseline demographic characteristics between the TRI and TFI groups, except for the incidence of dyslipidemia (TRI 23.7% vs TFI 12.6%, p = 0.023). Multivariate logistic regression analysis revealed lower incidence of composite severe bleeding complications (hazard ratio 0.34, 95% CI 0.12 to 0.99, p = 0.049) and lower incidence of in-hospital mortality than TFI group (hazard ratio 0.74, 95% CI 0.62 to 0.88, p = 0.042). In conclusion, this study suggests that the TRI for patients with anemia may be translated into better prognosis in terms of lower rates of bleeding complications and in-hospital mortality.

Malignant pericardial mesothelioma is a rare and progressive cardiac tumor. There is no established standard treatment and the prognosis is poor. Most patients were retrospectively diagnosed from surgery or autopsy due to absence of specific clinical manifestation. Most patients with pericardial mesothelioma have demonstrated constrictive physiology on echocardiography or cardiac catheterization. Therefore, pericardial mesothelioma was often misdiagnosed as other causes of constrictive pericarditis. We report a case of primary pericardial mesothelioma misdiagnosed as pericardial metastasis of unknown origin.

Objectives The aim of this study was to determine which drug-eluting stent (DES) is preferable for the treatment of ST-segment elevation myocardial infarction (STEMI) and to elucidate the impact of diabetes mellitus on the outcome of each DES. Background Recent studies have shown the benefit of DES in patients with STEMI. Diabetes mellitus might differentially affect outcomes of each DES. Methods We analyzed the large-scale, prospective, observational KAMIR (Korea Acute Myocardial Infarction Registry) study, which enrolled 4,416 STEMI patients (26% with diabetes) treated with paclitaxel-eluting stent (PES) or sirolimus-eluting stent (SES). Primary outcome was major adverse cardiac event (MACE), defined as a composite of mortality, nonfatal myocardial infarction, and target lesion revascularization (TLR). Results In the overall population, the MACE rate at 1 year was significantly higher in the PES than the SES group (11.6% vs. 8.6%, p = 0.014), which was mainly due to increased TLR (3.7% vs. 1.8%, p Conclusions The PES was inferior to the SES in the overall population, with regard to the occurrence of MACE and TLR. However, subgroup analysis for diabetic subjects showed no differences in clinical outcomes between PES and SES. These results suggest that diabetes differentially affects the outcome of first-generation DES.

This study was conducted to explore the geometrical changes of the mitral annulus during systole. The 3D shape of the mitral annulus was reconstructed in 13 normal subjects who had normal structure of the mitral apparatus using real-time 3D echocardiography (RT3DE) and 3D computer software. The two orthogonal (antero-posterior and commissure-commissure) dimensions, the areas (2D projected and 3D surface) and the non-planarity of the mitral annulus were estimated during early, mid and late systole. We demonstrated that the MA had a "saddle shape" appearance and it consistently enlarged mainly in the antero-posterior direction from early to late systole with lessening of its non-planarity, as was determined by 3D reconstruction using RT3DE and 3D computer software.

Background: Ventricular late potentials (LPs) obtained by the signal-averaged electrocardiogram (SAECG) have prognostic significance as independent predictors of arrhythmic events after an acute myocardial infarction (AMI). Angiotensin receptor blockers reduce the overall mortality and risk of sudden cardiac death in postinfarction patients. The aim of this study was to investigate the effect of early losartan therapy on ventricular LPs, a noninvasive method for the evaluation of arrhythmogenic substrates in AMI patients. Methods: The study included 97 patients with their first AMI. Forty-eight patients (39 men and 9 women, aged 58.8 ± 13.19 years), received early losartan therapy. The control group consisted of 49 patients (38 men and 11 women, aged 59.55 ± 11.0 years), did not received early losartan therapy. The SAECG was performed at admission and day 14. Results: The baseline clinical, angiographic characteristics, and reperfusion methods were similar in both groups. The baseline SAECG findings were also similar in the two groups. There was a significant decrease in the rate of LP, between the first and last SAECG recordings, after reperfusion therapy in the losartan group. All of the parameters of LPs were significantly improved in the losartan group on the last SAECG recordings. Conclusion: The results of this study showed that losartan treatment, early after an AMI, reduced the incidence of LP and may thus favorably affect arrhythmia substrates.

Purpose A maximum P-wave duration (Pmax) of ≥ 110 msec and a P-wave dispersion (PWD) ≥ 40 msec are accepted indicators of a disturbance in interatrial conduction and an inhomogeneous propagation of the sinus impulse, respectively. The left atrial (LA) volume has been reported to be strongly associated with a systolic and diastolic dysfunction and is considered to be an index of atrial remodeling. We aimed to investigate the relationship between LA volume and Pmax or PWD in patients with congestive heart failure (CHF). Patients and Methods Sixty-one patients with CHF were enrolled in this study. The study population was classified into four groups: two groups were divided according to the Pmax (≥ 110 msec or < 110 ms), and the other two groups were formed based on the PWD (≥ 40 msec or < 40 msec). The left atrial volume index (LAVi) was measured by three-dimensional (3-D) transthoracic echocardiography. The Pmax and PWD were measured from a 12-lead electrocardiogram. Results There were significant differences in the ejection fraction (EF), diastolic function, and LAVi between patients with a Pmax ≥ 110 ms or a PWD ≥ 40 ms and those with a Pmax < 110 ms or a PWD < 40 ms. The LAVi was independently associated with a disturbance in interatrial conduction and an inhomogeneous propagation of the sinus impulse. The LAVi can be used to identify patients with a disturbance in interatrial conduction and an inhomogeneous propagation of the sinus impulse with reasonably good accuracy. Conclusion We concluded that a disturbance in interatrial conduction and an inhomogenous propagation of the sinus impulse in patients with CHF is associated with an increase in the LA volume and a deleterious systolic and diastolic dysfunction.

This study was done to explore the 3D geometry of the normal tricuspid annulus and compare it with the mitral annulus (MA), using real-time 3D echocardiography (RT3DE) and newly developed 3D computer software.Thirteen left ventricular (LV) and 13 right ventricular (RV) volumetric images were obtained using RT3DE from normal subjects. LV and RV volumetric data were segmented into 16 rotational apical planes (angle increment=11.25 degrees ) around the rotational axis from the apex through the center of two annuli, using newly developed 3D software (TomTec, Co., Munich, Germany). Two hinge points of the MA and the TA were traced in each plane during early and late systole. The MA and the TA were then automatically reconstructed with those 32 traced points. 3D surface (3DMAA, 3DTAA) and 2D projected areas (2DMAA, 2DTAA) of the annuli were calculated automatically as well, from those fitted data. For a comparison between the two annuli, the 3D and 2D area measurements of both annuli were corrected (c) according to the height of each patient (c2DMAA, c2DTAA, c3DMAA, and c3DTAA). Non-planarity of the annuli was estimated by their non-planar angles (MA: the angle between the anterior and posterior parts of the annulus; TA: the angle between the septal and free wall parts of the annulus).The TA revealed a less non-planar saddle shape than did the MA, which had a significantly wider non-planar angle (167.7+/-3.2 vs 145.5+/-6.1 degrees , p0.01) and a round or oval appearance on the projected view. The c2DTAA was significantly larger than the c2DMAA during early systole (p0.01). However, there was no significant difference between the c3DTAA and c3DMAA during early and late systole (p0.01).We assessed the 3D geometry of the MA and the TA by 3D reconstruction using RT3DE and newly developed computer software. The TA had a less non-planar shape compared with the MA, with either a round or oval appearance on the projected view.

Background: Recent technical developments with high-resolution real-time 3 dimensional echocardiography (RT3DE) facilitate the acquisition of high quality images and the analysis of segmental volume—time curves (VTCs). Aims: To assess left ventricular (LV) asynchrony using the VTCs of 16 segments by RT3DE, and to evaluate accuracy compared to tissue Doppler imaging (TDI). Methods: Twenty-three heart failure (HF) patients (LVEF: 25±6%, age: 60±13 years) and 16 normal controls underwent TDI and RT3DE. The standard deviation (SD3) of the end systolic time reaching minimal systolic volume for the 16 segments on VTCs was obtained by RT3DE. The standard deviation (SD2) of the electromechanical coupling time for the 8 segments was measured using TDI. Results: SD3 was markedly higher in HF patients than in controls (7.7±2.5 vs 1.5±1.0%, P

Introduction: The use of radial artery is gradually increasing because transradial approach have shown less mortality and bleeding complications compared to transfermoral approach. But, there is little known about the differences according to radial access site except for fluoroscopic time and learning curve. Hypothesis: We aimed to compare the success rate, procedural factors and radiation exposure according to radial access site in patients who performed coronary angiography (CAG). Methods: The study population was derived from TRI prospective registry from 20 institutes in Korea from Feb 2013 to Sep 2013. Exclusion criteria were patients with data missing≥30%, invalid data, less than 19-year old patients, patient received interventional treatment, and patient who performed CAG via femoral approach. A total of 3496 among 5779 patients was assessed for data analysis. Success rate for CAG, crossover rate, procedural factors, fluoroscopic time and fluoroscopic dose were compared between right radial (RR) and left radial (LR) approach. Results: Mean age was 62.9±11.6 years and male was 1974 patients (56.5%). The use or EMLA cream was higher in LR group (29.2% vs. 14.0%, p Conclusions: In KOTRI analysis, success rate for CAG was higher in RR group, but radiation time and dose were lower in LR group. Most common cause of crossover was puncture failure.

Background and Objectives Although increasing evidence has indicated that radial access is a beneficial technique, few studies have focused on Korean subjects. The aim of this study was to evaluate current practice of coronary angiography (CAG) and percutaneous coronary intervention (PCI) using radial access in South Korea. Subjects and Methods A total of 6338 subjects were analyzed from Korean Transradial Intervention prospective registry that was conducted at 20 centers in Korea. After evaluating the initial access, subjects intended for radial access were assessed for their baseline, procedure-related, and complication data. Subjects were categorized into three groups: group of overall subjects (n=5554); group of subjects who underwent PCI (n=1780); and group of subjects who underwent primary percutaneous coronary intervention (PPCI) (n=167). Results The rate of radial artery as an initial access and the rate of access site crossover was 87.6% and 4.4%, respectively, in overall subjects. Those rates were 82.4% and 8.1%, respectively, in subjects who underwent PCI, and 60.1% and 4.8%, respectively, in subjects who underwent PPCI. For subjects who underwent CAG, a 6-F introducer sheath and a 5-F angiographic catheter was the most commonly used. During PCI, a 6-F introducer sheath (90.6%) and a 6-F guiding catheter were standardly used. Conclusion The large prospective registry allowed us to present the current practice of CAG and PCI using radial access. These data provides evidence to achieve consensus on radial access in CAG and PCI in the Korean population.

Background: The detection of residual stenosis of infarct related artery (IRA) at early stage after acute myocardial infarction (AMI) is crucial in clinical decision making for interventional revascularization. The aim of this study was to evaluate the relevancy of early dipyridamole stress myocardial SPECT to detect functionally and luminologically significant residual stenosis of IRA after AMI. Methods : Twenty five consecutive patients (M:F=19:6, age 56+13yrs) with AMI underwent SPECT and coronary angiography within 5 days of the attack. Infarct related arteries with FFR ( 0.75 and diameter stenosis (OST) )70% were regarded to have functionally and morphologically significant residual stenosis. Reversible perfusion defect was defined if there was improvement of the perfusion score more than one grade in infarct segments on rest images of SPECT compared with stress images. Results : Mean FFR and DST were 0.76±0.14 and 74±15%. SPECT showed no significant correlation with both FFR and DST with Kendall's coefficiency of 0.28 (p=0.05) and 0.13 (p=0.35). The sensitivity and specificity of SPECT to detect functionally and morphologically significant residual stenosis were 92%, 31% and 83%, 29%. Conclusion: The early dipyridamole stress myocardial SPECT after AMI does not seem to be a useful non-invasive test for the detection of functionally and luminologically significant residual stenosis of IRA.

Background: Although prompt reperfusion treatment restores normal epicardial flow, microvascular dysfunction may persist in some patients with acute coronary syndrome (ACS). Impaired myocardial perfusion is caused by intraluminal platelets, fibrin thrombi and neutrophil plugging; antiplatelet agents play a significant role in terms of protecting against thrombus microembolization. A novel antiplatelet agent, ticagrelor, is a non-thienopyridine, direct P2Y12 blocker that has shown greater, more rapid and more consistent platelet inhibition than clopidogrel. However, the effects of ticagrelor on the prevention of microvascular dysfunction are uncertain. The present study is a comparison between clopidogrel and ticagrelor use for preventing microvascular dysfunction in patients with ST elevation or non-ST elevation myocardial infarction (STEMI or NSTEMI, respectively). Methods/design: The TIME trial is a single-center, randomized, open-label, parallel-arm study designed to demonstrate the superiority of ticagrelor over clopidogrel. A total of 152 patients with a spectrum of STEMI or NSTEMI will undergo prospective random assignment to clopidogrel or ticagrelor (1:1 ratio). The primary endpoint is an index of microcirculatory resistance (IMR) measured after percutaneous coronary intervention (PCI); the secondary endpoint is wall motion score index assessed at 3 months by using echocardiography. Discussion: The TIME trial is the first study designed to compare the protective effect of clopidogrel and ticagrelor on coronary microvascular dysfunction in patients with STEMI and NSTEMI. Trial registration: ClinicalTrials.gov: NCT02026219. Registration date: 24 December 2013.

Aims We aimed to investigate whether thrombus aspiration could preserve the index of microcirculatory resistance (IMR) after primary percutaneous coronary intervention (PCI) in patients with ST-elevation myocardial infarction (STEMI). Methods and results Sixty-three patients with STEMI were randomised into two groups: primary PCI after thrombus aspiration (aspiration group, n=33) and primary PCI without thrombus aspiration (non-aspiration group, n=30). IMR was measured using a pressure-temperature sensor-tipped coronary wire. Echocardiography was performed at baseline and at six-month follow-up. No significant differences in baseline ejection fraction (EF, 47.3±8.5% vs. 49.5±7.8%, p=0.281) and baseline wall motion score index (WMSI, 1.45±0.31 vs. 1.37±0.27, p=0.299) were observed between the two groups. However, significant differences in IMR (23.5±10.2 U vs. 34.2±21.7 U, p=0.018), %E2%88%86EF (follow-up EF - baseline EF; 3.33±4.6% vs. 0.73±1.9%, p=0.005), and %E2%88%86WMSI (follow-up WMSI - baseline WMSI; -0.121±0.16 vs. -0.004±0.07, p=0.001) were observed between the two groups. Conclusions Thrombus aspiration as an adjunctive method to primary PCI for STEMI may preserve microvascular integrity and have beneficial effects on myocardial microcirculation.

Besides poor clinical outcomes, female gender has been known as a high-risk factor for bleeding complications. This study aimed to investigate the impact of gender on clinical outcomes and bleeding complications after transradial coronary intervention (TRI). The Korean TRI registry is a retrospective multicenter registry with 4,890 patients who underwent percutaneous coronary intervention in 2009 at 12 centers. To compare clinical outcomes and bleeding complications between the male and female groups, we performed a propensity score matching in patients who received TRI. A total of 1,194 patients (597 in each group) were studied. The primary outcome was 1-year major adverse cardiac events, including all-cause mortality, myocardial infarction, target vessel revascularization, and stroke. The secondary outcome was major bleeding (composite of bleeding requiring transfusion of ≥2 units of packed cells or bleeding that was fatal). The proportion of major adverse cardiac events was similar between the 2 groups (6.2% vs 4.7%, p = 0.308). The female group had a greater incidence of major bleeding (0.3% vs 3.2%, p0.001). On multivariate analysis, female gender (odds ratio [OR] 7.748, 95% confidence interval [CI] 1.767 to 13.399), age ≥75 years (OR 5.824, 95% CI 2.085 to 16.274), and chronic kidney disease (OR 7.264, 95% CI 2.369 to 12.276) were independent predictors of major bleeding. In conclusion, the female gender had a tendency for more bleeding complications than male gender after TRI without difference in the clinical outcome.

Submitral left ventricular aneurysm has been exclusively recognized in the young African population and its occurrence in other than black Africans is rarely reported. Here we describe two surgical cases of submitral left ventricular aneurysm in Asian elderly persons. Although the aneurysms were typically located beneath the posterior mitral valve leaflet, we could identify diseased coronary arteries as well, unlike the reports in the literature asserting that this type of aneurysm occurs in the absence of coronary disease. The possible racial difference with regard to the etiology is addressed.

We investigated whether the presence of J wave on the surface electrocardiography (sECG) could be a potential risk factor for ventricular fibrillation (VF) during acute myocardial infarction (AMI). We performed a retrospective study of 317 patients diagnosed with AMI in a single center from 2009 to 2012. Among the enrolled 296 patients, 22 (13.5%) patients were selected as a VF group. The J wave on the sECG was defined as a J point elevation manifested through QRS notching or slurring at least 1 mm above the baseline in at least two leads. We found that the incidence of J wave on the sECG was significantly higher in the VF group. We also confirmed that several conventional risk factors of VF were significantly related to VF during AMI; time delays from the onset of chest pain, blood concentrations of creatine phosphokinase and incidence of ST-segment elevation. Multiple logistic regression analysis demonstrated that the presence of J wave and the presence of a ST-segment elevation were independent predictors of VF during AMI. This study demonstrated that the presence of J wave on the sECG is significantly related to VF during AMI. Graphical Abstract Keywords: J Wave, Ventricular Fibrillation, Acute Myocardial Infarction INTRODUCTION Primary ventricular fibrillation (PVF) during acute myocardial infarction (AMI) refers to VF that occurs early (usually < 48 hr post myocardial infarction), and is not associated with recurrent ischemia or heart failure (1). The incidence of VF was reported to be more than 10% during AMI, and VF usually occurs in a few hours after the onset of chest pain (1). VF is the most frequent cause of death in association with AMI because it usually occurs before medical contact (1). Recent studies have demonstrated that J wave on the sECG has been associated with idiopathic VF in patients who do not have structural heart disease (2). A recent study also reported that the presence of J wave is associated with ventricular arrhythmia in patients who have chronic coronary artery disease (3). So far, few studies reported that the presence of J wave in sECG is associated with VF during AMI (1, 4, 5, 6). Several variables, including J wave, were reported as significant predictors of VF, but failed to get statistical significance. Through this study, we planned to evaluate that the presence of J wave on the sECG could be a potential risk factor for VF during AMI.

Recent studies suggest that the intracoronary administration of bone marrow (BM)-derived mesenchymal stem cells (MSCs) may improve left ventricular function in patients with acute myocardial infarction (AMI). However, there is still argumentative for the safety and efficacy of MSCs in the AMI setting. We thus performed a randomized pilot study to investigate the safety and efficacy of MSCs in patients with AMI. Eighty patients with AMI after successful reperfusion therapy were randomly assigned and received an intracoronary administration of autologous BM-derived MSCs into the infarct related artery at 1 month. During follow-up period, 58 patients completed the trial. The primary endpoint was changes in left ventricular ejection fraction (LVEF) by single-photon emission computed tomography (SPECT) at 6 month. We also evaluated treatment-related adverse events. The absolute improvement in the LVEF by SPECT at 6 month was greater in the BM-derived MSCs group than in the control group (5.9% ± 8.5% vs 1.6% ± 7.0%; P=0.037). There was no treatment-related toxicity during intracoronary administration of MSCs. No significant adverse cardiovascular events occurred during follow-up. In conclusion, the intracoronary infusion of human BM-derived MSCs at 1 month is tolerable and safe with modest improvement in LVEF at 6-month follow-up by SPECT. (ClinicalTrials.gov registration number: NCT01392105).

Background and objectives We evaluated the utility of two-dimensional (2D) and three-dimensional (3D) left ventricular (LV) global myocardial deformity parameters for assessing LV diastolic function by comparing invasive measures of LV performance. Subjects and methods Echocardiography and LV pressure were assessed in 39 patients. Myocardial LV longitudinal, circumferential, and radial deformations, as well as area strain, were evaluated utilizing 2D and 3D speckle tracking software. The 2D early diastolic strain rate (2D-SRe) was measured from the 3 apical and 3 short axis views. The 3D diastolic index (3D-DI) was calculated by the % change of global strain during the first one-third of the diastolic period. LV end diastolic pressure (LVEDP) and the rate of LV pressure change (dP/dt) were collected using a pressure-conducted catheter and tau was calculated. Results dP/dtmin were related to early mitral annular velocity (e'), 2D-SRelong, 2D-SReradial, as well as 3D-DIlong, and 3D-DIas. Additionally, LVEDP was associated with the ratio of mitral early diastolic velocity (E) to 2D-SRelong, 2D-SRecirc, 2D-SReradial, 3D-DIlong, 3D-DIcirc, and 3D-DIas. E/2D-SRelong, E/2D-SReradial, E/3D-DIlong, and E/3D-DIas were comparable with E/e' in predicting patients with elevated LVEDP. Among those patients with E/e' of 8 to 15, E/3D-DIlong provided incremental value in identifying those with LVEDP ≥15 mm Hg. Conclusion 2D-SRelong, 2D-SReradial, 3D-DIlong, and 3D-DIas were related to LV relaxation, and the ratios of E to those parameters were associated with LVEDP. In addition, among patients with indeterminate E/e', E/3D-DIlong offered incremental value in predicting elevated LVEDP, suggesting it may provide supplementary information in the evaluation of LV diastolic function.

Paclitaxel-eluting stents (PESs) have been shown to inhibit neointimal hyperplasia after percutaneous coronary intervention. Coroflex Please (B Braun, Melsungen, Germany) is a newly developed PES. We compared the clinical and angiographic efficacy of Coroflex Please with Taxus Liberte (Boston Scientific, Natick, MA) in a real-world practice.We performed a prospective, open-label, randomized, controlled study that enrolled 945 patients undergoing percutaneous coronary interventions in 18 centers in Korea. The primary end point was clinically driven target vessel revascularization at 9 months. The baseline characteristics were mostly similar and comparable between 2 groups. At 9 months, the incidence of clinically driven target vessel revascularization was 14.6% for Coroflex and 6.4% for Taxus, which was significantly different (hazard ratio 2.43, 95% CI 1.50-3.94, noninferiority P value = 1.000). This is well corroborated by the difference of in-stent late loss between 2 stents (0.71 ± 0.64 mm vs 0.52 ± 0.50 mm, P.001) by 9-month follow-up angiography (n = 415 vs 215). Among secondary clinical end points, stent thrombosis (definite and probable) for 1 year was 2.2% in Coroflex and 1.3% in Taxus (P = .317). Also, myocardial infarction for 9 months was higher in Coroflex group than that in Taxus (4.9% vs 1.6%, P = .012), which was partly contributed by the higher incidence of periprocedural myocardial infarction in Coroflex arm (2.2% vs 0.3%, P = .028).Coroflex Please was inferior to Taxus Liberte with regard to clinical and angiographic efficacy.

A 67-year-old male patient was admitted with an abrupt sudden cardiac death. He represented with an extreme electrical storm of 30 times of ventricular fibrillation (VF) episodes on one day. External shocks were performed to terminate VF. Transient J-wave in the inferior-lateral leads and Brugada electrocardiography pattern on the right precordial leads appeared during the electrical storm. And J-wave disappeared after the termination of electrical storm. We report a case of the appearance of J-wave during electrical storm in a patient with Brugada syndrome.

Bortezomib is an inhibitor of 26S proteasome, which is an effective treatment for multiple myeloma. The common adverse effects of bortezomib are asthenic conditions, gastrointestinal disturbances, and peripheral neuropathy. Here we describe a patient with dyspnea and general weakness because of complete atrioventricular block while receiving bortezomib. We immediately stopped bortezomib, and after inserting a permanent VDD pacemaker, the patients' symptoms disappeared.

Purpose We aimed to discover clinical and angiographic predictors of microvascular dysfunction using the index of microcirculatory resistance (IMR) in patients with ST-segment elevation myocardial infarction (STEMI). Materials and Methods We enrolled 113 patients with STEMI (age, 56±11 years; 95 men) who underwent primary percutaneous coronary intervention (PCI). The IMR was measured with a pressure sensor/thermistor-tipped guidewire after primary PCI. The patients were divided into three groups based on IMR values: Low IMR [31 U (48.1±17.1 U), n=37]. Results The age of the Low IMR group was significantly lower than that of the Mid and High IMR groups. The door-to-balloon time was

Despite recovered normal epicardial coronary flow after primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI), microvascular damage and dysfunction limit the effect of primary PCI. The purpose of this study was to evaluate whether manual thrombectomy

Spontaneous coronary artery dissection is a rare cause of acute coronary syndrome and sudden cardiac death. The incidence, causes, pathogenesis, and treatment have not been defined clearly, but spontaneous coronary artery dissection should be considered in young patients without major cardiovascular risk factors or in patients in the peripartum period who present with acute coronary syndrome. The treatment is often challenging. Medical treatment is usually considered, and percutaneous coronary intervention or coronary artery bypass surgery may be possible in some patients. We herein report two cases of middle-aged males with myocardial infarction who were treated with percutaneous coronary angioplasty.

The prevalence of persistent left superior vena cava (PLSVC) in the general population has been estimated to be approximately 0.3%, as determined by autopsy. PLSVC is hemodynamically insignificant if it is not associated with other congenital cardiac anomalies, and usually goes unrecognized until a left superior approach to the heart is required. Here, we report a 60-year-old male diagnosed with dilated cardiomyopathy, who had survived an episode of sudden cardiac arrest with documented ventricular fibrillation. PLSVC was recognized incidentally while implanting an implantable cardioverter-defibrillator (ICD). The ICD was successfully implanted through the left superior vena cava via the coronary sinus using a straight stylet and an active fixation device. (Korean J Med 2014;87:328-333)

We compared the reproducibility of thallium 201 and technetium 99m sestamibi (MIBI) gated single photon emission computed tomography (SPECT) measurement of myocardial function using the Germano algorithm (J Nucl Med 1995;36:2138-47).Gated SPECT acquisition was repeated in the same position in 30 patients who received Tl-201 and in 26 who received Tc-99m-MIBI. The quantification of end-diastolic volume (EDV), end-systolic volume (ESV), and ejection fraction (EF) on Tl-201 and Tc-99m-MIBI gated SPECT was processed independently with Cedars-Sinai QGS (Quantitative Gated SPECT) software. The reproducibility of the measurement of ventricular function on Tl-201 gated SPECT was compared with that of Tc-99m-MIBI gated SPECT. Correlation between the 2 measurements for volumes and EF was excellent for the repeated gated SPECT studies of Tl-201 (r = 0.928 to 0.986, P.05) and Tc-99m-MIBI (r = 0.979 to 0.997, P.05). However, Bland-Altman analysis revealed the 95% limits of agreement (2 SDs) for volumes and EF were narrower by repeated Tc-99m-MIBI gated SPECT (EDV 14.1 mL, ESV 9.4 mL, EF 5.5%) than by repeated Tl-201 gated SPECT (EDV 24.1 mL, ESV 18.6 mL, EF 10.3%). The root-mean-square values of the coefficient of variation for volumes and EF were smaller by repeated Tc-99m-MIBI gated SPECT (EDV 2.1 mL, ESV 2.7 mL, EF 2.3%) than by repeated Tl-201 gated SPECT (EDV 3.2 mL, ESV 3.5 mL, EF 5.2%).QGS provides an excellent correlation between repeated gated SPECT with Tl-201 and Tc-99m-MIBI. However, Tc-99m-MIBI provides more reproducible volumes and EF than Tl-201. Tc-99m-MIBI gated SPECT is the preferable method for the clinical monitoring of ventricular function.

Posttraumatic saccular aneurysm of the right coronary artery is a rare complication of nonpenetrating chest trauma. We observed a posttraumatic coronary aneurysm for 3 years and noted that the aneurysm has changed in shape, with partial obliteration of the aneurysm sac, and that its clinical course was uneventful with conservative treatment. Surgical removal of aneurysms has been advocated in the literature; however, conservative medical treatment and a wait-and-see policy can be considered as a treatment modality for posttraumatic coronary aneurysm.