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

In animal models, expression of nerve growth factor (NGF) is increased after necrotic myocardial injury. Whether radiofrequency (RF) catheter ablation increases NGF expression in humans is unclear.The purpose of this study was to determine NGF concentrations in the aorta, coronary sinus, and peripheral veins before and after RF ablation in patients.We sampled blood from aorta and either great cardiac vein (group 1, N = 18) or proximal (group 2, N = 20) coronary sinus before and after RF ablation. In group 3 (N = 21), peripheral venous blood was sampled before and after RF ablation and then up to postoperative day 7. In group 4 (N = 10), we sampled peripheral venous blood during diagnostic electrophysiologic study. The NGF concentration was determined by enzyme-linked immunosorbent assay. Transcardiac NGF concentration was the difference in NGF concentrations between coronary sinus and aorta.There was no change in transcardiac NGF concentrations in groups 1 and 2. In group 3, the NGF level did not change significantly from before the procedure (17.10 +/- 15.80 ng/mL) to immediately after the procedure (14.46 +/- 10.36 ng/mL). However, NGF levels increased significantly to 31.24 +/- 19.82 ng/mL (N = 21, P.0001) on postoperative day 1, 26.23 +/- 16.89 ng/mL (N = 20, P.001) on postoperative day 2, and 22.01 +/- 11.35 ng/mL (N = 16, P = .003) on postoperative day 3. NGF concentrations did not change significantly in group 4.RF ablation did not result in a detectable increase of transcardiac NGF concentration immediately after the procedure. However, the systemic NGF concentration increased significantly on postoperative days 1 to 3, suggesting that RF ablation resulted in increased NGF expression.

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

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

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

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

A 17-year-old high school student presented with a history of habitual faintings. On 24-hour Holter monitoring, cardiac asystoles were recorded, the longest lasting approximately 7 or 8 seconds during venipuncture procedures. The asystole associated with venipuncture demonstrated the cardioinhibitory effects of vasovagal reaction with blood-injury phobia. He also had a positive response during head-up tilt test showing hypotension and relative bradycardia after intravenous isoproterenol injection. After administration of oral beta blocker, he did not show further or recurrent cardiac asystole during blood injury procedure on electrocardiographic examination. Venipuncture is the most common invasive medical procedure performed in hospital settings. While venipuncture is considered to be reasonably safe, serious complication may occur even when only a small volume of blood is withdrawn. Therefore, medical personnel should be prepared to provide appropriate care.

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

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

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

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

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

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

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

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

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

Spontaneous medialstinal emphysema (pneumomediastinum) and pneumopericardium may be defined as the presence of free air or gas in the mediastinal structures and in the pericardial sac without an apparent precipitating cause. It most frequently occurs in young healthy adults without serious underlying pulmonary disease. Although pneumomediastinum and pneumopericardium is often asymptomatic, it may cause pain in the neck and chest, dysphonia and shortness of breath. Treatment is supportive unless the patient has a history of trauma from foreign body aspiration. The course of spontaneous pneumomediastinum and pneumopericardium is usually benign and self-limited. A case of spontaneous pneumomediastinum, pneumopericardium and subcutaneous emphysema in a 20-year-old male is reported in this paper.

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

Cardiac myxomas are histologically benign but and pulmonary edema in seventeen (68%) patients. may be lethal because of their strategic position. It Sixteen (64%) patients had abnormal electrocarmay mimic every cardiovascular or systemic disease, diographic findings that included sinus tachycardia, and can be missed without a high index of suspicion nonspecific ST-T wave change, left atrial enlarge[1]. Rapid advances have been made in cardiovascument, right bundle branch block, atrial fibrillation. In lar imaging, particularly in echocardiography, which laboratory findings, anemia was observed in eighteen is the most important modality in the preoperative (72%) patients, and leukocytosis was noted in six diagnosis of cardiac myxomas. We reviewed twenty(24%) patients. An erythrocyte sedimentation rate five patients with cardiac myxoma who underwent was found to be elevated in twelve of fifteen(80%) excision of the tumor at Catholic University Medical patients. In all of the patients, preoperative diagnosis Center between 1984 and 1999. The patients’ medical was confirmed by echocardiography, and surgical records were reviewed retrospectively, and special excision of the myxoma was performed as soon as attention was given to clinical presentation, physical possible without further diagnosis. The tumor size examination, chest X-ray, electrocardiogram, laborawas from 131.732.7 to 3.536.538 cm and from 18 tory findings, echocardiographic findings, operative to 200 g in weight. The stalk of tumors was found in findings, and postoperative course. The study group 18 (72%) patients, and hemorrhage and calcification consisted of six male (24%) and nineteen female of tumors in twenty (80%) and nine (36%) patients, (76%) patients. The patients’ ages ranged from 23 to respectively. Most myxomas in the left atrium were 64 years (mean 48) at the time of diagnosis. There located at the border of the oval fossa [sixteen (64%) were twenty-three (92%) left atrial and two (8%) patients] and the others at the base of interatrial right atrial myxomas. The most common symptoms septum, posterior atrial wall, and anterior atrial wall were associated with mitral obstruction in nineteen in descending order of frequency. There was no (76%) patients such as dyspnea on exertion, palpitaperioperative mortality. Early postoperative complition, and recurrent syncope. Embolic episodes cations controlled with medical treatment occurred in occurred in five (20%) patients. Twenty (80%) five patients: wound infection in two; Torsades de patients had abnormal findings at their cardiac aupointes in one; atrial fibrillation in one and acute scultation, systolic murmur in twelve, diastolic murrenal failure in one patient. Most patients were mur in eight, and tumor plop in four patients. Chest discharged within 2 weeks of the operation. In X-ray showed cardiomegaly, left atrial enlargement, sixteen (64%) patients who could be reevaluated, follow-up ranged from 4 months to 15 years. One *Corresponding author. Cardiology Department, St. Mary’s Hospital, patient who underwent tricuspid annuloplasty for No. 62 Yoido-dong, Youngdungpo-Ku 150-713, Seoul, South Korea. Tel.: severe tricuspid valve regurgitation died of intractable 182-2-3779-1325; fax: 182-2-3779-1374. E-mail address: younhj@cmc.cuk.ac.kr (H.-J. Youn). right heart failure and pulmonary hypertension 5

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

Objectives Infective endocarditis is still one of the important fatal diseases in Korea, especially when systemic embolisms are supervene. So, identification of patients who are in the high risk of embolism and who can be helped by early surgical intervention is very important. Considering these, we tried to elaborate the risk factors for the systemic embolism in patients with an infective endocarditis and the influence of systemic embolism on the mortality and morbidity in patients with an infective endocarditis. Methods We retrospectively reviewed the clinical records of 97 patients who were admitted with the infective endocarditis between January 1983 and October 1993. Results Among 97 patients, 80 patients met our diagnostic criteria. The mean age of patients was 38 years old. There were 43 males and 37 females. The mean duration of fever since the fever developed by history was 38 days. Valvular heart disease was the most frequent underlying heart disease. Mitral regurgitation and aortic regurgitation were the most common among valvular heart diseases. Pneumonia and acute pharyngotonsillitis were the most frequent predisposing factors of infective endocarditis. Blood cultures were positive in 51 patients (63.8%). Streptococcus viridans was the organism isolated most frequently, and Staphylococcus aureus was the second most frequently isolated one. Vegetations were detected in 58 patients (76.3%) by an echocardiography. Mitral valve and aortic valve were the most frequently involved. Incidence rate of embolism was 50% and the most frequent embolism site was the central nervous system and extremities were the next. Embolism occurred at the mean of 37 days after onset of fever. Overall in-hospital mortality rate was 26.3% and a cardiac-origin was the major cause of death. The only statistically significant risk factor for mortality was systemic embolism. The analysis of the relation between an incidence of embolism and the multivariables (age, presence of vegetation, location of vegetation, size of vegetation, causative organisms) showed that only the growth of Staphylococcus aureus had a significant trend toward a risk of subsequent systemic embolism. Conclusion This study suggests that systemic emboli increases the mortality rate in patients with infective endocarditis. Age of patients, presence of vegetation, size and location of vegetation are not the risk factors for embolism, while certain organism, especially Staphylococcus aureus, could be a risk factor for the systemic embolism.

Background : In vitro experimental studies have reported that transforming growth factor-β 1 (TGF-β 1) stimulates the production of α -smooth muscle actin (α -SMA) in porcine valves. However, the relation between TGF-β 1 and α -SMA in myxomatous valves has not been elucidated. Methods : We classified 27 subjects into two groups: 1) myxomatous group (M:F=11:12, mean age=55±15 years) and 2) rheumatic group (M:F=3:1, mean age=41±17 years) according to preoperative echocardiographic and postoperative histologic findings. Twenty-seven valve specimens from the patients who underwent valve replacement were obtained. Tissue samples were analyzed by immunohistochemistry for TGF-β 1 and α -SMA. The positively stained areas were measured using an image analysis program (Image Pro-Plus 4.5), and then the TGF-β 1 volume fraction (TGF-VF) and α -SMA volume fraction (α -SMA-VF) were calculated. Results : TGF-VF in myxomatous valves was higher than in rheumatic valves (2,759±2,294 vs 864±276, p=0.04). α -SMA-VF in myxomatous valves was higher than in rheumatic valves (4,122±2,275 vs 2,421±844, p=0.002). There was a significant correlation between TGF-β 1 and α -SMA in myxomatous valves (r=0.38, p=0.04). There was no significant correlation between TGF-β 1 and α -SMA in rheumatic valves (r=-0.50, p=0.67). Conclusions : TGF-β 1 and α -SMA may be related to the pathogenesis of myxomatous valves. The activation of TGF-β 1 might increase the expression of α -SMA in human myxomatous valves.

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

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

Background and Objectives: Vascular endothelial growth factor (VEGF) is a potent endothelial cell-specific mitogen. This study was undertaken to test the hypothesis that the neointima hyperplasia induced by a balloon injury is inhibited by blocking VEGF and VEGF receptor-1 (VEGFR-1) with anti-VEGF peptides. Materials and Methods: Anti-VEGF RRKRRR peptide (dRK6) and anti-VEGFR-1 peptide (anti-flt-1) were synthesized at Pohang University of Science and Technology, Korea. Male Sprague-Dawley rats, weighing 300-350 g, were subcutaneously injected 0.5 mg/kg of dRK6 or 0.5 mg/kg of anti-flt-1, dissolved in phosphate buffer solution, 2 days before induction of a carotid balloon-injury, and then daily in the same manner post carotid balloon injury for 2 weeks. Results: Neointima formation was suppressed in both the dRK6 and anti-flt-1 groups compared to that in the untreated controls at 2 weeks post carotid balloon-injury (neointimal area; control group 0.44±0.09 mm 2 , dRK6 group 0.25±0.05 mm 2 , anti-flt-1 group 0.19±0.05 mm 2 , p

A 59-year-old woman was admitted because of lethargy. She had been treated for heart failure for 5 years before admission, which progressed to include lower-extremity edema as well as orthopnea and nocturnal dyspnea. The serial ECGs and echocardiographic findings are summarized in Figs 1⇓ and 2⇓. Forearm skin, rectal (Fig 3⇓), and endomyocardial biopsies (Fig 4⇓) were performed. On the basis of our findings (Figs …

Background and Objectives：The degree of coronary vasoconstriction induced by acetylcholine administeration can vary. We compared the prognosis between coronary vasospasm and intermediate vasoconstriction, which were both induced by acetylcholine administration. Subjects and Methods：The subjects were 156 patients with the coronary vasospasm or intermediate vasoconstriction, as observed on the acetylcholine provocation tests that were performed from January, 2000 to January, 2004. The patients with a spasm showing greater than 90% reduction of vessel diameter along with chest pain or ST changes or both were classified as having ‘strong positive vasospasm’ (n=113). The patients with 70-90% reduction of diameter were classified as having ‘intermediate vasoconstriction’ (n=43). The mortality, frequency of chest pain and clinical events were then analyzed. Results：A smoking history (p

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

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

Background and Objectives：Passive smoking increases the risk of cardiovascular disease, but the factors responsible for this association remain largely unknown. We sought to determine whether passive smoke exposure is associated with systemic inflammation in a dose-dependent fashion, which is a known risk factor for cardiovascular events. Subjects and Methods：We analyzed the data of self-reported non-smokers, ≥40 years of age, who were from the Third National Health and Nutrition Examination Survey (n=6,595). We quantified the passive nicotine exposure by dividing the non-smokers into quartiles, as based on the serum cotinine values. We used multiple linear and logistic regression models to determine the independent relationship between serum cotinine and the levels of C-reactive protein, fibrinogen and leukocytes, and the platelet expression. Results： After adjustments were done for age, gender, body mass index and race, the participants in the highest serum cotinine quartile (quartile 4) had circulating platelet, fibrinogen and homocysteine levels that were 6,893/μL higher (95% confidence interval [CI]: 1,886 to 11,900/μL, p=0.007), 8.74 mg/dL (95% CI: 2.63 to 14.84 mg/dL, p=0.005) and 0.90 μmol/L (95% CI: 0.36 to 1.43 (μmol/L, p=0.001), respectively, than in those in the lowest quartile of serum cotinine (quartile 1). There was a dose-dependent increase in the circulating fibrinogen, homocysteine and platelet levels across the quartiles of cotinine. Conclusion：These findings indicate that even among nonsmokers, elevated serum cotinine is an independent risk factor for systemic inflammation. This suggests that passive smoke exposure promotes systemic inflammatory response in a dose-dependent fashion. These observations may explain why passive smoking is a risk factor for atherosclerosis and cardiovascular events. (Korean Circulation J 2006;36:510-515)

Background and Objectives:LMWH as a periprocedural anticoagulant during PCI has not yet been extensively studied. The aim of this study is to compare the clinical outcomes of enoxaparin to those of unfractionated heparin (UH) during elective PCI. Subjects and Methods:The eligible patients were randomized 1:1 into two treatment arms, either a single IV bolus of enoxaparin (75 IU/kg) or UH (100 IU/kg). The patients who had received any anticoagulants at therapeutic doses were excluded in this study. Data on patient characteristics, angiographic complications, laboratory variables and the in-hospital and 1-month clinical outcomes were compared between the two groups. Results:Of the 139 patients enrolled in this study, 68 received enoxaparin and 71 received UH. The patients’ demographic and angiographic characteristics (gender, weight, creatinine and the PCI target vessel) were not different except for age between the groups. Multi-vessel angioplasty was performed in 59 (42.4%) patients. At least one stent was implanted in 130 (93.5%) patients. The sheath was removed immediately after PCI, except for one case, and then a collagen plug was applied in all the cases. There were no significant differences in angiographic complications like no reflow, thrombus at the treated lesion site, occlusion of collateral branches, distal embolism, dissection, coronary rupture or abrupt closure. Cardiac markers including CK (6 [8.8%] in the LMWH group vs 8 [11.3%] in the UH group), CK-MB (6 [8.8%] vs 8 [11.3%], respectively), and troponin-I (6 [8.8%] vs 10 [14.1%], respectively) were slightly increased after PCI compared to the last value obtained before the procedure in both groups, but the differences were not statistically significant. One patient in the enoxaparin arm and 2 patients in the UH arm developed NSTEMI during their admission. Four patients from the UH arm and 3 from the enoxaparin arm experienced hematoma at the puncture site. After discharge, no other events were reported at the 1-month follow-up. Conclusion:The use of enoxaparin (75 IU/kg) during elective PCI was effective and safe as using UH. Enoxaparin could be used like UH as a periprocedural anticoagulant in the elective PCI setting. (Korean Circulation J 2006;36:573-577)

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

Background and Objectives:Osteoprotegerin (OPG) is a decoy receptor for receptor nuclear factor-kB ligand (RANKL). We sought to evaluate the association between the serum OPG level and the target lesion calcium (TLC) in those patients suffering with coronary artery disease (CAD). Subjects and Methods:We assayed the serum OPG levels in 65 CAD patients (mean age: 62±10 yrs, M:F=46:19) with using enzyme immunoassay, and these patient underwent intravascular ultrasound (IVUS) examinations of their target lesions. The degree of TLC was estimated by the maximum arc of calcium and also the calcified plaque surface area that was calculated from the serial cross-section IVUS images. Results:The median serum OPG levels were greater in the subjects with TLC than in the subjects without TLC (1.36 vs 0.95 ng/mL, respectively, p

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

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

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

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

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

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

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

Background and Objectives：Receptor for advanced glycosylation end product (RAGE) plays an important role in the development of myocardial fibrosis in diabetics. Activation of peroxisome proliferator activated receptor (PPAR)-γ agonist, rosiglitazone, reduces the RAGE expression. We investigated whether rosiglitazone could prevent left ventricle (LV) diastolic dysfunction and attenuate the myocardial fibrosis in a type 2 diabetic rat model. Materials and Methods：Otsuka Long-Evans Tokushima Fatty (OLETF) rats were treated with rosiglitazone (20 mg/kg/d) for 20 weeks. At the age of 20 and 40 weeks, all rats underwent intraperitoneal glucose tolerance tests, hemodynamic studies and Doppler echocardiography. At the age of 40 weeks, the hearts were examined by performing histopathological and immunohistochemical analyses. Results：At the age of 40 weeks, rosiglitazone significant improved the parameters of the LV diastolic function such as the E/A ratio (treated vs. untreated: 1.7±0.1 vs. 1.5±0.1, p