Ga Yeon Lee

Usefulness of High-Sensitivity Troponin I for the Monitoring of Subclinical Acute Cellular Rejection After Cardiac Transplantation

BACKGROUND There are conflicting data about the role of cardiac troponin I (cTnI) as determined by means of conventional methods for the prediction of acute rejection after heart transplantation (HT). The purpose of this study was to evaluate whether cTnI as measured by means of the early prototype high-sensitivity assay (hs-cTnI) can predict acute rejection episode after HT compared with grade of rejection in endomyocardial biopsy (EMB). METHODS This was a single-center cross-sectional study evaluating cTnI levels with the use of both hs-cTnI and current less sensitive conventional cTnI (conv-cTnI) assays measured at the time of EMB after HT. We calculated an index ratio of observed cTnI to expected mean cTnI for each individual patient defined as the mean cTnI measurements at EMB 60 days after HT. RESULTS A total of 252 biopsies from 47 patients were included in this study. In the multivariable mixed model analysis in relation to the presence of acute rejection 60 days after HT, hs-cTnI level was significantly related to the presence of rejection (P = .010). The hs-cTnI ratio index was significantly higher at the time of rejection (median, 1.37; interquartile range [IQR], 1.23-2.88) compared with those without rejection (median, 0.90; IQR, 0.51-1.16; P < .001). In receiver operating characteristic curve analysis, an hs-cTnI ratio index of ≥1.17 could predict the acute rejection with a sensitivity of 82.4% and a specificity of 77.1%. CONCLUSIONS An increased hs-cTnI ratio index was significantly related to rejection episodes. Serial monitoring of hs-cTnI and comparing it with the values without rejection might be useful for the detection of acute rejection after HT.

Outcomes of de novo and acute decompensated heart failure patients according to ejection fraction

Objective There are conflicting results among previous studies regarding the prognosis of heart failure with preserved ejection fraction (HFpEF) compared with heart failure with reduced ejection fraction (HFrEF). This study aimed to compare the outcomes of patients with de novo acute heart failure (AHF) or acute decompensated HF (ADHF) according to HFpEF (EF≥50%), or HFrEF (EF<40%) and to define the prognosis of patients with HF with mid-range EF (HFmrEF, 40≤EF<50%). Methods Between March 2011 and February 2014, 5625 consecutive patients with AHF were recruited from 10 university hospitals. A total of 5414 (96.2%) patients with EF data were enrolled, which consisted of 2867 (53.0%) patients with de novo and 2547 (47.0%) with ADHF. Each of the enrolled group was stratified by EF. Results In de novo, all-cause death rates were not significantly different between HFpEF and HFrEF (HFpEF vs HFrEF, 206/744 (27.7%) vs 438/1631 (26.9%), HRadj 1.15, 95% CI 0.96 to 1.38, p=0.14). However, among patients with ADHF, HFrEF had a significantly higher mortality rate compared with HFpEF (HFpEF vs HFrEF, 245/613 (40.0%) vs 694/1551 (44.7%), HRadj 1.25, 95% CI 1.06 to 1.47, p=0.007). Also, in ADHF, HFmrEF was associated with a significantly lower mortality rate within 1 year compared with HFrEF (HFmrEF vs HFrEF, 88/383 (23.0%) vs 430/1551 (27.7%), HRadj 1.31, 95% CI 1.03 to 1.65, p=0.03), but a significantly higher mortality rate after 1 year compared with HFpEF (HFmrEF vs HFpEF, 83/295 (28.1%) vs 101/469 (21.5%), HRadj 0.70, 95% CI 0.52 to 0.96, p=0.02). Conclusions HFpEF may indicate a better prognosis compared with HFrEF in ADHF, but not in de novo AHF. For patients with ADHF, the prognosis associated with HFmrEF was similar to that of HFpEF within the first year following hospitalisation and similar to HFrEF 1  year after hospitalisation.

Asp58Ala is the Predominant Mutation of the TTR Gene in Korean Patients with Hereditary Transthyretin‐Related Amyloidosis

Hereditary transthyretin (TTR)‐related amyloidosis (ATTR) seems to be a rare autosomal‐dominant inherited form of systemic amyloidosis. Studies indicate considerable heterogeneity in the diseases presentation and genotype; however, there is little data from Korea, where the prevalence of hereditary ATTR is very low. In this study, we investigated the phenotypic and genotypic spectra of hereditary ATTR in Korea. Direct sequencing analysis was performed to detect TTR gene mutations in amyloidosis patients whose results of TTR immunohistochemical staining were positive or equivocal. Clinical presentation was categorized as exclusively cardiac, exclusively neurologic, or mixed phenotype. Of 12 genetic tests performed, seven were positive for TTR mutations. D58A (c.173A>C) was the most common mutation in this study (57%, 4/7). The majority of those patients with hereditary ATTR had the mixed phenotype (86%, 6/7). The patients with D58A mutation had older ages of disease onset (median, 61 years vs. 42 years; P = 0.08), and a higher incidence of gastrointestinal involvement (75% vs. 0%; P = 0.03) than those with other identified TTR mutations. A significant male predominance was also noted in this study (P = 0.01).

Double Orifice Mitral Valve with Bicuspid Aortic Valve in Real Time Three‐Dimensional Transesophageal Echocardiographic Examination

A 41-year-old male was referred to our hospital for the evaluation of the recently aggravated palpitation and the cardiomegaly detected on chest x-ray examination. The electrocardiogram revealed atrial flutter with variable conduction, with the heart rate around 70–100 beats/min. Transthoracic echocardiographic examination (TTE) showed moderate mitral stenosis (mean pressure gradient at mitral valve = 6.2 mmHg) with a band-like structure in the mid portion of the opened mitral valve (Fig. 1A). Additionally, a raphe between right coronary cusp and left coronary cusp was suspected (Fig. 1B). In transesophageal echocardiographic examination (TEE), accelerated jet flows in two different directions were seen at mitral valve, which suggested two different passages through mitral valve (Fig. 2). In the real time three-dimensional (3D) TEE, double orifice of mitral valve was clearly demonstrated (Fig. 3A). And a chordae belonging to one papillary muscle was attached to the band-like structure of mitral valve (Fig. 3B). Bicuspid aortic valve was also confirmed (Fig. 4). Double orifice mitral valve (DOMV) is a rare form of congenital heart disease. In the largest report of 27 DOMV postmortem cases, bicuspid aortic valve was found in 2 patients (8%) among 27 DOMV cases.1 And the other study reported six cases (33%) of concomitant bicuspid aortic valve among 18 patients of DOMV with intact

Prognostic Significance of Left Axis Deviation in Acute Heart Failure Patients with Left Bundle branch block: an Analysis from the Korean Acute Heart Failure (KorAHF) Registry

Background and Objectives The prognostic impact of left axis deviation (LAD) on clinical outcomes in acute heart failure syndrome (AHFS) with left bundle branch block (LBBB) is unknown. The aim of this study was to determine the prognostic significance of axis deviation in acute heart failure patients with LBBB. Methods Between March 2011 and February 2014, 292 consecutive AHFS patients with LBBB were recruited from 10 tertiary university hospitals. They were divided into groups with no LAD (n=189) or with LAD (n=103) groups according to QRS axis <−30 degree. The primary outcome was all-cause mortality. Results The median follow-up duration was 24 months. On multivariate analysis, the rate of all-cause death did not significantly differ between the normal axis and LAD groups (39.7% vs. 46.6%, adjusted hazard ratio, 1.01; 95% confidence interval, 0.66, 1.53; p=0.97). However, on the multiple linear regression analysis to evaluate the predictors of the left ventricular ejection fraction (LVEF), presence of LAD significantly predicted a worse LVEF (adjusted beta, −3.25; 95% confidence interval, −5.82, −0.67; p=0.01). Right ventricle (RV) dilatation was defined as at least 2 of 3 electrocardiographic criteria (late R in lead aVR, low voltages in limb leads, and R/S ratio <1 in lead V5) and was more frequent in the LAD group than in the normal axis group (p<0.001). Conclusions Among the AHFS with LBBB patients, LAD did not predict mortality, but it could be used as a significant predictor of worse LVEF and RV dilatation (Trial registry at KorAHF registry, ClinicalTrial.gov, NCT01389843).

The successful implantation of continuous-flow left ventricular assist device as a destination therapy in Korea: echocardiographic assessment.

Left ventricular assist device (LVAD) is a good treatment option for the patients ineligible for cardiac transplantation. Several studies have demonstrated that a ventricular assist device improves the quality of life and prognosis of the patients with end-stage heart failure. A 75-yr-old man debilitated with New York Heart Association (NYHA) functional class III-IV due to severe left ventricular systolic dysfunction received LVAD implantation as a destination therapy. The patient was discharged with improved functional status (NYHA functional class II) after appropriate cardiac rehabilitation and education about how to manage the device and potential emergency situations. This is the first case of successful continuous-flow LVAD implantation as a destination therapy in Korea.

Effects of angiotensin receptor blocker at discharge in patients with heart failure with reduced ejection fraction: Korean Acute Heart Failure (KorAHF) registry

BACKGROUND After introduction of up-titration strategy, there are limited data on comparison between the effects of angiotensin converting enzyme inhibitors (ACEI) and angiotensin receptor blocker (ARB) in patients with heart failure with reduced ejection fraction (HFrEF). The study sought to investigate the association between treatment with ARB at discharge and clinical outcomes in patients with HFrEF compared with treatment with ACEI or no renin angiotensin system blocker (RASB). METHODS The KorAHF registry is a prospective multicenter cohort and included patients who were hospitalized for acute heart failure (AHF). We studied 3005 patients with HFrEF (<40%), and divided into ARB (n=1190), ACEI (n=1090), and no RASB (n=725) groups. Propensity score matching was performed. RESULTS All-cause death occurred in 346 patients (29.1%) in the ARB group, 315 patients (28.9%) in the ACEI group, and 305 (42.1%) in the no RASB group. After propensity score matching (ARB vs. ACEI, 827 pairs), there was no significant difference between the two groups in the rate of death (HR 0.91, 95% CI 0.76-1.09, p=0.32). All-cause death was significantly lower in the ARB group than in the no RASB group (ARB vs. no RASB, 538 pairs, HR 0.69, 95% CI 0.56-0.83, p<0.001). The ARB group had a significantly lower discontinuation rate than the ACEI group (20.8% vs. 33.6%, p<0.001). CONCLUSIONS For treatment of AHF with reduced EF after hospitalization, ARB at discharge shows a mortality benefit comparable to that of ACEI. In addition, tolerability of medication was greater for ARB than for ACEI.

Clinical features of idiopathic restrictive cardiomyopathy: A retrospective multicenter cohort study over 2 decades

Abstract Idiopathic restrictive cardiomyopathy (RCMP) has not been fully understood because this disease is difficult to diagnose. The present study aimed to assess the clinical profile and outcome of idiopathic RCMP from a multicenter cohort. This investigation is a retrospective study of consecutive patients with idiopathic RCMP at 10 centers in Korea between 1990 and 2010. We evaluated the clinical characteristics of the patients and prognostic factors associated with mortality using multivariate Cox proportional hazards regression analyses. The study included 53 patients (26 men, 49.1%). During a median follow-up of 1.7 years, 17 patients (32.1%) died and 5 patients (9.4%) received a heart transplant. The 5-year survival rate of the overall patients was 64.4% ± 7.8%. In multivariable analyses, the predictors of mortality were tricuspid regurgitation (TR) ≥ moderate (hazard ratio [HR] 32.55, P < .001) and left ventricular end-diastolic diameter (LVEDD) (HR 0.85, P < .001). Idiopathic RCMP showed unfavorable prognosis. Advanced TR and lower LVEDD are independent adverse predictors of mortality in patients with idiopathic RCMP.