Guang-Won Seo

Impact of Carvedilol Versus β1-Selective β Blockers (Bisoprolol, Metoprolol, and Nebivolol) in Patients With Acute Myocardial Infarction Undergoing Percutaneous Coronary Intervention

Although β blocker (BB) has constituted one of the mainstays of evidence-based therapy for patients with acute myocardial infarction (AMI), the comparative efficacy of different BBs remains uncertain. We sought to determine the comparative effectiveness of nonselective BB carvedilol and the most frequently prescribed β1-selective BBs (bisoprolol, metoprolol, and nebivolol) in patients with AMI undergoing percutaneous coronary intervention (PCI). A total of 7,863 patients were selected from the prospective national AMI registry, and patients were divided into carvedilol group (n = 6,231) and β1-selective BB group (n = 1,632) at hospital discharge. The primary end point was all-cause death or MI during follow-up. During a mean follow-up of 243 ± 144 days, all-cause death or MI occurred in 94 patients (1.5%) in the carvedilol group versus 31 patients (1.9%) in the β1-selective BB group (adjusted hazard ratio 0.81, 95% confidence interval 0.54 to 1.22, p = 0.32). This result was consistent across various risk subgroups. The risks of all-cause death, cardiac death, and MI were also similar between the groups. After propensity-score matching, no difference was observed in the rate of all-cause death or MI (1.7% in the carvedilol vs 1.9% in the β1-selective BB group, adjusted hazard ratio 0.84, 95% confidence interval 0.49 to 1.46, p = 0.55). In conclusion, no differences in the risk of all-cause death or MI were observed between the carvedilol and β1-selective BB groups in contemporary practice of the treatment for AMI.

ECG features and proarrhythmic potentials of therapeutic hypothermia

Objective Hypothermia can induce ECG J waves. Recent studies suggest that J waves may be associated with ventricular fibrillation (VF) in patients with structurally normal hearts. However, little is known about the ECG features, clinical significance or arrhythmogenic potentials of therapeutic hypothermia (TH)-induced J waves. Methods We analysed ECGs from 240 patients who underwent TH at six major university hospitals in Korea between August 2010 and December 2013. The prevalence, amplitudes and distributions of the J waves and the development of malignant arrhythmia were analysed. Results The average patient body temperature was 33.5±1.0°C during TH. J waves were observed in 98 patients (40.8%). They were newly developed in 91 cases, and pre-existing J waves were augmented in seven patients. J waves during TH were primarily observed in leads II, III, aVF and V4–6. The average amplitude of the J waves was 0.239±0.152 mV. There were four VF events during TH. These events occurred in three patients who were finally diagnosed with Brugada syndrome, idiopathic VF or early repolarisation syndrome, respectively, and in one patient with non-cardiac aetiology (asphyxia). Conclusions J waves were recorded in about 40% of the patients who received TH. They were most frequently observed in the inferior limb leads or lateral precordial leads. Life-threatening VF occurred only rarely (1.7%) during TH and were mainly observed in patients with primary arrhythmic disorder. Although a causal relationship between TH-induced J waves and VF remains unknown, administering TH to this potentially susceptible, high-risk population may require careful attention.

Coronary-pulmonary artery fistula—multiple diagnostic imaging modalities

Coronary artery fistula is rare anomalies. Most adult patients are usually asymptomatic. A fistula is incidentally identified in the adult using echocardiography. Coronary angiography is considered the standard tool to confirm a coronary artery fistula. However, multidetector computed tomography (MDCT) angiography is considered a good alternative to coronary angiography.

A Large Pericardial Cyst Compressing the Left Atrium Presenting as a Pericardiopleural Efussion

Pericardial cysts are rare congenital abnormalities with a reported incidence rate of 1:100,000, accounting for about 7.6% of all mediastinal masses. These cysts frequently occur in the right cardiophrenic angle and their diagnosis is usually suspected after an abnormal chest X-ray is obtained. Herein, we present a case of pericardial cyst compressing the left atrium complicated by a pericardial effusion and pleural effusion in a 62 year-old man with chest discomfort and dyspnoea. After the pericardial cyst was surgically removed, the histopathological examination revealed an inflamed pericardial cyst lined with mesothelial cells.

Low Pressure Pulmonary Artery Aneurysm with Atrial Septal Defect

Pulmonary artery (PA) aneurysm is a rare finding in the thoracic cavity, accompanied by pulmonary hypertension. Clinical presentation of PA aneurysms is usually asymptomatic. The guideline for PA aneurysm treatment is unclear. We report an unusual case of low pressure PA aneurysm associated with atrial septal defect in a 69-year-old man.

Benign Mature Teratoma in Anterior Mediastinum

Teratoma of mediastinum is rare germ cell tumor. Anterior mediastinum is the most common extragonadal site. Benign mediastinal teratoma accounts for 60% of all mediastinal germ cell tumors. Benign mature teratoma has excellent prognosis after surgical excision. We present a case of 20-year-old woman diagnosed as benign mature teratoma which compressed main pulmonary trunk. The patient underwent surgical excision.

Veno-veno-arterial ECMO support for acute myocarditis combined with ARDS: a case report

Background In patients who developed a combined situation of severe acute respiratory distress syndrome with refractory hypoxemia and acute cardiac failure with circulatory collapse, traditional veno-venous or veno-arterial extracorporeal membrane oxygenation approach alone may not be sufficient enough to maintain both an acceptable range of gas exchange and a hemodynamic stability. Case report A 27-year-old male patient was suffering from severe acute respiratory distress syndrome caused by community-acquired pneumonia and acute myocarditis with circulatory shock. After mechnical ventilation for respiratory support, he was in a persistently refractory shock state. Veno-veno-arterial mode of extracorporeal membrane oxygenation was thus applied to provide both respiratory and circulatory support simultaneously, with good success. Discussion Modifying to a veno-veno-arterial mode can be another alternative strategy in a combined situation of refractory respiratory and cardiac failure, thus providing not only respiratory support but also circulatory support. In veno-veno-arterial mode, the returning circuit from the pump was divided with a Y connector into 2 reinfusion circuits; each reinfusion circuit was connected to the contralateral side femoral vein and artery, respectively. The distribution of reinfusion flow was adjusted depending on the patients cardiopulmonary status. Conclusions Although there is no consensus about the veno-veno-arterial mode of extracorporeal membrane oxygenation, this combined mode can be helpful in patients with acute refractory respiratory and cardiac failure, as shown in the present case. We need further experience and improvements in the circuit system used in the veno-veno-arterial mode of ECMO.

Congenital Partial Defect of the Left Pericardium Presenting as Chest Pain

Congenital pericardial defect is a rare cardiac defect with variable clinical presentations. It is usually an unexpected finding during cardiac surgery or autopsy. The clinical detection of congenital absence of pericardium is important because of its life-threatening complications such as fatal myocardial strangulation, myocardial ischaemia and sudden death. We present a patient with the incidental finding of left-sided partial defect of the pericardium during evaluation of chest pain.

Fatal Left Ventricular Free Wall Rupture following Acute Myocardial Infarction

A 67 year-old woman who had no specific history presented in the emergency room with complaints of sudden chest pain, vomiting and syncope. The patient was conscious and physical examination showed heart rate 52 beats/min, blood pressure 60/30 mm Hg, temperature 36.5˚C. Heart sound was faint. Electrocardiogram showed ST elevation at II, III, aVF and sinus bradycardia (Fig. 1). Chest X-ray revealed pulmonary oedema (Fig. 2). The levels of CK-MB (30.3 ng/nL), troponin I(9.8 ng/mL) and Pro-BNP 2399 pg/mL were elevated. Transthoracic echocardiography revealed basal inferior wall rupture of left ventricle. Defect size was 2.27 cm. There were no regional wall motional abnormalities except basal inferior wall (Fig. 3). The patient‘s condition progressively worsened and took a rapid downhill course, despite aggressive haemodynamic support. Finally the patient died. Cardiac rupture is one of the serious complications of acute myocardial infarction. Chest pain, bradycardia, unexplained emesis, and syncope may be signs of cardiac rupture [1,2].

Extension of catheter ablation and outcome for ventricular tachycardia or premature ventricular contractions from the right ventricular outflow tract

Objective We aimed to determine whether the extension of ablation could influence the ablation outcome for ventricular tachycardia (VT)/premature ventricular contractions (PVCs) from the right ventricular outflow tract (RVOT). Methods and results The radiofrequency catheter ablation results of 33 VT/6 frequent PVCs from the RVOT were analysed. The ablation extension was divided into 3 categories from the final successful ablation point with the earliest activation: (I) focal ablation (15 cases); ablation at 1 or 2 points; (II) focal with extended ablation (12 cases); focal and surrounding area ablation (maximum ≤1 cm) after elimination of clinical VT/PVCs; and (III) broad ablation (12 cases); continued broad ablation (maximum >1 cm) after elimination of clinical VT/PVCs. Acute termination was defined as the complete elimination and non-inducibility of clinical VT/PVCs during the procedure. For the mean follow-up of 12.8 months, the recurrence rate was not significantly different among the groups (P = 0.49). The mean procedure time was longer in group II, but ablation times and complication rates were not different among the groups. When acute termination was achieved, the overall recurrence rate was 7.6%. However, when confirming absence of the clinical VT/PVCs using 24-hour Holter monitoring immediately after the procedure, the recurrence rate was 2.7%. Conclusions Ablation extension did not affect ablation outcome of VT/PVCs from the RVOT. Confirmation of absence of clinical VT/PVCs using 24-hour Holter monitoring immediately after the procedure could guarantee long-term success.