Hee-Hwa Ho

Recurrent acute heart failure caused by sliding hiatus hernia

The case is reported of a 75 year old woman who presented with recurrent nocturnal episodes of acute pulmonary oedema. The cause was uncertain as she had normal cardiothoracic ratio on chest radiography and normal left ventricular systolic and diastolic function by transthoracic echocardiogram. Another transthoracic echocardiogram was repeated when she was recumbent for an hour and had a full stomach. It showed a striking finding of severe left atrial compression by an external structure. Computed tomography of the thorax showed an intrathoracic mass behind the left atrium causing external compression of the left atrium suggestive of a sliding hiatus hernia. Cardiac catheterisation confirmed the diagnosis by showing a pronounced rise of pulmonary capillary wedge pressure in the recumbent position compared with the sitting up position.

Are MADIT II Criteria for Implantable Cardioverter Defibrillator Implantation Appropriate for Chinese Patients

MADIT II Criteria for Implantable Cardioverter. Background: MADIT‐II demonstrated that prophylactic implantation of an implantable cardioverter‐defibrillator (ICD) device prevents sudden cardiac death (SCD) in patients with myocardial infarction (MI) and impaired left ventricular ejection fraction (LVEF). It remains unclear whether the MADIT‐II criteria for ICD implantation are appropriate for Chinese patients.

Modified crush technique with double kissing balloon inflation (sleeve technique): A novel technique for coronary bifurcation lesions

We report a modified crush technique with double kissing balloon inflation (the sleeve technique) in an attempt to increase the success rate of final kissing balloon inflation, which has been shown to improve the angiographic outcomes of side branch in bifurcation lesions. A stent was advanced across the side branch with protrusion of 3–5 mm of proximal stent segment into the main vessel. At the same time, a size‐matched balloon with length long enough to cover the bifurcation as well as the protruding stent segment was placed in the main vessel. The side‐branch stent is deployed first, the wire and stent balloon are removed. This is followed by balloon inflation in main vessel at high pressure to crush the protruding stent segment against vessel wall. The side branch is then rewired, two balloons are advanced to the main vessel and side branch, and the bifurcation is kissed with balloons the first time. The side branch is now like a new sleeve. The balloon and wire of the side branch are removed. Another stent was positioned and then deployed in the main vessel. The side branch is rewired the second time, two balloons are advanced to the main vessel and side branch again, followed by final (second) kissing balloon inflation of the bifurcation. The sleeve technique has been employed in six consecutive patients with 100% success rate of final kissing balloon inflation. There was no major adverse cardiac events or stent thrombosis encountered within 30 days of percutaneous coronary intervention.

Relationship between changes in heart rate recovery after cardiac rehabilitation on cardiovascular mortality in patients with myocardial infarction.

BACKGROUND Heart rate recovery (HRR) at predischarge exercise stress test predicts all-cause mortality in patients with myocardial infarction (MI), but the relationship between improvement in HRR with exercise training and clinical outcomes remains unclear. OBJECTIVE The purpose of this study was to evaluate the effect of change in HRR after exercise training on clinical outcomes in MI patients. METHODS The study included 386 consecutive patients with recent MI who were enrolled into our cardiac rehabilitation program. All patients underwent symptom-limited treadmill testing at baseline and after exercise training, and were prospectively followed-up in the outpatient clinic. RESULTS Treadmill testing revealed significant improvement in HRR after 8 weeks of exercise training (17.5 +/- 10.0 bpm to 19.0 +/- 12.3 bpm, P = .011). After follow-up of 79 +/- 41 months, 40 (10.4%) patients died of cardiac events. Multivariate Cox regression analysis revealed that diabetes (hazard ratio [HR] 2.28, 95% confidence interval [CI] 1.01-5.19, P = .049), statin use (HR 0.36, 95% CI 0.16-0.80, P = .012), baseline resting heart rate > or =65 bpm (HR 5.37, 95% CI 1.33-21.61, P = .018), post-training HRR <12 bpm (HR 2.49, 95% CI 1.10-5.63, P = .028), left ventricular ejection fraction < or =30% (HR 4.70, 95% CI 1.34-16.46, P = .016), and exercise capacity < or =4 metabolic equivalents (HR 3.63, 95% CI 1.17-11.28, P = .026) were independent predictors of cardiac death. Patients who failed to improve HRR from <12 bpm to > or =12 bpm after exercise training had significantly higher mortality (HR 6.2, 95% CI 1.3-29.2, P = .022). CONCLUSION Exercise training improved HRR in patients with recent MI, and patients with HRR increased to > or =12 bpm had better cardiac survival.

Stenting of coronary bifurcation lesions by using modified crush technique with double kissing balloon inflation (sleeve technique): Immediate procedure result and short‐term clinical outcomes

Background: Sleeve technique is a modified version of crush technique. It is specifically designed to increase the success rate of final kissing balloon inflation, which used to be a major limitation of the latter. Objectives: The aim of this study was to examine the feasibility, safety, and early clinical outcomes of sleeve technique in stenting different types (de novo, in‐stent restenotic or in‐stent bifurcation) of coronary bifurcation lesions at different locations. Methods: From August 2005 to May 2006, 41 consecutive patients with symptomatic, nonleft‐main coronary bifurcation stenoses of diameter narrowing ≥50% were treated with two‐stent strategy, using sleeve technique. Results: The mean age was 63.6 ± 11.6 years with male predominance (70.7%). High prevalence of diabetes mellitus (31.7%), total occlusion (22.0%), and multi‐vessel disease (65.9%) was observed in this cohort. Intravenous abciximab was given in 35 (85.4%) patients. Final kissing balloon inflation was successfully performed in all patients. The minimal luminal diameter in main vessel and side branch was increased from 0.97 ± 0.53 mm and 0.81 ± 0.45 mm to 2.76 ± 0.34 mm and 2.22 ± 0.35 mm, respectively. The mean procedure time was only 66.6 ± 24.6 min. There was one (2.4%) case of subacute stent thrombosis presented as non‐Q‐wave myocardial infarction at day 3 postprocedure. The resultant in‐hospital and 30‐day major adverse cardiac event rate were both 2.4%. Conclusions: Sleeve technique is a feasible and efficient approach in stenting of coronary bifurcation stenoses.

β-blocker in post-myocardial infarct survivors with preserved left ventricular systolic function

Background:  Long‐term β‐blockade therapy is beneficial in post‐myocardial infarct (MI) patients with left ventricular (LV) dysfunction; nevertheless, its benefit in post‐MI patients with preserved LV function remains unclear. The objective of this study is to investigate the effects of long‐term β‐blockade therapy on the clinical outcomes in post‐MI patients with preserved LV function.

Virtual histology by intravascular ultrasound study on degenerative aortocoronary saphenous vein grafts

Data of virtual histology (VH) acquired by intravascular ultrasound (IVUS) on saphenous vein graft (SVG) lesions is lacking. This study sought to report the VH IVUS findings in degenerative aortocoronary SVG lesions and correlate various types of plaque compositions (fibrous, fibro-fatty, dense calcium, and necrotic core) with different clinical and lesion characteristics. Virtual histology IVUS was performed on SVG in 38 symptomatic patients with a history of coronary artery bypass grafting, who underwent percutaneous coronary intervention on either native vessels or SVG. Measurements were made at the image slice with the smallest lumen. A total of 54 SVG lesions were analyzed; the mean graft age was 13.7 ± 4.0 years. The mean vessel size was 5.0 ± 1.0 mm; plaque area was 13.4 ± 7.3 mm2, and plaque burden was 63.0% ± 15.0%. Fibrous tissue represented the major plaque component (62.1% ± 17.1%). Lesions with a plaque burden of ≥70% were associated with positive remodeling, larger vessel size, higher percentage of fibro-fatty tissue, but lower percentage of dense calcium. Plaque burden was found to be positively correlated with remodeling index (r = 0.37, P = 0.01) and % fibro-fatty tissue (r = 0.49, P < 0.001) but negatively correlated with % dense calcium (r= −0.31, P = 0.03). The severity of SVG atherosclerosis paralleled with a proportional increase in fibro-fatty tissue. Unstable plaques in SVG were associated with positive remodeling, lipid-rich atheroma, and less calcium deposition, similar to the VH IVUS findings in native coronary arteries.

Zotarolimus-eluting stent utilization in small-vessel coronary artery disease (ZEUS)

The role of the second-generation zotarolimus-eluting stent RESOLUTE in small-vessel coronary artery disease is unclear. The aim of this study was examine the angiographic results of RESOLUTE in de novo coronary lesions of ≥50 % diameter stenosis in target vessels ≤2.5 mm. From August 2008 to April 2010, 142 symptomatic patients with 159 lesions who fitted the inclusion criteria were treated with RESOLUTE. The mean age of patients was 66 ± 10 years, with male predominance (66 %). Diabetes mellitus was found in 62 (43.7 %) patients, whereas multivessel disease was observed in 105 (73.9 %). The mean stent size and length used were 2.33 ± 0.13 and 22 ± 8 mm, respectively. Follow-up angiography was performed on 143 (89.9 %) lesions in 127 (89.4 %) patients at a mean of 10.3 ± 3.6 months. Angiographic restenosis was found in 9 (6.3 %) lesions; the late loss was 0.26 ± 0.34 mm. At 1-year follow-up there were four cardiovascular deaths, two nonfatal myocardial infarctions, and six repeated revascularizations. The resultant major adverse cardiac event rate was 8.5 %. The use of RESOLUTE to treat small-vessel disease is associated with good clinical and angiographic outcomes at 1 year.

Successful use of endothelial progenitor cell capture stents in two cases of acute coronary syndrome complicated by major bleeding episodes

Abstract We report on the successful use of endothelial progenitor cell (EPC) capture stents in 2 cases of acute myocardial infarction (MI) that was complicated by major bleeding episodes requiring blood transfusion and necessitating early discontinuation of anti-thrombotic/anti-plaletet agents.

Long‐term Clinical Outcomes of Drug‐Eluting Stents Vs Bare‐Metal Stents in Chinese Patients

There is limited data on the magnitude of the problem of drug‐eluting stent (DES) thrombosis in the Asian population.