Hyun Suk Yang

Prognostic Significance of Cerebral Metabolic Abnormalities in Patients With Congestive Heart Failure

Background—Cerebral metabolic abnormalities were proposed as a potential marker of disease severity in congestive heart failure (CHF), but their prognostic significance remains uncertain. Methods and Results—We investigated the prognostic value of cerebral metabolic abnormalities in 130 consecutive patients with advanced CHF (100 men aged 42.6±11.9 years; left ventricular ejection fraction, 22.2±6.2%). Proton magnetic resonance spectroscopy data were obtained from localized regions (≈8 mL) of the occipital gray matter and the parietal white matter. The primary end point was the occurrence of death after the proton magnetic resonance spectroscopy. During follow-up (18.5±14.4 months), 21 patients died and 15 underwent urgent heart transplantation. In the Cox proportional model, occipital metabolites (N-acetylaspartate, creatine, choline, and myoinositol), parietal N-acetylaspartate level, and the duration of CHF symptoms (>12 months) were validated as univariate predictors of death. In multivariate Cox analyses, however, the occipital N-acetylaspartate level was an independent predictor of death (hazard ratio, 0.52; 95% CI, 0.41 to 0.67;P <0.001). An analysis with respect to the combined end point of death or urgent transplantation showed similar results. The best cutoff value (9.0 mmol/kg) for occipital N-acetylaspartate level had 75% sensitivity and 67% specificity to predict mortality. Conclusions—The occipital N-acetylaspartate level is a powerful and independent predictor of CHF mortality, suggesting that cerebral metabolic abnormalities may be used as a new prognostic marker in the assessment of patients with CHF.

Determinants and Prognostic Implications of Terminal QRS Complex Distortion in Patients Treated With Primary Angioplasty for Acute Myocardial Infarction

Terminal QRS complex distortion on admission has an impact on a patients prognosis after primary angioplasty for acute myocardial infarction (AMI). We evaluated the determinants and prognostic significance of terminal QRS complex distortion in 153 consecutive patients with AMI after primary angioplasty. The study population was divided into 2 groups according to the presence (group I, n = 41) or absence (group II, n = 112) of terminal QRS complex distortion. The primary end points were the occurrence, within 6 weeks after AMI, of death, nonfatal reinfarction, or congestive heart failure. Baseline characteristics were similar between the 2 groups. However, patients in group I had higher peak levels of serum creatine kinase than those in group II (5,100 +/- 3,100 vs 3,000 +/- 1,800 U/L, respectively, p <0.01). The rate of angiographic no-reflow (Thrombolysis In Myocardial Infarction flow grade < or =2) was 31.7% in group I and 10.7% in group II (p <0.01). The predischarge left ventricular ejection fraction was 45.0 +/- 12.0% in group I and 54.0 +/- 8.0% in group II (p <0.01). Multivariate analysis identified the pressure-derived fractional collateral flow index and the culprit lesion in the left anterior descending coronary artery as independent determinants of the terminal QRS complex distortion. No patients died during 6 weeks of follow-up. The 2 groups were similar for life-threatening arrhythmia or reinfarction. However, there were more patients in group I than in group II with congestive heart failure (26.8% vs 5.4%, respectively, p <0.01) or who reached the primary end points (29.3% vs 5.4%, respectively, p <0.01). In conclusion, terminal QRS complex distortion on admission is associated with poor clinical outcome after primary angioplasty for AMI, and collateral flow may have a major influence on terminal QRS complex distortion during AMI.

Real-Time 3-Dimensional Transesophageal Echocardiography

With the increase in cardiac transcatheter interventions, multiplane 2-dimensional transesophageal echocardiography (TEE) and intracardiac echocardiography have emerged as guiding tools, but they have potential limitations in clarifying the spatial relationship of the catheters relative to surrounding structures.1 Recently, the use of real-time 3-dimensional (3D) transthoracic echocardiography has been reported in Amplatzer closure device procedures2 and in endomyocardial diagnostic and therapeutic procedures.3 The real-time 3D technology now has been merged with TEE to provide superior high resolution for the real-time volume image from the …With the increase in cardiac transcatheter interventions, multiplane 2-dimensional transesophageal echocardiography (TEE) and intracardiac echocardiography have emerged as guiding tools, but they have potential limitations in clarifying the spatial relationship of the catheters relative to surrounding structures.1 Recently, the use of real-time 3-dimensional (3D) transthoracic echocardiography has been reported in Amplatzer closure device procedures2 and in endomyocardial diagnostic and therapeutic procedures.3 The real-time 3D technology now has been merged with TEE to provide superior high resolution for the real-time volume image from the …

Left Atrial Fibroma in Gardner Syndrome

A 72-year-old man with a history of hypertension and hyperlipidemia was referred for bradycardia and ectopic atrial rhythm on his ECG. His past medical history was remarkable for recurrent multiple colonic adenomatous polyps, multiple subcutaneous lipomas, seborrheic keratoses, an atrophic left kidney from retroperitoneal fibrosis, and left Bell palsy. He had a family history of colon polyps in his brother and a benign cecal mass in his son. Conventional 2-dimensional transthoracic and transesophageal echocardiograms (TEE) with contrast revealed a left atrial (LA) mass (4.0×3.7 cm2) attached to the atrial septum (Figure 1). Cardiac computed tomography suggested a LA mass encroaching toward the entrance of the right pulmonary veins with nearly total obstruction (Figure 2). A coronary angiogram showed neither significant coronary arterial stenosis nor feeding arteries for the mass. The patient was referred to a cardiac surgeon with a presumptive diagnosis of LA myxoma; however, intraoperative TEE and surgical inspection revealed a large and hard mass between the right superior and inferior pulmonary veins that did not impinge on their inflows, involving the posterior and superior LA walls, atrial septum, and the right atrial wall. Multiple echo-guided biopsies of the mass confirmed the mass to be a benign cardiac fibroma …A 72-year-old man with a history of hypertension and hyperlipidemia was referred for bradycardia and ectopic atrial rhythm on his ECG. His past medical history was remarkable for recurrent multiple colonic adenomatous polyps, multiple subcutaneous lipomas, seborrheic keratoses, an atrophic left kidney from retroperitoneal fibrosis, and left Bell palsy. He had a family history of colon polyps in his brother and a benign cecal mass in his son. Conventional 2-dimensional transthoracic and transesophageal echocardiograms (TEE) with contrast revealed a left atrial (LA) mass (4.0×3.7 cm2) attached to the atrial septum (Figure 1). Cardiac computed tomography suggested a LA mass encroaching toward the entrance of the right pulmonary veins with nearly total obstruction (Figure 2). A coronary angiogram showed neither significant coronary arterial stenosis nor feeding arteries for the mass. The patient was referred to a cardiac surgeon with a presumptive diagnosis of LA myxoma; however, intraoperative TEE and surgical inspection revealed a large and hard mass between the right superior and inferior pulmonary veins that did not impinge on their inflows, involving the posterior and superior LA walls, atrial septum, and the right atrial wall. Multiple echo-guided biopsies of the mass confirmed the mass to be a benign cardiac fibroma …

In vivo intraocular pressure monitoring during microincision vitrectomy with and without active control of infusion pressure

Purpose To evaluate intraocular pressure (IOP) fluctuation during vitrectomy, we directly monitored IOP in vivo using 2 vitrectomy machines with or without constant infusion pressure monitoring and control. Methods Among 61 eyes of 61 consecutive patients, 32 were assigned to the Accurus system (group 1) and 29 were assigned to the Constellation system (group 2) in this prospective case series. The IOP fluctuations were evaluated during routine vitrectomy procedures. Results The initial IOP before vitrectomy was 20.3 ± 2.4 mm Hg in group 1 using a conventional vented gas forced infusion system and 20.0 ± 0.0 mm Hg in group 2 using active IOP control at 20 mm Hg (p = 0.532). However, the average IOP change during core vitrectomy was -8.6 ± 4.3 mm Hg in group 1 and -0.8 ± 1.1 in group 2 (p<00.001). Maximum IOP was significantly decreased in group 1 (-17.0 ± 2.6 mm Hg) compared with that in group 2 (-4.1 ± 2.2 mm Hg) (p<00.001). Partial ocular collapse was observed during vitrectomy only in group 1 (78.1%). Peak IOP significantly increased during scleral compression and gas and fluid injection but was not significantly different between the groups (all p≥0.147). The IOP fluctuation range was 50-70 mm Hg in both groups. Conclusions The IOP fluctuated significantly during routine vitrectomy using both systems. Hypotony and partial ocular collapse were more frequently observed during vitrectomy with the Accurus system than with the Constellation system. Both systems were vulnerable to IOP surge during indentation and intravitreal injection.