Jae Kean Ryu

Reference Values for the Augmentation Index and Pulse Pressure in Apparently Healthy Korean Subjects

Background and Objectives Arterial stiffness is a precursor to premature cardiovascular disease. The augmentation index (AI) and pulse pressure (PP) are cardiovascular risk factors. The aim of this study was to define the diagnostic values of the AI and PP from the peripheral arterial and central aortic waveforms in healthy subjects. Subjects and Methods We recruited 522 consecutive subjects (mean age 46.3±9.6 years, 290 males) who came to our facility for a comprehensive medical testing. We measured the body mass index (BMI), blood pressure, peripheral and central PP, and a pulse wave analysis that included the central and peripheral AI. Results The peripheral and central AIs in the female subjects were significantly higher than that in the male subjects (p<0.001). The peripheral and central PPs in the subjects with hyperlipidemia were significantly higher than subjects with normal lipid profiles (p<0.001). The peripheral and central PPs and peripheral and central AIs significantly increased with age. Conclusion Pending validation in prospective outcome-based studies, a peripheral PP of 70 mmHg, central PP of 50 mmHg, peripheral AI of 100%, and central AI of 40% may be preliminary values in adult subjects.

Anomalous Origin of the Left Coronary Artery from the Pulmonary Artery Initially Visualized by Echocardiography and Multidetector Computed Tomography Coronary Angiography

Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital anomaly associated with very high mortality during infancy. We report a 35-year-old female patient with ALCAPA initially visualized by echocardiography. She visited outpatient department presenting with intermittent chest discomfort for 3 weeks. Transthoracic echocardiography showed left coronary artery arising from main pulmonary artery and abundant septal color flow Doppler signals. Transesophageal echocardiography clearly revealed markedly dilated and tortuous right coronary artery showing windsock appearance. Multidetector computed tomography and coronary angiography enabled visualization of anomalous left coronary artery originating from left side of main pulmonary trunk. After treadmill exercise test which showed ST-segment depression presenting inducible myocardial ischemia, patient underwent direct re-implantation of the anomalous coronary artery into the aorta without any complication.

Postoperative Atrial Fibrillation After Noncardiothoracic Surgery: Is It Different From After Cardiothoracic Surgery?

Postoperative atrial fibrillation (AF) is the most common arrhythmia that occurs after both cardiac and noncardiac surgery. It is associated with an increased morbidity, longer hospital stay and higher hospital costs. In addition, one of the most important clinical consequences of postoperative AF might be an increased incidence of perioperative stroke.1) There have been many investigations on the incidence, predictors, prophylactic strategies, and management of postoperative AF in patients undergoing cardiothoracic surgery. However, few studies have investigated the incidence and consequences of AF after noncardiothoracic surgery. Refer to the page 100-104 New onset AF after cardiac surgery has been reported to occur in 12 to 40 percent of patients after coronary artery bypass surgery, and the rate is even higher after valve replacement surgery, as high as 60%.2) Predictors associated with an increased risk of postoperative AF, after cardiac surgery, include advanced age, postoperative electrolyte shifts, pericarditis, a history of preoperative AF, a history of congestive heart failure, and chronic obstructive pulmonary disease. Focusing on the incidence and risk factors associated with new onset AF after thoracic (noncardiac) surgery, Vaporciyan and colleagues reported on 2,588 patients and found that the overall incidence of postoperative AF was 12.3%, somewhat lower than that with cardiac surgery; this is consistent with the results of previous reports.3),4) Significant multivariate predictors of AF after thoracic surgery include a male gender, older patient age, history of congestive heart failure, history of arrhythmias, and history of peripheral vascular disease.5) New onset AF, after cardiac and thoracic surgery, is likely triggered by direct intrathoracic stimulation or atrial irritation. It is, therefore, not surprising that the incidence of AF has been found to be lower when surgery does not involve the thorax. In one prospective series of 916 patients over 40 years of age undergoing major noncardiothoracic surgery, the incidence of AF was 2.5%;6) another more recently published study reported much lower incidence, 0.37%.7) Sohn and colleagues added and extended the observations on the topic of AF after noncardiothoracic surgery in this issue of the journal. They report the incidence of postoperative AF after noncardiothoracic surgery was 0.39%, and found that it was a relatively rare complication; it was associated with older age, and emergency surgery, and it extended the hospital stay. Their observations of significant multivariate predictors are different from those reported by Vaporciyan and colleagues. However, diverse patient groups were studied and different cardiac monitoring was used. Therefore, interpretation of the results should be made with consideration of the differences between the studies. The clinicians, especially cardiologists who are likely to care for patients prone to postoperative cardiac complications, consider which patients might benefit from prophylactic strategies. Prospective randomized trials have examined the utility of variety of pharmacological agents and nonpharmacological methods for prophylaxis in patients undergoing cardiothoracic surgery. Although the results have been conflicting, most investigators would agree that β-blockers can serve as effective prophylactic treatment with amiodarone and sotalol as alternative medications. It is uncertain whether such prophylactic medication would be effective in patients undergoing noncardiothoracic surgery because the mechanism of the postoperative AF might be somewhat different. If postoperative AF results from a preexisting electrophysiological substrate with a superimposed trigger, the latter factor might be more important in noncardiothoracic surgery. Therefore, extrapolation of the prophylactic strategies used in patients undergoing cardiothoracic surgery to the entire population of patients undergoing noncardiac surgery may not be warranted.8) Although most episodes of postoperative AF are self-limited, the natural course of postoperative AF after noncardiothoracic surgery should be defined. AF persisting for longer than 48 hours is associated with an increased risk of stroke or transient ischemic attack. Thus, after 48 hours of AF, anticoagulation should be considered, weighing the potential benefits against the risk of postoperative bleeding.9) The article reported by Sohn and colleagues raises concern with regard to postoperative AF after noncardiothoracic surgery; they suggest that it might be different from AF after cardiothoracic surgery in its pathogenesis, natural course and required management. To date, there have been no randomized controlled trials on new onset AF complicating noncardiothoracic surgery. Therefore, larger trials are needed to provide evidence based safe and effective strategies for the management of new onset AF in patients undergoing noncardiothoracic surgery.

Usefulness of the Doppler Flow of the Ophthalmic Artery in the Evaluation of Carotid and Coronary Atherosclerosis

Background and Objectives There is little information about the relationship between the Doppler flow of the ophthalmic artery (OA) and carotid and coronary atherosclerosis. The aim of the investigation was to assess the clinical usefulness of the Doppler flow of the OA to estimate the severity of carotid and coronary atherosclerosis. Subjects and Methods The study was a retrospective analysis of the findings in 140 patients (mean age: 60 years, male: 64%) who underwent coronary angiography (CA) for the evaluation of typical angina between July 2010 and October 2011 in our single center. The severity of coronary artery stenosis was based on the Gensini score (GS). Significant coronary artery disease (CAD) was defined as the obstruction of over 75% of the major coronary arteries confirmed with CA. The pulsed Doppler flow of the OA and carotid ultrasound were performed before CA. Results The mean systolic velocity/mean diastolic velocity (MSV/MDV), pulsatile index and resistance index in the Doppler flow of the OA were identified as significant and independent correlations with carotid intima-media thickness, and MSV/MDV was identified to have a significant and independent correlation with the GS. MSV/MDV >2.1 was the independent predictor for significant CAD {odds ratio (OR) 3.8, 95% confidence interval (CI) 1.5-9.7, p=0.005} and carotid plaque (OR 2.8, 95% CI 1.1-7.0, p=0.028), after adjustment for CAD-associated factors. Conclusion The Doppler flow of the OA might be a useful predictor of the severity of carotid and coronary atherosclerosis.