Joon Hyouk Choi

Application of veno-arterial-venous extracorporeal membrane oxygenation in differential hypoxia

Veno-arterial extracorporeal membrane oxygenation (ECMO) through the femoral vein and artery may cause differential hypoxia, i.e., lower PaO2 in the upper body than in the lower body, because of normal cardiac output with severe impairment of pulmonary function. Hereby, we report the diagnosis and the treatment of differential hypoxia caused by veno-arterial ECMO. A 39-year-old man received cardiopulmonary resuscitation from a cardiac arrest due to acute myocardial infarction. Even after more than 30 min of resuscitation, spontaneous circulation had not resumed. Next, we performed veno-arterial ECMO through the femoral artery and vein, and the patient recovered consciousness on the second day of ECMO. On day 5 of ECMO, he lost consciousness again and presented a generalized tonic-clonic seizure, and an electroencephalogram showed delta waves suggesting diffuse cerebral cortical dysfunction. While an echocardiogram revealed improvements in myocardial function, a follow up chest radiograph showed increasing massive parenchymal infiltrations, and gas analysis of blood from the right radial artery revealed severe hypoxemia. These findings indicated a definite diagnosis of differential hypoxia, and therefore, we inserted a 17-Fr cannula into the left subclavian vein as a return cannula. The patient’s consciousness and pulmonary infiltrations were improved 2 days after veno-arterial-venous ECMO, and the electroencephalogram showed normal findings. To our knowledge, this is the first report of successful clinical management of differential hypoxia. We suggest that veno-arterial-venous ECMO could be the treatment of choice for differential hypoxia resulting from veno-arterial ECMO.

Effectiveness of Mechanical Embolectomy for Septic Embolus in the Cerebral Artery Complicated with Infective Endocarditis

There has been a controversy over data of thrombolytic and endovascular surgical treatment about cerebral infarction secondary to infective endocarditis. We report a woman who received early mechanical embolectomy as a treatment of acute stroke with infective endocarditis. A 35-yr-old woman was hospitalized due to right hemiparesis. Brain image showed cerebral infarction at the middle cerebral artery and echocardiography demonstrated vegetation at the mitral valve. She was successfully treated with embolectomy and parenteral antibiotics without any neurologic sequelae. This report shows that the early retrieve of septic cerebral emboli can be a helpful treatment of acute stroke associated with endocarditis.

Determining the necessity for right heart catheterization in pulmonary hypertension associated with connective tissue diseases assessed by echocardiography

The prognosis of pulmonary hypertension (PH) in systemic sclerosis (SSC) and in systemic lupus erythematosus (SLE) is different. According to the guidelines, right heart catheterization (RHC) is necessary in pulmonary arterial hypertension (PAH) associated with connective tissue diseases (CTD). However, there is little supporting evidence. Therefore, we attempted to determine the necessity for RHC and the causes of differences in prognosis of PH by comparing SSC to SLE.

Ring-shaped calcific constrictive pericarditis strangling the heart: a case report.

Constrictive pericarditis is caused by fibrosis and calcification of the pericardium, processes that inhibit diastolic filling of the heart. For the diagnosis of constrictive pericarditis, a combined approach is used to evaluate the morphologic pericardial abnormalities in conjunction with assessment of the functional and hemodynamic changes. We report novel findings of chest computed tomography (CT) and chest roentgenogram with respect to a ring-shaped pericardial calcification on atrioventricular groove causing strangulation of the heart in the patient with constrictive pericarditis, which is anatomically rarer than other severe cases of constrictive pericarditis encasing the entire heart.

Pseudonormal or Restrictive Filling Pattern of Left Ventricle Predicts Poor Prognosis in Patients with Ischemic Heart Disease Presenting as Acute Heart Failure

BACKGROUND In patients with acute heart failure (AHF), diastolic dysfunction, especially pseudonormal (PN) or restrictive filling pattern (RFP) of left ventricle (LV), is considered to be implicated in a poor prognosis. However, prognostic significance of diastolic dysfunction in patients with ischemic heart disease (IHD) has been rarely investigated in Korea. METHODS We enrolled 138 patients with IHD presenting as AHF and sinus rhythm during echocardiographic study. Diastolic dysfunction of LV was graded as ≥ 2 (group 1) or 1 (group 2) according to usual algorithm using E/A ratio and deceleration time of mitral inflow, E′/A′ ratio of tissue Doppler echocardiography and left atrial size. RESULTS Patients in group 1 showed higher 2-year mortality rate (36.2% ± 6.7%) than those in group 2 (13.6% ± 4.5%; p = 0.008). Two-year mortality rate of patient with LV ejection fraction (LVEF) < 40% (26.8% ± 6.0%) was not different from those with LVEF 40%–49% (28.0% ± 8.0%) or ≥ 50% (13.7% ± 7.4%; p = 0.442). On univariate analysis, PN or RFP of LV, higher stage of chronic kidney disease (CKD) and higher New York Heart Association (NYHA) functional class were poor prognostic factors, but LVEF or older age ≥ 75 years did not predict 2-year mortality. On multivariate analysis, PN or RFP of LV (hazard ratio [HR], 2.52; 95% confidence interval [CI], 1.09–5.84; p = 0.031), higher stage of CKD (HR, 1.57; 95% CI, 1.14–2.17; p = 0.006) and higher NYHA functional class (HR, 1.81; 95% CI, 1.11–2.94; p = 0.017) were still significant prognostic factors for 2-year mortality. CONCLUSIONS PN or RFP of LV was a more useful prognostic factor for long-term mortality than LVEF in patients with IHD presenting as AHF.

Arterial Stiffness in Subacute Stroke: Changing Pattern and Relationship with Functional Recovery

BACKGROUND To examine changing patterns in arterial stiffness and functional outcome in patients with subacute stroke, and to determine which parameter shows a strong correlation with the reversal of arterial stiffness, during a 3-month period of comprehensive rehabilitation therapy. METHODS This descriptive, observational cohort study enrolled 60 patients (43 male and 17 female; average age, 62.7 years), and all received conventional rehabilitation therapy, during a 3-month period. Brachial-ankle pulse wave velocity (baPWV) was measured as an index of arterial stiffness. Functional assessments included the 6-minute walk test (6MWT), Fugl-Meyer Assessment of hemiparetic upper and lower limbs, the functional ambulatory category, the Berg balance scale, the Korean Mini-Mental Status Examination, and the Korean-Modified Barthel Index. All measurements were conducted at baseline and 1 and 3 months after stroke onset. RESULTS Rehabilitation therapy resulted in a statistically significant improvement in baPWV since 3 months post stroke. Another functional outcome measure showed statistically significant improvements since 1 month after rehabilitation. Multivariable linear regression analysis revealed that a change in baPWV was significantly correlated with changes in the 6MWT. CONCLUSIONS Three months of comprehensive rehabilitation therapy led to statistically significant improvements in arterial stiffness and functional outcomes during the subacute phase of stroke. Thus, the comprehensive rehabilitation focused on improving gait endurance would be warranted in subacute stroke patients.

Inferior Vena Cava Filter Thrombus: a Possible Cause of an Unanticipated Finding of (99m)Tc-labeled Red Blood Cell Scintigraphy.

Abstract99mTc-labeled red blood cell scintigraphy, a sensitive and specific diagnostic test, is useful for patients suspected of suffering from active gastrointestinal bleeding. This study follows a case of a patient who was suspected of gastrointestinal bleeding after an inferior vena cava filter was inserted due to a deep vein thrombosis of the femoral vein. To evaluate an exact focus of bleeding, 99mTc-labeled red blood cell scintigraphy was executed. Herein, an unanticipated finding of 99mTc-labeled red blood cell scintigraphy probably due to a thrombus on the inferior vena cava filter is reported.

Erratum: Psychiatric Characteristics of the Cardiac Outpatients with Chest Pain

[This corrects the article on p. 169 in vol. 46, PMID: 27014347.].