Ju Hyeon Oh

Factors Related to Prehospital Time Delay in Acute ST-Segment Elevation Myocardial Infarction

Despite recent successful efforts to shorten the door-to-balloon time in patients with acute ST-segment elevation myocardial infarction (STEMI), prehospital delay remains unaffected. Nonetheless, the factors associated with prehospital delay have not been clearly identified in Korea. We retrospectively evaluated 423 patients with STEMI. The mean symptom onset-to-door time was 255 ± 285 (median: 150) min. The patients were analyzed in two groups according to symptom onset-to-door time (short delay group: ≤ 180 min vs long delay group: > 180 min). Inhospital mortality was significantly higher in long delay group (6.9% vs 2.8%; P = 0.048). Among sociodemographic and clinical variables, diabetes, low educational level, triage via other hospital, use of private transport and night time onset were more prevalent in long delay group (21% vs 30%; P = 0.038, 47% vs 59%; P = 0.013, 72% vs 82%; P = 0.027, 25% vs 41%; P < 0.001 and 33% vs 48%; P = 0.002, respectively). In multivariate analysis, low educational level (1.66 [1.08-2.56]; P = 0.021), symptom onset during night time (1.97 [1.27-3.04]; P = 0.002), triage via other hospital (1.83 [1.58-5.10]; P = 0.001) and private transport were significantly associated with prehospital delay (3.02 [1.81-5.06]; P < 0.001). In conclusion, prehospital delay is more frequent in patients with low educational level, symptom onset during night time, triage via other hospitals, and private transport, and is associated with higher inhospital mortality.

The Impact of Stressor Patterns on Clinical Features in Patients With Tako‐tsubo Cardiomyopathy: Experiences of Two Tertiary Cardiovascular Centers

Tako‐tsubo cardiomyopathy (TTC) is typically triggered by an acute emotional or physical stress event. The aim of this study was to investigate the impact of stressor patterns on clinical features, laboratory parameters, and electrocardiographic and echocardiographic findings in patients with TTC.

Correlation of Electrocardiographic Changes and Myocardial Fibrosis in Patients With Hypertrophic Cardiomyopathy Detected by Cardiac Magnetic Resonance Imaging

Despite several electrophysiologic and pathologic studies, the cause of electrocardiographic (ECG) changes in patients with hypertrophic cardiomyopathy (HCM) remains unclear. Late gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR) imaging can detect myocardial fibrosis. We aimed to assess the relationship between ECG findings and LGE in such patients.

Long-Term Clinical Outcomes of True and Non-True Bifurcation Lesions According to Medina Classification – Results From the COBIS (COronary BIfurcation Stent) II Registry –

BACKGROUND Little is known about the clinical outcomes of patients with different types of coronary bifurcation lesions. We sought to compare long-term clinical outcomes of patients with true or non-true bifurcation lesions who underwent percutaneous coronary intervention. METHODSANDRESULTS We compared major adverse cardiac events (MACE: cardiac death, myocardial infarction [MI], or target lesion revascularization) between 1,502 patients with true bifurcation lesions (51.8%) and 1,395 with non-true bifurcation lesions (48.2%). True bifurcation lesions were defined as Medina classification (1.1.1), (1.0.1), or (0.1.1) lesions. During a median follow-up of 36 months, MACE occurred in 296 (10.2%) patients. Patients with true bifurcation lesions had a significantly higher risk of MACE than those with non-true bifurcation lesions (HR 1.39; 95% CI 1.08-1.80; P=0.01). Among true bifurcation lesions, Medina (1.1.1) and (0.1.1) were associated with a higher risk of cardiac death or MI than Medina (1.0.1) (HR 4.15; 95% CI 1.01-17.1; P=0.05). During the procedure, side branch occlusion occurred more frequently in Medina (1.1.1) and (1.0.1) than Medina (0.1.1) lesions (11.5% vs. 7.4%, P=0.03). CONCLUSIONS Patients with true bifurcation lesions had worse clinical outcomes than those with non-true bifurcation lesions. Procedural and long-term clinical outcomes differed according to the type of bifurcation lesion. These findings should be considered in future bifurcation studies.

Diagnostic patterns in the evaluation of patients presenting with syncope at the emergency or outpatient department.

Purpose Patterns of syncope evaluation vary widely among physicians and hospitals. The aim of this study was to assess current diagnostic patterns and medical costs in the evaluation of patients presenting with syncope at the emergency department (ED) or the outpatient department (OPD) of a referral hospital. Materials and Methods This study included 171 consecutive patients with syncope, who visited the ED or OPD between January 2009 and July 2009. Results The ED group had fewer episodes of syncope [2 (1-2) vs. 2 (1-5), p=0.014] and fewer prodromal symptoms (81.5% vs. 93.3%, p=0.018) than the OPD group. Diagnostic tests were more frequently performed in the ED group than in the OPD group (6.2±1.7 vs. 5.3±2.0; p=0.012). In addition, tests with low diagnostic yields were more frequently used in the ED group than in the OPD group. The total cost of syncope evaluation per patient was higher in the ED group than in the OPD group [823000 (440000-1408000) won vs. 420000 (186000-766000) won, p<0.001]. Conclusion There were some differences in the clinical characteristics of patients and diagnostic patterns in the evaluation of syncope between the ED and the OPD groups. Therefore, a selective diagnostic approach according to the presentation site is needed to improve diagnostic yields and to reduce the time and costs of evaluation of syncope.

Noncompaction of the myocardium coexistent with bronchiectasis and polycystic kidney disease.

Noncompaction of the ventricular myocardium (NCM) is a disorder of unknown aetiology characterised by numerous, prominent ventricular trabeculations and deep intertrabecular recesses. Polycystic kidney disease (PKD) is characterised by the formation of multiple cysts in the kidneys and liver and, less frequently, in the pancreas. Cardiovascular abnormalities in PKD involve hypertension, mitral valve prolapse, intracranial aneurysms and pulmonary abnormalities include primary ciliary dyskinesia and bronchiectasis. Several case reports have described the possible association between PKD and NCM. However, NCM, PKD and bronchiectasis have not previously been correlated. This is the first case of NCM coupled with PKD and bronchiectasis.

Intravenous leiomyomatosis with intracardiac extension

A 56-year-old woman with a 1-year history of dyspnea on exertion was referred due to worsening shortness of breath. She had undergone a hysterectomy for benign leiomyoma 10 years earlier. Transthoracic echocardiography, computed tomography angiography, and magnetic resonance imaging showed a large right atrial mass extending to the right common iliac vein through the inferior vena cava. One-stage complete resection of the tumor was performed using cardiopulmonary bypass. Under circulatory arrest, the cardiac extent of the tumor was excised after opening the right atrium (Figure 1A), and the rest of the tumor was removed after opening the right common iliac vein. A portion of the uterine tumor extended to the right atrium through the inferior vena cava (Figure 1B). This rare benign tumor can cause severe heart failure, pulmonary embolization, or sudden death due to incursion into the atriovenous orifice. Complete removal of the tumor is the treatment of choice because regrowth or recurrences are frequent. Asian Cardiovascular & Thoracic Annals 19(2) 179 The Author(s) 2011 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492311400100 aan.sagepub.com

Preoperative, Postoperative and One-Year Follow-Up of N-Terminal Pro-B-Type Natriuretic Peptide Levels in Volume Overload of Aortic Regurgitation: Comparison with Pressure Overload of Aortic Stenosis

Objectives: Limited data are available regarding the impact of pressure or volume overload on the clinical or echocardiographic parameters and the levels of N-terminal pro-B-type natriuretic peptide (NT-proBNP) in patients with chronic severe aortic valve diseases. We aimed to investigate and compare the relationships between these parameters in such patients. Methods: One hundred twenty-four consecutive patients who underwent aortic valve replacement for chronic severe aortic valve diseases were enrolled. Plasma NT- proBNP was measured and echocardiographic parameters were recorded before surgery, before discharge and 12 months after surgery. Results: NT-proBNP levels were significantly higher in patients with aortic regurgitation (AR) (n = 63) than in those with aortic stenosis (n = 61) (1,836.0 ± 376.1 vs. 508.4 ± 74.5 pg/ml, p = 0.001). There was a significant relationship between NT-proBNP levels and left ventricular mass index (LVMI) in AR (r = 0.436, p = 0.002) and a weaker, but significant, relationship between NT-proBNP levels and LVMI in aortic stenosis patients (r = 0.290, p = 0.046). In the AR group, preoperative NT-proBNP levels positively correlated with LVMI regression during the 12 months after surgery (r = 0.488, p = 0.001). Conclusion: NT-proBNP levels may reflect LVMI changes that are caused by volume overload rather than pressure overload in chronic aortic valve diseases. Higher preoperative NT-proBNP levels may predict left ventricular reverse remodeling early after surgery for chronic severe AR.

Cardioprotective Effects of Intracoronary Morphine in ST‐Segment Elevation Myocardial Infarction Patients Undergoing Primary Percutaneous Coronary Intervention: A Prospective, Randomized Trial

Background A cardioprotective role of morphine acting via opioid receptors has been demonstrated, and previous preclinical studies have reported that morphine could reduce reperfusion injury and myocardial infarct size in a way similar to that of ischemic periconditioning. This study aimed to evaluate the effect of intracoronary morphine on myocardial infarct size in patients with ST‐elevation myocardial infarction undergoing primary percutaneous coronary intervention. Methods and Results This study was designed as a 2‐center, prospective, randomized, open‐label, blinded end point trial. A total of 91 ST‐elevation myocardial infarction patients with thrombolysis in myocardial infarction flow grade of 0 to 1 undergoing primary percutaneous coronary intervention were randomly assigned to a morphine or control group at a 1:1 ratio. The morphine group received 3 mg of morphine sulfate diluted with 3 mL of normal saline, and the control group received 3 mL of normal saline into a coronary artery immediately after restoration of coronary flow. The primary end point was myocardial infarct size assessed by cardiac magnetic resonance imaging The cardiac magnetic resonance images were evaluated for 42 and 38 patients in the morphine and control groups, respectively. Myocardial infarct size was not different between the 2 groups (25.6±11.2% versus 24.6±10.5%, P=0.77), nor was the extent of microvascular obstruction or myocardial salvage index (6.0±6.3% versus 5.1±4.6%, P=0.91; 31.1±15.2% versus 30.3±10.9%, P=0.75, respectively). There was no difference in peak creatine kinase‐MB level, final thrombolysis in myocardial infarction flow, myocardial brush grade, or complete resolution of ST‐segment. Conclusions Intracoronary morphine administration could not reduce myocardial infarct size in ST‐elevation myocardial infarction patients undergoing primary percutaneous coronary intervention. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT01738100.

Usefulness of an Implantable Loop Recorder in Patients with Syncope of an Unknown Cause

Purpose The mechanisms underlying syncope remain unknown in about 20% of patients with recurrent syncope. The implantable loop recorder (ILR) has been shown to be a useful diagnostic tool in patients with unexplained syncope even after negative initial evaluations. Nevertheless, ILR has rarely been used in clinical practice. Materials and Methods This study included 18 consecutive patients who had an ILR implanted at our center because of recurrent unexplained syncope after extensive diagnostic tests between February 2006 and June 2011. Results Diagnosis was confirmed in 10 (55.6%) of the 18 enrolled patients (13 males, 61±15 years). The confirmed diagnoses included sick sinus syndrome (n=6, 60%), advanced atrioventricular block (n=2, 20%) and ventricular tachyarrhythmia (n=2, 20%). The mean follow-up durations of the total study subjects and the diagnosed patients were 11.3±10.6 months and 5.6±9.2 months, respectively. Of the 10 diagnosed patients, 8 (80%) were diagnosed within 6 months of loop recorder implantation. Conclusion ILR may be a valuable and effective diagnostic tool for patients with unexplained syncope.