Jung Yeon Chin

Extracorporeal membrane oxygenation saved a mother and her son from fulminant peripartum cardiomyopathy

A 34‐year‐old full‐term pregnant woman presented with abruptly aggravating dyspnea. A chest X‐ray showed pulmonary edema, and an echocardiogram revealed a left ventricular ejection fraction of 39%. Despite conventional medical treatment for acute heart failure and mechanical ventilation, hypoxia and metabolic acidosis were aggravated, and the fetal heart rate decreased to 90 b.p.m., suggestive of fetal distress. We decided to initiate extracorporeal membrane oxygenation (ECMO) and perform a cesarean section. The infant was successfully delivered without hypoxic brain damage. The patient was weaned from ECMO 6 days after delivery and was extubated 1 day after discontinuation of ECMO. Left ventricular systolic function had completely recovered at this time. This is the first report of a patient with peripartum cardiomyopathy who had a successful delivery with the support of ECMO, demonstrating that ECMO can serve as a rescue therapy, not only treating peripartum cardiomyopathy but also permitting a safe delivery.

Diastolic Dysfunction Induced by a High-Fat Diet Is Associated with Mitochondrial Abnormality and Adenosine Triphosphate Levels in Rats

Background Obesity is well-known as a risk factor for heart failure, including diastolic dysfunction. However, this mechanism in high-fat diet (HFD)-induced obese rats remain controversial. The purpose of this study was to investigate whether cardiac dysfunction develops when rats are fed with a HFD for 10 weeks; additionally, we sought to investigate the association between mitochondrial abnormalities, adenosine triphosphate (ATP) levels and cardiac dysfunction. Methods We examined myocardia in Wistar rats after 10 weeks of HFD (45 kcal% fat, n=6) or standard diet (SD, n=6). Echocardiography, histomorphologic analysis, and electron microscopy were performed. The expression levels of mitochondrial oxidative phosphorylation (OXPHOS) subunit genes, peroxisome-proliferator-activated receptor γ co-activator-1α (PGC1α) and anti-oxidant enzymes were assessed. Markers of oxidative stress damage, mitochondrial DNA copy number and myocardial ATP level were also examined. Results After 10 weeks, the body weight of the HFD group (349.6±22.7 g) was significantly higher than that of the SD group (286.8±14.9 g), and the perigonadal and epicardial fat weights of the HFD group were significantly higher than that of the SD group. Histomorphologic and electron microscopic images were similar between the two groups. However, in the myocardium of the HFD group, the expression levels of OXPHOS subunit NDUFB5 in complex I and PGC1α, and the mitochondrial DNA copy number were decreased and the oxidative stress damage marker 8-hydroxydeoxyguanosine was increased, accompanied by reduced ATP levels. Conclusion Diastolic dysfunction was accompanied by the mitochondrial abnormality and reduced ATP levels in the myocardium of 10 weeks-HFD-induced rats.

Major determinant of the occurrence of pacing-induced cardiomyopathy in complete atrioventricular block: a multicentre, retrospective analysis over a 15-year period in South Korea

Objectives The predictors of pacing-induced cardiomyopathy (PICM) for complete atrioventricular block (CAVB) have not yet been defined. The aim of this study was to investigate the major determinant of the occurrence of PICM. Setting This is a multicentre, retrospective analysis of CAVB from tertiary referral centres in Daejeon, South Korea. Participants A cohort of 900 consecutive patients with an implanted pacemaker was collected from December 2001 to August 2015. Of these, a total of 130 patients with CAVB with pacing-dependent rhythm who underwent ECG and echocardiogram before and after implantation were analysed for the occurrence of PICM. Outcome measures Cox proportional hazards models evaluated the determinant of PICM by ECG, device parameters and echocardiogram over a mean of 4.5 years. Results PICM was observed in 16.1% (n=21) of all patients with CAVB (age, 64±11 years; male, 36.2%). The preimplant left ventricular (LV) ejection fraction (66%±9% vs 66%±8%) and non-apical pacing (40.4% vs 33.3%) were similar; however, the native QRS duration (124±34 ms vs 149±32 ms) and the paced QRS duration (pQRSd) (139±29 ms vs 167±28 ms) were significantly different between the two groups. The postimplant LV ejection fraction (61%±7% vs 31%±8%) was also significantly different at the end of follow-up. A pQRSd significantly correlated with PICM (HR 1.05, 95% CI 1.02 to 1.09, P=0.001). A pQRSd with a cut-off value of above 140 ms had a sensitivity of 95% while a pQRSd with a cut-off value of above 167 ms had a specificity of 90% for PICM. Conclusion In patients with CAVB with pacing-dependent rhythm, regardless of the pacing site, the pQRSd is a major determinant of the occurrence of PICM.

Predictors of acute myocarditis in complicated scrub typhus: an endemic province in the Republic of Korea

Background/Aims Scrub typhus is known as a self-limited infectious disease. Cardiac complication is uncommon and usually not life-threatening. Until now, few cases of fulminant myocarditis by scrub typhus have been reported. So, we investigated incidence and predictors of acute myocarditis in severe scrub typhus. Methods We retrospectively reviewed 89 patients among 91 scrub typhus confirmed patients who examined an echocardiogram and cardiac biomarkers from 2005 to 2015 in the intensive care unit at our hospital. We excluded two patients who didn’t have electrocardiography. Patients were divided into two groups and compared between scrub typhus with (n = 13) and without (n = 76) acute myocarditis. Results Age, sex, and underlying diseases were similar between the groups. The existence of eschar and duration of general ache and fever were similar between the groups. However, patients with acute myocarditis had more elevated total bilirubin, high incidence of ST elevations and paroxysmal atrial fibrillation (PAF) than those without acute myocarditis. Receiver operating characteristic analysis showed that the PAF was a predictor of myocarditis with a sensitivity of 70% and specificity of 84%. Predictive power of combination of ST-segment elevation and PAF was significantly associated with myocarditis in the multivariate analysis (odds ratio, 1.57; 95% confidence interval [CI], 1.21 to 11.7; p = 0.041) and area under the curve was 0.947 (95% CI, 0.878 to 0.983; p < 0.001). Conclusions Acute myocarditis with scrub typhus may be more common than previously reported. Patients with high bilirubin and PAF are at increased risk of acute myocarditis with scrub typhus. These patients warrant closer follow-up and echocardiogram would be needed.

Focal ablation for atrial tachycardia from the double-exit of the Marshall bundle inducing atrial fibrillation

Atrial fibrillation (AF) from the ligament/vein of Marshall (LOM/VOM) has previously been described. We report the case of a 23‐year‐old woman with an antiarrhythmic drug‐resistant AF induced by two distinct atrial tachycardias (ATs). Focal ablation of these ATs from the double‐exit of the Marshall bundle using a three‐dimensional map eliminated AF triggering, even though pulmonary vein electrical isolation is the cornerstone for paroxysmal AF. Such mechanisms are important as triggering factors to plan ablation for paroxysmal AF. Focal ablation for triggering and inducing AF, originating from the double‐exit of the Marshall bundle may be effective in eliminating AF in young patients.

PS 02-81 COMPARISON OF EFFICACY AND TOLERABILITY OF LERCARDIPINE AND AMLODIPINE ON INTIMA–MEDIA THICKNESS IN NEWLY DIAGNOSED HYPERTENSIVE PATIENTS

Objective: We compared the efficacy and tolerability of the lercardipine and amlodpine on intima–media thickness (IMT) in newly diagnosed hypertensive patients. Design and Method: An open label, controlled, randomized, parallel-group study was conducted on 100 newly diagnosed hypertensive patients (blood pressure [BP] > 140/90 mmHg) from Oct 2010 to May 2012 in Eulji University Hospital. Patients were allocated randomly two groups to receive amlodipine 5–10 mg or Lercardipine10–20 mg and followed up for 2 years. The endpoint was the change from baseline of the combined mean maximum far wall IMT of carotid artery, evaluated by repeated measurement analysis of the treatment effect and adverse events after first and second years of treatment. Results: Both lercanidipine and amlodipine were similarly able to significantly reduce mean systolic BP (SBP)/diastolic BP (DBP), mean 24hr day-time and night-time BP monitor. In particular, mean SBP/DBP was reduced from 160 ± 21/94 ± 13 mmHg to 142 ± 21/87 ± 12 mmHg in the lercanidipine group (p < 0.001 for both SBP and DBP) and from 163 ± 18/96 ± 12 mmHg to 141 ± 19/81 ± 14 mmHg in the amlodipine-treated group (p < 0.001 for both SBP and DBP). After 2 years of treatment, amlodipine decreased IMT by 0.089 mm [95% confidence interval (CI) 0.144 - 0.037]. Lecardipine decreased IMT by 0.065 mm (95% CI 0.124 - 0.010). No statistical difference was observed between the two treatments in the reduction of IMT. Both treatments achieved the greatest reduction of IMT after first and year, whereas the reduction in BP was maintained. Lercanidipine showed a better tolerability profile than amlodipine, with fewer adverse events and a lower percentage of patients suffering from peripheral edema. Conclusions: Lercanidipine is as effective as amlodipine reduced IMT to a similar extent in newly diagnosed hypertensive patients and presents tolerablility in the adverse events.

PS 11-21 NON-NECESSITY FOR 24 HOURS BLOOD PRESSURE MONITOR IN PATIENTS WITH ACUTE HYPERTENSIVE CRISIS DURING TWO-YEARS FOLLOW-UP

Objective: The recommendation of 24 hours blood pressure (BP) monitor was uncertain for anti-hypertensive treatment strategy in hypertensive crisis. We analyzed and evaluated the necessity of 24 hour BP monitor for anti-hypertensive treatment strategy in hypertensive crisis. Design and Method: We retrospectively analyzed consecutive 300 patients who all undertaken 24hr BP monitor, ECG, 24 h, echocardiogram between Mar 2013 and Dec 2013 in Cardiology, Eulji University Hospital, Deajeon, South Korea. We classified the patients into two group; age < 55 (n = 152) and ≥55 (n = 148) with 24 hr BP monitor in patients with hypertensive crisis and follow-up during two years. Results: The average age (39 ± 11 vs. 67 ± 9) and initial emergency visit (17.8 % vs. 14.9 %, p = 0.535) were compared. Previously treating hypertension (26.3 % vs. 39.2 %, p = 0.001), diabetes (2.6 % vs. 13.5 %, p = 0.001) and coronary artery disease (0.0 % vs. 6.8 %, p = 0.001) was higher in old age. During daytime 24hr BP monitor, there were average systolic BP (133 ± 13 mmHg vs. 130 ± 12 mmHg, p = 0.104) and diastolic BP (88 ± 11 mmHg vs. 82 ± 8 mmHg, p < 0.001). During nighttime 24hr BP monitor, there were average systolic BP (124 ± 14 mmHg vs. 122 ± 18 mmHg, p = 0.018) and diastolic BP (83 ± 48 mmHg vs. 75 ± 10 mmHg, p = 0.051). The level of initial glomerular filtration rate (108 ± 26 vs. 93 ± 29, p < 0.001), the proportion of left ventricular hypertrophy in electrocardiogram (11.5 % vs. 13.6 %, p = 0.670) and echocardiogram (13.6 % vs. 9.1 %, p = 0.312) was similar. During two-year follow-up, the total cardiac and cerebral events were rare and similar between two groups. (1 vs. 2, p = 0.916). Conclusions: We demonstrated that 24hr BP monitor may not be needed for anti-hypertensive strategy in patients with acute hypertensive crisis for two-year follow-up.