Kyoung-Suk Rhee

Right Phrenic Nerve Injury Following Electrical Disconnection of the Right Superior Pulmonary Vein

This report describes a case of transient paresis of the right diaphragm following the transcatheter radiofrequency ablation for the electrical disconnection of pulmonary veins, which recovered completely during the observational period in a 61‐year‐old woman with paroxysmal atrial fibrillation. For electrical disconnection of pulmonary veins, careful preventive measures for phrenic nerve damage are required.

A randomized comparison of sirolimus- versus paclitaxel-eluting stent implantation in patients with diabetes mellitus 2-year clinical outcomes of the DES-DIABETES trial.

To the Editor:nnThe presence of diabetes mellitus has been associated with an increased risk of restenosis and unfavorable clinical outcomes in the era of bare-metal stents (BMS) or drug-eluting stents (DES). Previous studies found sirolimus-eluting stents (SES) to have greater efficacy than

Left atrionodal connections in typical and atypical atrioventricular nodal reentrant tachycardias: activation sequence in the coronary sinus and results of radiofrequency catheter ablation.

Introduction: The presence of atrionodal connections and coronary sinus (CS) breakthrough in atrioventricular nodal reentrant tachycardia (AVNRT) has been suggested. However, the incidence, anatomic relationship with reentrant circuit, and results of catheter ablation are unknown.

De Novo Autoimmune Hepatitis in Korean Children After Liver Transplantation: A Single Institution's Experience

INTRODUCTIONnDe novo autoimmune hepatitis (AIH) after orthotopic liver transplantation (OLT) has been described as a new type of late graft dysfunction in children who have not undergone transplantation for previous autoimmune liver disease. The purpose of this study was to evaluate the clinical aspects of de novo AIH among children following OLT.nnnPATIENTS AND METHODSnBetween January 1994 and May 2007, 149 children underwent OLT, including 1 with recurrent AIH who was excluded from this study, whereas 4 others developed de novo AIH (2.7%; n = 4/148). We analyzed the demographics, laboratory characteristics, and response to treatment of the 4 children with de novo AIH following OLT.nnnRESULTSnThe 4 patients were all girls with a median interval after OLT to presentation of 6.5 years (range, 0.7-8.8 years). The median age when de novo AIH developed was 12.4 years (range, 8.7-17.3 years). All cases were detected by abnormal liver function tests, namely, increased aspartate aminotransferase (AST; median, 322 IU/L; range, 181-919 IU/L). One patient showed elevated immunoglobulin G. Three patients displayed positive antinuclear antibodies. All were seronegative for smooth muscle antibody and liver-kidney microsomal type 1 antibody. One patient showed anti-mitochondrial antibody. All patients were treated with steroids with or without azathioprine. The liver function tests in these 4 patients, improved by at least 50% during the first month of treatment, responding to steroid treatment with or without azathioprine.nnnCONCLUSIONnIn preadolescent or adolescent female patients with unexplained graft dysfunction after OLT, it is important to recognize de novo AIH rapidly and to develop an adequate diagnostic strategy, including evaluation of serum autoantibodies, immunoglobulin G, and liver biopsy.

Can Chest Roentgenogram Predict the Posture Dependent Changes of Atrial Sensing Performance in Patients with a VDD Pacemaker

The VDD pacemaker is useful for sequential pacing with a single lead but carries a risk of sensing failure. This study was designed to evaluate the relationship between the relative position of atrial lead and atrial sensitivity in different postures in patients with VDD pacemakers. Atrial sensitivity determination and chest roentgenography was performed in the supine and standing position 3 months after implantation in 25 patients with VDD pacemakers. Measurements of cardiac longitudinal length (from the top of the aortic arch to the diaphragm) and distances from the floating electrode to the upper margin of the seventh thoracic vertebra (D‐T7), to the top of the aortic arch (D‐knob), to the lateral wall of right atrium (D‐wall), and the D‐knob/cardiac longitudinal length (D‐Ratio) were performed. Atrial signal amplitude decreased with the standing compared to the supine position in eight patients (group I) and increased or did not change in the other 17 patients (group II). In group I, the change of the D‐ratio was greater (0.073 vs 0.035, P < 0.01), and the change of the cardiac longitudinal length with standing position was greater (18.4 ± 7.3 vs 12.1 ± 8.8 mm, P < 0.05) than in group II. The change of atrial sensitivity was related to the change of the atrial electrode position with different postures. Decreased atrial‐sensed amplitude was observed in patients who had a greater change in the cardiac longitudinal length while standing. Thus, a decrease in atrial sensitivity with standing may be predicted by the positional changes of the cardiac silhouette on roentgenography before the procedure.

Early Bloodstream Infection After Pediatric Living Donor Living Transplantation

To determine the perioperative risk factors for bacterial infections after pediatric living donor liver transplantation (LDLT), we investigated the clinical profiles of 149 children who underwent pediatric LDLT between 1994 and 2008. Bacterial infections were diagnosed based on guidelines proposed by the Centers for Disease Control. We observed 36 bloodstream infections (BSIs) in 32/149 (21.5%) patients (0.24 infections per patient), which, 21 (58.3%) BSIs in 19 patients were due to gram-positive and 15 (41.7%) in 13 patients to gram-negative organisms. The most common pathogens of early BSI were coagulase-negative Staphylococcus; (n = 11; 30.6%) and Klebsiella pneumoniae (n = 8; 22.2%). The most common site of early BSI was catheter-related (n = 14; 38.9%). Multivariate analysis showed that age ≤ 1 year (P < .05; odds ratio [OR] = 3.90; 95% CI, 1.83-15.26) and bile duct complications (P < .05; OR = 6.2, 95% CI = 3.21-35.23) were significant independent risk factors for early BSIs. More cautious management of pediatric LDLTs may be necessary for younger age children particularly with postoperative biliary complications.

Elevated coronary whole blood viscosity in acute coronary syndrome patients

OBJECTIVESnAs most clinical studies measure whole blood viscosity (WBV) from peripheral samples, potential differences in WBV obtained from the coronary arteries are often ignored. This study investigated differences in WBV measured from coronary artery specimens in patients with and without acute coronary syndrome (ACS).nnnMETHODS AND RESULTSnConsecutive patients with chest pain who underwent diagnostic coronary angiography were divided into two groups [non-ACS (n = 16), ACS (n = 22)]. The ACS group consisted of unstable angina (n = 13) and acute myocardial infarction (n = 9) patients. Two blood samples were obtained from each patient at the both coronary artery ostia prior to coronary angiography. Low-shear and high-shear blood viscosities (BVs) were measured at shear rates of 1 and 300 s-1, respectively, by a scanning capillary tube viscometer (Bio-Visco Inc., South Korea). Both low-shear and high-shear BVs obtained from peripheral, left and right coronary arteries were not different in both groups. Mean coronary low-shear WBV values obtained in ACS group were 29.2% higher than those in non-ACS group (295.3 ± 87.2 mP vs. 228.5 ± 69.2 mP, p = 0.016). Mean coronary high-shear WBV values obtained in ACS group were 15.6% higher than those in non-ACS group (42.9 ± 10.0 mP vs. 37.1 ± 4.6 mP, p = 0.036).nnnCONCLUSIONSnDirect measurement of WBV from the coronary artery showed no differences with peripheral samples. Future larger studies are needed to clarify our results.

A Large, Free-Floating Right Atrial Thrombus Evoking Periodic Dizziness

A 62-year-old man suffered from exertional dyspnea and repetitive momentary dizziness that began occurring just after forceful chest beating to end an episode of acute shortness of breath 3 days prior. His blood pressure was 102/66 mmHg. His D-dimer level (435 µg/L) and N-terminal pro-brain natriuretic peptide level (2,863 pg/mL) were elevated. Electrocardiography exhibited atrial fibrillation with a regular junctional rhythm and a rate of 56 bpm. An intracardiac mass and acute thromboembolism in both pulmonary arteries (APTE) were diagnosed by computed tomography (Fig. 1A and 1B). Echocardiography revealed a very large 60 × 50 mm deformable mass f loating freely in the markedly enlarged right atrium (RA), plugging the right ventricle through the tricuspid valve and periodically occupying the entire cavity (Fig. 1C). Emergent surgery was performed to remove the mass and the APTE. The RA mass was a Chinese moon cake-like thrombus (65 × 55 × 20 mm) (Fig. 2). Two remnant stalks were found on the RA wall. Pathology confirmed that the mass was an organized thrombus and that the stalks were degenerative muscular tissue. n n n nFigure 1 n n(A, B) Computerized tomographic images showing a mass floating in the right heart (A, black arrows) and embolism in both pulmonary arteries (B, white arrows)

Correlation of Electrotonic Monophasic Action Potential Shortening with Short‐Term Memory in Human Atrium

To determine the presence of memory in human atria, we recorded monophasic action potential (MAP) at the high right atrium (HRA) in 21 patients. After reaching a steady state at 600 ms, HRA pacing was switched to the coronary sinus (CS) pacing to alter the activation sequence. After 20 minutes of CS pacing, pacing was continued at HRA to record the memory effect of CS pacing. Atrial memory was defined as the change in HRA MAP duration (MAPd) after 20 minutes of altered activation sequence. Baseline MAPd was 229 ± 31 ms, which was shortened to 226 ± 24 ms immediately after CS pacing. After 20 minutes of CS pacing, HRA MAPd during HRA pacing was 220 ± 28 ms, which was significantly shorter than the baseline MAPd (P = 0.003). The degree of atrial memory was associated with the degree of initial electrotonic MAPd changes caused by the altered activation sequence. These results suggest that memory phenomenon exists in human atria, and it can be expressed as a change in MAPd.