Man Jong Baek

Multiple cardiac perforations and pulmonary embolism caused by cement leakage after percutaneous vertebroplasty

Percutaneous vertebroplasty is a minimally invasive procedure in which polymethylmethacrylate polymer is used to treat painful diseased vertebral bodies. However, despite its minimally invasive nature and relative safety, cement leakage beyond involved vertebral bodies into the venous system can induce devastating cardiovascular complications. Here, the authors report a case of multiple cardiac perforations and pulmonary embolism caused by cement leakage after percutaneous vertebroplasty.

Endoscopic Evaluation of the Quality of the Anastomosis After Esophagectomy with Gastric Tube Reconstruction

BackgroundThe morbidity and mortality of anastomotic complications after esophagectomy have gradually decreased in recent years. However, swallowing difficulties and reflux continue to burden patients jeopardizing their quality of life. In the present study we performed endoscopic evaluation of the outcomes of esophagogastrostomy by analyzing the presence of anastomotic stenosis and reflux esophagitis.MethodsA retrospective analysis was carried out on 74 patients who underwent esophagogastrostomy after esophagectomy by one surgeon between January 1995 and December 2004. Fifty-three patients had an endoscopic examination during follow-up (29xa0±xa023.6xa0months, rangexa0=xa05–111xa0months). Reflux esophagitis and stenosis at the anastomostic site were analyzed according to the surgical technique used and the location of the esophagogastrostomy.ResultsThe mean age at the time of repair was 60.3xa0±xa08.87 (rangexa0=xa039–81) years. Cervical anastomosis was performed in 26 patients and intrathoracic anastomosis in 27 patients. No significant statistical difference in the frequency of anastomotic stenosis was observed between the two groups (pxa0=xa00.829); reflux esophagitis was noted in three patients in the cervical anastomosis group and in 14 patients in the intrathoracic anastomosis group (pxa0=xa00.041). For all patients, 23 received a hand-sewn esophagogastric anastomosis and 30 a circular stapled one. There was no significant statistical difference in anastomotic stenosis (pxa0=xa00.689) and reflux esophagitis (pxa0=xa00.879) in comparisons between the two groups.ConclusionCervical anastomosis resulted in a better outcome for esophagogastrostomy by lowering the risk of reflux esophagitis; this outcome might improve the patient’s quality of life.

Primary endobronchial leiomyosarcoma. Diagnosis following expectoration of tumor fragment.

A case is presented with spontaneous expectoration of a small piece of solid tissue. Pathologic examination of the expectorated tissue was found to be consistent with leiomyosarcoma. After further work-up, there was no evidence of another primary site of leiomyosarcoma except for the right lower lobe. Right lower lobectomy was performed. The surgical specimen showed a tumor that was histologically identical to the patient’s previous expectorated tissue. To the authors’ knowledge, this is the first report of partial expectoration of a primary endobronchial leiomyosarcoma.

Percutaneous coronary intervention versus optimal medical therapy for chronic total coronary occlusion with well-developed collaterals

Background The impact of percutaneous coronary intervention (PCI) on chronic total occlusion in patients with well‐developed collaterals is not clear. Methods and Results A total of 640 chronic total occlusion patients with collateral flow grade ≥2 were divided into 2 groups; chronic total occlusion patients either treated with PCI (the PCI group; n=305) or optimal medical therapy (the optimal medical therapy group; n=335). To adjust for potential confounders, a propensity score matching analysis was performed. Major clinical outcomes were compared between the 2 groups up to 5 years. In the entire population, the PCI group had a lower hazard of myocardial infarction (hazard ratio [HR], 0.177; P=0.039; 95% confidence interval [CI], 0.03–0.91) and the composite of total death or myocardial infarction (HR, 0.298; P=0.017; 95% CI, 0.11–0.80); however, it showed higher hazard of target lesion revascularization (HR, 3.942; P=0.003; 95% CI, 1.58–9.81) and target vessel revascularization (HR, 4.218; P=0.001; 95% CI, 1.85–9.60). After propensity score matching, a total of 158 matched pairs were generated. Although the PCI group showed a higher hazard of target lesion revascularization (HR, 2.868; P=0.027; 95% CI, 1.13–7.31) and target vessel revascularization (HR=2.62; P=0.022; 95% CI, 1.15–5.97), it still exhibited a lower incidence of the composite of total death or myocardial infarction (HR, 0.263; P=0.017; 95% CI, 0.087–0.790). The mean ejection fraction was improved from 47.8% to 51.6% (P<0.001) after PCI. Conclusions In our study, successful revascularization by PCI for chronic total occlusion lesions with well‐developed collaterals was associated with lower incidence of death and myocardial infarction, improved left ventricular function, but increased repeat revascularization rate.

Sinus of Valsalva Aneurysm From Left Sinus: Value of Angioscopic View of a 3-Dimensional Computed Tomographic Angiography

A 57-year-old man was referred for exertional chest pain and a mediastinal mass. Computed tomographic angiography (CTA) revealed a huge aneurysm arising from the left sinus of Valsalva (Figure 1, Video I in the online-only Data Supplement). The opening of aneurysm was 18 mm in its largest diameter. Because the left coronary arteries were stretched and narrowed, the chest pain was considered to be caused by the aneurysm. The right coronary artery and other cardiac structures were normal. In transthoracic echocardiography, there was mild aortic and mitral regurgitation. The transesophageal echocardiography also showed competent aortic valve and aneurysm. However, it was not clear whether the aortic valve annulus was intact or not (Video II in the online-only Data Supplement). To understand the anatomy of aortic root complex, including aortic valve, coronary ostium, …

Hyperuricaemia and development of type 2 diabetes mellitus in Asian population

Recently, meta‐analysis studies reported that hyperuricaemia is associated with higher incidence of type 2 diabetes mellitus (T2DM), however, there are limited data on the Asian population. The aim of this observational study is to estimate the long‐term impact of hyperuricaemia on the new‐onset T2DM and cardiovascular events. This study is based on a single‐centre, all‐comers, and large retrospective cohort. Subjects that visited from January 2004 to February 2014 were enrolled using the electronic database of Korea University Guro Hospital. A total of 10 505 patients without a history of T2DM were analyzed for uric acid, fasting glucose and haemoglobin (Hb) A1c level. Inclusion criteria included both Hb A1c <5.7% and fasting glucose level <100 mg/dL without T2DM. Hyperuricaemia was defined as a uric acid level ≥7.0 mg/dL in men, and ≥6.5 mg/dL in women. To adjust baseline confounders, a propensity score matching (PSM) analysis was performed. The impact of hyperuricaemia on the new‐onset T2DM and cardiovascular events were compared with the non‐hyperuricaemia during the 5‐year clinical follow‐up. After PSM, baseline characteristics of both groups were balanced. In a 5‐year follow‐up, the hyperuricaemia itself was a strong independent predictor of the incidence of new‐onset T2DM (HR, 1.78; 95% CI, 1.12 to 2.8). Hyperuricaemia was a strong independent predictor of new‐onset T2DM, which suggests a substantial implication for a correlation between uric acid concentration and insulin resistance (or insulin sensitivity). Also, hyperuricaemia is substantially implicated in cardiovascular risks and the further long‐term cardiovascular events in the crude population, but it is not an independent predictor of long‐term cardiovascular mortality in the matched population.

Selective ß1-blockers are not associated with new-onset diabetes mellitus in hypertensive patients

Background: Although ß-blockers are known to increase new-onset diabetes mellitus (DM), previous evidence have been controversial. It has been suggested that newer vasodilatory ß-blockers yield better glycemic control than older nonselective agents. The aim of this study was to evaluate the diabetogenicity of currently used newer ß-blockers based on ß1 receptor selectivity in a series of Asian population. Methods: We investigated a total of 65,686 hypertensive patients without DM from 2004 to 2014. Patients with hemoglobin (Hb) A1c ⩽6.0%, fasting blood glucose ⩽110 mg/dL, and no history of diabetes or diabetic treatment were enrolled for analysis. Patients were divided into the ß-blockers group and non-ß-blockers group. Propensity score matching (PSM) analysis using a logistic regression model was performed to adjust for potential confounders. The primary end point was the cumulative incidence of new-onset DM, defined as a fasting blood glucose ≥126 mg/dL or HbA1c ≥6.5%, and major adverse cardiac and cerebral events (MACCE), defined as a composite of total death, nonfatal myocardial infarction, and cerebrovascular accidents. We investigated predictors of new-onset DM and MACCE based on 2 models, including clinical risk factors and co-medications, respectively. Results: Mean follow-up duration was 30.91 ± 23.14 months in the entire group before adjustment. The ß-blockers group had a significantly higher incidence of new-onset DM and MACCE than the non-ß-blockers group. After PSM, analysis of a total of 2284 patients (1142 pairs, C-statistic = 0.752) showed no difference between the 2 groups in new-onset DM or MACCE. In multivariate analysis after PSM, baseline HbA1c, stroke, heart failure, nonselective ß-blockers, and age were independent predictors of new-onset DM. Selective ß1-blockers did not increase new-onset DM after adjustment for other antihypertensive medication and statins. Conclusions: In the era of newer ß-blockers, selective ß1-blockers were not associated with new-onset DM. More evidence is needed to verify this relationship and the underlying mechanisms.

Five-year outcomes of successful percutaneous coronary intervention with drug-eluting stents versus medical therapy for chronic total occlusions

Purpose Many recent studies have reported that successful percutaneous coronary intervention (PCI) with drug-eluting stents (DESs) for chronic total occlusion (CTO) has more beneficial effects than failed CTO-PCI; however, there are only limited data available from comparisons of successful CTO-PCI with medical therapy (MT) in the Korean population. Materials and Methods A total of 840 consecutive CTO patients who underwent diagnostic coronary angiography, receiving either PCI with DESs or MT, were enrolled. Patients were divided into two groups according to the treatment assigned. To adjust for potential confounders, propensity score matching (PSM) analysis was performed using logistic regression. Individual major clinical outcomes and major adverse cardiac events, a composite of total death, myocardial infarction (MI), stroke, and revascularization, were compared between the two groups up to 5 years. Results After PSM, two propensity-matched groups (265 pairs, n=530) were generated, and the baseline characteristics were balanced. Although the PCI group showed a higher incidence of target lesion and vessel revascularization on CTO, the incidence of MI tended to be lower [hazard ratio (HR): 0.339, 95% confidence interval (CI): 0.110 to 1.043, p=0.059] and the composite of total death or MI was lower (HR: 0.454, 95% CI: 0.224 to 0.919, p=0.028), compared with the MT group up to 5 years. Conclusion In this study, successful CTO PCI with DESs was associated with a higher risk of repeat PCI for the target vessel, but showed a reduced incidence of death or MI.

Routine angiographic follow-up versus clinical follow-up in patients with diabetes following percutaneous coronary intervention with drug-eluting stents in Korean population

AIMSnThe usefulness of routine angiographic follow-up (RAF) and clinical follow-up (CF) after percutaneous coronary intervention (PCI) in patients with diabetes is not well understood. We compare 3-year clinical outcomes of RAF and CF in diabetic patients underwent PCI with drug-eluting stents (DES).nnnMETHODSnA total of 843 patients with diabetes who underwent PCI with DES were enrolled. RAF was performed at 6-9u202fmonths after PCI (nu202f=u202f426). Rest of patients were medically managed and clinically followed (nu202f=u202f417); symptom-driven events were captured. After propensity score matched analysis, 2 propensity-matched groups (262 pairs, nu202f=u202f524, C-statisticu202f=u202f0.750) were generated. The primary endpoint was major adverse cardiac events (MACE), the composite of total death, non-fatal myocardial infarction (MI), target lesion revascularization (TLR), target vessel revascularization (TVR), non-target vessel revascularization (Non-TVR).nnnRESULTSnDuring the 3-year follow-up period, the cumulative incidence of target lesion revascularization [TLR: hazard ratio (HR), 4.07; 95% confidence interval (CI), 1.18-9.34; pu202f=u202f0.001], target vessel revascularization (TVR: HR, 4.02; 95% CI, 1.93-8.40; pu202f<u202f0.001), non-TVR (HR, 4.92; 95% CI, 1.68-14.4; pu202f=u202f0.004) and major adverse cardiac events (MACE: HR, 2.53; 95% CI, 1.60-4.01, pu202f<u202f0.001) were significantly higher in the RAF group. However, the incidence of total death, non-fatal MI were similar between the two groups.nnnCONCLUSIONSnRAF following index PCI with DES in patients with diabetes was associated with increased incidence of revascularization and MACE without changes of death or re-infarction rates and increased TLR and TVR rates in both first- and second-generation DES.

The association of chronic air pollutants with coronary artery spasm, vasospastic angina, and endothelial dysfunction

Background We evaluated the effect of chronic exposure to air pollutants (APs) on coronary endothelial function and significant coronary artery spasm (CAS) as assessed by intracoronary acetylcholine (ACH) provocation test. Patients and methods A total of 6430 patients with typical or atypical chest pain who underwent intracoronary ACH provocation test were enrolled. We obtained data on APs from the Korean National Institute of Environmental Research (http://www.nier.go.kr/). APs are largely divided into two types: particulate matter with aerodynamic diameter of less than or equal to 10u2009µm in size (PM10) and gaseous pollutants such as nitrogen dioxide, sulfur dioxide, carbon monoxide, and ozone. The primary endpoint is the incidence of significant CAS and its associated parameters during ACH provocation test. Results The incidence of CAS was positively correlated with an exposure duration of PM10, whereas nitrogen dioxide, sulfur dioxide, carbon monoxide, and ozone were shown to be unrelated to CAS. During the ACH provocation test, as PM10 increased, the frequency of CAS was increased, and the incidence of transient ST-segment elevation was also increased. There was a trend toward higher incidence of spontaneous spasm as PM10 increased. The mean exposure level of PM10 was 51.3±25.4u2009µg/m3. The CAS risk increased by 4% when the level of PM10 increased by 20u2009µg/m3 by an adjusted Cox regression analysis. Conclusion CAS incidence is closely related to exposure to PMs but not to gaseous pollutants. Particularly, higher exposure concentrations and longer exposure duration of PM10 increased the risk of CAS. These important findings provide a plausible mechanism that links air pollution to vasospastic angina and provide new insights into environmental factors.