Myeong Gun Kim

Successful management of portopulmonary hypertension with beraprost

Portopulmonary hypertension is a complication of chronic liver disease, which has significant effects on survival and prognosis. Although the pathogenesis of pulmonary arterial hypertension has been well known, portopulmonary hypertension is often underestimated in patients with chronic liver disease. Every clinician who manages patients with chronic liver disease complaining of dyspnea should consider portopulmonary hypertension because this disorder requires special treatment. Herein, a 40-year-old woman with liver cirrhosis who complained of dyspnea on exercise is presented. She was diagnosed with portopulmonary hypertension by echocardiography and right-heart catheterization. Beraprost was used to reduce the pulmonary arterial pressure and improve the symptoms. Her symptoms were improved after 2 weeks, and improved symptoms and reduced pulmonary arterial pressure were sustained for 18 months.

Thrombotic Occlusion of Stent Graft Limbs due to Severe Angulation of Aortic Neck in Endovascular Repair of Abdominal Aortic Aneurysm.

Endovascular aneurysm repair (EVAR) is a safe alternative to open surgical repair for an abdominal aortic aneurysm. However, unfavorable aortic anatomy of the aneurysm has restricted the widespread use of EVAR. Anatomic limitation is most often related to characteristics of the proximal neck anatomy. In this report, we described a patient with a severely angulated proximal neck who underwent EVAR, but required repeat intervention because of thrombotic occlusion of stent graft limbs.

Obesity and Hypertension in Association with Diastolic Dysfunction Could Reduce Exercise Capacity.

Background and Objectives Empirical evidence is lacking on the cumulative disease burden of obesity and hypertension and its impact on cardiac function and exercise capacity. The purpose of this study was to determine whether the presence of obesity and hypertension together was associated with cardiac dysfunction and exercise capacity. Subjects and Methods Using a retrospective study design, medical records were reviewed for echocardiographic and treadmill exercise stress test data. Subjects were grouped according to four categories: normal control, obese, hypertensive, or obese and hypertensive. Results Obese, hypertensive persons showed significantly lower Ea and E/A ratio and greater E/Ea ratio, deceleration time, left ventricular (LV) mass, and LV mass index compared to their counter parts (normal control, obese and/or hypertensive) (all p<0.05), after controlling for age and sex. After controlling for age and sex, significant differences in exercise capacity indices were found, with the obese group having shorter exercise time, lower metabolic equivalents, and lower maximal oxygen uptake than the normal control, hypertensive, or both groups (all p<0.05). The hypertensive or obese and hypertensive group had greater maximal blood pressure compared with the normal control group (all p<0.001). Obese and hypertensive persons were approximately three times more likely to have diastolic dysfunction (odd ratio=2.96, p=0.001), when compared to the reference group (normotensive, non-obese, or hypertensive only persons). Conclusion Diastolic dysfunction was associated with obesity and/or hypertension. The cumulative risk of obesity and hypertension and their impact on diastolic dysfunction which could be modifiable could reduce exercise capacity.

Clinical Significance of Dynamic Left Ventricular Outflow Tract Obstruction During Dobutamine Stress Echocardiography in Women With Suspected Coronary Artery Disease

BACKGROUND Although dobutamine stress echocardiography (DSE) is frequently associated with dynamic left ventricular outflow tract obstruction (DLVOTO), little is known about its clinical significance in women with suspected coronary artery disease (CAD). METHODSANDRESULTS One hundred and two female patients (57±10 years) who underwent DSE as part of the Korean womens chest pain registry study were included. Doppler echocardiography was performed during DSE to assess the presence of DLVOTO. Patients with DLVOTO (n=52) were older than those without DLVOTO (n=50; P=0.001). Hypertension was more prevalent in patients with DLVOTO (P=0.02). Patients with DLVOTO had smaller LV diameter, but higher LV mass index and relative wall thickness (P<0.05 for all). LV diastolic function (as reflected by late diastolic velocity, deceleration time of early diastolic velocity [E], and ratio of E velocity to early diastolic mitral annular velocity), was worse in patients with DLVOTO (P<0.05 for all). Patients with DLVOTO had shorter exercise time (P=0.02) and lower amount of work (P=0.04) than patients without DLVOTO. DSE-provoked DLVOTO was not related to the presence of CAD in these patients. CONCLUSIONS In Korean women with suspected CAD, DSE-provoked DLVOTO is correlated with LV concentric remodeling and LV diastolic dysfunction, and may be associated with limited exercise tolerance and symptoms of chest pain.

Protective effect of angulated aorta for saving coronary artery during endovascular repair for ascending aortic pseudoaneurysm

Ascending aortic pseudoaneurysm is a rare complication after cardiothoracic surgery and the open surgical repair for this complication is challenging. We report on a patient who developed an ascending aortic pseudoaneurysm after aortic valve replacement (AVR), which was treated successfully with endovascular therapy. Our case showed that angulation of the ascending aorta is one of factors for consideration in application of endovascular therapy and endovascular therapy might be an option for management of ascending aortic pathology in patients with high surgical risk, particularly patients with a severely angulated proximal ascending aorta.

A Comparison of Two Brands of Clopidogrel in Patients With Drug-Eluting Stent Implantation

Background and Objectives Although generic clopidogrel is widely used, clinical efficacy and safety between generic and original clopidogrel had not been well evaluated. The aim of this study was to evaluate the clinical outcomes of 2 oral formulations of clopidogrel 75 mg tablets in patients with coronary artery disease (CAD) undergoing drug-eluting stent (DES) implantation. Subjects and Methods Between July 2006 and February 2009, 428 patients that underwent implantation with DES for CAD and completed >1 year of clinical follow-up were enrolled in this study. Patients were divided into the following 2 groups based on treatment formulation, Platless® (test formulation, n=211) or Plavix® (reference formulation, n=217). The incidence of 1-year major adverse cardiovascular and cerebrovascular event (MACCE) and stent thrombosis (ST) were retrospectively reviewed. Results The baseline demographic and procedural characteristics were not significantly different between two treatment groups. The incidence of 1-year MACCEs was 8.5% {19/211, 2 deaths, 4 myocardial infarctions (MIs), 2 strokes, and 11 target vessel revascularizations (TVRs)} in Platless® group vs. 7.4% (16/217, 4 deaths, 1 MI, 2 strokes, and 9 TVRs) in Plavix® group (p=0.66). The incidence of 1-year ST was 0.5% (1 definite and subacute ST) in Platless® group vs. 0% in Plavix® group (p=0.49). Conclusion In this study, the 2 tablet preparations of clopidogrel showed similar rates of MACCEs, but additional prospective randomized studies with pharmacodynamics and platelet reactivity are needed to conclude whether generic clopidgrel may replace original clopidogrel.

Right Coronary Cusp Prolapse Resembling Subpulmonic Stenosis in an Old Adult Patient with Ventricular Septal Defect

Ventricular septal defect (VSD) can be associated with various complications such as aortic regurgitation (AR). AR in VSD come from a deficiency or hypoplasia of the conal septum which leads to abnormal apposition in diastole and prolapse of the poorly supported noncoronary or right coronary cusp through the VSD into the right ventricle resembling subpulmonic stenosis and subsequently results in distortion of the aortic valve and progressive AR. AR often increases in severity with age and it indicates a worse prognosis. Therefore, appropriate timing of surgical repair in progressive AR in VSD might be important. Until now, many earlier experiences about surgical repair of AR complicating VSD were on adolescents or young adults. We reported a case of AR in 48-year-old male patient with right coronary cusp prolapse complicating the subarterial type of VSD which was properly assessed by echocardiography and was successfully treated with surgical repair. Right coronary cusp or noncoronary cusp prolapse should be suspected in AR complicating VSD through proper echocardiographic assessment and the surgical repair on VSD and distorted aortic valve should be considered in the old patient, as well as the young.

WHAT KIND OF MESENCHYMAL STEM CELL IS PROMISING IN THE PREVENTION OF PULMONARY ARTERIAL HYPERTENSION IN A MURINE MODEL

Background: Administration of human adipose tissue, bone marrow, or umbilical cord blood-derived mesenchymal stem cell (AD, BD, or UCB-MSC) has shown promising clinical outcomes in animal models of pulmonary arterial hypertension (PAH), however which source of MSC has the greatest therapeutic

615 EXERCISE FITNESS IS ASSOCIATED WITH CARDIAC FUNCTION

Background: According to the previous reports, the cardiorespiratory fitness(CRF) is significantly associated with cardiovascular disease, and low CRF is independent predictor of cardiovascular disease. However, less is known about the relationship between CRF and cardiac function. To find out relationship of them, we analyzed CRF and echocardiographic parameters associated with cardiac function. Methods: The study subjects were 300 healthy peoples (150 men) who had no major cardiovascular risks such as hypertension, diabetes and chronic renal failure. To analyze CRF and cardiac function, we used the parameters such as VO2Max and maximal exercise capacity (METs) of treadmill exercise test using Bruce-protocol and transthoracic echocardiography data. Results: The mean age of the subjects was 44±14 years in men and 52±12 years in women. VO2Max showed positive correlation with E/A ratio in both men (r=0.25, p value = 0.002) and women (r=0.310, p value < 0.001), and maximal exercise capacity (METs) showed positive correlation with E/A ratio in both gender (M: r=0.157, p value = 0.046 / F: r=0.179, p value = 0.031). VO2Max showed negative correlation with left atrial diameter in men (r = - 0.25, p value = 0.002). Conclusion: Among the echocardiography parameters, E/A ratio increased with VO2Max and maximal exercise capacity. We carefully suppose that CRF probably associated with diastolic cardiac function.

COMPARISON OF INFLAMMATORY MARKERS FOR PREDICTION OF NEOINTIMAL HYPERPLASIA PROLIFERATION AFTER DRUG-ELUTING STENT IMPLANTATION

Methods: We performed PCI with a single DES in 42 consecutive stable angina patients (26 men; 59.7±10.1 years of age). The plasma hs-CRP, IL-6 and MMP-9 values were serially measured before the PCI and at 24, 72 hours after the PCI. The difference (Δ) of each inflammatory markers between baseline and each stages after intervention was calculated. Patients were grouped into quartiles according to inflammatory marker and Δ inflammatory marker values at each stage. An angiography and IVUS study were performed at pre and post PCI and 9 months after the PCI in all patients.