Myeong Ki Hong

Ergonovine echocardiography as a screening test for diagnosis of vasospastic angina before coronary angiography

OBJECTIVESnIn patients with chest pain suggestive of variant angina, we performed this prospective study to test the specificity and diagnostic validity of ergonovine echocardiography (detection of regional wall motion abnormality during bedside ergonovine challenge) as a screening procedure before coronary angiography.nnnBACKGROUNDnSpasm provocation test outside the catheterization room has generally not been accepted as a safe diagnostic method.nnnMETHODSnErgonovine echocardiography was performed in 80 consecutive patients with chest pain syndrome after confirmation of negative treadmill or normal stress myocardial perfusion scan results using thallium-201. A bolus of ergonovine maleate was injected at 5-min intervals up to a total cumulative dosage of 0.35 mg with echocardiographic monitoring of left ventricular wall motion. A 12-lead electrocardiogram (ECG) was also recorded every 3 min after each ergonovine injection. Positive test results were development of regional wall motion abnormalities or transient ST segment elevation or depression >0.1 mV in any single lead of the 12-lead ECG. Coronary angiography was undertaken within 2 +/- 4 days (mean +/- SD) after ergonovine echocardiography, and the spasm provocation test with acetylcholine or ergonovine was performed in patients with normal angiographic findings or lumen diameter narrowing <70%.nnnRESULTSnOn the basis of angiographic criteria, 56 patients had coronary vasospasm; this finding was later ruled out in 19 patients with near-normal angiographic results by a negative response on the spasm provocation test. In the remaining five patients, coronary spasm provocation was not performed because they revealed a high degree of fixed stenosis (lumen diameter narrowing 97 +/- 4%). Ergonovine echocardiography could diagnose coronary vasospasm before angiography, with a sensitivity of 91% (51 of 56 patients, 95% confidence interval [CI] 84% TO 98%) and specificity of 88% (21 of 24 patients, 95% CI 75% to 100%). Of 53 patients showing regional wall motion abnormalities during ergonovine echocardiography, characteristic ST segment elevation in the simultaneously recorded ECG was observed in only 20 (38%). There were no complications, including myocardial infarction or fatal arrhythmia, during the test.nnnCONCLUSIONSnErgonovine echocardiography before coronary angiography is safe and can be used as a reliable diagnostic screening test for coronary vasospasm in patients with negative treadmill or normal stress myocardial perfusion scan results. These findings suggest that invasive coronary angiography can be avoided in selected patients for the diagnosis of vasospastic angina.

Catastrophic Catecholamine-Induced Cardiomyopathy Mimicking Acute Myocardial Infarction, Rescued by Extracorporeal Membrane Oxygenation (ECMO) in Pheochromocytoma

Pheochromocytoma is a rare disorder and functioning tumor composed of chromaffin cells that secrete catecholamines. Patients with a pheochromocytoma crisis have a high mortality in spite of aggressive therapy. We present a case with a severe acute catecholamine cardiomyopathy presenting ST segment elevation with cardiogenic shock after hemorrhage into a left suprarenal tumor. Intra-aortic balloon pump (IABP) support, combined with inotropic therapy, was performed. However, the patient deteriorated rapidly and was unresponsive to a full dose of inotropics and IABP. We decided to apply extracorporeal membrane oxygenation (ECMO) device for the patient. His clinical state began to improve 3 days after ECMO. After achieving hemodynamic stabilization, he underwent successful laparoscopic left adrenalectomy. He needed no further cardiac medication after discharge.

Improvement in exercise capacity and exercise blood pressure response after transcoronary alcohol ablation therapy of septal hypertrophy in hypertrophic cardiomyopathy

Transcoronary alcohol ablation (TAA) therapy of septal hypertrophy was recently proposed as a therapeutic modality for obstructive hypertrophic cardiomyopathy (HC). However, questions remain about the effect of TAA on exercise performance. We performed a time-course analysis of exercise capacity and exercise hemodynamics in 20 patients with symptomatic obstructive HC after TAA. Symptom-limited bicycle exercise testing was performed before and 3 and 12 months after TAA, and cardiac catheterization at 3-month follow-up. The pressure gradient of the left ventricular outflow tract immediately decreased from 58 +/- 8 to 4 +/- 1 mm Hg at rest (p <0.01) and from 143 +/- 11 to 30 +/- 6 mm Hg after extrasystole (p <0.01), but partially recovered at 3-month follow-up (14 +/- 4 and 40 +/- 9 mm Hg, respectively). Left ventricular end-diastolic pressure was not changed after TAA. Peak oxygen consumption increased from 19 +/- 2 to 23 +/- 1 ml/kg/min (p < 0.01) and exercise duration from 573 +/- 47 to 742 +/- 46 seconds (p <0.01) at 3-month follow-up, but thereafter reached a plateau. Abnormal patterns of exercise blood pressure response were shown in 9 patients but normalized after TAA. Major complications occurred in 4 patients: no reflow to the left anterior descending coronary artery in 2 patients and ventricular tachycardia requiring cardioversion in 2 patients. During the follow-up period, all patients survived with symptomatic improvement in 17 patients. Thus, TAA is a promising therapeutic modality with improvement in exercise capacity and abnormal exercise blood pressure response in obstructive HC. However, potential serious complications should be considered in the application of TAA.

Change of QT dispersion following PTCA in angina patients

Background and Objectives:QT dispersion (QTd represents the inhomogeneity of ventricular repolarization and has been suggested to predict ventricular arrhythmia in patients with coronary artery disease (CAD. This study investigates the short-term effect of percutaneous transluminal coronary angioplasty (PTCA on QTd in patients with CAD and no history of previous myocardial infarct. Materials and Methods:In 84 angina pat- ients (65 men and 19 women, mean age of 58.3±9.0 yeras who underwent successful PTCA of single coronary artery, ECG was checked in baseline, immediate, 1day and 1 month after PTCA. QTd and corrected QTd (c- QTd were measured in these ECGs by digitizer. Results:PTCA was performed at left anterior descending artery (LAD in 56, left circumflex artery (LCx in 12 and right coronary artery (RCA in 16 patients. Mean and standard error of QTd (c-QTd at baseline, immediate, 1day and 1month after PTCA was 51.3±4.2 (50.7 ±4.1, 54.2±4.5 (52.8±4.5, 47.7±4.3 (48.5±4.8 and 36.3±4.5 (37.5±4.6 msec, respectively. QTd and c- QTd significantly decreased at 1 month following PTCA. The difference was more prominent in pateints with LAD lesion than LCx or RCA lesion and independent of gender, severity of stenosis and use of beta-blockers. Conclusion:QTd decreases in CAD patients with no history of myocardial infarct at 1 month following suc- cessful PTCA. This may facilitate a favorable recovery from inhomogenous repolarization. These findings call for long-term follow-up of QTd and the incidence of ventricular tachyarrhythmias and sudden death following successful PTCA. (Korean Circulation J 1998;28(9 :1487-1492