Pil Sang Song

Percutaneous coronary intervention for nonculprit vessels in cardiogenic shock complicating ST-segment elevation acute myocardial infarction.

Objectives:We investigated the clinical impact of multivessel percutaneous coronary intervention in ST-segment elevation myocardial infarction complicated by cardiogenic shock with multivessel disease. Design:A prospective, multicenter, observational study. Setting:Cardiac ICU of a university hospital. Patients:Between November 2005 and September 2010, 338 patients were selected. Inclusion criteria were as follows: 1) ST-segment elevation myocardial infarction with cardiogenic shock and 2) multivessel disease with successful primary percutaneous coronary intervention for the infarct-related artery. Patients were divided into multivessel percutaneous coronary intervention and culprit-only percutaneous coronary intervention. Interventions:None. Measurements and Main Results:Primary outcome was all-cause mortality. Median follow-up duration was 224 days (interquartile range, 46–383 d). Multivessel percutaneous coronary intervention was performed during the primary percutaneous coronary intervention in 60 patients (17.8%). In-hospital mortality was similar in both groups (multivessel percutaneous coronary intervention vs culprit-only percutaneous coronary intervention, 31.7% vs 24.5%; p = 0.247). All-cause mortality during follow-up was not significantly different between the two groups after adjusting for patient, angiographic, and procedural characteristics as well as propensity scores for receiving multivessel percutaneous coronary intervention (35.0% vs 30.6%; adjusted hazard ratio, 1.06; 95% CI, 0.61–1.86; p = 0.831). There were no significant differences between the groups in rates of major adverse cardiac events (41.7% vs 37.1%; adjusted hazard ratio, 1.03; 95% CI, 0.62–1.71; p = 0.908) and any revascularization (6.7% vs 4.7%; adjusted hazard ratio, 1.88; 95% CI, 0.51–6.89; p = 0.344). Conclusions:Multivessel percutaneous coronary intervention could not reduce the prevalence of mortality in patients with cardiogenic shock complicating ST-segment elevation myocardial infarction and multivessel disease during primary percutaneous coronary intervention.

Prognostic value of admission blood glucose level in patients with and without diabetes mellitus who sustain ST segment elevation myocardial infarction complicated by cardiogenic shock

IntroductionAdmission blood glucose (BG) level is a predictor of mortality in patients with ST-segment elevation myocardial infarction (STEMI). However, limited data are available relating admission BG to mortality in patients with STEMI complicated by cardiogenic shock, and it is not known whether diabetic status has an independent effect on this relationship.MethodsBetween November 2005 and September 2010, 816 STEMI patients with cardiogenic shock were enrolled in a nationwide, prospective, multi-center registry; 239 (29.3%) had diabetes mellitus (DM). Patients were categorized according to BG levels at admission: <7.8, 7.8–10.9, 11.0–16.5 and ≥ 16.6 mmol/L. The primary outcome was 30-day mortality. The added values of BG to the Thrombolysis in Myocardial Infarction (TIMI) and Global Registry of Acute Coronary Events (GRACE) scores were assessed by receiver operating characteristic curves and integrated discrimination improvement analyses.ResultsThirty-day mortality was higher in patients with higher admission BG (20.4%, 23.3%, 39.8%, and 43.1% p < 0.001). Among non-diabetic patients, 30-day mortality was predicted by TIMI scores with a c-statistic of 0.615 (95% confidence interval [CI], 0.561–0.662) and GRACE scores with a c-statistic of 0.652 (95% CI, 0.604–0.695). Incorporation of admission BG increased the c-statistic for TIMI score to 0.685 (95% CI, 0.639–0.720, p < 0.001) and GRACE score to 0.708 (95% CI 0.664–0.742, p < 0.001). Additional predictive values for BG were not observed for diabetes. Integrated discrimination improvements (TIMI vs. additional BG and GRACE vs. additional BG) were 0.041 (p < 0.001) and 0.039 (p < 0.001) in non-diabetic patients.ConclusionsIn a cohort of patients with STEMI complicated by cardiogenic shock, admission BG was an independent predictor of increased risk of mortality only among patients without DM.

Peripheral Artery Disease in Korean Patients Undergoing Percutaneous Coronary Intervention: Prevalence and Association with Coronary Artery Disease Severity

Peripheral artery disease (PAD) is an important marker for the risk stratification of patients with coronary artery disease (CAD). We investigated the prevalence of PAD in patients undergoing percutaneous coronary intervention (PCI) with CAD and the relationship between ankle-brachial pressure index (ABPI) and CAD severity. A total of 711 patients undergoing PCI for CAD from August 2009 to August 2011 were enrolled. PAD diagnosis was made using the ABPI. The prevalence of PAD was 12.8%. In PAD patients, mean values of right and left ABPI were 0.71 ± 0.15 and 0.73 ± 0.15. Patients with PAD had a higher prevalence of left main coronary disease (14.3% vs 5.8%, P = 0.003), more frequently had multivessel lesions (74.9% vs 52.1%, P < 0.001) and had higher SYNTAX score (18.2 ± 12.3 vs 13.1 ± 8.26, P = 0.002). Using multivariate analysis, we determined that left main CAD (OR, 2.954; 95% CI, 1.418-6.152, P = 0.004) and multivessel CAD (OR, 2.321; 95% CI, 1.363-3.953, P = 0.002) were both independently associated with PAD. We recommend that ABPI-based PAD screening should be implemented in all patients undergoing PCI with CAD, especially in severe cases.

Seizure-Like Activities during Head-Up Tilt Test-Induced Syncope

Purpose Some patients with neurally mediated reflex syncope may be misdiagnosed as epilepsy because myoclonic jerky movements are observed during syncope. The seizure-like activities during the head-up tilt test (HUT) have been rarely reported. The purpose of this study was to assess the characteristics of these seizure-like activities and evaluate whether there are differences in the clinical characteristics and hemodynamic parameters of patients with neurally mediated reflex syncope with and without seizure-like activities during HUT-induced syncope. Materials and Methods The medical records of 1,383 consecutive patients with a positive HUT were retrospectively reviewed, and 226 patients were included in this study. Results Of 226 patients, 13 (5.75%) showed seizure-like activities, with 5 of these (2.21%) having multifocal myoclonic jerky movements, 5 (2.21%) having focal seizure-like activity involving one extremity, and 3 (1.33%) having upward deviation of eye ball. Comparison of patients with and without seizure-like activities revealed no significant differences in terms of clinical variables and hemodynamic parameters during HUT. Conclusion Seizure-like activities occurred occasionally during HUT-induced syncope in patients with neurally mediated reflex syncope. The seizure-like activities during HUT might not be related to the severity of the syncopal episodes or hemodynamic changes during HUT.

Periprocedural myocardial infarction is not associated with an increased risk of long-term cardiac mortality after coronary bifurcation stenting ☆

BACKGROUND Debate continues over the importance of periprocedural myocardial infarction (PMI) after percutaneous coronary intervention (PCI). We evaluated the prognostic significance of PMI in patients undergoing PCI for bifurcation lesions. METHODS Between January 2004 and June 2006, patients from 16 centers who received non-left main bifurcation lesion PCIs were enrolled. PMI was defined as a peak creatine kinase-myocardial band (CK-MB) ≥ 3 times the upper limit of normal after PCI. We compared long-term cardiac mortality between patients with and without PMI. RESULTS Among the 1188 patients, PMI occurred in 119 (10.0%). Left ventricular ejection fraction<50% (adjusted hazard ratio [HR]: 2.08, 95% confidence interval [CI]: 1.13-3.82, p=0.018), multi-vessel coronary artery disease (adjusted HR: 2.28, 95% CI: 1.36-3.81, p=0.002), and PCI-related acute closure in a side branch (adjusted HR: 3.34, 95% CI: 1.23-9.02, p=0.018) were the significant risk factors for PMI. During the median follow-up of 22.7 months, the unadjusted rate of long-term cardiac mortality was significantly higher in patients with PMI than in those without PMI (2.5% vs. 0.7%, p=0.026). After multivariable adjustment, the relationship between PMI and short-term (≤ 30 day) cardiac mortality was significant (adjusted HR: 12.32, 95% CI: 1.07-141.37, p=0.044). However, PMI was not an independent prognostic factor of long-term cardiac mortality (adjusted HR: 2.59, 95% CI: 0.62-10.85, p=0.20). CONCLUSIONS PMI occurs in patients with a higher prevalence of adverse cardiac risks and predicts short-term but not long-term cardiac mortality in patients undergoing bifurcation lesion PCI.

Impact of Acute Coronary Syndrome Classification and Procedural Technique on Clinical Outcomes in Patients With Coronary Bifurcation Lesions Treated With Drug‐Eluting Stents

We examined the impact of non–ST‐segment elevation acute coronary syndrome (NSTE‐ACS) on clinical outcomes in patients with bifurcation lesions treated with drug‐eluting stents.

Impact of coronary bifurcation angle on clinical outcomes after percutaneous coronary intervention in real-world practice: results from the COBIS registry.

Objectives: Bifurcation angle has emerged as a predictor of outcome after percutaneous coronary intervention (PCI) for bifurcation lesions. We investigated the impact of bifurcation angle on clinical outcomes in patients undergoing bifurcation lesion PCI. Methods: Consecutive patients who received PCI for bifurcation lesions were enrolled from 16 centers in Korea between January 2004 and June 2006. Patients were divided into low-angle and high-angle groups using the median bifurcation angle (50°). We compared major adverse cardiac events, including cardiac death, myocardial infarction and target lesion revascularization as well as periprocedural outcomes between the 2 groups. Results: We evaluated 1,432 patients with bifurcation lesions with a median follow-up duration of 21 months. The rates of interventional side branch procedures such as guide-wiring of side branches, side-branch ballooning, final kissing ballooning and side-branch stenting were higher in the low-angle group. However, the incidences of major adverse cardiac events and target lesion revascularization were not significantly different between the 2 groups (6.6 vs. 6.9%, p = 0.856 and 4.6 vs. 5.7%, p = 0.375, respectively). Conclusions: Bifurcation angle may not influence long-term clinical outcome in patients with non-left main bifurcation lesion undergoing PCI despite its association with more interventional side-branch procedures.

A Case of Stent Graft Infection Coupled With Aorto-Esophageal Fistula Following Thoracic Endovascular Aortic Repair in a Complex Patient

The incidence of peri-stent graft infection (PGI) following thoracic endovascular aortic repair (TEVAR) is low, but the associated mortality rates are extremely high. The diagnosis of this complication can be difficult due to nonspecific symptoms. Here, we report a case of PGI combined with an aorto-esophageal fistula (AEF) diagnosed by computed tomography (CT) and positron emission tomography (PET) imaging after TEVAR. A 50-year-old woman with a history of diabetes mellitus and chronic hemodialysis had received a stent graft for a contained rupture of a pseudoaneurysm of the descending thoracic aorta. Three months after stent-grafting, she experienced back pain. CT and PET imaging suggested a PGI. The patient underwent surgical treatment for PGI with AEF.

A Case of a Senile Systemic Amyloidosis Patient Presenting With Angina Pectoris and Dilated Cardiomyopathy

A 77-year-old man visited our hospital complaining of aggravated exertional chest pain. He was diagnosed with syndrome X 7 years ago and underwent medical treatment in a regional hospital. Coronary angiography and echocardiography did not show any significant abnormalities. On the seventh in-hospital day, cardiogenic shock developed and echocardiography showed a dilated left ventricular (LV) cavity and severe LV systolic dysfunction. We thus inserted an intra-aortic balloon pump for hemodynamic support and were forced to maintain it because of weaning failure several times. Finally, heart transplantation was the decided necessary procedure. After successful heart transplantation, the biopsy specimen revealed a wild-type transthyretin deposition indicating senile systemic amyloidosis in the intramuscular coronary vessels and interstitium. Cardiac biopsy at the 4-year follow-up showed no recurrence of amyloid deposition.

Long-Term Outcomes of Sirolimus-Eluting Stents vs Paclitaxel-Eluting Stents in Unprotected Left Main Coronary Artery Bifurcation Lesions

The treatment of unprotected left main coronary artery (uLMCA) bifurcation lesions remains challenging.