Pum Joon Kim

Stents versus Coronary-Artery Bypass Grafting for Left Main Coronary Artery Disease

BACKGROUND Several studies have compared the treatment effects of coronary stenting and coronary-artery bypass grafting (CABG). However, there are limited data regarding the long-term outcomes of these two interventions for patients with unprotected left main coronary artery disease. METHODS We evaluated 1102 patients with unprotected left main coronary artery disease who underwent stent implantation and 1138 patients who underwent CABG in Korea between January 2000 and June 2006. We compared adverse outcomes (death; a composite outcome of death, Q-wave myocardial infarction, or stroke; and target-vessel revascularization) with the use of propensity-score matching in the overall cohort and in separate subgroups according to type of stent. RESULTS In the overall matched cohort, there was no significant difference between the stenting and CABG groups in the risk of death (hazard ratio for the stenting group, 1.18; 95% confidence interval [CI], 0.77 to 1.80) or the risk of the composite outcome (hazard ratio for the stenting group, 1.10; 95% CI, 0.75 to 1.62). The rates of target-vessel revascularization were significantly higher in the group that received stents than in the group that underwent CABG (hazard ratio, 4.76; 95% CI, 2.80 to 8.11). Comparisons of the group that received bare-metal stents with the group that underwent CABG and of the group that received drug-eluting stents with the group that underwent CABG produced similar results, although there was a trend toward higher rates of death and the composite end point in the group that received drug-eluting stents. CONCLUSIONS In a cohort of patients with unprotected left main coronary artery disease, we found no significant difference in rates of death or of the composite end point of death, Q-wave myocardial infarction, or stroke between patients receiving stents and those undergoing CABG. However, stenting, even with drug-eluting stents, was associated with higher rates of target-vessel revascularization than was CABG.

Long-term safety and efficacy of stenting versus coronary artery bypass grafting for unprotected left main coronary artery disease: 5-year results from the MAIN-COMPARE (Revascularization for Unprotected Left Main Coronary Artery Stenosis: Comparison of Percutaneous Coronary Angioplasty Versus Surgical Revascularization) registry.

OBJECTIVES We performed the long-term follow-up of a large cohort of patients in a multicenter study receiving left main coronary artery (LMCA) revascularization. BACKGROUND Limited information is available on long-term outcomes for patients with unprotected LMCA disease who underwent coronary stent procedure or coronary artery bypass grafting (CABG). METHODS We evaluated 2,240 patients with unprotected LMCA disease who received coronary stents (n = 1,102; 318 with bare-metal stents and 784 with drug-eluting stents) or underwent CABG (n = 1,138) between 2000 and 2006 and for whom complete follow-up data were available for at least 3 to 9 years (median 5.2 years). The 5-year adverse outcomes (death; a composite outcome of death, Q-wave myocardial infarction [MI], or stroke; and target vessel revascularization [TVR]) were compared with the use of the inverse probability of treatment weighted method and propensity-score matching. RESULTS After adjustment for differences in baseline risk factors with the inverse probability of treatment weighting, the 5-year risk of death (hazard ratio [HR]: 1.13; 95% confidence interval [CI]: 0.88 to 1.44, p = 0.35) and the combined risk of death, Q-wave MI, or stroke (HR: 1.07; 95% CI: 0.84 to 1.37, p = 0.59) were not significantly different for patients undergoing stenting versus CABG. The risk of TVR was significantly higher in the stenting group than in the CABG group (HR: 5.11; 95% CI: 3.52 to 7.42, p < 0.001). Similar results were obtained in comparisons of bare-metal stent with concurrent CABG and of drug-eluting stent with concurrent CABG. In further analysis with propensity-score matching, overall findings were consistent. CONCLUSIONS During 5-year follow-up, stenting showed similar rates of mortality and of the composite of death, Q-wave MI, or stroke but higher rates of TVR as compared with CABG for patients with unprotected LMCA disease.

Nuclear localization of β-catenin is an important prognostic factor in hepatoblastoma

In this study, mutational and immunohistochemical analyses of β‐catenin were performed in 30 hepatoblastomas, to assess the prevalence of alterations of the Wnt pathway with respect to clinicopathological parameters and survival. Four missense mutations of β‐catenin (13.3%) were detected and there was strong immunoreactivity for β‐catenin in the cytoplasm and/or the nucleus in 97% of hepatoblastomas. Nuclear and cytoplasmic staining was demonstrated in 19 of 30 tumours (63%), while ten revealed only cytoplasmic staining. Statistically, this nuclear β‐catenin staining was significantly higher in the embryonal (Fisher exact test; p=0.00393) or undifferentiated type (p=0.00156) of hepatoblastoma than in the fetal type, but there was no difference between clinical stages I and II and clinical stages III and IV (p=0.175). Cumulative survival curves showed that nuclear β‐catenin staining (generalized Wilcoxon test; p=0.0088), undifferentiated histological type (p=0.0305), and clinical stages III and IV (p=0.0107) were significantly correlated with shorter survival time in these patients. Moreover, Cox multivariate analysis provides evidence that nuclear β‐catenin staining is the most important prognostic factor for survival (p=0.0090). It is therefore concluded that immunohistochemical analysis of β‐catenin might be a useful clinical tool for estimating the prognosis for patients with hepatoblastoma. Copyright

Somatic mutations in the death domain of the Fas (Apo-1/CD95) gene in gastric cancer.

It is now believed that genes regulating apoptosis are also important variables in cancer development. Fas, a transmembrane protein of the tumour necrosis factor receptor family, is a key molecule for cell death signalling. The mutation of the primary structure of the Fas gene might also be one of the possible mechanisms that disrupt Fas‐mediated apoptosis in tumour cells. The purpose of this study was to determine whether somatic mutation of the Fas gene could be involved in the tumourigenesis of gastric cancer. Polymerase chain reaction (PCR)‐based loss of heterozygosity (LOH) analysis with two intragenic polymorphic markers, and mutation analysis for the entire coding regions of the Fas gene were performed in 43 cases of gastric cancer, using PCR–single‐strand conformational polymorphism sequencing. Five (11.6%) missense mutations were detected, only in the death domain of the Fas gene. Although these mutations were observed only in intestinal‐type gastric cancers, there was no statistically significant difference in the frequency of Fas mutation between intestinal‐ and diffuse‐type gastric cancer (p=0.068). Nine LOH out of 22 informative cases were also detected with one or both markers (41%). Three of them demonstrated a somatic mutation in the remaining allele, indicating the inactivation of both alleles. These results suggest that genetic alterations of the Fas gene may not only be limited to gastric cancer cell protection through Fas resistance, but may also play an important role in tumour promotion and/or progression in a subset of gastric cancer. Copyright

The Association Between Current Helicobacter pylori Infection and Coronary Artery Disease

Background The role of Helicobacter pylori (H. pylori) in the pathogenesis of coronary artery disease (CAD) is still controversial, and the relation between current H. pylori infection and CAD has not been fully examined. This study evaluated the relation between H. pylori infection as confirmed by gastroduodenoscopic biopsy and CAD. Methods We determined the presence of H. pylori infections, via gastroduodenoscopy, in 88 patients of the normal coronary angiographic group and also in 175 patients of the CAD group, and the latter patients had more than 50% coronary stenosis angiographically demonstrated. We excluded those patients with a history of previous H. pylori eradication and/or malignancy. A small piece of tissue from the antrum, which was obtained by gastroduodenoscopic biopsy, was stained by Warthin-starry silver stain. We defined a negative staining result that there was no stained tissue in the sample and the stained tissue was also positive for H. pylori infection. Results There was no significant difference, except for gender, age, smoking and high density lipoprotein cholesterol (HDL-c), of the demographic and laboratory characteristics between the groups. Twenty seven (30.7%) patients of the normal control group and 71 (40.6%) patients of the CAD group were positive of H. pylori infection, yet there was no statistical difference. We angiographically followed up the 80 patients of the CAD group who were treated by percutaneous coronary intervention (PCI) at 6 to 9 months after their primary intervention. Twenty two (37.9%) of the 58 patients of the H. pylori negative group and 10 (45.5%) of the 22 patients of the H. pylori positive group were treated with reintervention, but reintervention was also not significantly different between the group with H. pylori infection and the group without the infection. Conclusions These data indicated that H. pylori infection had a modest influence on CAD and progressive atheroma, but the showed a tendency to increase. Further studies are needed to evaluate the relationship between H. pylori infection and CAD.

Prognosis of Large, Symptomatic Pericardial Effusion Treated by Echo-guided Percutaneous Pericardiocentesis

The causes and prognosis of pericardial effusion (PE) may be different according to time, region, economy, and hospital. This study was performed to evaluate the etiology, clinical outcome, and prognosis of patients with large, symptomatic PE treated by echo‐guided pericardiocentesis at Kangnam St. Marys Hopital (the Catholic University of Korea, Seoul, Korea).

Long-term clinical outcomes of overlapping heterogeneous drug-eluting stents compared with homogeneous drug-eluting stents

Objectives To evaluate long-term clinical outcomes of overlapping heterogeneous drug-eluting stents (DES) compared with homogeneous DES. Design and setting The catholic medical centre coronary intervention database is a multicentre database of percutaneous coronary intervention with DES. This database contains data on consecutive patients from eight coronary intervention centres in Korea. Patients Overlapping homogeneous DES were used in 940 patients and overlapping heterogeneous DES in 140 patients between January 2005 and June 2010. Intervention The study enrolled patients with one-vessel disease treated with two overlapping DES in one lesion. Main outcome measures The study end point was the occurrence of major adverse cardiac events (MACE), defined as cardiac death, myocardial infarction (MI) or target lesion revascularisation (TRL). Results The two patient groups had similar baseline clinical and angiographic characteristics. MACE, cardiac death, MI and TRL rates, were not significantly different between the homogeneous and heterogeneous DES groups (9.9% vs 11.4%, p=0.574; 2.7% vs 3.6%, p=0.578; 1.5% vs 1.4%, p=1.000; 5.7% vs 6.4%, p=0.747, respectively). In addition, it was found that overlap with second-generation DES may be safe and effective, and the sirolimus-eluting stent (SES)+SES group had higher rate of MACE-free survival than the paclitaxel-eluting stent (PES)+PES group (p=0.014). Conclusions Overlapping heterogeneous DES and overlapping homogeneous DES had similar long-term safety and efficacy outcomes.

Direct comparison of B-type natriuretic peptide and N-terminal pro-BNP for assessment of cardiac function in a large population of symptomatic patients

BACKGROUNDS B-type natriuretic peptide (BNP) and N-terminal pro-BNP (NTproBNP) levels showed frequent discrepancies in individual patients. OBJECTIVES The aims were 1) to compare the abilities of BNP and NTproBNP for the detection of left ventricular systolic dysfunction (LVSD) or diastolic dysfunction (LVDD) in the symptomatic patients, and 2) to assess the direct correlation and its independent determinants between them. METHODS 1032 patients with dyspnea underwent BNP and NTproBNP measurements simultaneously. 967/1032 (93.7%) patients underwent echocardiography. Using the receiver operation characteristic curve analyses for the detection of LVSD (EF<45%) or advanced LVDD, the area under the curves (AUC) of both biomarkers was compared according to age, gender, body mass index (BMI), hemoglobin (Hb), and glomerular filtration rate (eGFR). Using multiple regression analysis, the direct correlation and its independent determinants were identified between them. RESULTS In the entire population, the AUCs of BNP and NTproBNP had no significant differences (LVSD: 0.909 vs. 0.893, p=0.20; advanced LVDD: 0.897 vs. 0.879, p=0.13). In patients with BMI<25, the AUCs of BNP were significantly higher than those of NTproBNP (LVSD: 0.897 vs. 0.869, p=0.03; advanced LVDD: 0.916 vs. 0.885, p=0.02). They had strong correlation (r=0.895, p<0.001) and LVEF, eGFR<60 ml/min, Hb<12 g/dl and use of diuretics were the independent determinants between them. CONCLUSION BNP and NTproBNP displayed strong correlation and near-identical performances for the screening of cardiac dysfunction. However, LVEF, renal function, Hb and use of diuretics should be considered for clinical interpretation.

Anterolateral Papillary Muscle Rupture Complicated by the Obstruction of a Single Diagonal Branch

A 66-year-old woman presented with a sudden onset of anterior chest pain lasting 2 days and a 1-year history of atrial fibrillation. She had never taken medication for the atrial fibrillation, and this was her first episode of chest pain. The physical examination, including cardiac enzymes, ECG, and echocardiogram, showed that she had acute myocardial infarction with severe mitral regurgitation (Figure 1). There was no evidence of systemic embolism other …

Persistent coronary artery spasm documented by follow-up coronary angiography in patients with symptomatic remission of variant angina

For patients with variant angina it is very important to start medical therapy using calcium-channel blockers. However, the decision of physicians regarding whether to decrease the dose of the drug or discontinue it is controversial. We investigated whether the nature of spasm is remissive and whether the termination of medications is safe. The subjects studied were included in the Vasospastic Angina in Catholic Medical Center Registry from March 2001 to December 2009. We analyzed 37 patients (62 lesions) with variant angina, diagnosed using coronary angiography (CAG) and he acetylcholine provocation test, without any organic coronary stenosis, whose symptoms were well controlled after medication. The follow-up CAG with provocation test was performed at a median interval of 44 months. The characteristics of spasm were analyzed on each pair of CAGs. The study group consisted of 23 men (62.2 %) and 14 women (37.8 %) with a mean age of 59 ± 11.1 years. The follow-up CAG with provocation test showed that the characteristics of the spasmodic nature were consistent with the first test in all patients. Although the patients with variant angina had no chest pain after medical treatment, the spasmodic nature of coronary arteries still remained. We may decrease the drug dosage after carefully checking the patient’s symptoms but recommend not discontinuing therapy, even if the patient is asymptomatic.