Se-Joong Rim

Outcomes of medically treated patients with aortic intramural hematoma

PURPOSE Aortic intramural hematoma has been considered a precursor of aortic dissection, and the same treatment strategy, usually involving surgery, has been applied to both conditions. However, the outcomes of patients with aortic intramural hematoma who are treated medically, including the remodeling process that occurs after an acute event, are not known. SUBJECT AND METHODS A total of 124 patients with acute aortic intramural hematoma (41 in the proximal aorta and 83 in the distal aorta) was enrolled from five institutions in South Korea. Patients received medical treatment without surgery. A follow-up imaging study was performed in 105 patients. RESULTS Pericardial (59% [n = 24] vs. 11% [n = 9], P <0.004) and pleural effusions (63% [n = 26] vs. 45% [n = 37], P = 0.05) were more common in patients with the proximal type than in those with the distal type. In-hospital mortality was somewhat higher with proximal hematomas (7% [n = 3 deaths] vs. 1% [n = 1 death], P = 0.11). A follow-up imaging study in 36 patients with proximal hematomas confirmed resorption of the hematoma in 24 patients (67%) and development of aortic dissection in 9 (25%). Resorption was confirmed in 54 (78%) of the 69 patients with distal hematomas who underwent follow-up imaging; localized aortic dissection developed in 11 (16%) of these patients. The 3-year survival rate was 78% in the proximal type and 87% in the distal type (P = 0.10). CONCLUSION Patients with aortic intramural hematoma had a high rate of resorption with medical treatment regardless of the affected site. Further investigation is necessary to determine the optimal treatment strategy and timing of surgical intervention, especially for patients with proximal hematomas.

Echocardiographic and morphologic characteristics of left atrial myxoma and their relation to systemic embolism.

We examined the relation between the echocardiographic morphology of cardiac myxoma and systemic embolism in 25 patients. Two distinct types of myxoma could be identified by echocardiography: round type characterized by solid and round shape with nonmobile surface (n = 13, 52%), and polypoid type characterized by soft and irregular shape with mobile surface (n = 12, 48%); multiple regression analysis revealed the polypoid type of tumor was the only independent predictor of systemic embolism (p = 0.0029).

Enhanced Detection of Right-to-Left Shunt Through Patent Foramen Ovale by Transthoracic Contrast Echocardiography Using Harmonic Imaging

When the results of transesophageal echocardiography was regarded as the gold standard for detecting a patent foramen ovale (PFO) in 136 consecutive patients referred for evaluation of cardiac source of embolism, transthoracic harmonic imaging using saline contrast was superior to fundamental imaging in accuracy for detecting a PFO (sensitivity, 22.5%; specificity [p < 0.05] and sensitivity, 100%; specificity 100%, respectively.)

Exaggerated Blood Pressure Response to Exercise Is Associated With Augmented Rise of Angiotensin II During Exercise

OBJECTIVES The aim of this study was to investigate the association between an exaggerated blood pressure (BP) response to exercise and augmented angiotensin (Ang) II rise during exercise. BACKGROUND Although a central pressor effect of Ang II has been implicated in the pathogenesis of hypertension, the relationship between Ang II and exaggerated BP response to exercise is unclear. METHODS Thirty-six subjects with an exaggerated BP response to exercise (18 men, age 50 +/- 16 years, Group II) were compared with 36 age- and gender-matched control subjects (18 men, age 50 +/- 16 years, Group I) with normal BP reactivity. The subjects who had resting BP >or=140/90 mm Hg or were treated with any antihypertensive drugs were excluded. The blood was sampled at rest and immediately after peak exercise for measurement of renin, Ang II, aldosterone, and catecholamine. RESULTS At rest, there were no significant differences in BP, renin, aldosterone, and catecholamine levels between the 2 groups. The renin, aldosterone, and catecholamine were increased during exercise, but there were no significant differences between the groups. However, log Ang II at rest (0.78 +/- 0.32 vs. 0.98 +/- 0.38, p = 0.004) and peak exercise (0.84 +/- 0.35 vs. 1.17 +/- 0.51, p < 0.001) and the magnitude of the increment of log Ang II with exercise (0.06 +/- 0.12 vs. 0.19 +/- 0.20, p = 0.003) were significantly higher in the exaggerated BP response group. CONCLUSIONS An exaggerated BP response to exercise was associated with augmented rise of Ang II during exercise.

Prediction of Left Atrial Fibrosis With Speckle Tracking Echocardiography in Mitral Valve Disease: A Comparative Study With Histopathology

Background and Objectives Left atrial (LA) fibrosis is a main determinant of LA remodeling and development of atrial fibrillation. However, non-invasive prediction of LA fibrosis is challenging. We investigated whether preoperative LA strain as measured by speckle tracking echocardiography could predict the degree of LA fibrosis and LA reverse remodeling after mitral valve (MV) surgery. Subjects and Methods Speckle tracking echocardiography and LA volume measurements were performed in 50 patients one day before MV surgery. LA tissues were obtained during the surgery, and the degrees of their interstitial fibroses were measured. LA volume measurements were repeated within 30 days after surgery (n=50) and 1-year later (n=39). Results Left atrial global strain was significantly correlated with the degree of LA fibrosis (r=-0.55, p<0.001), and its correlation was independent of age, underlying rhythm, presence of rheumatic heart disease and type of predominant MV disease (B=-1.37, 95% confidence interval -2.32 - -0.41, p=0.006). The degree of LA fibrosis was significantly correlated with early (r=-0.337, p=0.017) and 1-year (r=-0.477, p=0.002) percent LA volume reduction after MV surgery, but LA global strain was not significant. Conclusion Left atrial strain as measured by speckle tracking echocardiography might be helpful for predicting the degree of LA fibrosis in patients with MV disease.

Recovery and recurrence of left ventricular systolic dysfunction in patients with idiopathic dilated cardiomyopathy

BACKGROUND Some patients with nonischemic left ventricular (LV) systolic failure recover to have normal LV systolic function. However, few studies on the rates of recovery and recurrence have been reported, and no definitive indicators that can predict the recurrence of LV dysfunction in recovered idiopathic dilated cardiomyopathy (IDCMP) patients have been determined. It was hypothesized that patients who recovered from nonischemic LV dysfunction have a substantial risk for recurrent heart failure. METHODS Forty-two patients (32 men) with IDCMP (mean [+/- SD] age 56.9+/-8.7 years) who recovered from systolic heart failure (LV ejection fraction [LVEF] of 26.5+/-6.9% at initial presentation) to a near-normal state (LVEF of 40% or greater, and a 10% increase or greater in absolute value) were monitored for recurrence of LV systolic dysfunction. Patients with significant coronary artery disease were excluded. Patients were monitored for 41.0+/-26.3 months after recovery (LVEF 53.4+/-7.6%) from LV dysfunction. RESULTS LV systolic dysfunction reappeared (LVEF 27.5+/-8.1%) during the follow-up period in eight of 42 patients (19.0%). No significant difference between the groups with or without recurrent heart failure was observed in the baseline clinical and echocardiographic characteristics. However, more patients in the recurred IDCMP group than those in the group that maintained the recovery state had discontinued antiheart failure medication (62.5% versus 5.9%, P<0.05). CONCLUSIONS LV dysfunction recurs in some patients with reversible IDCMP. The recurrence was significantly correlated with the discontinuation of antiheart failure drugs. The results suggest that continuous medical therapy may be mandatory in patients who recover from LV systolic dysfunction.

Lipoprotein(a) and LDL Particle Size Are Related to the Severity of Coronary Artery Disease

Background: The pathophysiological role and metabolic pathway of Lp(a) have not been clearly defined. An association between Lp(a) and oxidative low-density lipoprotein (LDL) were recently reported. And small dense LDL (sd-LDL) were associated with circulating malondialdehyde-modified LDL. We investigated the relationships between serum Lp(a) level and LDL particle size in coronary artery disease (CAD) patients. Further, we investigated the relationships of sd-LDL and Lp(a) with the extent and severity of CAD. Methods: A total of 490 patients (mean: 60.5 ± 11.5 years old) who underwent coronary angiography to evaluate chest pain were investigated. Patients were classified into two groups, a CAD group (n = 256), who had significant stenosis observed by coronary angiogram, and a control group (n = 234), who had normal, or minimal coronary arteries. CAD severity was measured by Gensini scores. The distribution of the LDL subfraction was analyzed using a Quantimetrix Lipoprint LDL System. Results: The serum Lp(a) concentration was correlated with the fraction of sd-LDL (r = 0.193, p < 0.001) and mean LDL size (r = 0.160, p = 0.003). The Lp(a) level and mean LDL particle size were significantly correlated with a high Gensini score. LDL particle size in the CAD group was smaller than in the control group (26.74 ± 0.64 vs. 26.43 ± 0.93 nm, p < 0.001). The Gensini score was significantly higher in small LDL with high Lp(a) level groups. Conclusion: The positive correlation of the level of Lp(a) and sd-LDL fraction were demonstrated. The mechanism of this association is not clearly defined; we can suggest that it may stem from the individual atherogenic condition that linked to increased oxidative stress. Both increased Lp(a) and sd-LDL fraction were correlated with the severity of CAD.

Association of aortic plaque with intracranial atherosclerosis in patients with stroke

Objective: To determine whether there is a relationship between aortic plaques and intracranial (IC) atherosclerosis. Methods: We reviewed 922 patients with stroke who had both transesophageal echocardiography and cerebral angiography. The plaques of these patients were classified as either complex aortic plaques (CAP), which protruded ≥4 mm or were present as mobile lesions in the proximal aorta, or simple aortic plaques (SAP), which were <4 mm or present in the descending aorta. Cerebral artery atherosclerosis was classified as either an IC or extracranial (EC) atherosclerosis. Results: Among the 922 patients, we found aortic plaques in 237 patients (26%). There were 111 (47%) patients of SAP, 74 (31%) patients with CAP, and 52 (22%) patients that had both SAP and CAP. Angiography showed IC or EC atherosclerosis in 511 patients (55%). The presence of aortic plaques was significantly associated with IC or EC atherosclerosis. The significance appeared to be due to the strong association between the presence of SAP and IC atherosclerosis (51% SAP vs 35% no plaques; odds ratio = 1.94, 95% CI: 1.17 to 3.21). In the multiple logistic regression analysis, SAP were independent predictors of IC atherosclerosis Conclusions: The presence of simple aortic plaques may be a marker of advanced vascular disease. Detection of simple aortic plaques during transesophageal echocardiography may have clinical implications because patients with these plaques frequently had concomitant intracranial atherosclerosis, a risk factor for stroke.

Impact of Metabolic Syndrome and Its Individual Components on the Presence and Severity of Angiographic Coronary Artery Disease

Purpose Metabolic syndrome (MS) has been reported as a potential risk factor of coronary artery disease (CAD). The aims of this study were to assess whether there was a relationship between MS score and CAD angiographic severity, and to assess the predictive value of individual components of MS for CAD. Materials and Methods We retrospectively enrolled 632 patients who underwent coronary angiography for suspected CAD (394 men, 61.0 ± 10.6 years of age). MS was defined by the National Cholesterol Education Program criteria with the waist criterion modified into a body mass index (BMI) of more than 25 kg/m2. The MS score defined as the number of MS components. CAD was defined as > 50% luminal diameter stenosis of at least one major epicardial coronary artery. CAD angiographic severity was evaluated with a Gensini scoring system. Results Of the patients, 497 (78.6%) had CAD and 283 (44.8%) were diagnosed with MS. The MS score was significantly related to the Gensini score. High fasting blood glucose (FBG) was the only predictive factor for CAD. A cluster including high FBG, high blood pressure (BP), and low high-density lipoprotein cholesterol (HDL-C) showed the highest CAD risk. Conclusion The MS score correlates with the angiographic severity of CAD. The predictive ability of MS for CAD was carried almost completely by high FBG, and individual traits with high BP and low HDL-C may act synergistically as risk factors for CAD.

Local increase in microparticles from the aspirate of culprit coronary arteries in patients with ST-segment elevation myocardial infarction.

OBJECTIVE It has been reported that the levels of procoagulant microparticles (MPs) are increased in patients with acute coronary syndromes and this may contribute to the formation of intracoronary thrombi. In the current study, we investigated the presence of locally elevated MPs within the culprit coronary arteries of patients with ST-segment elevation myocardial infarction (STEMI). METHODS The study population consisted of 45 patients with STEMI who underwent primary percutaneous coronary intervention (PCI), and 16 control patients. Before and after PCI, blood samples were collected from the femoral artery and from the culprit coronary arteries. In controls, only peripheral blood was obtained. MPs were measured by a solid-phase capture assay using a commercial kit. The cell origins of MPs were determined by antigenic capture with specific antibodies. RESULTS Baseline levels of MPs in patients with STEMI were higher than in controls. Before PCI, the levels of MPs were significantly higher in culprit coronary arteries than in peripheral arteries in STEMI patients (20.7 ± 15.5 vs. 14.6 ± 15.4 nM phosphatidylserine (PS) equivalent, p = 0.027). MPs from the culprit coronary artery were significantly reduced after PCI (20.7 ± 15.5 vs. 14.3 ± 14.9 nM PS equivalent, p = 0.010). Similarly, the locally increased levels of endothelial- and platelet-derived MPs within the culprit coronary arteries were significantly decreased after PCI. CONCLUSION Locally increased levels of MPs in culprit coronary arteries and their significant reduction after successful PCI suggest a potential role in coronary atherothrombosis in the early period of STEMI.