Seung-Yun Cho

Effect of oral administration of testosterone on brachial arterial vasoreactivity in men with coronary artery disease

H igh androgen levels in men have been regarded as a risk factor for coronary artery disease (CAD). However, it has recently been demonstrated that supplements of androgens inhibit atheroma formation in castrated male animals, suggesting that testosterone may be antiatherosclerotic. In men with angina pectoris, a significant inverse correlation was found between plasma testosterone levels and the extent of CAD, demonstrating that low testosterone levels could be a risk factor for CAD. Other reports suggest that testosterone replacement therapy in men with CAD has a beneficial effect on angina pectoris and exercise-induced ST-segment depression. Another study showed that testosterone enhanced endotheliumindependent coronary artery dilation and flow-mediated brachial arterial vasoreactivity in men with CAD. In this study, we assessed the effects of oral testosterone administration on brachial arterial vasoreactivity in men with CAD. • • • Thirty-five men (aged 58 8 years) with CAD were randomized to placebo (n 17) or treatment group (n 18). Demographics of the study group are summarized in Table 1. Diagnostic criteria of CAD are a history of unstable and stable angina pectoris with angiographic evidence ( 50% stenosis of lumen diameter). Exclusion criteria were inflammatory disease or malignancy, ejection fraction 45%, clinical evidence of heart failure, and Q-wave myocardial infarction within 3 months before the study. The treatment group completed oral administration of 160 mg of testosterone undecanoate (Andriol, N.V. Organon, Oss, The Netherlands) daily for 4 weeks followed by 80 mg testosterone undecanoate for 8 weeks, in addition to their current medication. Using high-resolution ultrasound, we assessed brachial arterial vasoreactivity to reactive hyperemia (flow-mediated dilation) and sublingual nitroglycerin (nitroglycerin-mediated dilation) at baseline and after 12 weeks of treatment. Patients taking nitrates discontinued therapy 24 hours before the study to avoid nitrate tolerance. A 10-MHz linear phased-array ultrasound transducer (GE Vigmed Ultrasound, Horten, Norway) was used to image the dominant arm brachial artery longitudinally 3 to 5 cm just above the antecubital fossa. All patients rested in the supine position for 10 minutes in a quiet room. After the depth and gain setting were optimized to identify the vessel wall, the brachial artery diameter was measured from the anterior to the posterior interface between the media and the adventitia and determined at end-diastole on B mode. Reactive hyperemia was induced by inflation and then deflation of a pneumatic cuff placed around the upper arm. The blood pressure cuff was inflated to 250 mm Hg for 5 minutes. After release of the cuff, brachial artery diameter was measured within the first 15 seconds of reactive hyperemia. The brachial artery was allowed to return to the baseline level until 10 minutes after cuff release. Then, a further baseline brachial artery diameter was obtained. Nitroglycerin, 0.6 mg, was then given sublingually, and the brachial artery diameter was measured for the ensuing 3 minutes. The percent change in diameter caused by reactive hyperemia was calculated by dividing the difference from baseline end-diastolic diameter by the baseline value. The percent change in diameter caused by nitroglycerin administration was also calculated in the same way. Blood pressure and heart rate were measured before the examination. All data were calculated as an average of 4 consecutive cardiac cycles. Early morning blood sampling for fasting lipid profiles was performed and plasma-free testosterone levels were obtained immediately before ultrasound imaging and 12 weeks later. A standard radioimmunoassay method was used for analysis (DSL-4900 kit, Diagnostic System Laboratory Inc., Houston, Texas). All descriptive data are presented as mean SD and analyzed using SPSS for Windows 9.0 (SPSS Inc., Chicago, Illinois) From the Cardiology Division, Yonsei Cardiovascular Center and Cardiovascular Research Institute, College of Medicine, Seoul; and Department of Food and Nutrition, College of Ecology, Yonsei University, Seoul, South Korea. Dr. Jang’s address is: Cardiology Division, Yonsei Cardiovascular Center, Yonsei University College of Medicine, 134, Shinchon-Dong, Seodaemun-Gu, Seoul 120-752, South Korea. E-mail: jangys1212@yumc.yonsei.ac.kr. Manuscript received August 10, 2001; revised manuscript received and accepted December 10, 2001. TABLE 1 Clinical Characteristics of Study Group

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).

Successful Treatment of Isolated Spontaneous Superior Mesenteric Artery Dissection with Stent Placement

Isolated dissection of superior mesenteric artery is a rare condition and is usually treated surgically. We treated a patient with severe abdominal pain who was angiographically confirmed to have superior mesenteric artery thrombosis associated with isolated spontaneous dissection. He was treated initially by thrombolysis and oral anticoagulation, but recurrent symptoms developed with radiologic evidence of disease progression. We performed superior mesenteric artery stenting and recovery was uneventful.

Quantification of regional calcium burden in chronic total occlusion by 64-slice multi-detector computed tomography and procedural outcomes of percutaneous coronary intervention

BACKGROUND One of the most important reasons for failure of percutaneous coronary intervention (PCI) in chronic total occlusion (CTO) is calcified plaque, which either prevents passage of guide wire or ruptures after balloon inflation. We sought to evaluate whether quantified calcium contents of CTO on multi-detector computed tomography (MDCT) correlate with immediate procedural outcomes. METHODS Sixty-four patients with 72 CTO lesions who underwent 64-slice MDCT prior to PCI were investigated. The lesions were divided into 2 groups according to procedural outcomes (55 lesions with PCI-success group, 17 lesions with PCI-failure group). Clinical, angiographic and MDCT parameters, including regional calcium volume (RCaV), regional calcium score (RCaS), regional calcium equivalent mass (RCaEq), and relative calcium area at the most calcified cross section of CTO (%CaS/CSA), were compared between the two groups. RESULTS The duration of CTO was shorter in PCI-success group than PCI-failure group (7.16 ± 10.5 vs 15.59 ± 14.92 months, p=0.011), and the procedural success rate was 76.3%. Regional calcium-related parameters (RCaV 52.86 ± 58.39 vs 7.26 ± 15.27 mm(3), p<0.001; RCaS 72.71 ± 78.4 vs 9.66 ± 20.2, p<0.001; RCaEq 12.58 ± 12.97 vs 1.84 ± 3.716 mgCaHA, p<0.001; %CaS/CSA 53.9 ± 20.3 vs 30.4 ± 17.1%, p=0.009) in the occluded segment were higher and the occlusion length was longer (37.44 ± 27.48 vs 22.00 ± 18.04 mm, p<0.021) in PCI-failure group compared to PCI-success group. Multivariate regression analysis showed that only %CaS/CSA was a significant determinant of PCI-failure. CONCLUSIONS Precise quantification of regional calcification and measurement of the occluded segment by high resolution MDCT can deliver important information for predicting procedural outcomes in PCI of CTO.

Isolated Noncompaction of the Ventricular Myocardium: Contrast Echocardiographic Findings and Review of the Literature

Isolated noncompaction of the ventricular myocardium (INVM) is a rare congenital anomaly. We report a case of INVM in an adult, which was diagnosed using contrast echocardiography.

The clopidogrel resistance can be attenuated with triple antiplatelet therapy in patients undergoing drug-eluting stents implantation

BACKGROUND Triple antiplatelet therapy may have a beneficial effect on prevention of thrombotic complication in patients undergoing coronary stenting. We investigated the prevalence of aspirin and clopidogrel resistance in patients treated with dual and triple antiplatelet regimen after percutaneous coronary intervention (PCI) with drug-eluting stents (DES). METHODS A total of 400 consecutive patients underwent successful PCI with DES were randomly assigned to therapy with dual antiplatelet regimens (aspirin plus clopidogrel, Group I, n = 200) and triple antiplatelet regimens (aspirin plus clopidogrel plus cilostazol, Group II, n = 200) At two weeks after PCI, aspirin and clopidogrel resistance were assayed in 379 patients (Group I, n = 186; Group II, n = 193) by using the VerifyNow System. RESULTS In Group I, 21 (11.3%) patients had aspirin resistance and 74 (40.0%) had clopidogrel resistance. In Group II, 19 (9.8%) were resistant to aspirin and 38 (19.7%) to clopidogrel. The aspirin reaction unit (ARU) was not significantly different between groups (448+/-67 vs. 439+/-64, P = 0.200), but the percent inhibition of clopidogrel was higher in Group II (41.4+/-24.3%,) comparing with that of Group I (26.5+/-18.7%, P < 0.001). CONCLUSION With triple antiplatelet therapy, the prevalence of clopidogrel resistance can be attenuated in patients undergoing PCI with DES.

Usefulness of cilostazol versus ticlopidine in coronary artery stenting

A combination of ticlopidine and aspirin has been accepted as the standard antithrombotic regimen after coronary stenting. However, ticlopidine poses serious side effects such as neutropenia or thrombocytopenia. Cilostazol, a cyclic adenosine monophosphate phosphodiesterase inhibitor, is a novel antiplatelet agent with vasodilatory properties. We compared the efficacy and safety of cilostazol plus aspirin (C+A) with ticlopidine plus aspirin (T+A) in elective coronary stenting. Three hundred patients were randomly assigned to receive C+A or T+A 2 days before stenting. The primary end point was a composite of angiographic stent thrombosis, or major cardiac events (death, myocardial infarction, bypass surgery, repeat intervention) at 30 days. The secondary end points were bleeding vascular complications, neutropenia, thrombocytopenia, or side effects requiring discontinuation of the drugs at 30 days. The primary end point was reached in 1.4% in the C+A group and 2.0% in the T+A group (p = 1.0). The rate of bleeding vascular complications was 1.4% in the C+A group and 2.0% in the T+A group (p = 1.0). The rate of drug-related side effects was not statistically different between the 2 groups but slightly higher in the T+A group than in the C+A group (2.7% vs 0.7%, p = 0.37). However, neutropenia was seen in 2 patients only in the T+A group. As a poststenting antithrombotic, C+A is as effective as T+A in preventing major cardiac events including stent thrombosis, and safer in that it does not cause neutropenia despite the fact that there is no statistical difference in the incidence of adverse effects and complications.

Clinical and echocardiographic predictors of outcomes in patients with apical hypertrophic cardiomyopathy.

Apical hypertrophic cardiomyopathy (HC) is considered to have a favorable prognosis, but recent observations have suggested less benign clinical courses. We investigated the outcomes in patients with apical HC and evaluated the predictors. All 454 patients with apical HC (316 men, age 61 ± 11 years) were recruited. Major cardiovascular events (MACE) were defined as unplanned hospitalization because of heart failure, stroke, or cardiovascular mortality. The patients were divided into 2 groups: group 1 with MACE and group 2 without MACE. During the follow-up period (43 ± 20 months), the all-cause mortality rate was 9% (39 of 454), and 110 patients (25%) had MACE. The subjects in group 1 were older and a greater proportion had diabetes, hypertension, and atrial fibrillation. On the echocardiogram, the left atrial volume index (left atrial volume index 36 ± 17 vs 31 ± 12 ml/m(2)), transmitral E velocity (65 ± 17 vs 61 ± 16 cm/s), mitral annulus Ea velocity (4.5 ± 1.4 vs 5.1 ± 1.8 cm/s), Sa velocity (5.8 ± 1.4 vs 6.6 ± 1.4 cm/s), E/Ea ratio (15 ± 5 vs 13 ± 5), and right ventricular systolic pressure (31 ± 8 vs 28 ± 7 mm Hg) were significantly different between groups 1 and 2 (p <0.05 for all). The left atrial volume index (for each 1-ml/m(2) increase, hazard ratio 1.01, 95% confidence interval 1.00 to 1.03; p = 0.047), Sa velocity (hazard ratio 0.83, 95% confidence interval 0.72 to 0.96, p = 0.014), and E/Ea ratio (hazard ratio 1.04, 95% confidence interval 1.00 to 1.09, p = 0.030) were independent predictors of a poor prognosis, along with age and the presence of diabetes or hypertension. In conclusion, the clinical outcomes of patients with apical HC were less benign in older patients and in those with hypertension or diabetes. In addition, the left atrial volume index, Sa velocity, and E/Ea ratio were predicters of a poor prognosis in patients with apical HC.

Incidence and natural history of coronary artery aneurysm developing after drug-eluting stent implantation.

AIMS There is a growing concern about the occurrence of coronary artery aneurysms (CAAs) after drug-eluting stent (DES) implantation and their long-term course. We assessed the occurrence and the factors affecting the long-term outcome of DES-associated CAA. METHODS AND RESULTS We analyzed 3,612 consecutive patients (4,419 lesions) who underwent follow-up angiography after DES implantation. All 34 CAAs (0.76% per lesion) in 29 patients (0.8% per patient) were detected at follow-up, and the mean elapsed time from DES implantation to CAA diagnosis was 414 ± 213 days. Angiographically, CAAs developed almost exclusively in complex (type B2/C) de novo lesions (30 [88.2%] of 34 lesions), and lesion length was significantly greater in patients with CAA than without CAA (26.9 ± 9.03 vs 23.1 ± 7.14 mm; P = .004). Myocardial infarction with stent thrombosis occurred in 5 patients with CAA (17.2%), 4 of whom were on aspirin only without clopidogrel. CONCLUSION Although CAAs rarely develop after DES implantation and show mostly favorable clinical courses, long-term maintenance of clopidogrel therapy might be required to minimize occurrence of adverse clinical events resulting from stent thrombosis.

Percutaneous Stent-Graft Repair of Mycotic Common Femoral Artery Aneurysm

Purpose: To report successful percutaneous repair of a peripheral mycotic aneurysm as a bridge to standard surgical therapy. Case Report: An aneurysm of the left common femoral artery was diagnosed in a 43-year-old man with subacute infective endocarditis. A Jostent stent-graft was percutaneously deployed to exclude the mycotic lesion. Computed tomography at 8 months after the procedure documented aneurysm regression and stent-graft patency without evidence of infection. Arteriography at 18 months has confirmed continued stent-graft patency and the patient remains asymptomatic. Conclusions: The standard management of mycotic aneurysms is usually by surgical resection and repair. However, this case suggests that percutaneous stent-graft implantation may be an option for the treatment of mycotic aneurysms.