Shin-Jae Kim

Remote ischemic preconditioning in hemodialysis: a pilot study

Hemodialysis (HD)-induced myocardial ischemia is associated with an elevated cardiac troponin T, and is common in asymptomatic patients undergoing conventional HD. Remote ischemic preconditioning (RIPC) has a protective effect against myocardial ischemia–reperfusion injury. We hypothesized that RIPC also has a protective effect on HD-induced myocardial injury. Chronic HD patients were randomized to the control group or the RIPC group. RIPC was induced by transient occlusion of blood flow to the arm with a blood-pressure cuff for 5 min, followed by 5 min of deflation. Three cycles of inflation and deflation were undertaken before every HD session for 1 month (total 12 times). The primary outcome was the change in cardiac troponin T (cTnT) level at day 28 from baseline. Demographic and baseline laboratory values were not different between the control (n = 17) and the RIPC groups (n = 17). cTnT levels tended to decrease from day 2 in the RIPC group through to 28 days, in contrast to no change in the control group. There were significant differences in the change of cTnT level at day 28 from baseline [Control, median; −0.002 ng/ml (interquartile range −0.008 to 0.018) versus RIPC, median; −0.015 ng/ml (interquartile range −0.055 to 0.004), P = 0.012]. RIPC reduced cTnT release in chronic conventional HD patients, suggesting that this simple, cheap, safe, and well-tolerated procedure has a protective effect against HD-induced ischemia.

Abnormal Motion of the Interventricular Septum after Coronary Artery Bypass Graft Surgery: Comprehensive Evaluation with MR Imaging

Objective To define the mechanism associated with abnormal septal motion (ASM) after coronary artery bypass graft surgery (CABG) using comprehensive MR imaging techniques. Materials and Methods Eighteen patients (mean age, 58 ± 12 years; 15 males) were studied with comprehensive MR imaging using rest/stress perfusion, rest cine, and delayed enhancement (DE)-MR techniques before and after CABG. Myocardial tagging was also performed following CABG. Septal wall motion was compared in the ASM and non-ASM groups. Preoperative and postoperative results with regard to septal wall motion in the ASM group were also compared. We then analyzed circumferential strain after CABG in both the septal and lateral walls in the ASM group. Results All patients had normal septal wall motion and perfusion without evidence of non-viable myocardium prior to surgery. Postoperatively, ASM at rest and/or stress state was documented in 10 patients (56%). However, all of these had normal rest/stress perfusion and DE findings at the septum. Septal wall motion after CABG in the ASM group was significantly lower than that in the non-ASM group (2.1±5.3 mm vs. 14.9±4.7 mm in the non-ASM group; p < 0.001). In the ASM group, the degree of septal wall motion showed a significant decrease after CABG (preoperative vs. postoperative = 15.8±4.5 mm vs. 2.1±5.3 mm; p = 0.007). In the ASM group after CABG, circumferential shortening of the septum was even larger than that of the lateral wall (-20.89±5.41 vs. -15.41±3.7, p < 0.05) Conclusion Abnormal septal motion might not be caused by ischemic insult. We suggest that ASM might occur due to an increase in anterior cardiac mobility after incision of the pericardium.

A Case of Cardiac Lymphangioma Presenting as a Cystic Mass in the Right Atrium

A 44-year-old woman underwent surgery for an asymptomatic primary tumor of the heart located in the right atrium. The tumor was detected incidentally during follow-up computed tomography for a resected breast cancer. The mass, lying along the lower portion of the right atrial septum, was homogenous and cystic in nature, as detected by transthoracic and transesophageal echocardiography. Complete resection was performed via a median sternotomy under cardiopulmonary bypass. The postoperative course was uneventful. However, the histological result was surprising: the mass was a cardiac lymphangioma.

Cystic changes in desmoplastic fibroma of bone: A new MRI finding

AIM To evaluate the magnetic resonance imaging features of desmoplastic fibroma (DF) of bone. MATERIALS AND METHODS Two radiologists retrospectively evaluated imaging findings of pathologically confirmed DFs in eight patients. Involved sites and longitudinal location in long bones were evaluated using radiography and computed tomography (CT). At MRI, the presence of low signal areas on T2-weighted images (low-T2), enhancement, cystic changes, and locations of the mass were evaluated. The location of masses was evaluated, based on cortical disruption and adjacent soft-tissue extension. RESULTS Involved sites were the femur in three patients, the tibia in two, and the humerus, fibula, and pubic bone in one each. Of the seven masses in the long bones, three were located in the epi- and metaphysis, two in the meta- and diaphysis, one in the diaphysis, and one in the epiphysis. Seven masses had areas of low T2-weighted or heterogeneous enhancement, and three (38%) showed cystic changes. cortical disruption was seen at MRI in six of eight patients (88%). CONCLUSION DFs contained cystic change. Cortical disruption may also occur, which may cause confusion with malignant lesions.

Remote Ischemic Preconditioning for the Prevention of Contrast-Induced Acute Kidney Injury in Diabetics Receiving Elective Percutaneous Coronary Intervention

Objective Remote ischemic preconditioning (RIPC) induces transient episodes of ischemia by the occlusion of blood flow in non-target tissue, before a subsequent ischemia-reperfusion injury. When RIPC is applied before percutaneous coronary intervention (PCI), the kidneys may be protected against ischemia-reperfusion injury and subsequently contrast-induced acute kidney injury (CI-AKI). The aim of this study was to evaluate the efficacy of RIPC for the prevention of CI-AKI in patients with diabetes with pre-existing chronic kidney disease (CKD) undergoing elective PCI. Methods This randomized, double-blind, sham-controlled study enrolled patients with diabetes scheduled for elective PCI with eGFR ≤60 ml/min/1.73 m2 or urinary albumin creatinine ratio of >300 mg/g to receive either RIPC or the sham ischemic preconditioning. Results One hundred and two patients (68.9 ± 8.2 years old, 47.1% men) were included. Baseline eGFR, creatinine and serum NGAL was similar between RIPC and control groups (48.5 ± 12 ml/min vs. 46.6 ± 10 ml/min, p = 0.391; 1.42 ± 0.58 mg/dl vs. 1.41 ± 0.34 mg/dl, p = 0.924; and 136.0 ± 45.0 ng/ml vs. 137.6 ± 43.3 ng/ml, p = 0.961, respectively). CI-AKI occurred in 13.7% (14/102) of the total subjects, with both RIPC and control groups having an equal incidence of 13.7% (7/51). No significant differences were seen in creatinine, NGAL, cardiac enzymes (troponin T, CKMB) and hs-CRP between the groups post-procedure. Conclusions In this study, RIPC applied prior to elective PCI was not effective in preventing CI-AKI in patients with diabetes with pre-existing CKD. Trial Registration ClinicalTrials.gov NCT02329444

N-terminal pro-B-type natriuretic peptide as a marker of disease severity in patients with pericardial effusions

Backgraound/Aims N-terminal pro-B-type natriuretic peptide (NT-proBNP) has recently been introduced as a useful marker in diagnosing underlying disease in patients with dyspnea and for determining the prognosis of patients with heart failure. The purpose of this study was to evaluate the value of the NT-proBNP as a marker of disease severity in patients with pericardial effusions. Methods We enrolled 69 consecutive patients who showed moderate or large pericardial effusion with preserved left ventricular (LV) systolic function; 42 patients finally participated in the study, and 13 (31.0%) of them showed cardiac tamponade. We analyzed the etiologies, the clinical and echocardiographic variables, and the serum NT-proBNP levels in these patients. Results The mean NT-proBNP level was 751±1002 ng/L (range 5 to 5289), and the median level was 385 ng/L (interquartile range 152 to 844). The NT-proBNP levels were higher in those patients with jugular venous distension (p=0.002), pulsus paradoxus (p=0.016), heart rate ≥100/min (p=0.006), cardiac tamponade (p=0.001), large pericardial effusion (p=0.029), exaggerated respiratory variation of the transmitral inflow (p=0.006), or plethora of the inferior vena cava (p=0.01). The NT-proBNP levels showed significant correlation with heart rate (r=0.517, p<0.001) and the diameter of the inferior vena cava (r=0.329, p=0.03). Conclusion NT-proBNP may be useful as a marker of disease severity in patients suffering from pericardial effusion, but further prospective studies with more patients will be needed.

The N-terminal pro-B-type natriuretic peptide as a predictor of disease progression in patients with pericardial effusion

BACKGROUND The purpose of this study was to evaluate the value of N-terminal pro-B-type natriuretic peptide (NT-proBNP) as a predictor of disease progression in patients with pericardial effusions (PE). METHOD We retrospectively studied consecutive patients that had moderate or large PEs. Patients with pericardial events, such as reaccumulation of PE, persistent drainage through a catheter longer than one week, or newly developed constrictive pericarditis were defined as the progression group (Group A), and patients without these findings were defined as the group with no progression (Group B). The NT-proBNP assay was performed when PE was detected. RESULTS Compared to Group B (27 patients), Group A (15 patients) exhibited lower systolic and diastolic blood pressures (106 ± 13 vs. 118 ± 19 mm Hg, p=0.028; 69 ± 9 vs. 75 ± 11 mm Hg, p=0.047), higher NT-proBNP levels (1063 ± 756 vs. 578 ± 1090 ng/L, p=0.002), larger inferior vena cava (21 ± 6 vs. 17 ± 5 mm, p=0.039) and higher estimated right ventricular systolic pressure (37 ± 5 vs. 32 ± 6 mm Hg, p=0.024). NT-proBNP was the only independent predictor of disease progression (p=0.034) by multivariate regression analysis. The receiver-operating characteristic curve analysis showed that NT-proBNP values ≥ 548 ng/L demonstrated a sensitivity of 80% and a specificity of 78% for identifying disease progression (p=0.001). CONCLUSIONS The NT-proBNP value may predict disease progression in patients with PE. However, additional prospective studies with more patients are needed.

A Case of Perimembranous Ventricular Septal Defect Associated with Sinus of Valsalva Aneurysm Mimicking Membranous Septal Aneurysm

Sinus of Valsalva aneurysms are rare. Sinus of Valsalva aneurysms are frequently associated with ventricular septal defect (VSD) and aortic regurgitation. They often remain asymptomatic until abruptly presenting with acute chest pain and heart failure secondary to rupture. Here, we describe a case of 20-year-old man who presented with chest pain with a history of VSD. Initial work-up concluded that the patient had VSD associated membranous septal aneurysm. Four years later, the patient presented with symptoms of heart failure. Work-up showed that the ruptured sinus of Valsalva aneurysm was the cause of symptoms. Due to its close proximity to the aortic annulus, sinus of Valsalva aneurysm should be differentiated from membranous septal aneurysm.

A Case of Constrictive Pericarditis Associated With Huge Epicardial Fat Volume

Massive deposits of fat around heart are seen in overweight persons and are associated with coronary artery disease. Investigators have focused on the clinical significance of epicardial fat with respect to metabolic effects such as insulin resistance and inflammation, but the mechanical effects, such as constriction, have been largely ignored. We present an unusual case of a 59-year-old woman with obesity and diabetes mellitus who had been undergoing peritoneal dialysis due to end-stage renal disease, and who developed constrictive pericarditis, possibly secondary to extensive epicardial fatty accumulation.

Congenital Double-Orifice Mitral Valve with Mitral Regurgitation due to Flail Leaflet in an Elderly Patient

We report here on a case of double-orifice mitral valve with mitral regurgitation in a 75-year-old female who had complaints of mild dyspnea. Transthoracic and transesophageal echocardiography showed two orifices that were supplied by their own chordae from a different papillary muscle. Color Doppler echocardiography revealed moderate to severe mitral regurgitation due to the flail posterior leaflet of the anterolateral orifice. Except for the persistent left superior vena cava, no other congenital anomaly was demonstrated. The patient became asymptomatic with the administration of angiotensin-converting enzyme inhibitor and diuretics, and she has been scheduled for long term follow-up.