Sung Ho Lee

Cardiovascular manifestations of Takayasu arteritis and their relationship to the disease activity: analysis of 204 Korean patients at a single center.

Takayasus arteritis (TA) is primary vasculitis. Cardiac involvements in TA is due to the consequences of the vascular lesions as well as the primary pathology of the heart. The disease activity of TA is known to influence the prognosis of TA. We hypothesized that the cardiovascular involvement of TA is related to the disease activity. We evaluated the cardiovascular manifestations of TA, and we assessed their relation to the disease activity of TA. Two hundred four patients were diagnosed with TA from September, 1994 to March, 2009 according to the diagnostic criteria of the 1990 American College of Rheumatology. Their clinical features and the laboratory, angiographic and echocardiographic findings were retrospectively reviewed. The group with active disease activity was defined as satisfying one of the following criteria: i) an elevated ESR or CRP level, ii) thickened arterial wall with mural enhancement on CT or MR angiography, and iii) carotidynia at the time of the initial diagnosis. One hundred thirty nine patients (69.2%) were classified as the active group. The cardiovascular signs and symptoms were not generally different between the active and inactive groups. The active TA patients had more frequent involvement of the ascending aorta and the aortic arch and its main branches than did the inactive group. The active group showed a higher incidence of significant aortic valve regurgitation and pulmonary hypertension, and a higher level of NT-proBNP. These findings suggest that disease activity plays an important role for the cardiovascular manifestations of TA. The TA patients with higher activity have more cardiovascular morbidity compared to the TA patients with low disease activity.

Prognosis after tilt training in patients with recurrent vasovagal syncope

Vasovagal syncope (VVS) is a sudden and transient loss of consciousness, mediated by emotional or orthostatic stress. Although VVS is not associated with an increased rate of mortality, quality of life deteriorates in conjunction with the frequency of recurrences. A wide variety of pharmacological (β-blocker or α-agonist, SSRI, mineralocorticoid, etc.) and non-pharmacologic treatments (cardiac pacing, reassurance, an increase in dietary salt and fluid intake, etc.) have been proposed for recurrent VVS, but the effect of treatments is limited [1–7]. Tilt training or home orthostatic self-training has also been shown to have only a limited effect [8–12]. Nevertheless, we experienced the efficacy of tilt training programs in hospital admissions for some patients with recurrent VVS. We performed a study to evaluate the prognosis after tilt training in 119 patients with recurrent VVS and to determine the predictors of recurrence after tilt training. A total of 132 consecutive patients who had a positive response to HUTwith orwithout subsequent isoproterenol infusionwere eligible for this study at Samsung Medical Center, Seoul, Korea, between January 2004 andMay 2012. Three patients were excluded because of structural heart disease (1 patient — sick sinus syndrome, 2 patients — valvular heart disease), and 10 patients were lost to follow-up. Thus, themedical records and HUTcase report forms of these 119 patients (57men and 62 women, mean age 32.3 years, range 12–66 years) were retrospectively reviewed. The diagnosis of VVS was predicted based on a positive response on the head-up tilt test (HUT) and the exclusion of all other possible causes of syncope. No patients who suffered from structural heart diseasewere enrolled in this study. This studywas approved byour institutional ethics committee. The first phase of HUTwas performed as follows: the patients were tilted to an angle of 70° for 30 min or until symptoms appeared. If a negative responsewas registered in thefirst phase, the secondphase of HUT, which lasted 15 min, was performed. Isoproterenol was intravenously administered at an initial rate of 1 μg/min during the second phase. The infusion rate was increased by 1 μg/min every 3 min to a maximumof 5 μg/min.We also conducted continuous ECGmonitoring of heart rate and rhythm, and each patients blood pressure was noninvasively measured beat-to-beat using a Finapres (OhMeda Monitoring systems, Englewood, CO, USA) during HUT. The reproduction of syncope or presyncope constituted the end of the test. Heart rate and blood pressure immediately before or during syncope were used to define a positive response onHUT. Positive responseswere also classified according to the criteria provided in a previous study [13]: type 1 (vasodepressive), type 2 (cardioinhibitory), and type 3 (mixed). Tilt duration was defined as the interval from the start of HUT to the discontinuation of HUT due to loss of consciousness or a positive response on HUT. Patients were enrolled in this study upon the registration of a positive response on HUT. The tilt training program consisted of twice daily sessions until 3 consecutive negative HUT results were obtained during hospital admission. At every training session, we re-evaluated the patient responses to HUT. The tilt training and re-evaluations were conducted in the same laboratory, using protocols identical to those for the baseline HUT. Patients did not take any medication with possible beneficial effects on neurally-mediated syncope. In order to determine the effects of tilt training in preventing VVS, patients were requested to report any recurrences of spontaneous syncope, presyncope, or other symptoms. Data about recurrences after the tilt training program were obtained via questionnaires during outpatient visits or by telephone interview. Of 119 patients, 81 patients (68%) were found to show vasodepressive type, 9 patients (7.7%) showed cardioinhibitory type, and 29 patients (24.3%) showed mixed type. The mean total number of tilt training sessions was 5.5, the mean total duration of tilt training was 261 min, and 115 patients (96.6%) successfully had 3 consecutive negative HUT results during tilt training. Themean follow-up duration was 22.5 months. Syncope recurred in 31 of 119 VVS patients (26.1%) who performed tilt training. The recurrence rate of syncope was 12.6% at 1 year, 21.0% at 3 years, and 24.4% at 5 years after tilt training (Fig.1). Between the two groups of tilt training patients according to recurrence of VVS (31 patients with recurrence versus 88 patients without), there were no significant differences in baseline clinical characteristics or parameters of HUT, except age (years) and time-totilt syncope (min). The recurrence group was younger than the nonrecurrence group (28.5 ± 10.2 years vs. 33.8 ± 13.7 years, p =0.027). The time-to-tilt syncope (min) during HUT was different between the groups, and the recurrence group had a longer parameter compared to the non-recurrence group (p = 0.006). The frequency of syncope seemed to be higher in the recurrence group (10.4 ± 11.3 vs. 6.3 ± 10.1, p = 0.079). Gender; duration of symptoms (months); previous history of syncope; type of VVS; basal BP (mm Hg); phase of positive HUT response; total number of tilt training sessions; and total time of tilt training (min) were not significantly different between the

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.

Risk Factors between Patients with Lone and Non-Lone Atrial Fibrillation

Clinical factors such as tall stature, lean body mass, obstructive sleep apnea, alcohol or caffeine, smoking, endurance sports, and genetic factors are proposed as risk factors for lone atrial fibrillation (LAF). The KORAF (KORean Atrial Fibrillation) study is a retrospective multicenter registry that enrolled 3,570 consecutive atrial fibrillation (AF) patients. Data on risk factors were available for 2,133 patients, of whom 398 (18.7%) were identified as having LAF. In univariate analysis, patients with LAF were more likely to be men (82.4% vs 59.8%, P < 0.001) and current smokers (25.9% vs 15.6%, P < 0.01), alcohol drinkers (55.3% vs 31.2%, P < 0.01) and frequent consumers of caffeinated beverages (> 2 cups/day) (31.7% vs 19.3%, P < 0.01), and have a family history of AF (9.0% vs 2.6%, P < 0.001) than the non-LAF patients. Multivariate analysis showed that male gender (OR, 2.30; 95% CI, 1.61-3.27, P < 0.01), family history of AF (OR, 3.12; 95% CI, 1.91-5.12, P < 0.01), current alcohol use (OR, 2.01; 95% CI, 1.46-2.76, P < 0.01), and frequent caffeinated beverage consumption (OR, 1.66; 95% CI, 1.20-2.29, P < 0.01) were independently associated with LAF. In Korean patients, LAF is more closely associated with male gender, family history of AF, current alcohol and frequent caffeinated beverage consumption than non-LAF.

Prevalence and Clinical Factors of Anxiety and Depression in Neurally Mediated and Unexplained Syncope

Purpose Several studies have demonstrated that psychiatric disorders such as anxiety, depression and panic attack are associated with syncope, especially vasovagal and unexplained syncope (US). The aim of this study was to compare the prevalence of anxiety and depression between patients with neurally mediated syncope (NMS) and US and to investigate the clinical factors associated with anxiety and depression. Materials and Methods Between January 2009 and March 2010, 383 patients with syncopal episodes completed a Hospital Anxiety and Depression Scale questionnaire to assess symptoms of anxiety and depression. Inclusion criteria were NMS and US. Exclusion criteria were cardiac syncope, orthostatic hypotension and other disorders mimicking syncope. After exclusion, 199 patients were included. Results There were 176 (88.4%) NMS patients and 23 (11.6%) US patients. The prevalence of abnormal anxiety and depression were not significantly different between the NMS and US groups (10.2% vs. 8.7%, p=0.99; 8.5% vs. 17.4%, p=0.24). Clinical factors associated with anxiety were female gender (p=0.01) and six or more recurrent syncopal episodes (p=0.01) by univariate analysis. The only factor associated with abnormal anxiety score (OR=20.26, 95% CI: 1.4-291.6, p=0.01) was more than six recurrent syncopal episodes, while a positive head-up tilt table testing response was inversely associated with abnormal depression score (OR=0.28, CI: 0.08-0.97, p=0.04) in the multiple logistic regression analysis. Conclusion Anxiety was associated with frequent syncopal episodes. Thus, anxiety might be considered in the management of syncope patients.

Delayed post-hypoxic leucoencephalopathy presenting akinetic mutism after traumatic cervical cord injury: a case report

Abstract Delayed post-hypoxic leucoencephalopathy is a demyelinating syndrome characterized by acute onset of neuropsychiatric symptoms including parkinsonism or akinetic mutism that occurs days to weeks after recovery from cerebral hypo-oxygenation. We encountered a patient who presented with an akinetic mute state late after cervical cord injury without a definite hypoxic event.

Hemodynamic parameters and baroreflex sensitivity during head-up tilt test in patients with neurally mediated syncope: LEE et al.

We aimed to investigate differences in hemodynamic parameters and the role of baroreflex sensitivity (BRS) in patients with a history of neurally mediated syncope (NMS) compared with a control group.

Right Ventricular Compression Mimicking Brugada-Like Electrocardiogram in a Patient with Recurrent Pectus Excavatum

Pectus excavatum (PE), the most common skeletal anomaly of chest wall, sometimes requires a surgical correction but recurrent PE is not uncommon. PE usually has a benign course; however, this chest deformity may be associated with symptomatic tachyarrhythmias due to mechanical compression. We report a case of a patient with recurrent PE after surgical correction presenting with palpitation and electrocardiogram (ECG) showing ST-segment elevation on the right precordial leads, which could be mistaken for a Brugada syndrome (BrS).

Clinical Factors Affecting Symptom Recurrence in Patients with Syncope

Purpose: Recurrent syncope leads to poor functional status and psychiatric impairment in patients with syncope. The aim of the study was to prospectively analyze the risk factors attributed to syncope recurrence. Materials and Methods: Between 2009 and 2010, 289 patients with all cause of syncope visited our institution. Syncope recurrences were followed for 1 year by telephone interview every 3 months. Results: We diagnosed 181 (63%) patients with neurally mediated syncope (NMS), 39 (13%) with orthostatic hypotension, 34 (12%) with cardiac syncope, and 35 (12%) with unexplained syncope. During the 1-year follow-up period, 19 (6.6%) patients suffered recurrent syncope. Kaplan-Meier curves showed that recurrent syncope was observed more often in patients with unexplained syncope compared with those with NMS (p < 0.01), and also observed more often in patients with six previous syncopal episodes compared to those with fewer episodes (p = 0.02). Cox regression analysis showed that the recurrence of syncope was significantly associated with more than six previous syncopal episodes (HR 5.38, 95% CI 1.17-24.71, p = 0.03) and that there was a tendency for association between recurrence of syncope and unexplained syncope (HR 6.13, 95% CI 0.96-39.1, p = 0.05). Conclusions: Patients with previous frequent syncopal episodes or unexplained syncope had higher rates of syncope recurrence during the follow up period.

Mid-Term Outcomes in Patients Implanted with Cardiac Resynchronization Therapy

We applied cardiac resynchronization therapy (CRT) for desynchronized heart failure patients. We evaluated clinical outcomes including morbidity, mortality, and echocardiographic parameters in 47 patients with implanted CRT in Korea from October 2005 to May 2013. The combined outcomes of hospitalization from heart failure, heart transplantation and death were the primary end point. Median follow-up period was 17.5 months. The primary outcomes listed above occurred in 10 (21.3%) patients. Two patients (4.3%) died after CRT and 8 (17%) patients were hospitalized for recurrent heart failure. Among patients hospitalized for heart failure, 2 (4.3%) patients underwent heart transplantation. The overall free rate of heart failure requiring hospitalization was 90.1% (95% CI, 0.81-0.99) over one year and 69.4% (95% CI, 0.47-0.91) over 3 yr. We observed improvement of the New York Heart Association classification (3.1±0.5 to 1.7±0.4), decreases in QRS duration (169.1 to 146.9 ms), decreases in left ventricular (LV) end-diastolic (255.0 to 220.1 mL) and end-systolic (194.4 to 159.4 mL) volume and increases in LV ejection fraction (22.5% to 31.1%) at 6 months after CRT. CRT improved symptoms and echocardiographic parameters in a relatively short period, resulting in low mortality and a decrease in hospitalization due to heart failure.