A 55-year-old woman presented with frequent episodes of syncope due to sinus pauses. During ambulatory Holter monitoring, atrial fibrillation and first-degree atrioventricular nodal block were observed. Magnetic resonance imaging and CT scans showed a tumor-like mass from the superior vena cava to the right atrial septum. Open chest cardiac biopsy was performed. The tumor was composed of proliferating IgG4-positive plasma cells and lymphocytes with surrounding sclerosis. The patient was diagnosed with IgG4-related sclerosing disease. Because of frequent sinus pauses and syncope, a permanent pacemaker was implanted. The cardiac mass was inoperable, but it did not progress during the one-year follow-up.
Atrial Septum/*pathology ; Female ; Humans ; Immunoglobulin G/*blood ; Middle Aged ; Pacemaker, Artificial ; Sclerosis/complications/diagnosis/therapy ; Syncope/etiology ; Vena Cava, Superior/*pathology

Resistant hypertension is defined as poorly controlled status of blood pressure despite of optimal use of three or more antihypertensive drugs of different classes, including diuretics. Although exact prevalence of resistant hypertension is not known, it has been reported to be 12.8% among patients treated with antihypertensive drugs. It is important to evaluate a possible secondary cause in patients with resistant hypertension. We report a case of resistant hypertension with renal artery segmental stenosis that was not revealed in renal Doppler study. Blood pressure of the patient was well controlled after renal balloon angioplasty.
Angioplasty, Balloon ; Antihypertensive Agents ; Blood Pressure ; Constriction, Pathologic ; Diuretics ; Humans ; Hypertension ; Prevalence ; Renal Artery

Despite the necessity of surgical aortic valve replacement, many patients with symptomatic severe aortic stenosis (AS) cannot undergo surgery because of their severe comorbidities. In these high-risk patients, percutaneous transcatheter aortic valve implantation (TAVI) can be safely accomplished. However, no study has shown that TAVI can be performed for patients with severe AS accompanied by acute decompensated heart failure. In this case report, 1 patient presented a case of severe pulmonary hypertension with decompensated heart failure after diagnosis with severe AS, and was successfully treated via emergency TAVI. Without any invasive treatment, acute decompensated heart failure with severe pulmonary hypertension is common in patients with severe AS, and it can increase mortality rates. In conclusion, TAVI can be considered one of the treatment options for severe as presented as acute decompensated heart failure patients with pulmonary hypertension.
Aortic Valve Stenosis ; Aortic Valve* ; Comorbidity ; Diagnosis ; Emergencies* ; Emergency Treatment ; Heart Failure ; Heart Valve Prosthesis Implantation ; Humans ; Hypertension, Pulmonary ; Mortality

Double atrial septum is very rare atrial septal malformation which has double layered atrial septum with persistent interatrial space between the two atria. Clinically, most cases of this anomaly are asymptomatic unless manifest as thromboembolic complications, such as stroke, or transient ischemic attack, that thrombus may be originated from this interatrial space. We report a case of a 69-year-old man who was diagnosed with isolated double atrial septum by transthoracic echocardiography.
Aged ; Atrial Septum* ; Echocardiography ; Humans ; Ischemic Attack, Transient ; Stroke ; Thrombosis

Intercoronary communication is a very rare congenital malformation, which differs from coronary collaterals in variable aspects. It is larger in diameter, extramural in location and more resembles normal mature arterial features histologically. There are no consensus for the definition of intercoronary communiations, but some reports have suggested their protective role against myocardial ischemia due to its dual blood supply system. We report the case of a 72 year-old male smoker who had chronic total occlusion at the proximal portion of right coronary artery, which was communicated with a normal left circumflex artery. Although the patient had chronic total occlusion and subsequent in stent restenosis, there were no presentations of acute coronary syndrome or myocardial infarction.
Acute Coronary Syndrome ; Arteries ; Consensus ; Coronary Occlusion ; Coronary Vessels ; Humans ; Male ; Myocardial Infarction ; Myocardial Ischemia ; Stents

PURPOSE: The identification of sick sinus syndrome (SSS) in patients with atrial flutter (AFL) is difficult before the termination of AFL. This study investigated the patient characteristics used in predicting a high risk of SSS after AFL ablation. MATERIALS AND METHODS: Out of 339 consecutive patients who had undergone radiofrequency ablation for AFL from 1991 to 2012, 27 (8%) had SSS (SSS group). We compared the clinical characteristics of patients with and without SSS (n=312, no-SSS group). RESULTS: The SSS group was more likely to have a lower body mass index (SSS: 22.5+/-3.2; no-SSS: 24.0+/-3.0 kg/m2; p=0.02), a history of atrial septal defects (ASD; SSS: 19%; no-SSS: 6%; p=0.01), a history of coronary artery bypass graft surgery (CABG; SSS: 11%; no-SSS: 2%; p=0.002), and a longer flutter cycle length (CL; SSS: 262.3+/-39.2; no-SSS: 243.0+/-40; p=0.02) than the no-SSS group. In multivariate analysis, a history of ASD [odds ratio (OR) 3.7, 95% confidence interval (CI) 1.2-11.4, p=0.02] and CABG (7.1, 95% CI 1.5-32.8, p=0.01) as well as longer flutter CL (1.1, 95% CI 1.0-1.2, p=0.04) were independent risk factors for SSS. CONCLUSION: A history of ASD and CABG as well as longer flutter CL increased the risk of SSS after AFL ablation. While half of the patients with SSS after AFL ablation experienced transient SSS, heart failure was associated with irreversible SSS.
Atrial Flutter/physiopathology/*surgery ; Catheter Ablation/*adverse effects ; Female ; Humans ; Male ; Middle Aged ; Multivariate Analysis ; Odds Ratio ; Risk Factors ; Sick Sinus Syndrome/*etiology/physiopathology ; Treatment Outcome

PURPOSE: Despite undergoing successful catheter ablation of typical atrial flutter (AFL), patients remain at increased risk for ischemic stroke. However, data on risk prediction tools for the development of stroke after AFL ablation are lacking. This study investigates whether CHA₂DS₂-VASc score is useful for predicting ischemic stroke after successful ablation of typical AFL. MATERIALS AND METHODS: A total of 293 patients (236 men, mean age 56.1±13.5 years) who underwent successful radiofrequency catheter ablation for typical AFL were included in this study. The clinical end point was occurrence of ischemic stroke during follow-up after AFL ablation. RESULTS: During the follow-up period (60.8±45.9 months), ischemic stroke occurred in 18 (6%) patients at a median of 34 months (interquartile range, 13–65 months). CHA₂DS₂-VASc score [hazard ratio 2.104; 95% confidence interval (CI), 1.624–2.726; p < 0.001] was an independent predictor for the occurrence of stroke after AFL ablation. The area under the receiver operating characteristic curve for CHA₂DS₂-VASc score was 0.798 (95% CI, 0.691–0.904). The CHA₂DS₂-VASc score could be used to stratify patients into two groups with different incidences of ischemic stroke (1.6% vs. 14.4%, p < 0.001) at a cutoff value of 2. CONCLUSION: CHA₂DS₂-VASc score is useful in a prediction model for the risk of stroke after catheter ablation of typical AFL.
Aged ; Aged, 80 and over ; Atrial Flutter/*surgery ; Brain Ischemia/epidemiology/*etiology ; Catheter Ablation/*adverse effects ; Female ; Follow-Up Studies ; Humans ; Incidence ; Middle Aged ; Postoperative Complications/*epidemiology ; Predictive Value of Tests ; Prognosis ; Proportional Hazards Models ; ROC Curve ; Risk Assessment/*methods ; Seoul/epidemiology ; Stroke/epidemiology/*etiology ; Treatment Outcome

BACKGROUND: A pandemic influenza outbreak started in 2009 by the number of patients discharged each year. But the result of H1N1 influenza vaccination is maintained for research and less state. The purpose of this study was to measure the antibody titers after H1N1 influenza vaccination toestimate demands of different standard vaccination in patients with chronic diseases and elderly patients. METHODS: From March 2010 to February 2011, we retrospectively reviewed the medical records of 55 patients admitted to a tertiary hospital. The H1N1 virus antibody titer of each patient was measured through enzyme-linked immunosorbent assay. Titers were measured post vaccination on day 1 and at 1, 3 and 6 months. RESULTS: A total of 55 patients were enrolled in this study. The comorbidities looked at were malignancy, cardiovascular disease, diabetes mellitus, renal disease, cerebrovascular disease, hematologic disease and infectious disease. Five patients (9.1%) had no comorbidities. Patients in their 50's had the highest positive response rate (58.3%). The antibody titers at 1 month after vaccination were not associated with the number of comorbidities. The ratio of positive response increased gradually at baseline (16.4%) to 1 month (47.8%). After 6 months, there remained no positive response. CONCLUSION: The H1N1 antibodies were unstable as the values of the titer changed at follow-up (1 month, 3 months, and 6 months). The positive response rates of those in their 50's and those who had chronic diseases were higher than others. The positive response rates showed that the ability to generate antibodies did not decrease with age or disease conditions.
Aged ; Antibodies ; Cardiovascular Diseases ; Chronic Disease ; Communicable Diseases ; Comorbidity ; Diabetes Mellitus ; Enzyme-Linked Immunosorbent Assay* ; Follow-Up Studies ; Hematologic Diseases ; Humans ; Influenza A Virus, H1N1 Subtype ; Influenza, Human* ; Medical Records ; Pandemics* ; Retrospective Studies ; Tertiary Care Centers ; Vaccination*

The rearrangement of c-ros oncogene 1 (ROS1) has been recently identified as an important molecular target in non small cell lung cancer (NSCLC). ROS1 rearrangement and epidermal growth factor receptor (EGFR) mutation were mutually exclusive each other in previous studies, and the clinical implication of co-existence of the two genetic alterations has not been determined. We report a case of 46-year-old female never-smoker NSCLC patient whose tumor harbored ROS1 rearrangement and EGFR mutation concomitantly. She had undergone curative surgery for stage IIIA NSCLC, and the recurrence in left pleura and brain occurred at 2 years after the surgery. She received several lines of chemotherapy including docetaxel plus carboplatin, erlotinib, pemetrexed, and gemcitabine. Erlotinib therapy showed a favorable treatment response with progression-free survival of 9.5 months and partial response of tumor on radiologic evaluations. This case represents a successful erlotinib treatment in a NSCLC patient with concurrent ROS1 rearrangement and EGFR mutation.
Adenocarcinoma* ; Brain ; Carboplatin ; Carcinoma, Non-Small-Cell Lung ; Disease-Free Survival ; Drug Therapy ; Female ; Humans ; Lung* ; Middle Aged ; Oncogenes ; Pleura ; Receptor, Epidermal Growth Factor ; Recurrence ; Small Cell Lung Carcinoma ; Erlotinib Hydrochloride ; Pemetrexed

Purpose: We investigated the clinical role of F-18 fluorodeoxyglucose (FDG) positron emission tomography-computed tomography(PET-CT) in the identification of the primary site and the selection of the optimal biopsy site in patients with suspectedbone metastasis of unknown primary site. Methods: The patients with suspected bone metastasis who underwent PET-CT for evaluation of primary site were enrolled inthis study. The primary sites were identified by the histopathologic or imaging studies and were classified according to the FDGuptake positivity of the primary site. To evaluate the guiding capability of PET-CT in biopsy site selection, we statisticallyanalyzed whether the biopsy site could be affected according to the presence of extra-skeletal FDG uptake. Results: Among 74 enrolled patients, 51 patients had a metastatic bone disease. The primary site was identified in 48 of 51patients (94.1%). Forty-six patients were eligible to test the association of clinical choice of biopsy site with PET positivity ofextra-skeletal lesion. The extra-skeletal biopsies were done in 42 out of 43 patients with positive extra-skeletal uptake lesions.Bone biopsies were inevitably performed in the other three patients without extra-skeletal uptake lesions. The association cameout to be significant (Fisher’s exact test, P< 0.001). Conclusion F-18 FDG PET-CT significantly contributed not only to identify the primary site but also to suggest optimal biopsysites in patients with suspected bone metastasis.