PURPOSE: In order to provide a systematic and standardized treatment course for MVD patients, a critical pathway (CP) program was developed and the results of its long term application were analyzed. METHODS: This was a methodological study. The CP was established and applied to 75 (step I) and 1,216 (step II). Another group of 56 with similar features was used as a control group. RESULTS: The application of CP turned out to be useful in many regards: the rate of hearing loss was reduced from 1.8% to 0% (step I) and 0.5% (step II), and low cranial nerve palsy was reduced from 1.8% to 1.3% and 0.7%, respectively. The length of hospitalization decreased by 2.56 days (25.2%) for step I and 3.05 days (30.0%) for step II. Days of ICU stay were reduced by 7.9% and 1.8%. The total cost per patient was reduced by 14.8% (step I). The cost per day was increased by 13.7% and 52.4%. An increase in the patient satisfaction index was noted, as shown in the ICU information guide (p=.002). CONCLUSION: The development and application of CP was found to improve the quality of medical treatment and the efficacy of hospital management in MVD patients. Well organized and efficient system and multidisciplinary teamwork are the key component of the successful application of CP.
Cranial Nerve Diseases ; Critical Pathways* ; Hearing Loss ; Hospitalization ; Humans ; Methods ; Microvascular Decompression Surgery* ; Patient Satisfaction ; Quality Control

BACKGROUND: Intimal tear or dissection is a serious complication after coronary angioplasty,sometimes which may develop an acute ischemic event. We evaluate the factor that may predict the development of dissection after angioplasty. METHODS: To identify the factors that development of dissection after angioplasty, the data of 52 patients identified as having dissection with or without immediate vessel closure were examined. Follow-up coronary angiogram was obtained in 22 out of 58 lesions at mean 5.6 month after angioplasty. RESULTS: Intimal dissection developed 58 lesion(31%) out of 177 lesions in 122 patients after PTCA. Ischemic complications, defined as ischemic chest pain, myocardial infarction, the need for coronary bypass surgery occured in 5 patients(9.6%) out of 52 patients with dissections. Significant correlates of a development of dissection were the lesion morphology of type C(P<0.01), more tight diameter stenosis before PTCA(P<0.01), and right coronary artery(P<0.02), especially in the proximal portion (P<0.05). There were no significant correlations of clinical pictures, whether complex or simple angioplasty and PTCA in single vessel disease or in multivessel disease. Morphologic feature of dissection was type A(radiolucency) in 22(38%), B(filling defect)in 14(24%), C(extra-luminal "cap")in 8(14%), D(spiral dissection)in 5(9%), E(filling defect with delayded antegrade flow)in 7(12%) and F(total occlusion) in 2(3%). Twenty-two(38%) dissection out of 58 were obtained follow-up angiogram at mean 5.6 month. Angiographic restenosis occured in 9(41%) lesions, which included more type A dissections (7/9,78%) compared to lesions with dissection healing (3/13, 23%)(P<0.001) at follow-up. Thirteen lesions with dissection healing at follow-up included more B and C dissection(B;54%,C;15%)and E dissection in 1. Furthermoremore restenosis occurred more prevalent in the infarct-related artery(P<0.001) and left anterior decending coronary artery lesion(P<0.01). There was somewhat higher diameter residual stenosis after angioplasty (32+/-11% vs 26+/-10%) in the lesions with restenosis, but there was no statistical significance. CONCLUSION: Intimal dissection after angioplasty occurred in 58(31%) leisions out of 122(177leisions) consecutive patients underwent PTCA developments if intimal dissection after PTCA significantly correlated with the lesions if type C, more tight diameter stenois before PTCA and right coronary artery. At mean 5.6months follow-up,angiographic restenosis occured in 41% of dissections, which had more included type A(radiolucency)dissections, infarct-related artery and left anterior descending coronary artery leision.
Angioplasty* ; Arteries ; Chest Pain ; Constriction, Pathologic ; Coronary Vessels ; Follow-Up Studies* ; Humans ; Myocardial Infarction

BACKGROUND: Large series of patients with symptomatic mitral stenosis have undergone percutaneous mitral balloon valvuloplasty(PMV) with use of the Inoue or double balloon technique. But to date the result of the two procedure have not been compared with a single series prospectively. METHODS: In order to assess the immediate hemodynamic results and the longterm efficacy of two different PMV technique, a prospective, randomized trial of PMV was performed using the Inoue balloon(Toray, I group) in 59 patients and the double balloons(a pair of Mansfield balloon. D group) in 61 patients with moderate to severe mitral stenosis. Before valvuloplasty, the patients series were comparable with regard to average age. gender, most clinical and echocardiographic variables. All the patients(120 patients, M/F 38/82, mean age 41+/-11 year) were preselected with good echoscore> or =9. RESULTS: The success rate was 83% in the I group and 89% in the D group when the success defined as mitral valve area(MVA)> or =1.5cm2 with 25% gain in MVA and mitral regurgitation> or =2+ at the end of procedure. The magnitude of increase of mitral valve area and decrease of mitral gradient, left atrial pressure and pulmonary arterial pressure were not significantly different in the Inoue and double balloon series(1.0+/-0.4 and 1.1+/-0.4cm2 for mitral vale area, 10.2+/-6.6 and 11.7+/-6.4mmHg for mitral gradient, 10.5+/-6,4 and 12.9 +/-7,3mmHg for left atrial pressure, and 8.7+/-7.3 and 10.1+/-9.4 mmHg for pulmonary artrial pressure respectively). Immediatly after dilation, the long diameter changes of the mitral orifice was more prominent in the D group(from 1.0+/-0.2 to 2.6+/-0.4cm p<0.01) than those in I series(from 1.1+/-0.4 to 2.3+/-0.3cm) Moreover, the magnitude of increase in the EF slop was significantly larger in the D group(31.9+/-17.0 vs 21.8+/-14.2mm/sec, p<0.001). The duration of total procedure(56+/-20 vs 84+/-24 min, p<0.002) and the fluoroscopic time (15+/-6 vs 25+/-11min, p<0.002) was significantly shorter in group I. The incidence of left to right shunt at the atrial level(Qp/Qs>1.5) was 3.4% in group I and 4.9% in group D. Severe mitral regurgitation> or =3+ occurred in 2 patients in each I(3.4%) and D(3.3%) group respectively. At follow-up, the mitral valve area was significantly decreased(1.6 in group I vs 1.8cm2 in group D, P<0.001 vs immediate after MVA) at 6 months and well maintained at 1 year follow-up in both groups. Until 6 months after valvuloplasty, the long diameter of orifice was greater in group D, however the difference was not apparent at 1 year follow-up. CONCLUSION: The Inoue and double balloon techniques obtained equivalent results of the success rate and the frequently of complications. However, the Inoue balloon technique reduced significantly fluoroscope time and total procedure duration. Double balloon technique afforded a longer longitudinal splitting of the commissure immediatly and 6 months after valvuloplasty. However the differences was not apparent at 1 year follow-up. Increased MVA was well maintained at 1 year in both groups. The severity of the newly developed mitral regurgitation immediately after valvuloplasty reduced significantly in 53% of the Inoue and 43% in the double balloon group at 6 months follow-up. In the view point of similiar immediate and late results of the two methods, the stepwise dilation with Doppler echocardiographic monitoring during the Inoue procedure appeared to be cumbersome.
Arterial Pressure ; Atrial Pressure ; Balloon Valvuloplasty* ; Echocardiography ; Follow-Up Studies* ; Hemodynamics ; Humans ; Incidence ; Mitral Valve ; Mitral Valve Insufficiency ; Mitral Valve Stenosis ; Prospective Studies

BACKGROUND: The value of coronary reperfusion resulting from Thrombolysis and/or coronary angioplasty in patients with evolving myocardial infarction has been rigorously evaluated and improved left venticular function and short-term survival rates have been demonstrated consistently in controlled studies. Benefits from delayed coronary angioplasty at 7-10 days after onset of acute myocardial infarction (AMI) without thrombolysis remains unclear. In order to assess the effect of delayed reperfusion in infarct-related artery(IRA), we analyzed the restenosis rate of IRA after successful coronary angioplasty and the change of left ventricular function at late follow-up angiogram. METHOD: Coronary angioplasty in 69 lesions of 55 patients(M/F:48/7, mean age 53 years) with acute myocardial infarction(AMI) were performed at 7-10 days after onset of AMI and follow-up coronary angiogram (25 lesions of 20 pts) with left ventriculogram were obtained at means 5.1 months(range 4-6 months) after angioplasty. Restenosis rate of dilated infaret-related arteries and the changes of left ventricular function after angioplasty were evaluated. RESULTS: The overall procedural success rate of delayed elective coronary angioplasty in patients with AMI was 86% with a higher success rate in subtotally occluded vessel(98%) than in the occluded IRA(64%). Complications included acute closure after large dissection in 1(1.6%) and on -hospital mortality due to cardiogenic shock in 1(1.8%). Angiographically restenosis rate of IRA was 65% at mean 5.1 months follow-up, which was relatively higher than that after non-IRA angioplasty in AMI(25%) and in patients with angina(24%). Left ventricular ejection fraction improved significantly from 47.2+/-12.7% to 58.8+/-8.6%(P<0.05) at follow-up. Patients who had a patent IRA at follow-up had a restenotic IRA at follow-up had no statistically significant improvement in EF(table 3). Patients with a left anterior descending artery(LAD) lesion had lower mean immediate EFs than patients with right coronary artery lesion, however the degree of improvement in EF at follow-up was more significant in patients with LAD lesion. CONCLUSIONS: Delayed elective angioplasty of IRA at 7-10 days after onset of AMI was relatively safe and had comparable procedural success rate. Higher restenosis rate(65%) of IRA at follow-up appeared to be related, at least on part, to the endothelial dysfunction after ischemic-reperfusion injury and clinically unstable status. Left ventricular function improved significantly after angioplasty at follow-up. Recovery of left ventricular function might be reated to whether or not the IRA had an angiographically restenosis at follow-up.
Angioplasty* ; Arteries ; Coronary Vessels ; Follow-Up Studies* ; Humans ; Mortality ; Myocardial Infarction* ; Myocardial Reperfusion ; Reperfusion ; Shock, Cardiogenic ; Stroke Volume ; Survival Rate ; Ventricular Function, Left

Hemifacial spasm (HFS) is characterized by tonic clonic contractions of the muscles innervated by the ipsilateral facial nerve. Compression of the facial nerve by an ectatic vessel is widely recognized as the most common underlying etiology. HFS needs to be differentiated from other causes of facial spasms, such as facial tic, ocular myokymia, and blepharospasm. To understand the overall craniofacial abnormalities and to perform the optimal surgical procedures for HFS, we are to review the prevalence, pathophysiology, differential diagnosis, details of each treatment modality, usefulness of brainstem auditory evoked potentials monitoring, debates on the facial EMG, clinical course, and complications from the literature published from 1995 to the present time.
Blepharospasm ; Craniofacial Abnormalities ; Diagnosis, Differential ; Evoked Potentials, Auditory, Brain Stem ; Facial Nerve ; Hemifacial Spasm* ; Microvascular Decompression Surgery ; Muscles ; Myokymia ; Prevalence ; Spasm ; Tics

No abstract available.
Pulmonary Artery*

Establishment of a noninvasive diagnostic method to document coronary vasospasm would be useful in the management of the patients with variant angina, especially in the screening of the patients, evaluation of the therapeutic efficacy of the prescribed drugs and determination of the activity of the disease. The present study was performed to clarify the clinical feasibility and diagnostic validity of bedside intravenous ergonovine test and to determine the variables affecting the diagnostic sensitivity of the test. The study group consisted of 59 patients with chest pain in whom diagnostic coronary angiography with intracoronary acetylcholine challenge test for the induction of coronary vasospasm was performed ; 30 patients were proven to have variant angina and 29 patients to have atypical chest pain. Bedside ergonovine test was done one day after the diagnostic coronary angiography and reversible ST segment displacement(elevation or depression) and/or T wave changes in ECG with ergonovine injection was used as the only positive criteria of the test. A bolus of ergonovine maleate(0.025 or 0.050mg) was injected intravenously at 5 minute intervals up to total cumulative dosage of 0.25 mg, and blood pressure and a 12-lead ECG were recorded every 3 minutes after each injection. Intravenous nitroglycerin of 0.25mg was administered for the termination of the test when hypertension(systolic BP>200mmHg), hypotension(systolic BP<90mmHg) or significant arrhythmia was observed. Twenty seven out of 30 patients with variant angina developed chest pain or discomport during the test and among them 22 showed simultaneous reversible ECG changes. In 29 patients with atypical chest pain 11 patients(38%) complained of chest pain or discomport without reversible ECG change during the test, and the overall sensitivity and specificity of the beside ergonovine test were 73% and 100% respectively. The mean cumulative dose of ergonovine which evoked the positive reponse was 117microgram. The patterns of reversible ECG changes of the positive response were variable : 50%(11/22) showed significant ST segment elevation, while ST segment depression(18%) and T wave changes without ST segment displacement(32%) were observed with ergonovine injection. Degree of disease activity of the variant angina, number of spasm-induced vessels and presence of concomitant fixed lesion are important variables affecting the sensitivity of the test. The changes of blood pressure and heart rate were minimal during the test and there was neither significant arrhythmia nor test-related mortality. Thus we concluded that bedside intravenous ergonovine test is a safe, sensitive and highly specific test for coronary vasospasm in selected group of patients with chest pain syndrome. Further study with other methods besides ECG to document myocardial ischemia seems to be necessary for improvement of the sensitivity of bedside ergonovine test.
Acetylcholine ; Arrhythmias, Cardiac ; Blood Pressure ; Chest Pain ; Coronary Angiography ; Coronary Vasospasm ; Diagnosis* ; Electrocardiography ; Ergonovine* ; Heart Rate ; Humans ; Mass Screening ; Mortality ; Myocardial Ischemia ; Nitroglycerin ; Sensitivity and Specificity

BACKGROUND: A small percentage of patients presenting with acute myocardial infarction are found to have angiographically normal or near normal coronary arteries. Thrombus, coronary spasm or coronary embolism have been thought to cause myocardial infarction in these circumstances. Acetylcholine(Ach) may dilate coronary arteries indirectly by releasing EDRF(endothelium derived relaxing factor), but constrict arterial smooth muscle when endothelium is dysfunctional or denuded. In this study, we observed Ach responses of infarct related arteries with and without stenotic leisions to clarify the possible etiologic role of vasospasm in ischemic heart disease. METHODS: Seven to ten days after acute myocardial infarction. Ach(100ug for left and 50ug for right )responses of infarct-related coronary was studied in 16 patients with angiographically normal coronary arteries(Group 1) and 15 patients with significant stenotic lesions(Group 2). Ach responses was also studied in 27 noninfarct related arteries(NIRA) of group 1 and 29 NIRAs of group2. The positive response was defined as total or subtotal occlusion after Ach injection. In 6 patients of group 1 with Ach(+), intravenous ergonovine(Erg) test was also performed after completion of Ach test. RESULTS: 1) Ach(+) responses of IRAs with or without significant coronary artery disease was more frequent(70%) than that of NIRAs(14%). 2) Ach(+) response of IRAs with angiographically normal coronary artery (87.5%) was more common than that with significant fixed disease(45.4%). 3) ACh and ergonovine induced vasospasm at the same site in 4 of group 1. CONCLUSIONS: In the majority of patients with normal coronary artery and acute myocardial infarction(AMI), Ach induced vasospasm in the IRAs. Ach(+) response occured more frequently in normal coronary arteries. These findings suggest that coronary vasospasm might etiologic role for AMI. especially in thoses patients with normal coronary artery. However our investigation failed clarify whether the those responses of IRAs to Ach was a cause or a result of myocardial infarction due to the post-ischemic injured endothelium. Ach and Erg induced vasospasm at the same site in 4 of group 1 which suggests that local hyperreactivity might be related to coronary spasm.
Acetylcholine* ; Arteries ; Coronary Artery Disease ; Coronary Vasospasm ; Coronary Vessels* ; Embolism ; Endothelium ; Ergonovine ; Humans ; Muscle, Smooth ; Myocardial Infarction ; Myocardial Ischemia ; Spasm ; Thrombosis

BACKGROUND: The purpose of this study was to evaluate the clinical feasibility of bedside intravenous ergonovine test with echocardiography as a noninvasive diagnostic method for coronary vasospasm. METHODS: Bedside ergonovine test was performed in 50 patients with chest pain one day after coronary angiography with spasm provocation test ; 30 patients showed positive results of provocation test while in 20 patients there was no evidence of coronary vasospasm. A bolus of ergonovine maleate(0.025 or 0.05mg) was injected at 5 min intervals up to total cumulative dosage of 0.35mg, and 12-leads ECG and 2D-echo were recorded every 3 min after each injection. Left ventricular wall motion was analyzed with a commercially available 'QUAD' system. The positive criteria of bedside ergonovine test included reversible ST segment elevation or depression, T wave changes in ECG(ECG criteria) and reversible regional wall motion abnormalities(RWMA) in Echo(Echo criteria). RESULTS: The overall sensitivity and specificity of ECG criteria were 73%(22/30) and 100% respectively ; The sensitivity of Echo criteria increased up to 90%(27/30) without the change of the specificity. Among 22 patients with reversible ECG changes only 73%(16/22) showed typical ST segment elevation while ST depression was recorded in 2 patients(9%) and minor T wave peaking or flattening without ST segment displacement in 4 patients(18%). Concomitant fixed coronary lesion does increase the sensitivity of the test compared to pure coronary vasospasm with ECG criteria(100% vs 60%, p<0.05). Mean dose of ergonovine with positive result was 173+/-95 microgram(mcg) and the amount of ergonovine for positive result was significantly larger in patients with low disease activity(Chest pain <5 times/week) than those with high disease activity(213+/-83 vs 123+/-86mcg, p<0.01). There was no procedure related mortality or fatal arrhythmias. CONCLUSIONS: Ergonovine echocardiography is a highly sensitive and specific test for coronary vasospasm and is safe in selected patients in whom the exercise test is negative and severe fixed coronary artery disease has been excluded. Presence of concomitant fixed coronary artery disease and the degree of clinical activity of coronary vasospasm may influence the results of this test.
Arrhythmias, Cardiac ; Chest Pain ; Coronary Angiography ; Coronary Artery Disease ; Coronary Vasospasm* ; Depression ; Echocardiography* ; Electrocardiography ; Ergonovine* ; Exercise Test ; Humans ; Mortality ; Sensitivity and Specificity ; Spasm

BACKGROUND: Although coronary bypass grafting has been shown to prolong life and to relieve symptoms in the early patients with symptomatic coronary artery disease, the operative mortality and morbidity are higher than in younger patients. For this reason percutaneous transluminal coronary angioplasty(PTCA) is a potentially attractive and less invasive alternative to bypass surgery in elderly patients. This study was done to evaluate the feasibility and the initial success rate of PTCA in patients over 70 years of age compared to younger patients group. METHODS: Patients were selected and grouped as I (age 50~69) and II (age over 70) from the consecutive patients who underwent coronary angioplasty at Asan Medical Center from July 1989 to October 1991. Coronary angioplasty was performed at 121 lesions in group I (92 patients) and at 44 lesions in group II (24 patients). RESULTS: Clinically unstable angina and angiographically multivessel disease were more frequent in the elderly patients than in younger patients.The overall initial success rate of PTCA for the elderly and younger patients group were 95.5% and 82.6% respectively. The rate of major complications of PTCA in the elderly patients was not different from that of younger patients:Acute myocardial infarction in 1, energency coronary bypass operation in 1 and cardiac tamponade in 1 patients. There was no difference in the rate of angiographic restenosis between elderly (27.8%) and younger patients group (35.7%). CONCLUSION: PTCA may be appropriate therapeutic modality in the selected group of elderly patients, with high initial success and low cpmplication rate, and follow-up study would be necessary to evaluate the rate of long-term survival and event-free survival after PTCA.
Aged* ; Angina, Unstable ; Angioplasty ; Angioplasty, Balloon, Coronary* ; Cardiac Tamponade ; Chungcheongnam-do ; Coronary Artery Disease ; Disease-Free Survival ; Follow-Up Studies* ; Humans ; Mortality ; Myocardial Infarction ; Transplants