A rare case of carpal tunnel syndrome caused by a thrombosed persistent median artery is presented here. The diagnosis was delayed due to the overlapping cervical radiculopathy. Acute severe pain and nocturnal paresthesia were chief complaints. Ultrasonography, magnetic resonance imaging, and computed tomography angiography revealed that the median nerve was compressed by the occluded median artery. Instead of surgery, conservative therapy was tried. It worked well for six months. The importance of using modalities for decision making of diagnosis and treatment is emphasized in this report.

Subdural injection of epidural anesthesia is rare and is usually undiagnosed during epidural anesthesia causing severely delayed maternal hypotension, hypoxia, and fetal distress. A 38-year-old primiparous woman was administered epidural labor analgesia at 40(+6) weeks' gestation, and developed progressive maternal respiratory depression, bradycardia, and hypotension after accidental subdural administration of the anesthetic agent. Furthermore, fetal distress occurred soon after administration. The patient was managed with oxygen, position changes, fluid resuscitation, and ephedrine. Intrauterine fetal resuscitation was successfully performed with atropine before cesarean section, and a healthy baby was delivered. Although subdural injection is uncommon, this case emphasizes the importance of anesthesiologists monitoring patients for a sufficient period after epidural labor analgesia, and being prepared to perform maternal or fetal resuscitation.
Analgesia ; Analgesia, Epidural ; Anesthesia, Epidural ; Anoxia ; Atropine ; Bradycardia ; Cesarean Section ; Ephedrine ; Female ; Fetal Distress ; Humans ; Hypotension ; Oxygen ; Pregnancy ; Respiratory Insufficiency ; Resuscitation ; Subdural Space

Heat and moisture exchanger filters (HMEF), used for humidification of patient respiratory gas and filtering microorganisms can cause airway obstruction. We experienced serious airway obstruction in a HMEF after making hydrothorax for high intensity focused ultrasound (HIFU) procedure. The airway obstruction was difficult to differentiate from severe bronchospasm irresponsive to bronchodilator therapy. It was relieved dramatically after we removed the filter from the breathing circuit as soon as we detected air-fluid meniscus in it.
Airway Obstruction ; Bronchial Spasm ; Hot Temperature ; Humans ; Hydrothorax ; Respiration

BACKGROUND AND OBJECTIVES: Platelet activation and aggregation, with resultant arterial thrombus formation, play pivotal roles in the pathophysiology of acute coronary syndrome (ACS). The efficacy of tirofiban, a specific inhibitor of the platelet glycoprotein IIb/IIIa receptor, combined with heparin, or low molecular heparin (LMWH), in the management of ACS were evaluated. SUBJECTS AND MEHTODS: One hundred seventeen patients (60.8+/-10.9 years, 76 male), with unstable angina or non-ST elevation myocardial infarction, who had ST-T changes and elevated troponin, were divided into 4 groups : Group I (n=30 : heparin alone), Group II (n=28 : LMWH, dalteparin alone), Group III (n=29 : tirofiban combined with heparin) and Group IV (n=30 : tirofiban with LMWH). The major adverse cardiac events (MACE) among the 4 groups, during 6-month clinical follow-ups, were compared. RESULTS: Percutaneous coronary intervention, or a coronary artery bypass graft, was performed in 23, 19, 19 and 22 patients from Groups I, II, III and IV, respectively (p=0.87). A minor bleeding complication developed in 2 (6.7%), 1 (3.6%), 1 (3.4%) and 2 patients (6.7%) in groups I, II, III and IV, respectively (p=0.79). During the six-month follow-up MACE occurred in 7 (30.4%), 6 (31.6%), 3 (15.8%) and 4 patients (18.2%) in groups I, II, III and IV, respectively (p=0.02 : Group I and II vs. Group III and IV). CONCLUSION: Tirofiban combined with LMWH is safe and may improve the long-term prognosis of patients with ACS.
Acute Coronary Syndrome* ; Angina, Unstable ; Angioplasty ; Blood Platelets* ; Coronary Artery Bypass ; Dalteparin ; Follow-Up Studies ; Glycoproteins* ; Hemorrhage ; Heparin ; Heparin, Low-Molecular-Weight* ; Humans ; Myocardial Infarction ; Percutaneous Coronary Intervention ; Platelet Activation ; Prognosis ; Thrombosis ; Transplants ; Troponin

A 28-year old male presented with chest pain of two hours duration. He had histories of 10 years smoking and 2 years of nephrotic syndrome, due to minimal change disease. His EKG showed marked ST segment elevations in the V3-6, I, II, III and aVF leads. The levels of cardiac enzymes were increased (CK: 481 U/l, CK-MB: 96 U/l and Troponin I: 4.8 ng/mL). The prothrombin and activated partial promboplastin times were normal. Accelerated tissue type plasminogen activator (100 mg) was administered at the emergency room, but his chest pain continued, with persistent ST segment elevations. An urgent coronary angiograph revealed huge multiple filling defects, suggestive of thrombi in the proximal left anterior descending artery (LAD), with thrombolysis in the myocardial infarction (TIMI) flow. A rescue percutaneous coronary intervention was performed using repeated angioplasties with a 3.0 mm balloon. However, the filling defects and distal LAD flow did not improve. We administered Abciximab (ReoPro(r)), and the LAD flow improved to a TIMI III flow, with resolution of the thrombus in the LAD. His clinical course was uneventful after discharge, and a left coronary angiogram, at the 6-month follow-up, showed no filling defects, with the TIMI III flow maintained.
Adult ; Angioplasty ; Arteries ; Blood Platelets ; Chest Pain ; Electrocardiography ; Emergency Service, Hospital ; Follow-Up Studies ; Humans ; Male ; Myocardial Infarction* ; Nephrosis, Lipoid ; Nephrotic Syndrome* ; Percutaneous Coronary Intervention ; Prothrombin ; Smoke ; Smoking ; Thrombosis ; Tissue Plasminogen Activator ; Troponin I

BACKGROUND: Intraventricular conduction disturbances, as manifested by increased QRS duration, are common in patients with advanced left ventricular (LV) dysfunction and adversely affect LV systolic and diastolic function. It has been reported that the patients with prolonged paced QRS duration have more serious heart disease, and the paced QRS duration can be a useful indicator of impaired LV function. Hemodynamic effects of paced QRS duration and pacing site during right ventricular (RV) pacing are unknown. METHODS: A total of 14 patients who underwent electrophysiologic study for paroxysmal supraventricular tachycardia at Chonnam National University Hospital were examined. All the patients had no structural heart disease. RV pacing was performed at 10 different sites with cycle length of 600 ms and 500 ms using a 6-7F deflectable quadripolar electrode catheter (Livewire, St. Jude Medical, Minneapolis, MN, USA). Systolic, diastolic, and mean blood pressures were measured after stabilization of blood pressure during pacing. RESULTS: Blood pressures (systolic/diastolic/mean) decreased from 146 +/- 31/95 +/- 28/125 +/- 23 mmHg to 128 +/- 33/80 +/- 25/107 +/- 20 mmHg, respectively. The change of QRS duration during pacing and the systolic blood pressure (SBP) before pacing were higher in the group with paced QRS duration greater than 140 msec (59.1 +/- 13.6 msec vs 84.9 +/- 18.7 msec, 141 +/- 30 mmHg vs 152 +/- 38 mmHg, p<0.001, p=0.011, respectively). The decrease of SBP during pacing was higher in the group with paced QRS duration greater than 140 msec (13 +/- 11 mmHg vs 24 +/- 14 mmHg, p=0.009). The decrease of SBP during pacing was related with QRS duration during pacing (r=0.500, p=0.001), the change of QRS duration during pacing (r=0.426, p=0.001), and SBP during sinus rhythm (r=0.342, p=0.001) on linear correlation analysis. Pacing site, however, did not affect acute hemodynamic change during pacing. The independent factors associated with the decrease of SBP during pacing were SBP before pacing and QRS duration during pacing. CONCLUSION: We concluded that acute deleterious hemodynamic effects of RV pacing are related with paced QRS duration but not with pacing site. Ventricuar pacing at the area of paced QRS duration less than 140 msec is recommended particularly in high risk patients.
Blood Pressure ; Catheters ; Electrodes ; Heart Diseases ; Hemodynamics* ; Humans ; Jeollanam-do ; Tachycardia, Supraventricular

BACKGROUND: Has been reported that patients exhibiting prolonged paced QRS duration tend to have more serious heart disease, and the paced QRS duration can be an effective indicator of impaired left ventricular function. However, the acute and chronic hemodynamic effects of paced QRS duration and pacing sites during right ventricular (RV) pacing remain unknown. METHODS: A total of 14 patients who underwent electrophysiologic study for paroxysmal supraventricular tachycardia were examined. RV pacing was performed at 10 different sites with cycle lengths of 600 ms and 500 ms utilizing a 6-7F deflectable quadripolar electrode catheter. Systolic, diastolic, and mean blood pressures during pacing were measured once the blood pressure was stabilized. RESULTS: During RV pacing, blood pressures (systolic/diastolic/mean) decreased. The change of post-pacing QRS duration and pre-pacing the systolic blood pressure (SBP) were greater in the group with paced QRS duration. The differences overall were greater than 140 ms. The SBP decrease during pacing was larger in the group exhibiting paced QRS duration of greater than 140 ms. The SBP decrease during pacing showed relation to QRS duration during pacing (r=0.500, p=0.001), the change of QRS duration post-pacing (r=0.426, p=0.001), and SBP during sinus rhythm (r=0.342, p=0.001) on linear correlation analysis. The pacing site, on the other hand, did not affect acute hemodynamic changes during pacing. CONCLUSION: Ventricular pacing of less than 40 ms at the area of paced QRS duration is recommended.
Blood Pressure/physiology ; *Cardiac Pacing, Artificial ; Electrophysiologic Techniques, Cardiac ; Female ; Heart Ventricles/*physiopathology ; Hemodynamic Processes/*physiology ; Humans ; Male ; Middle Aged ; Tachycardia, Supraventricular/physiopathology/*therapy

BACKGROUND: The inflammation is an important feature of atherosclerotic lesions, and peripheral monocytosis is known to be associated with increased coronary events and poor prognosis in acute myocardial infarction (AMI). The aim of this study was to determine the significance in clinical and angiographic outcomes, success rate of the percutaneous coronary intervention (PCI) and major adverse cardiac events and event-free survival rate after PCI according to the value of peripheral monocyte on admission. METHODS: A total of 127 patients with AMI who underwent PCI between June 2000 and June 2001 at Chonnam National University Hospital were divided into two groups: Group I (n=63, 61.7+/-10.9 years, male 71.4%) with normal monocyte count (<900/mm3, mean value=536+/-202/mm3) on admission and Group II (n=64, 61.7+/-13.4 years, male 78.1%) with elevated monocyte count ( 900/mm3, mean value=1,140+/-260/mm3) on admission. RESULTS: Baseline ejection fraction was lower in Group II than in Group I (Group I; 53.3+/-13.0% vs Group II; 45.0+/-11.7%, p=0.014). The value of C-reactive protein, troponin-T and troponin-I was higher in Group II than in Group I (Group I; 2.8+/-1.9 mg/dL, 1.98+/-1.53 ng/mL, 18.3+/-17.7 ng/mL vs Group II; 5.3+/-5.0 mg/dL, 3.34+/-2.54 ng/mL, 43.1+/-24.0 ng/mL, p=0.034, 0.020, 0.006, respectively). The incidence of target lesion revascularization was higher in Group II than in Group I during hospitalization and during 6-month clinical follow-up after PCI (1.6% vs 12.5%, 19.0% vs 31.3%, p=0.012, 0.015, respectively). The event-free survival rates were lower in Group II than in Group I during hospitalization and during 6-month follow-up after PCI (96.8% vs 84.4%, 71.4% vs 53.1%, p=0.006, 0.008, respectively). CONCLUSION: Peripheral monocytosis is associated with LV dysfunction and higher incidence of target lesion revascularization and worse mid-term event-free survival during hospitalization and at 6 months after PCI in patients with AMI.
Angioplasty ; C-Reactive Protein ; Coronary Disease ; Disease-Free Survival ; Follow-Up Studies ; Hospitalization ; Humans ; Incidence ; Inflammation ; Jeollanam-do ; Male ; Monocytes ; Myocardial Infarction* ; Percutaneous Coronary Intervention ; Prognosis ; Troponin I ; Troponin T

BACKGROUND: It is known that prolonged QRS duration (QRSd) in a 12-lead ECG is associated with decreased left ventricular (LV) systolic function in patients with dilated cardiomyopathy. Development of LV systolic dysfunction and prolongation of paced QRSd are often observed in patients with permanent pacemakers (PPM). However, the significance of prolonged paced QRSd in patients with PPM is not determined. METHODS: We studied sixty-four patients (male:female=27:37, mean age=57.6+/-15.4 years) who had been on PPM (DDD: 15, VDD: 18, VVI: 31) for more than one year (mean: 68.2+/-44.0 months). LV function was normal before implantation of PPM. The 12-lead ECG and echocardiography were recorded prior to implantation, immediately after implantation and at the last follow-up. RESULTS: Paced QRSd did not significantly increase during the follow-up period. LVEF at the last follow-up (LVEF-FU) was significantly lower than that prior to implantation (59.3+/-11.5% vs. 64.9+/-10.1%, p<0.001). Eleven (17.2%) patients developed LV systolic dysfunction (LVEF<50%) during the follow-up period. Paced QRSd at the last follow-up and diabetes mellitus were correlated with LV systolic dysfunction (R2=0.302, p<0.001). There was a significant negative correlation between the paced QRSd and LVEF-FU (r=-0.451, p<0.01) and between change of paced QRSd and that of LVEF during follow-up (r=-0.419, p<0.01). LVEF-FU was reduced more in patients with paced QRSd >or=180 ms than in patients without (44.4+/-12.0% vs. 61.7+/-9.5%, p<0.001). In predicting LV systolic dysfunction with the paced QRSd (cut-off value: 180 ms), sensitivity, specificity, positive and negative predictive values were 60.0%, 88.7%, 50.0% and 99.2%, respectively. The paced QRSd at the last follow-up was significantly correlated with paced QRSd immediately after implantation (r=0.542, p<0.01). CONCLUSION: LV systolic dysfunction after long-term right ventricular apical pacing may develop. Prolongation of paced QRSd 180 ms during follow-up may suggest development of LV systolic dysfunction. New technologies to minimize prolongation of paced QRSd should be investigated to prevent LV systolic dysfunction after permanent ventricular pacing.
Cardiomyopathy, Dilated ; Diabetes Mellitus ; Echocardiography ; Electrocardiography ; Follow-Up Studies ; Humans ; Sensitivity and Specificity ; Ventricular Dysfunction, Left* ; Ventricular Function

BACKGROUND: Atrial fibrillation (AF) is thought to beget AF by shortening atrial refractoriness and reversal of rate adaptation of atrial refractoriness. This phenomenon of electrophysiologic remodeling of the atria during AF has been reported to play a major role in inducibility and stability of AF. METHODS: Thirty-one patients with induced AF lasting >1 second during electrophysiologic study for documented or suspected supraventricular or ventricular tachycardia were included in this study. All the patients had no structural heart disease and history of AF. High right atrium (HRA) burst pacing or extra-stimulation was applied to induce AF. Eleven patients with AF sustained >or=3 min was grouped into Group I and 20 patients with AF <3 min into Group II. P wave duration and amplitude, left atrial (LA) size, atrial refractory period (ARP), intraatrial conduction time (IACT) from HRA electrode catheter to His bundle electrode catheter and characteristics of atrial activities during induced AF were compared between 2 groups. RESULTS: There was no difference in the distribution of underlying cardiac arrhythmias. P wave durations and amplitudes and echocardiographic LA sizes were similar between 2 groups. ARPs and IACTs in group I and II were similar (198.0 +/- 23.9 ms vs. 200.8 +/- 23.0 ms; 38.7 +/- 8.5 ms vs. 38.6 +/- 9.5 ms, respectively). During AF, mean interval of atrial activities in group I was significantly shorter than group II (156.6 +/- 24.2 ms vs. 187.6 +/- 28.0 ms, p<0.01). The degree of irregularity of atrial activities during AF was significantly higher in group I than group II (16.9 +/- 8.7 vs. 9.8 +/- 5.0, p<0.05). The duration of the atrial activities was wider in group I than group II (81.4 +/- 17.5 ms vs. 53.9 +/- 12.4 ms, p<0.001) and the amplitude was lower in group I than group II (56.1 +/- 36.0% vs. 109.0 +/- 51.8%, p<0.05), and the degree of fractionation was greater in group I than group II (4.8 +/- 1.1 vs. 3.2 +/- 0.5, p<0.05). CONCLUSION: These results suggest that shortening of atrial refractoriness and lengthening of local conduction time at the time of or shortly after induction of AF may play a major role in the induction and stabilization of AF.
Arrhythmias, Cardiac ; Atrial Fibrillation* ; Bundle of His ; Catheters ; Echocardiography ; Electrodes ; Electrophysiology ; Heart Atria ; Heart Diseases ; Humans ; Tachycardia, Ventricular