BACKGROUND AND OBJECTIVES: Discrepancy between angiographic percent (%) diameter stenosis and fractional flow reserve (FFR) exists in non-left main bifurcation lesions. The aim of this study was to compare angiographic stenosis severity and FFR in jailed ostial left circumflex artery (LCX) lesions after left main (LM)-to-left anterior descending artery (LAD) crossover stenting. SUBJECTS AND METHODS: Twenty-nine (n=29) patients with distal LM or ostial LAD lesions treated by LM-to-LAD crossover stenting were consecutively enrolled. After successful stenting, FFR was measured at the jailed LCX. Additional intervention was performed in lesions with FFR <0.8. RESULTS: The mean reference diameter of LCX was 3.1+/-0.4 mm, and percent diameter stenosis after crossover stenting was 56+/-21%. Angiographically significant stenosis (>50%) at the ostial LCX occurred in 59% (17/29) of cases. Among them, only five (29%) lesions had functional significance, and underwent additional procedure. During follow-up, three patients in the deferral group and two patients in the additional intervention group had target lesion revascularization. CONCLUSION: There was a discrepancy between angiographic percent diameter stenosis and FFR in jailed LCX lesions after LM crossover stenting.
Angiography ; Arteries ; Constriction, Pathologic ; Coronary Disease ; Follow-Up Studies ; Humans ; Stents

This study compared two-stent strategies for treatment of bifurcation lesions by stenting order, 'main across side first (A-family)' vs 'side branch first (S-family). The study population was patients from 16 centers in Korea who underwent drug eluting stent implantation with two-stent strategy (A-family:109, S-family:140 patients). The endpoints were cardiac death, myocardial infarction (MI), stent thrombosis (ST), and target lesion revascularization (TLR) during 3 years. During 440.8 person-years (median 20.2 months), there was 1 cardiac death, 4 MIs (including 2 STs), and 12 TLRs. Cumulative incidence of cardiac death, MI and ST was lower in A-family (0% in A-family vs 4.9% in S-family, P = 0.045). However, TLR rates were not different between the two groups (7.1% vs 6.2%, P = 0.682). Final kissing inflation (FKI) was a predictor of the hard-endpoint (hazard ratio 0.061; 95% CI 0.007-0.547, P = 0.013), but was not a predictor of TLR. The incidence of hard-endpoint of S-family with FKI was comparable to A-family, whereas S-family without FKI showed the poorest prognosis (1.1% vs 15.9%, retrospectively; P = 0.011). In conclusion, 'A-family' seems preferable to 'S-family' if both approaches are feasible. When two-stent strategy is used, every effort should be made to perform FKI, especially in 'S-family'.
Aged ; Angioplasty, Balloon, Coronary/*methods ; Coronary Stenosis/surgery/*therapy ; Death, Sudden, Cardiac/etiology ; *Drug-Eluting Stents ; Female ; Follow-Up Studies ; Humans ; Male ; Middle Aged ; Myocardial Infarction/etiology ; Myocardial Revascularization ; Thrombosis/etiology

A 69-year-old male presented with obstructive hypertrophic cardiomyopathy, mitral valve regurgitation, and myxomatous mitral valve prolapse. A spontaneous chordal rupture and acute severe mitral regurgitation resulted in abrupt clinical deterioration despite complete relief of severe left ventricular outflow tract obstruction and systolic anterior motion of the anterior mitral leaflet. The patient underwent extensive cardiac surgery due to intractable heart failure. Surgical procedures included a mitral valve replacement, a septal myectomy, and the Maze procedure.
Aged ; Cardiomyopathy, Hypertrophic ; Chordae Tendineae ; Heart Failure ; Humans ; Male ; Mitral Valve ; Mitral Valve Insufficiency ; Mitral Valve Prolapse ; Rupture ; Thoracic Surgery

BACKGROUND AND OBJECTIVES: Elevated hs-CRP (high sensitivity C-reactive protein) is well known as a biomarker reflecting the inflammatory process that might evoke the potential for microembolization of an atheromatous plaque, and imparts a poor prognosis in patients with coronary artery disease. We designed this study to evaluate whether the preprocedural hs-CRP level was associated with procedure-related myocardial injury following coronary stenting. SUBJECTS AND METHODS: We obtained the plasma hs-CRP level from angina patient, who underwent coronary stenting, within 24 hours prior to the procedure, and divided the patients into either the normal CRP (hs-CRP <3 mg/L) or elevated CRP groups (hs-CRP > or =3 mg/L). We defined the reduction of TMP (TIMI myocardial perfusion) grade as at least one decrease in the TMP grade following coronary stenting compared with the pre-procedural TMP. We also evaluate the procedure-related myocardial damage by measuring CK-MB leakage after stenting. RESULTS: We enrolled 279 lesions in 226 patients, who were divided into two groups: the normal CRP group (n=137, 1.28+/-0.71 mg/L) and the elevated CRP group (n=89, 6.89+/-4.23 mg/L). A reduction in the TMP grade was significantly more prevalent in the elevated CRP (20 lesions, 17.4%) compared to the normal CRP group (6 lesions, 3.7%, p=0.001). An elevated CRP level was related to an increased CK-MB leakage following stenting (elevated CRP group; 23 patients, 25.8%, normal CRP group; 21 patients, 15.3%, p=0.041). In a multivariable analysis, the only significant predictor of a reduction in the TMP grade following stenting was an elevated CRP level. CONCLUSION: Systemically detectable inflammatory activity, served by the plasma hs-CRP level, is associated with procedure-related microvascular injury, as assessed by a reduction in the TMP grade and CK-MB elevation following coronary stenting.
C-Reactive Protein ; Coronary Artery Disease ; Humans ; Microcirculation ; Plasma ; Prognosis ; Stents* ; Thymidine Monophosphate

BACKGROUND AND OBJECTIVES: The TIMI myocardial perfusion (TMP) grade is known as one of the methods to assess the viability of the myocardium in ischemic heart disease. This study was designed to assess the value of TMP grade itself and to evaluate the correlation with coronary flow reserve (CFR) in the prediction of left ventricular remodeling and functional change after percutaneous coronary intervention (PCI) in acute myocardial infarction (AMI). SUBJECTS AND METHODS: We measured CFR and TMP grade after successful elective PCI (diameter stenosis <0%, and TIMI flow 3) in 83 patients (mean age 55+/-1 years, 18 females) with AMI within 7 days of symptom onset. Left ventricular end diastolic volume index (LVEDVI), left ventricular end systolic volume index (LVESVI), ejection fraction (LVEF), and left ventricular regional wall motion score index (LVRWMSI) were assessed by echocardiography just before and at 9 months after angioplasty (mean 9+/-5 months). RESULTS: Although they had achieved (TIMI 0.021) TIMI 3 flow after successful intervention, 27 of 83 patients (32.5%) had impaired myocardial perfusion. After PCI, angiographic TMP grade was well correlated with CFR measured using Doppler wire (TMP 0/1;1.4+/-0.3, TMP 2;1.9+/-0.6, TMP 3;2.2+/-0.4, rs=0.618, p=0.000). Post-PCI TMP grade was significantly related to the change of LVEDVI (r=0.452, p=0.000), LVESVI (r=0.435, p=0.000), LVEF (r=0.281, p=0.010) and LVRWMSI (r=0.328, p=0.036). CONCLUSION: The TMP grade, a simple angiographic method, might be useful as a predictor of LV volume and functional change in AMI. In the cardiac catheterization laboratory, it could simply replace CFR for the assessment of myocardial viability in patients who receive an elective PCI within 7 days of AMI onset.
Angioplasty ; Cardiac Catheterization ; Cardiac Catheters ; Constriction, Pathologic ; Coronary Circulation ; Echocardiography ; Humans ; Myocardial Infarction* ; Myocardial Ischemia ; Myocardium ; Percutaneous Coronary Intervention ; Perfusion* ; Stents ; Stroke Volume ; Thymidine Monophosphate ; Ventricular Remodeling

BACKGROUND AND OBJECTIVES: Circulating B-type natriuretic peptide (BNP) has been used as a marker of left ventricular hypertrophy and heart failure, and known to be increased after exercise in healthy men as well as patients with left ventricular dysfunction. However, the relationship between exercise duration and BNP level, and the determinants of circulating BNP concentration during exercise have not been fully elucidated. For these reason, we measured circulating BNP level during exercise, and exercise-induced changes of cardiac function by echocardiography in healthy men. MATERIALS AND METHODS: Ten healthy male volunteers (mean age 27+/-3 year-old) underwent symptom-limited bicycle ergometer in supine position for 30 min. The workload started at 25 W for 6 min with increment of 50 W every 3 min. Blood samples for BNP were obtained at baseline, every 1 min for first 3 min, 25 W, 75 W, 125 W, peak exercise and 10 min after resting. RESULTS: BNP level was increased only at peak exercise (mean:5.3+/-0.5 vs 7.7+/-4.1 pg/ml, median:5.0 vs 6.3 pg/ml, p<0.05), not during submaximal exercise, and sustained 10 minutes after exercise (190+/-25 watt, 14.9+/-12 min). Peak BNP level was significantly correlated with baseline BNP level (r=0.723, p<0.05), E' (0.18+/-0.04 vs 0.29+/-0.08 m/sec, r=-0.649, p<0.05) and E/E' (4.18+/- 0.87 vs 5.66+/-2.31, r=0.769 p<0.01) by bivariate correlation analysis, but correlated with only baseline BNP level by multiple linear regression analysis (p<0.05). CONCLUSION: Circulating BNP concentration was minimally increased only after peak exercise in young healthy men, not increased at submaximal exercise The BNP concentration after exercise is only determined by baseline BNP level, not by duration and workload of exercise.
Echocardiography ; Echocardiography, Stress ; Heart Failure ; Humans ; Hypertrophy, Left Ventricular ; Linear Models ; Male ; Natriuretic Peptide, Brain* ; Supine Position ; Ventricular Dysfunction, Left ; Volunteers

BACKGROUND AND OBJECTIVES: By measuring the coronary flow reserve (CFR) and echocardiographic left ventricular function, the purpose of this study was to evaluate the effect of pre-infarction angina (PA) on myocardial protection in patients with acute myocardial infarction (AMI). SUBJECTS AND METHODS: Sixty-two patients (mean 54+/-10 years, 51 males) with first anterior AMI were studied. CFR, defined as the ratio of hyperemic (hAPV) to baseline APV (bAPV), was measured at least 24 hours after the onset of AMI at the left anterior descending artery (mean 7+/-4 days) with a Doppler wire. Echocardiography was performed at admission (baseline) and during follow-up periods (mean 9+/-7 month). All patients were divided into two groups according to the presence of PA within 72 hours prior to AMI:group A (with PA, n=27) and group B (without PA, n=35). RESULTS: Between the two groups, CFR were higher in group A (2.1+/-0.5 vs.1.6+/-0.5, p<0.001). The baseline left ventricular ejection fraction (LVEF, %) and wall motion score index (WMSI) were better in group A than in B (53.4+/-9.7 vs. 45.1+/-8.8, p=0.001;1.42+/-0.23 vs. 1.72+/-0.28, p<0.001, respectively). LVEF (%) and WMSI during follow-up periods were better in group A than in B (61.3+/-10.2 vs. 54.4+/-13.3, p=0.03;1.24+/-0.21 vs. 1.47+/-0.37, p=0.004, respectively). CONCLUSION: Patients with PA had a significantly higher CFR and better LVF at the baseline and during follow-up periods. This study suggests that brief and repeated myocardial ischemia prior to AMI as ischemic pre-conditioning might have the effect of myocardial protection.
Angina, Unstable* ; Arteries ; Blood Flow Velocity ; Echocardiography ; Follow-Up Studies ; Humans ; Ischemic Preconditioning* ; Myocardial Infarction ; Myocardial Ischemia ; Stroke Volume ; Ventricular Function, Left

The diagnostic and prognostic implication of exaggerated blood pressure response to exercise have been controversial, with opinions ranging from a benign process to a harbinger of potential cardiovascular morbidity. Endothelial dysfunction has been demonstrated in patients with atherosclerosis and as a risk factor for coronary artery disease. However, whether the cause of exercise-induced hypertension might be related to endothelial dysfunction has not been well elucidated. We evaluated endothelial function in patients who showed a systolic blood pressure > or =210 mmHg in males and > or = 190 mmHg in females during treadmill exercise test. We measured the endothelial function of the brachial artery in 35 patients with exercise-induced hypertension, and in 35 age- and gender-matched normal control subjects, by a high resolution ultrasound technique, and the concentration of NO2-/NO3- and cyclic guanosine monophosphate (GMP). Endothelial-dependent vasodilation was impaired in patients with hypertension compared to normal controls (3.14+/-0.61 vs. 6.5+/-0.76%, p < 0.05). The extent of vasodilation was significantly correlated with age (r=-0.28, p < 0.05) and systolic blood pressure difference (r=-0.36, p < 0.05). The levels of NO2-/NO3- and cyclic GMP at maximal exercise were significantly higher than those at rest and recovery in both controls and the hypertensive group (p < 0.05). Although there was no significant difference in the increment of NO2-/NO3- during maximal exercise between the controls and hypertensive group (55+/-17 vs. 56+/-12micromol/L, p=NS), cyclic GMP level during maximal exercise was significantly higher in the control group than the hypertensive group (10+/-1.8 vs. 8.3+/-2.5 pmol/ml, p 0.05). Patients with exercise-induced hypertension have poor endothelium-dependent vasodilation due to an impaired nitric oxide/cyclic GMP pathway, which may play a significant role in increasing blood pressure during exercise with inadequate peripheral adjustment to changing cardiac output.
Adult ; Cyclic GMP/*metabolism ; Endothelium, Vascular/*physiopathology ; *Exercise ; Female ; Human ; Hypertension/*etiology/*physiopathology ; Male ; Middle Aged ; Nitric Oxide/*metabolism

BACKGROUND AND OBJECTIVES: This is a comparative, randomized, multi-centered, angiographic trial for the comparison of TNK-tPA with rt-PA, in Korean patients with an acute myocardial infarction (AMI). SUBJECTS AND METHODS: Fifty four patients that were eligible for thrombolysis, diagnosed with an AMI, were randomized into two groups:TNK-tPA (single bolus injection, 25-50 mg weight adjusted;n=25) or rt-PA (accelerated intravenous infusion, up to 100 mg;n=29) at the emergency room. The primary endpoint was the percentage of patients with a TIMI (Thrombolysis In Myocardial Infarction) III flow 90 min following the administration of the study drug. The secondary endpoints were an infarct-related artery patency at 90 min, the percentage of patients with ST segment resolution at 60 and 180 min, and at 30 days mortality. RESULTS: The baseline demographic data, including age, sex and body weight, and a medical history of prior myocardial infarction and risk factors were no different between the TNK-tPA and rt-PA groups. The pain-to-needle and door-to-needle times were also no different. The ST segment resolution was no different between the two groups. A TIMI grade 3, on a coronary angiogram, 90 min following the drug administration, was observed in 19 (76.0%) of the TNK-tPA and 17 (58.6%) of the rt-PA (p=0.24) patients. However, a TIMI grade more than 2 was higher in the TNK-tPA (100%;25/25) than in rt-PA group (72.4%;21/29)(p=0.0052). The in-hospital adverse events, and clinical outcomes at 30 days, were no different between the two groups. CONCLUSION: TNK-tPA is more convenient, and may be a preferred thrombolytic agent, for the revascularization of an AMI.
Arteries ; Body Weight ; Coronary Disease ; Emergency Service, Hospital ; Humans ; Infusions, Intravenous ; Mortality ; Myocardial Infarction ; Myocardial Revascularization ; Risk Factors ; Thrombolytic Therapy

BACKGROUND AND OBJECTIVES: Previous studies advocated the C-reactive protein (CRP) as an objective marker of the inflammatory reaction in cardiovascular disease, and an independent risk factor for predicting the progression of heart failure (HF) of an ischemic origin. However, it is unclear if this can also be applied to non-ischemic HF. We report the measurement of the CRP in non-ischemic dilated cardiomyopathy (DCM), and its relationship to the prognosis. SUBJECTS AND METHODS: Sixty-nine consecutive patients, with non-ischemic DCM, were enrolled based on their history, echocardiography and coronary angiography findings. The variables, including NYHA functional class, were examined. The CRP levels were measured with high sensitive turbidometry; and each patient followed up for 18 months. The endpoints of the study were considered as readmission and death. RESULTS: Out of the 69 patients, there were 47 (68%) were males and 22 (32%) females, with an average age of 60+/-12. The CRP level (mg/d) in the patients with DCM (1.66+/-2.91) was higher than in the controls (0.07+/-0.25;p<0.001), and increased in relation to the NYHA functional class on discharge (I:0.98+/-2.15, II:0.78+/-1.48, III:3.55+/-4.66, IV:2.94+/-2.39;p<0.01). During the follow-up, 19(28%) experienced the aggravation of HF and had higher CRP and NYHA functional classes, and lower Na+, K+ and hemoglobin levels. From a multiple regression analysis, only the K+ and NYHA functional class on discharge revealed significant relationships with the aggravation of HF (p<0.05). Moreover, an increased in the CRP level had a significant negative relation to the Na+ only (p<0.05). CONCLUSION: The patients with non-ischemic DCM exhibited an increase in CRP levels in relation to the severity of the HF. However, the levels of CRP in non-ischemic DCM could not elucidate the prognosis as with ischemic HF.
C-Reactive Protein* ; Cardiomyopathy, Dilated* ; Cardiovascular Diseases ; Coronary Angiography ; Echocardiography ; Female ; Follow-Up Studies ; Heart Failure ; Humans ; Male ; Prognosis ; Prospective Studies* ; Risk Factors