Difference in the Prevalence, Cardiac Function and Extent of Myocardial Fibrosis in the subtypes of Hypertrophic Cardiomyopathy

학위논문 (석사)-- 서울대학교 대학원 : 의학과 내과학 전공, 2016. 2. 손대원.서론: 비후성 심근병증은 급성 심장사의 위험도를 증가시키는 유전성 심장 질환으로 비후된 심근의 부위에 따라 여러 형태로 나뉜다. 또한 심장자기공명 지연조영증강의 양은 심근 섬유화를 반영하는 것으로 알려져 있으며, 심근 섬유화의 정도는 급성심장사의 위험도와 연관이 있을 것으로 추정되고 있다. 이 연구는 비후성 심근병증의 형태에 따른 임상적, 기능적 차이를 비교하고, 지연조영증강 패턴과 임상 양상과의 연관성을 확인하고자 한다. 방법: 심장자기공명영상 검사와 경흉부심초음파 검사를 시행한 비후성 심근병증 환자가 연구에 포함되었다. 좌심실 비후 부위에 따라 중격형, 심첨형, 혼합형, 동심형 심근병증으로 분류하였다. 지연조영증강 패턴은 그 양에 따라 fuzzy(흐림상), spotty(점상), patchy(반점상), conglomerate (집합상) 의 네 가지로 분류하였다. 결과: 총 96명의 환자들 중 중격형이 48%(46명), 심첨형이 31%(30명), 혼합형이 18%(17명), 동심형이 3%(3명)였다. 심첨형 비후성 심근병증 환자는 중격형에 비해 더 나이가 많았고 (심첨형 67.2±10.1세, 중격형 54.9±12.3세, p<0.001), 심방세동의 유병률이 통계적으로 유의하지는 않았으나 더 높은 경향을 보였다 (심첨형: 중격형: 혼합형 33%(10명): 13%(6명): 29%(5명), p=0.075). 하나 이상의 급성 심장사 위험 인자를 가진 경우는 중격형(39%,18명)과 혼합형(47%,8명)에서 심첨형(17%,5명)보다 흔히 관찰되었다. 심초음파 로 측정한 좌심실 이완기능의 표지자인 E velocity, E/E비율 등은 각 군간에 유의한 차이를 보이지 않았다. 지연조영증강은 94%(90명)에서 확인되었고, 그 중 23%(22명)은 fuzzy, 25%(24명)은 spotty, 34%(33명)은 patchy, 12%(11명)은 conglomerate 패턴으로 분류되었다. 지연조영증강의 양이 많을수록 더 젊었고 (fuzzy: spotty: patchy: conglomerate 64.4±12.3세: 64.3±10.3세: 56.5±12.9세: 51.6±11.6세, p=0.004), 남자가 많았다 (77% (17명): 54%(13명): 76%(25명): 92%(9명), p=0.017). 심근 섬유화의 중증도가 심할 수록 비지속성 심실빈맥의 병력이 유의하게 증가하였고 [18%(4명): 21%(5명): 39%(13명): 55%(6명), p=0.017], Conglomerate 패턴의 환자군에선 급성 심장사의 위험 인자를 하나 이상 가진 환자의 비율이 타군에 비해 유의하게 높았다 (14%(3명): 38%(9명): 30%(10명): 64%(7명), p=0.050). E velocity, E/E비율 등은 각 군 사이에 유의한 차이를 보이지 않았다. 결론: 한국인 집단에서 심첨형 비후성 심근병증은 서구인보다 흔히 관찰되었으며, 중격형 환자군보다 나이가 많고, 급성심장사의 위험 인자를 적게 가지고 있었다. 연조영증강의 양이 많은 환자들은 적은 환자들에 비해 더 젊고 급성심장사의 위험 인자를 많이 가진 양상을 보였다.서론 1 연구대상 및 방법 3 1. 연구 대상 3 2. 심장자기공명 영상 촬영 4 3. 심장자기공명영상 분석 4 4. 심초음파 검사 8 5. 통계 분석 8 결과 10 1. 대상 환자군의 임상적 특성 10 2. 비후성 심근병증 형태에 따른 기능적 차이 및 심근 섬유화 정도 비교 14 3. 지연조영증강 패턴에 따른 기능적 차이 및 심근 섬유화 정도 비교 19 고찰 24 결론 29 참고문헌 30 영문초록 36Maste

Pacemaker dependency after transcatheter aortic valve replacement compared to surgical aortic valve replacement

Transcatheter aortic valve replacement (TAVR) is a standard treatment indicated for severe aortic stenosis in high-risk patients. The objective of this study was to evaluate the incidence of pacemaker dependency after permanent pacemaker implantation (PPI) following TAVR or surgical aortic valve replacement (SAVR) and the risk of mortality at a tertiary center in Korea. In this retrospective study conducted at a single tertiary center, clinical outcomes related to pacemaker dependency were evaluated for patients implanted with pacemakers after TAVR from January 2012 to November 2018 and post-SAVR from January 2005 to May 2015. Investigators reviewed patients' electrocardiograms and baseline rhythms as well as conduction abnormalities. Pacemaker dependency was defined as a ventricular pacing rate &gt; 90% with an intrinsic rate of &lt;40 bpm during interrogation. Of 511 patients who underwent TAVR for severe AS, 37(7.3%) underwent PPI after a median duration of 6 (3-7) days, whereas pacemakers were implanted after a median interval of 13 (8-28) days post-SAVR in 10 of 663 patients (P &lt; .001). Pacemaker dependency was observed in 36 (97.3%) patients during 7 days immediately post-TAVR and in 25 (64.9%) patients between 8 and 180 days post-TAVR. Pacemaker dependency occurred after 180 days in 17 (50%) patients with TAVR and in 4 (44.4%) patients with SAVR. Twelve (41.4%) patients were pacemaker-dependent after 365 days post-TAVR. Pacemaker dependency did not differ at 6 months after TAVR vs SAVR. In patients undergoing post-TAVR PPI, 58.6% were not pacemaker-dependent at 1 year after the TAVR procedure

Prevalence, predictors, prognostic significance, and effect of techniques on outcomes of coronary lesion calcification following implantation of drug-eluting stents: a patient-level pooled analysis of stent-specific, multicenter, prospective IRIS-DES registries

Aims There is limited information on the clinical relevance and procedural impact of coronary artery calcification (CAC) in the contemporary percutaneous coronary intervention (PCI) setting. This study sought to determine the incidence and clinical significance of procedural techniques on the outcomes in 'real-world' patients with CAC undergoing PCI with drug-eluting stents (DESs). Methods and results Using patient-level data from seven stent-specific, prospective DES registries, we evaluated 17 084 patients who underwent PCI with various DES types between July 2007 and July 2015. The primary outcome was target-vessel failure (TVF), defined as a composite of cardiac death, target-vessel myocardial infarction, or target-vessel revascularization. Outcomes through 3 years (and between 0-1 and 1-3 years) were assessed according to CAC status (none/mild vs. moderate/severe) and stenting technique (predilation or post-dilation). Among 17 084 patients with 22 739 lesions included in the pooled dataset, moderate to severe CAC was observed in 11.3% of patients (10.1% of lesions). Older age, lower BMI, diabetes, hypertension, family history of coronary artery disease, and renal failure were independent predictors of moderate/severe CAC. The presence of moderate/severe CAC was significantly associated with an adjusted risk of TVF at 3 years [hazard ratio, 1.37; 95% confidence interval (CI), 1.19-1.58; P &lt; 0.001]. For severe CAC, optimal lesion preparation with predilation was associated with a lower 3-year rate of TVF (no vs. yes, 22.3 vs. 12.8%), in which the effect of predilation was prominent at the late period of 1-3 years (hazard ratio, 0.28; 95% CI, 0.12-0.69; P = 0.003) than at the early period through 1 year (hazard ratio, 1.16; 95% CI, 0.37-3.71; P = 0.80). However, post-dilation (with a high-pressure noncompliant balloon) had no effect on the outcome. Conclusions In this study, moderate/severe CAC was common (similar to 10%) and strongly associated with TVF during 3 years of follow-up. For severe CAC, optimal lesion preparation with pre-balloon dilation has a significant effect on long-term outcomes, especially during the late period beyond 1 year. Clinical Trial Registration - URL: http://www.clinicaltrials.gov. Unique identifier: NCT01186133. Coron Artery Dis 32: 42-50 Copyright (c) 2020 Wolters Kluwer Health, Inc. All rights reserved

Comparison of simple versus complex stenting in patients with true distal left main bifurcation lesions

Introduction: Distal left main (LM) bifurcation disease is one of the most challenging lesion subsets for percutaneous coronary intervention (PCI) and optimal stenting strategy for such complex lesions is still debated. This study aimed to compare clinical outcomes following single versus dual stenting for true distal LM bifurcation lesions. Methods: Patients with true distal LM bifurcation lesions (type 1,1,1 or 0,1,1: both left anterior descending and circumflex artery &gt;2.5 mm diameter) receiving PCI with drug-eluting stents (DES) from two large clinical registries were evaluated. The primary outcome was target-lesion failure (TLF), defined as a composite of cardiac death, target-vessel myocardial infarction (MI), or target-lesion revascularization (TLR). Outcomes were compared with the use of propensity scores and inverse probability-weighting adjustment to reduce treatment selection bias. Results: Among 1,002 patients undergoing true distal LM PCI, 440 (43.9%) and 562 (56.1%) were treated with single and dual stents, respectively. The TLF rates at 3 year was 20.3% in the single-stent group and 24.1% in the dual-stenting group (log-rank p = 0.18). The adjusted risk for TLF did not differ significantly between two groups (hazard ratio [HR] with dual-stent vs. single-stent: 1.27, 95% confidence interval [CI]: 0.95?1.71). The adjusted risks for death, MI, repeat revascularization, or stent thrombosis were also similar between the single- and dual-stenting groups. Conclusions: In patients undergoing PCI for true distal LM disease, single- and dual-stent strategies showed a similar adjusted risk of TLF at 3 years. Our findings should be confirmed or refuted through large, randomized clinical trials

Ten-year outcomes of early generation sirolimus- versus paclitaxel-eluting stents in patients with left main coronary artery disease

To compare 10-year outcomes after implantation of sirolimus-eluting stents (SES) versus paclitaxel-eluting stents (PES) for left main coronary artery (LMCA) stenosis. Very long-term outcome data of patients with LMCA disease treated with drug-eluting stents (DES) have not been well described. In 10-year extended follow-up of the MAINCOMPARE registry, we evaluated 778 patients with unprotected LMCA stenosis who were treated with SES (n = 607) or PES (n = 171) between January 2000 and June 2006. The primary composite outcome (a composite of death, myocardial infarction [MI] or target-vessel revascularization [TVR]) was compared with an inverse-probability-of-treatment-weighting (IPTW) adjustment. Clinical events have linearly accumulated over 10 years. At 10 years, there were no significant differences between SES and PES in the observed rates of the primary composite outcome (42.0% vs. 47.4%; hazard ratio [HR] 0.85; 95% confidence interval [CI] 0.66-1.10), and definite stent thrombosis (ST) (1.9% vs. 1.8%; HR 1.02, 95% CI 0.28-3.64). In the IPTW-adjusted analyses, there were no significant differences between SES and PES in the risks for the primary composite outcome (HR 0.89, 95% CI 0.65-1.14) or definite ST (adjusted HR 1.05, 95% CI 0.29-3.90). In patients who underwent DES implantation, high overall adverse clinical event rates (with a linearly increasing event rate over time) were observed during extended follow-up. At 10 years, there were no measurable differences in outcomes between patients treated with SES vs. PES for LMCA disease. The incidence of stent thrombosis was quite low and comparable between the groups

Incidence, Predictors, and Prognostic Impact of Immediate Improvement in Left Ventricular Systolic Function After Transcatheter Aortic Valve Implantation

Immediate improvement in left ventricular ejection fraction (LVEF) following transcatheter aortic valve implantation (TAVI) is common; however, data on the pattern and prognostic value of this improvement are limited. To evaluate the incidence, predictors, and clinical impact of immediate improvement in LVEF, we studied 694 consecutive patient who had underwent successful TAVI for severe aortic stenosis (AS) between March 2010 and December 2019. We defined immediate improvement of LVEF as an absolute increase of &gt;= 5% in LVEF at post-procedure echocardiogram. The primary outcome was major adverse cardiac or cerebrovascular event (MACCE), defined as a composite of death from cardiovascular cause, myocardial infarction, stroke, or rehospitalization from cardiovascular cause. Among them, 160 patients showed immediate improvement in LVEF. The independent predictors of immediate LVEF improvement were absence of hypertension and baseline significant aortic regurgitation, and greater baseline LV mass index. Immediate improvement in LVEF was significantly associated with a lower risk of MACCE (adjusted hazard ratio, 0.48; 95% confidence interval, 0.28-0.81; p = 0.01). In conclusion, approximately one-fourth of patients with severe AS who underwent TAVI showed immediate improvement in LVEF during index hospitalization. Immediate LVEF recovery was associated with a lower risk of MACCE during follow-up. (C) 2021 Elsevier Inc. All rights reserved