Coronary perforation is an undesirable complication during percutaneous coronary intervention (PCI). We reviewed the cases of overt coronary perforation in our institute and analyzed their clinical backgrounds, the characteristics of the target lesion, management, and clinical outcomes. Between 1991 and 2005, we experienced 12 cases (0.35%) of coronary perforation in a total of 3415 PCI procedures. The perforation occurred during the use of debulking devices in 3 cases, immediately after stenting in 2, immediately after postdilatation of the stent in 2, and during wiring in 3 cases. Restoration was attempted by long inflation of a balloon in 7 cases, implantation of a covered stent graft in 1, and emergency surgical repair in 1 case. Subsequent cardiac tamponade occurred in 3 patients who required pericardiocentesis, and 1 patient died due to congestive heart failure. Administration of protamine was effective in stopping the bleeding in 6 patients, whereas continuation of antiplatelet therapy resulted in no overt rebleeding. Coronary perforation during PCI is a rare complication but is associated with significant morbidity and mortality. Intravenous administration of protamine is effective when it is used in conjunction with nonsurgical devices for initial management of perforation.

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Objectives:
To investigate the late outcomes of sirolimus-eluting stent implantation in patients with coronary artery disease.
Background:
Drug-eluting stents reduce intimal hyperplasia, which is the main cause of in-stent restenosis. Sirolimus-eluting stents significantly reduce clinical and angiographic restenosis and improve event-free survival.
Methods:
The study population consisted of 207 patients (273 stents) who had undergone coronary Cypher stent implantation. Patients were eligible for enrollment if there was symptomatic coronary artery disease or positive exercise testing, and angiographic evidence of single or multivessel disease with a target lesion stenosis of ≥ 70% in a ≥ 2.25 mm vessel. Follow-up coronary angiography was performed 18 months after stent deployment. Patients were followed-up for a mean of 24.7 ± 7.4 months.
Results:
All patients survived after stent implantation, but 5 (2.4%) patients experienced acute ST elevation myocardial infarction and 4 (1.9%) patients developed non-Q wave myocardial infarction following angioplasty. Recurrent angina pectoris was observed in 16 (7.7%) patients (11 stable angina pectoris and 5 unstable angina pectoris). Angiographic evidence of restenosis was observed in these 20 (9.66%) patients. The 5 other patients had noncritical angiographic restenosis. Eleven (5.3%) patients underwent angioplasty because of restenosis, and coronary artery bypass grafting was conducted in the other 9 (4.3%) patients.
Conclusion:
The results of the present study indicate that Cypher stents could be implanted with a very high success rate and have encouraging long-term angiographic and clinical results.

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Background:
A reliable, noninvasive assessment of plaque configuration would constitute an important step forward for predicting complications following percutaneous coronary intervention (PCI). Multislice computed tomography (MSCT) holds promise with respect to allowing for differentiation of coronary lesion configuration. However, it has not yet been clarified whether the characteristics of coronary artery plaque measured by MSCT predict complications after PCI. The aim of this study was to investigate the relationship between plaque configuration and complications after coronary intervention in patients with stable angina pectoris.
Methods:
MSCT was performed in patients with angina pectoris who were scheduled for PCI prospectively, and 26 patients (70 ± 11 years, 18 males) with coronary artery plaque in a stenotic coronary artery measured by MSCT were recruited for this study. Thirty-five plaques in the stenotic coronary lesions were divided into 3 groups based on the CT density as soft, intermediate, and hard, and were compared with the complications after PCI.
Results:
The soft plaque group before PCI (n = 11) was significantly associated with the appearance of slow flow (n = 4) or a compromised side branch (n = 1) after PCI, whereas the hard plaque group before PCI (n = 17) was associated with the appearance of dissection (n = 2) or perforation (n = 1) after PCI (P = 0.004). The intermediate plaque group (n = 7) had only one complication, a compromised side branch (n = 1).
Conclusion:
Coronary arterial plaque characterized by MSCT can predict intervention-related complication. It may be important for the risk stratification of the patients scheduled to undergo PCI to investigate plaque configuration by MSCT.

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Second-degree heart block or complete heart block (CHB) is a relatively frequent complication of acute inferior wall myocardial infarction (AIWMI). This study investigated whether the PercuSurge device can prevent procedure-related CHB or can shorten CHB recovery time in patients with AIWMI undergoing primary percutaneous coronary intervention (PCI). Between May 2002 and April 2005, a PercuSurge device was utilized in 113 patients (study population, group 1) with AIWMI due to obstruction of the right coronary artery (RCA) with a reference lumen diameter (RLD) ≥ 3.5 mm.
The control subjects (group 2) consisted of 119 patients who experienced AIWMI due to RCA obstruction with a RLD ≥ 3.5 mm from May 2000 to April 2002. The combined incidence of new onset of CHB following the interventional procedure was significantly higher in group 2 than in group 1. Additionally, recovery time from CHB to first-degree heart block or normal sinus rhythm was remarkably longer in group 2 than in group 1. Furthermore, the duration of hospitalization in group 2 was significantly longer than in group 1. Multiple stepwise analyses demonstrated that the PercuSurge device was the only independent predictor of preventing new onset of CHB during the procedure. Additionally, this mechanical device along with final TIMI-3 flow and final myocardial blush grade ≥ 2 was independently associated with reducing recovery time from CHB. In conclusion, the PercuSurge device can prevent procedure-related CHB and shorten the recovery time for CHB in patients with AIWMI undergoing primary PCI.

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Background:
Our study was planned to investigate the relationship between plasma levels of serum amyloid A protein (SAA) concentrations and the subsequent left ventricular systolic function in patients with acute myocardial infarction (AMI) treated with primary coronary angioplasty.
Methods and Results:
Reperfusion by primary percutaneous coronary intervention was successful in 486 consecutive AMI patients who were admitted within 12 hours of onset. Plasma SAA concentrations were evaluated 24 hours after onset. Left ventricular (LV) function was serially determined by left ventriculography performed in the acute (soon after recanalization) and chronic phases (6 months after onset). (I) There was no significant correlation between SAA concentration and acute phase left ventricular ejection fraction (LVEF) or regional wall motion (RWM). (II) The SAA concentration was significantly correlated with both highly sensitive C-reactive protein (hs-CRP) and the peak-CK value (hs-CRP: r = 0.69, P < 0.0001, peak-CK: r = 0.21, P = 0.0003). (III) SAA was significantly negatively correlated with both LVEF and RWM in the chronic phase (LVEF: r = -0.42, P = 0.001; RWM: r = -0.41, P = 0.007). (IV) The plasma level of SAA also showed a significant negative correlation with the differences in LVEF between the 2 stages (delta-LVEF) (r = -0.43, P = 0.02).
Conclusion:
In the setting of AMI, plasma SAA concentrations may be closely related to subsequent left-ventricular systolic dysfunction.

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The aim of this preliminary, prospective, randomized study was to compare rotation thromboelastography (roTEG) results and D-dimer levels in off-pump versus on-pump coronary surgery in order to identify the activation of fibrinolysis.
Twenty patients scheduled for coronary bypass grafting were assessed (off-pump group A, n = 10; on-pump group B, n = 10). Blood samples for roTEG examination were taken preoperatively (t₀), 15 minutes after sternotomy (t₁), on the completion of peripheral bypass anastomoses (t₂), and at the end of procedures (t₃). The time points for D-dimer levels analyses were before operation, at the end of procedures, and 24 hours later.
A certain degree of roTEG signs of fibrinolysis was noticed at time t₂ in both groups and in group B these marks were quite widely, but not significantly expressed (P for intergroup differences for Lysis on Set Time at 60 and 150 minutes were P = 0.190 and P = 0.122, respectively), borderline differences were found for Maximum Clot Firmness (P = 0.082) with a lower mean value for group B (arithmetic means [95% confidence intervals] - 57.7 [54.2; 61.2] mm). Completely expressed roTEG signs of hyperfibrinolysis were observed in 2 patients from group B. In group B also the highest geometric means of D-dimers (1326.0 [943.5; 1863.6] ng mL^-1) and thus a dramatic intergroup difference (P < 0.001) were observed at the end of surgery; 24 hours later the significantly elevated D-dimer levels in both groups (A: 1070.0 [723.5; 1582.6] versus B: 1093.3 [732.0; 1632.9] ng mL^-1) were equalized (P = 0.932).
Our roTEG results display a slightly greater, but fairly subtle activation of fibrinolysis during the course of cardiopulmonary bypass, compared to off-pump cardiac surgery.

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Objective:
To follow-up and estimate cardiac function in 11 heart failure patients with moderate to severe mitral regurgitation who underwent cardiac resynchronization therapy (CRT) and to compare echocardiography to the rebreathing method (indirect Fick method) which were used for estimation.
Design:
Prospective, observational, clinical study.
Setting:
University teaching hospital.
Methods:
Eleven cases (8 males and 3 females) were selected and followed-up during presurgery, postsurgery, and 1, 3, and 6 months after pacemaker implantation. Stroke volume was measured by echocardiography (Simpson's method and velocity-time integral method) and rebreathing each time.
Results:
Correlations were found between stroke volume with the rebreathing method (RSV) and stroke volume with the velocity-time integral (VSV), R = 0.89, although ANOVA, the q test, and paired t test showed no statistical differences between them. Stroke volume with Simpson's rule (SSV) was poorly correlated with stroke volume using the Indirect Fick method (RSV) and with stroke volume using the velocity-time integral method (VSV) (R = 0.58 and 0.54, respectively).
Conclusion:
The rebreathing method (indirect FICK method) and velocity-time integral method are noninvasive methods with which to measure cardiac function and exhibited good correlation during the follow-up study.

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Background:
In patients with aortic stenosis (AS), the clinical outcome worsens after the development of angina, syncope, and heart failure. This study was performed to elucidate whether the outcome with AS was also poor in patients with diastolic heart failure.
Methods and Results:
Fifty-two patients who had undergone aortic valve replacement (AVR) for AS were retrospectively classified into 3 groups (G) on the basis of LV ejection fraction (EF) and pulmonary wedge pressure (PWP): G-1) normal LVEF, low PWP (EF ≥ 45% and PWP < 16 mmHg; n = 35), G-2) normal LVEF, high PWP (EF ≥ 45% and PWP ≥ 16 mmHg; n = 8), and G-3) low LVEF (EF < 45%; n = 9). Among these 3 groups, we compared the outcome after AVR. None of the patients died after the operation in AS with preserved LVEF irrespective of the PWP, whereas there were 3 cardiac deaths in AS with low EF irrespective of the PWP.
Conclusions:
In patients with AS, diastolic heart failure developed in addition to systolic heart failure. The development of LV systolic dysfunction in AS was regarded as poor during the postoperative course, but diastolic heart failure did not affect the outcome. The occurrence of heart failure with preserved systolic function may have a slightly better prognosis and may still be suitable for AVR.

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Aim:
The aim of the present study was to investigate right ventricular (RV) myocardial textural properties in asymptomatic and symptomatic mitral stenosis (MS) patients with normal RV systolic function using integrated backscatter (IBS).
Methods:
The study included 40 patients with MS of moderate or severe degree. Patients were classified into 2 groups according to NYHA class (asymptomatic group, NYHA class I, symptomatic group, NYHA class II-III). RV pulsed-wave tissue Doppler imaging (TDI) and IBS analyses were performed in all patients. Isovolumic contraction time (IVCT), systolic wave velocity (S), isovolumic relaxation time (IVRT), early diastolic wave velocity (E), and late diastolic wave velocity (A) were measured by TDI. IBS amplitude (IB) and cyclic variation (CV) of the RV lateral wall in the parasternal long-axis view were measured by IBS. CV was calculated by subtracting systolic IB from diastolic IB.
Results:
IVRT (54.2 ± 11.9 ms versus 86.2 ± 16.2 ms, P < 0.001) and A wave amplitude (10.2 ± 2.1 cm/s versus 13.6 ± 1.8 cm/s, P < 0.05) were higher whereas E wave amplitude (11.7 ± 1.6 cm/s and 10.3 ± 1.5 cm/s, P < 0.05) and E/A ratio (1.3 ± 0.3 versus 0.7 ± 0.1, P < 0.001) were lower in group 2. Symptomatic patients had a lower CV value of RV (9.5 ± 3.4 dB versus 6.7 ± 1.9 dB, P = 0.004). There was a positive correlation between CV and E/A (r = 0.964, P < 0.001)
Conclusion:
Symptomatic isolated MS patients had RV echo texture changes and diastolic dysfunction in comparison to asymptomatic ones with similar mitral valve areas in the presence of normal RV systolic function. In isolated MS, both pulsed-wave TDI and IBS may aid in the detection of RV diastolic pathology.

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Diastolic heart failure affects approximately 40%-50% of patients presenting with signs and symptoms of heart failure. The aim of this study was to investigate the relationship between brain natriuretic peptide (BNP) levels and functional capacity in patients admitted with dyspnea and diagnosed with isolated diastolic dysfunction.
Fifty-four patients (mean age, 57.4 ± 8.5 years) with class-2 dyspnea with isolated diastolic dysfunction were enrolled. Serum levels of BNP were measured, and peak oxygen consumption (peak VO₂), anaerobic threshold (AT), and metabolic equivalent (MET) values were determined with a cardiopulmonary exercise test (CPET).
There was a negative correlation between BNP levels and exercise duration (P < 0.05, r = -0.304), AT (P < 0.05, r = -0.380), and number of MET (P < 0.05, r = -0.322) determined by CPET. When patients were divided into 2 groups according to BNP levels; BNP ≤ 50 pg/mL (n = 40) versus BNP > 50 pg/mL (n = 14) and analyzed, those with BNP levels > 50 pg/mL had lower peak VO₂ (P = 0.05) and anaerobic threshold (P = 0.01) compared with patients with BNP ≤ 50 pg/mL.
The results suggest that BNP levels provide an indication about the functional capacity determined by CPET in patients admitted with dyspnea and isolated diastolic dysfunction.

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Patients with hypothyroidism have an increased risk of coronary artery disease because of significant changes in lipid metabolism and arterial hypertension. We report a 67-year-old man who developed acute myocardial infarction following hormone replacement in hypothyroidism in spite of no previous cardiac symptoms and no ischemia in intravenous dipyridamole myocardial perfusion imaging. Careful examination for ischemic heart disease should be performed before hormone replacement in hypothyroidism.

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We report a patient with a snake-shaped, mobile mass in the right atrium. The mass was determined to be an elongated Eustachian valve which was a persistent part of the embryologic valve of the sinus venosus.

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Mechanical alternans is observed in patients with severe left ventricular dysfunction. We report a case of dilated cardiomyopathy with mechanical alternans. He presented with a remarkable decrease in plasma brain natriuretic peptide (BNP) levels after β-blocker therapy despite persistency of the mechanical alternans. Mechanical alternans may persist after improvement of hemodynamics, diastolic function, and plasma BNP levels. Mechanical alternans may reflect persistent organic or functional myocardial damage such as abnormal intracellular Ca²⁺ cycling in cardiomyocytes.

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A 69-year-old man had been suffering from recurrent syncope induced by laughter since the age of 58. His syncope was reproduced by head-up tilt testing with isoproterenol infusion and we concluded that his laughter-induced syncope was one type of neurally mediated syndrome (NMS). His daughter also had NMS and her syncope was treated with propranolol. Propranolol and midodrine hydrochloride, an alpha₁-adrenergic stimulant, were effective at preventing his laughter-induced syncope. This is a case report of laughter-induced syncope with a familial predisposition successfully treated with the combination of the nonselective beta-blocker propranolol and the alpha₁-stimulator midodrine.

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