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1.  Mitochondrial DNA 4977bp Deletion Mutation in Peripheral Blood Reflects Atrial Remodeling in Patients with Non-Valvular Atrial Fibrillation 
Yonsei Medical Journal  2014;56(1):53-61.
Purpose
Recently, mitochondrial DNA 4977bp deletion (mtDNA4977-mut), a somatic mutation related to oxidative stress, has been shown to be associated with atrial fibrillation (AF). We hypothesized that patient age, as well as electroanatomical characteristics of fibrillating left atrial (LA), vary depending on the presence of mtDNA4977-mut in peripheral blood among patients with non-valvular AF.
Materials and Methods
Analyzing clinical and electroanatomical characteristics, we investigated the presence of the mtDNA4977-mut in peripheral blood of 212 patients (51.1±13.2 years old, 83.5% male) undergoing catheter ablation for non-valvular AF, as well as 212 age-matched control subjects.
Results
The overall frequency of peripheral blood mtDNA4977-mut in patients with AF and controls was not significantly different (24.5% vs. 19.3%, p=0.197). When the AF patient group was stratified according to age, mtDNA4977-mut was more common (47.4% vs. 20.0%, p=0.019) in AF patients older than 65 years than their age-matched controls. Among AF patients, those with mtDNA4977-mut were older (58.1±11.9 years old vs. 48.8±11.9 years old, p<0.001). AF patients positive for the mtDNA mutation had greater LA dimension (p=0.014), higher mitral inflow peak velocity (E)/diastolic mitral annular velocity (Em) ratio (p<0.001), as well as lower endocardial voltage (p=0.035), and slower conduction velocity (p=0.048) in the posterior LA than those without the mutation. In multivariate analysis, E/Em ratio was found to be significantly associated with the presence of mtDNA4977-mut in peripheral blood.
Conclusion
mtDNA4977-mut, an age-related somatic mutation detected in the peripheral blood, is associated with advanced age and electro-anatomical remodeling of the atrium in non-valvular AF.
doi:10.3349/ymj.2015.56.1.53
PMCID: PMC4276778  PMID: 25510747
Atrial fibrillation; mitochondrial DNA; 4977bp deletion mutation; atrial remodeling
2.  Histological and Biochemical Comparisons between Right Atrium and Left Atrium in Patients with Mitral Valvular Atrial Fibrillation 
Korean Circulation Journal  2014;44(4):233-242.
Background and Objectives
It has been known that the dominant driver of atrial fibrillation (AF) exists in the left atrium (LA) and the incidence of systemic thromboembolism is higher than that of pulmonary thromboembolism in patients with AF. Therefore, we hypothesized that histological and biochemical characteristics of the LA and the right atrium (RA) are different in patients with mitral valvular AF.
Subjects and Methods
We analyzed the histology and messenger ribonucleic acid (mRNA) or protein expression associated with endothelial function and thrombogenesis in 33 human atrial appendage tissues (20 LA tissues, 13 RA tissues) taken from 25 patients {57.7±11.3 years old, 44% males, AF: sinus rhythm (SR)=17:8} with mitral valve disease. We also performed whole mRNA quantification in 8 tissues (both LA and RA tissues from 4 patients) by using next generation sequencing (NGS).
Results
1) The degree of fibrosis (p=0.001) and subendocardial smooth muscle thickness (p=0.004) were significantly greater in the LA than in the RA. 2) More advanced matrix fibrosis was found in the LA of patients with AF than in the LA of patients with SR (p=0.046), but not in the RA. 3) There was no LA-RA difference in protein (Western blot) and mRNA {quantitative real-time polymerase chain reaction (qRT-PCR)} expressions of NF-κB, 3-NT, CD31, E-selectin, inducible NO synthase, stromal cell-derived factor-1α, Endothelin-1, platelet-derived growth factor, myeloperoxidase, or NCX, except for higher mRNA expression of HCN4 in the RA (qRT-PCR, p=0.026) and that of KCNN1 in the LA (NGS, p=0.016).
Conclusion
More advanced matrix and subendocardial remodeling were noticed in the LA than in the RA in patients with mitral valvular AF. However, the expressions of tissue factors associated with thrombogenesis were not significantly different between the RA and the LA.
doi:10.4070/kcj.2014.44.4.233
PMCID: PMC4117844  PMID: 25089135
Atrial fibrillation; Mitral valve disease; Fibrosis; Subendocardium
3.  Endovascular Repair of Aortoiliac Aneurysm Using Bifurcated Stent Grafts with Sandwich Technique for Preserving the Internal Iliac Artery 
Korean Circulation Journal  2013;43(9):628-631.
In this case, we describe a case of a 76-year-old male with extensive aortoiliac aneurysms treated by endovascular aneurysm repair using the sandwich technique in order to preserve left internal iliac artery perfusion. The sandwich technique refers to the deployment of multiple paralleled stent grafts into main distal and side branches in overlapping with a single proximal stent graft. The procedure was successfully performed without complications. Post-procedural CT angiography demonstrated patent stent grafts without any endoleak. The strengths and limitations of the sandwich technique need to be investigated in large-scale, long-term clinical trials.
doi:10.4070/kcj.2013.43.9.628
PMCID: PMC3808859  PMID: 24174964
Endovascular procedures; Stents; Aortic aneurysm; Iliac; Aneurysm
4.  A Case of Abdominal Aortic Aneurysm with Short Angulated Proximal Neck Treated with the Chimney Graft Technique 
Korean Circulation Journal  2013;43(6):416-421.
Endovascular aneurysm repair (EVAR) using stent grafts has shown to be an effective alternative to surgical repair in treating an abdominal aortic aneurysm (AAA). EVAR is associated with shorter hospital stays, less blood loss, shorter operating times, and lower early morbidity and mortality compared to open surgical repair, although EVAR required a higher reintervention rate during a longer follow-up period. However, short or severely an angulated infrarenal proximal aortic neck is considered unsuitable for EVAR. The chimney graft technique is a modified procedure based on the deployment of a covered or bare-metal stent parallel to the main aortic endograft within the aneurysm, thereby creating a conduit that runs outside the aortic main endograft to preserve flow to the aortic branches. In this case report, we present a 78-year-old patient with an AAA with a short and severely angulated proximal neck who was successfully treated by EVAR using the chimney graft technique.
doi:10.4070/kcj.2013.43.6.416
PMCID: PMC3717426  PMID: 23882292
Aortic aneurysm, abdominal; Endovascular techniques
5.  Hybrid Treatment for Thoracic Aortic Aneurysm Combined with Aberrant Right Subclavian Artery 
Korean Circulation Journal  2013;43(1):66-69.
An aberrant right subclavian artery (ARSA) is the most common vascular abnormality of the aortic arch and is associated with development of aneurysms in 3-8% of these anomalies. In this case report, we describe an 84-year-old man with a symptomatic ARSA treated with staged hybrid procedure combining surgical replacement of the ascending aorta and bilateral carotid-to-subclavian artery bypass with implantation of a stent graft in the aortic arch and descending aorta. Our case suggests that a less invasive hybrid therapy can be performed successfully for the treatment of ARSA with aneurysmal change in patients at high surgical risk.
doi:10.4070/kcj.2013.43.1.66
PMCID: PMC3569571  PMID: 23407812
Aberrant right subclavian artery; Aortic aneurysm, thoracic; Endovascular procedures
6.  Serial Plasma Levels of Angiogenic Factors in Patients With ST-Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention 
Korean Circulation Journal  2012;42(7):464-470.
Background and Objectives
Patients with acute myocardial infarction show varying degrees of collateral development. However, the relationships between angiogenic factors and degree of collaterals are not well known.
Subjects and Methods
Fifty-nine patients (mean age, 59±10 years) with ST-segment elevation myocardial infarction (STEMI) underwent primary percutaneous coronary intervention (PCI). Patients were divided into one of 2 groups: group I (Rentrop collateral grade 0/1, n=34) or group II (grade 2/3, n=25). Plasma levels of vascular endothelial growth factor (VEGF), soluble VEGF receptor (sFlt-1), angiopoietin (Ang)-2, and soluble Tie-2 at baseline, 24 and 48 hours after PCI were measured.
Results
There were fewer diabetic patients and higher incidence of previous angina and multi-vessel disease in group II. Group II had a lower left ventricular ejection fraction and a trend toward longer pain-to-balloon time. Plasma levels of Ang-2, sFlt-1 were elevated prior to primary PCI and decreased after PCI, whereas plasma level of VEGF was relatively low initially, however rose after PCI. sTie-2 levels showed no significant interval change in group I, but decreased over time in group II. VEGF, sFlt-1, and Tie-2 levels did not differ between the groups at each time point. However, plasma levels of Ang-2 were higher in group I than in group II at baseline and at 48 hours.
Conclusion
Presence of collaterals in STEMI patients undergoing primary PCI was associated with lesser rise in Ang-2 plasma level. VEGF showed a delayed response to acute ischemia compared to Ang-2. Clinical implications of our findings need to be investigated in further studies.
doi:10.4070/kcj.2012.42.7.464
PMCID: PMC3409395  PMID: 22870080
Myocardial infarction; Angiogenesis modulating agents; Vascular endothelial growth factor; Angiopoietin-2
7.  Effects of Combination Therapy with Celecoxib and Doxycycline on Neointimal Hyperplasia and Inflammatory Biomarkers in Coronary Artery Disease Patients Treated with Bare Metal Stents 
Yonsei Medical Journal  2011;53(1):68-75.
Purpose
Cyclooxygenase (COX)-2 and matrix metalloproteinase (MMP)-9 play a key role in the pathogenesis of in-stent restenosis. We investigated the effect of a short-term therapy of celecoxib, a COX-2 inhibitor, with or without doxycycline, an MMP inhibitor, after coronary stenting on inflammatory biomarkers and neointimal hyperplasia.
Materials and Methods
A total of 75 patients (86 lesions) treated with bare metal stents were randomized into three groups: 1) combination therapy (200 mg celecoxib and 20 mg doxycycline, both twice daily), 2) celecoxib (200 mg twice daily) only, and 3) non-therapy control. Celecoxib and doxycycline were administered for 3 weeks after coronary stenting. The primary endpoint was neointimal volume obstruction by intravascular ultrasound (IVUS) at 6 months. The secondary endpoints included clinical outcomes, angiographic data, and changes in blood levels of inflammatory biomarkers.
Results
Follow-up IVUS revealed no significant difference in the neointimal volume obstruction among the three treatment groups. There was no difference in cardiac deaths, myocardial infarctions, target lesion revascularization or stent thrombosis among the groups. Blood levels of high-sensitivity C-reactive protein, soluble CD40 ligand, and MMP-9 varied widely 48 hours and 3 weeks after coronary stenting, however, they did not show any significant difference among the groups.
Conclusion
Our study failed to demonstrate any beneficial effects of the short-term therapy with celecoxib and doxycycline or with celecoxib alone in the suppression of inflammatory biomarkers or in the inhibition of neointimal hyperplasia. Large scale randomized trials are necessary to define the role of anti-inflammatory therapy in the inhibition of neointimal hyperplasia.
doi:10.3349/ymj.2012.53.1.68
PMCID: PMC3250318  PMID: 22187234
Celecoxib; coronary artery disease; coronary stent; neointimal hyperplasia; inflammation
9.  Endovascular Treatment of Isolated Common Iliac Artery Aneurysms With Short Necks Using Bifurcated Stent-Grafts 
Korean Circulation Journal  2010;40(7):343-347.
Elective surgical repair has traditionally been considered to be the treatment of choice for the exclusion of isolated iliac artery aneurysms (IAAs). Recently, endovascular repair has evolved as an alternative to surgical repair, especially in patients at high surgical risk. However, in the absence of sufficient proximal necks, iliac artery aneurysms are not suitable for direct deployment of a tubular-shaped endograft. Here we report two cases of IAAs with short proximal necks that were excluded using an endovascular bifurcated stent-graft. The bifurcated stent-graft was successfully deployed with complete exclusion of the aneurysm. In neither case was there evidence of procedural failures. There were no signs of significant complications. We conclude that endovascular repair of IAAs with short proximal necks is feasible and efficient using an endovascular bifurcated stent-graft.
doi:10.4070/kcj.2010.40.7.343
PMCID: PMC2910292  PMID: 20664744
Iliac aneurysm; Stent; Endoluminal repair
10.  Acute Myocardial Infarction due to Polyarteritis Nodosa in a Young Female Patient 
Korean Circulation Journal  2010;40(4):197-200.
Coronary artery aneurysms are uncommon, are usually associated with atherosclerosis, and rarely involve all three major coronary arteries. The present report describes a rare case of a young female patient presenting with acute myocardial infarction (AMI). Coronary angiography revealed multiple severe aneurysmal and stenotic changes. Based on clinical feature and angiographic findings, it was strongly suspected that the patient had polyarteritis nodosa (PAN) complicated by AMI. The patient was treated with standard cardiac medications and immunosuppressive agents and has remained stable without further complications during a follow-up period of 6 months.
doi:10.4070/kcj.2010.40.4.197
PMCID: PMC2859338  PMID: 20421961
Coronary aneurysm; Myocardial infarction; Polyarteritis nodosa; Vasculitis
11.  Impact of Statin Treatment on Strut Coverage after Drug-Eluting Stent Implantation 
Yonsei Medical Journal  2014;56(1):45-52.
Purpose
To evaluate the effect of statin treatment on strut coverage after drug-eluting stent (DES) implantation.
Materials and Methods
In this study, 60 patients were randomly assigned to undergo sirolimus-eluting stent (SES) or biolimus-eluting stent (BES) implantation, after which patients were randomly treated with pitavastatin 2 mg or pravastatin 20 mg for 6 months. The degree of strut coverage was assessed by 6-month follow-up optical coherence tomography, which was performed in 52 DES-implanted patients.
Results
The percentages of uncovered struts were 19.4±14.7% in pitavastatin-treated patients (n=25) and 19.1±15.2% in pravastatin-treated patients (n=27; p=0.927). A lower percentage of uncovered struts was significantly correlated with a lower follow-up low-density lipoprotein (LDL) cholesterol level (r=0.486; p=0.009) and a greater decline of the LDL cholesterol level (r=-0.456; p=0.015) in SES-implanted patients, but not in BES-implanted patients. In SES-implanted patients, the percentage of uncovered struts was significantly lower among those with LDL cholesterol levels of less than 70 mg/dL after 6 months of follow-up (p=0.025), but no significant difference in this variable according to the follow-up LDL cholesterol level was noted among BES-implanted patients (p=0.971).
Conclusion
Lower follow-up LDL cholesterol levels, especially those less than 70 mg/dL, might have a protective effect against delayed strut coverage after DES implantation. This vascular healing effect of lower LDL cholesterol levels could differ according to the DES type.
doi:10.3349/ymj.2015.56.1.45
PMCID: PMC4276777  PMID: 25510746
Stent; optical coherence tomography; statin
12.  Serial Changes of Neointimal Tissue after Everolimus-Eluting Stent Implantation in Porcine Coronary Artery: An Optical Coherence Tomography Analysis 
BioMed Research International  2014;2014:851676.
Purposes. The serial changes in neointimal tissues were compared between everolimus-eluting stent (EES) and bare-metal stent (BMS) in the porcine coronary artery using optical coherence tomography (OCT). Methods. Serial (1, 3, and 6 month follow-up after stent implantation) OCT examinations were performed in 15 swine with 15 BMS- and 15 EES-treated lesions in porcine coronary arteries. Results. In BMS-implanted lesions, neointimal volume decreased from 7.3 mm3 to 6.9 mm3 and 6.4 mm3 at 1, 3, and 6 months follow-up without statistical significance (P = 0.369). At the time points of 1, 3, and 6 months, neointimal tissue appearance was mainly a homogeneous pattern (80.0%, 93.3%, and 100%, resp.), while the other pattern was layered. In contrast, in EES-implanted lesions, neointimal volume significantly increased from 4.8 mm3 to 9.8 mm3 between 1 and 3 months but significantly decreased to 8.6 mm3 between 3 and 6 months (P < 0.001). Between 1 and 3 months, the layered pattern of neointimal tissue increased from 26.7% to 66.7% but decreased to 20.0% between 3 and 6 months. Conclusions. EES had a biphasic pattern of neointimal amounts that correlated with changes in neointimal morphology.
doi:10.1155/2014/851676
PMCID: PMC4182891  PMID: 25309929
13.  Multidisciplinary Team Approach for Identifying Potential Candidate for Transcatheter Aortic Valve Implantation 
Yonsei Medical Journal  2014;55(5):1246-1252.
Purpose
We sought to evaluate the clinical usefulness of decision making by a multidisciplinary heart team for identifying potential candidates for transcatheter aortic valve implantation (TAVI) in patients with symptomatic severe aortic stenosis.
Materials and Methods
The multidisciplinary team consisted of two interventional cardiologists, two cardiovascular surgeons, one cardiac imaging specialist, and two cardiac anesthesiologists.
Results
Out of 60 patients who were screened as potential TAVI candidates, 31 patients were initially recommended as appropriate for TAVI, and 20 of these 31 eventually underwent TAVI. Twenty-two patients underwent surgical aortic valve replacement (AVR), and 17 patients received only medical treatment. Patients who underwent TAVI and medical therapy were older than those who underwent surgical AVR (p<0.001). The logistic Euroscore was significantly highest in the TAVI group and lowest in the surgical AVR group (p=0.012). Most patients in the TAVI group (90%) and the surgical AVR group (91%) had severe cardiac symptoms, but only 47% in the medical therapy group had severe symptoms. The cumulative percentages of survival without re-hospitalization or all-cause death at 6 months for the surgical AVR, TAVI, and medical therapy groups were 84%, 75%, and 28%, respectively (p=0.007, by log-rank).
Conclusion
TAVI was recommended in half of the potential candidates following a multidisciplinary team approach and was eventually performed in one-third of these patients. One-third of the patients who were initially considered potential candidates received surgical AVR with favorable clinical outcomes.
doi:10.3349/ymj.2014.55.5.1246
PMCID: PMC4108808  PMID: 25048481
Endovascular procedures; aortic stenosis; clinical outcomes
14.  Transcatheter Aortic Valve Implantation in a Patient with Previous Mitral Valve Replacement 
Korean Circulation Journal  2014;44(5):344-347.
Transcatheter aortic valve implantation (TAVI) has shown favorable outcomes in patients with severe symptomatic aortic valve stenosis who are at high surgical risk or are unsuitable candidates for open heart surgery. However, concerns exist over treating patients who have previously undergone mitral valve surgery due to the potential interference between the mitral prosthetic valve or ring and the TAVI device. In this case report, we present a patient with symptomatic severe aortic stenosis and previous mechanical mitral valve replacement who was successfully treated with TAVI using a CoreValve.
doi:10.4070/kcj.2014.44.5.344
PMCID: PMC4180612  PMID: 25278988
Aortic valve stenosis; Catheters; Heart valve prosthesis; Prosthesis implantation; Mitral valve
15.  Optical Coherence Tomographic Observation of Morphological Features of Neointimal Tissue after Drug-Eluting Stent Implantation 
Yonsei Medical Journal  2014;55(4):944-952.
Purpose
The impacts of different time courses and the degree of neointimal growth on neointimal morphology have not yet been sufficiently investigated. Therefore, we evaluated the morphological features of neointimal tissue after drug-eluting stent (DES) implantation using optical coherence tomography (OCT).
Materials and Methods
The morphological features of neointimal tissue in stented segments with a maximal percentage of cross-sectional area (CSA) stenosis of neointima were evaluated in 507 DES-treated lesions with >100 µm mean neointimal thickness on follow-up OCT. Neointimal tissue was categorized as homogeneous, heterogeneous, layered, or neoatherosclerotic.
Results
In lesions with <50% of neointimal CSA stenosis, homogeneous neointima (68.2%) was predominant, followed by heterogeneous neointima (14.1%) and layered neointima (14.1%). In lesions with ≥50% of neointimal CSA stenosis, layered neointima was most frequently observed (68.3%), followed by neoatherosclerotic neointima (25.2%). In subgroup analysis of lesions with ≥50% of neointimal CSA stenosis, 89.5% of the lesions with a stent age <30 months were layered neointima, while 62.3% of the lesions with a stent age ≥30 months were neoatherosclerotic neointima.
Conclusion
This study suggests that the OCT-detected morphology of DES neointimal tissue was different according to the follow-up time course and degree of neointimal hyperplasia.
doi:10.3349/ymj.2014.55.4.944
PMCID: PMC4075398  PMID: 24954322
Optical coherence tomography; stent; coronary artery disease
16.  Comparison of Full Lesion Coverage versus Spot Drug-Eluting Stent Implantation for Coronary Artery Stenoses 
Yonsei Medical Journal  2014;55(3):584-591.
Purpose
The aim of this study was to evaluate and compare the long-term clinical outcomes of the spot drug-eluting stent (DES) implantation strategy, which is used to minimize implanted stent length and the number of stents, versus full lesion coverage for treatment of coronary artery stenoses.
Materials and Methods
We evaluated 1-year clinical outcomes of 1619 patients with stent implantation for a single coronary lesion. They were divided into two groups: those treated by full lesion coverage (n=1200) and those treated with the spot stenting strategy (n=419). The combined occurrence of 1-year target vessel failure (TVF), including cardiac death, target-vessel related myocardial infarction, or ischemia-driven target-vessel revascularization was evaluated.
Results
The spot DES implantation group had a shorter stent length (23.14±9.70 mm vs. 25.44±13.24 mm, respectively; p<0.001) and a fewer number of stents (1.09±0.30 vs. 1.16±0.41, respectively; p<0.001), even though the average lesion length was similar to the full lesion coverage group (21.36±10.30 mm vs. 20.58±10.97 mm, respectively; p=0.206). Spot DES implantation was superior to full DES coverage with respect to 1-year TVF (1.4% vs. 3.3%, p=0.044). Cox proportional hazard model analysis showed that the risk for 1-year TVF was almost 60% lower among patients who received spot DESs compared to those who received full DES coverage after adjustment for other risk factors (HR=0.40, 95% confidence interval=0.17-0.98; p=0.046).
Conclusion
Minimizing stent length and the number of stents with overlapping by spot DES implantation may result in reduced rates of 1-year TVF, compared with full DES coverage.
doi:10.3349/ymj.2014.55.3.584
PMCID: PMC3990086  PMID: 24719123
Drug-eluting stents; percutaneous coronary intervention; coronary artery disease
17.  Retrograde Distal Superficial Femoral Artery Approach in the Supine Position for Chronic Superficial Femoral Artery Occlusion 
Korean Circulation Journal  2014;44(3):184-188.
Subintimal angioplasty is an effective method for the treatment of long superficial femoral artery (SFA) occlusions. One of the major limiting factors for the success of this procedure is the failure to re-enter the true lumen. The recently introduced luminal re-entry devices provide a high technical success rate, but failures can occur. In such cases, a retrograde popliteal approach can serve as a potential backup option. However, the need to reposition the patient remains a drawback. Here, we report a case of an 81-year-old male with a long SFA occlusion treated using a retrograde distal SFA approach in the supine position after the initial failure of antegrade angioplasty.
doi:10.4070/kcj.2014.44.3.184
PMCID: PMC4037641  PMID: 24876860
Peripheral arterial disease; Femoral artery; Angioplasty
18.  Prospective and Systematic Analysis of Unexpected Requests for Non-Cardiac Surgery or Other Invasive Procedures during the First Year after Drug-Eluting Stent Implantation 
Yonsei Medical Journal  2014;55(2):345-352.
Purpose
Unexpected requests for non-cardiac surgery requiring discontinuation of dual antiplatelet therapy (DAPT) frequently occur in daily clinical practice. The objectives of this study were to evaluate prevalence, timing and clinical outcomes of such unexpected requests for non-cardiac surgery or other invasive procedures during the first year after drug-eluting stents (DESs) implantation.
Materials and Methods
We prospectively investigated the prevalence, timing and clinical outcomes of unexpected requests for non-cardiac surgery or other procedures during the first year after DESs implantation in 2117 patients.
Results
The prevalence of requested non-cardiac surgery or invasive procedures was 14.6% in 310 requests and 12.3% in 261 patients. Among 310 requests, those were proposed in 11.3% <1 month, 30.0% between 1 and 3 months, 36.8% between 4 and 6 months and 21.9% between 7 and 12 months post-DES implantation. The rates of actual discontinuation of DAPT and non-cardiac surgery or procedure finally performed were 35.8% (111 of 310 requests) and 53.2% (165 of 310 requests), respectively. On multivariate regression analysis, the most significant determinants for actual discontinuation of DAPT were Endeavor zotarolimus-eluting stent implantation with 3-month DAPT (OR=5.54, 95% CI 2.95-10.44, p<0.001) and timing of request (OR=2.84, 95% CI 1.97-4.11, p<0.001). There were no patients with any death, myocardial infarction, or stent thrombosis related with actual discontinuation of DAPT.
Conclusion
Those unexpected requests with premature discontinuation of DAPT were relatively common and continuously proposed during the first year following DES implantation. No death, myocardial infarction or stent thrombosis occurred in patients with actual discontinuation of DAPT.
doi:10.3349/ymj.2014.55.2.345
PMCID: PMC3936620  PMID: 24532502
Antiplatelet therapy; drug-eluting stents; coronary artery disease
19.  Prognostic Usefulness of Metabolic Syndrome Compared with Diabetes in Korean Patients with Critical Lower Limb Ischemia Treated with Percutaneous Transluminal Angioplasty 
Yonsei Medical Journal  2013;55(1):46-52.
Purpose
Metabolic syndrome (MS) is a clinical condition that shares many common characteristics with diabetes. However, unlike diabetes, the usefulness of MS as a prognostic entity in peripheral arterial disease is uncertain. This study evaluated the prognostic usefulness of MS in critical lower limb ischemia (CLI) patients.
Materials and Methods
We compared the 2-year clinical outcomes in 101 consecutive CLI patients (66±14 years; 78% men) with 118 affected limbs treated with percutaneous transluminal angioplasty (PTA) according to the presence of MS and diabetes.
Results
The number of MS patients was 53 (52%), of which 45 (85%) had diabetes. During a 2-year follow-up, the incidence of clinical outcomes, including reintervention, major amputation, minor amputation, and survival, was not significantly different between MS and non-MS patients; however, the incidence of minor amputation was significantly higher in diabetic than in non-diabetic patients (42% vs. 17%; p=0.011). Cox regression analysis for the 2-year primary patency demonstrated no association between MS and 2-year primary patency [hazard ratio (HR), 1.02; 95% confidence interval (CI), 0.45-2.30; p=0.961], whereas there was a significant association between diabetes and 2-year primary patency (HR, 2.81; 95% CI, 1.02-7.72; p=0.046). Kaplan-Meier analysis revealed no significant difference in the 2-year primary patency between MS and non-MS patients; however, the 2-year primary patency was lower in diabetic than in non-diabetic patients (p=0.038).
Conclusion
As a prognostic concept, MS might conceal the adverse impact of diabetes on the prognosis of CLI patients treated with PTA.
doi:10.3349/ymj.2014.55.1.46
PMCID: PMC3874905  PMID: 24339286
Metabolic syndrome; diabetes; critical limb ischemia; angioplasty
21.  Comparison of Early Clinical Results of Transcatheter versus Surgical Aortic Valve Replacement in Symptomatic High Risk Severe Aortic Stenosis Patients 
Background
Transcatheter aortic valve implantation (TAVI) has been an alternative to conventional aortic valve replacement (AVR) in old and high risk patients. The goal of this study is to compare the early outcomes of conventional AVR vs. TAVI in high risk severe AS patients.
Methods
From January 2008 to July 2012, 44 high risk severe aortic stenosis patients underwent conventional AVR, and 15 patients underwent TAVI. We compared echocardiographic data, periprocedural complication, and survival. The mean follow-up duration was 14.5±10 months (AVR), and 6.8±3.5 months (TAVI), respectively.
Results
AVR group was younger (78.2±2.4 years vs. 82.2±3.0 years, p<0.001) and had lower operative risk (Euroscore: 9.4±2.7 vs. 11.0±2.0, p=0.044) than TAVI group. There was no significant difference in early mortality (11.4% vs. 13.3%, p=0.839), and 1 year survival (87.4%±5.3% vs. 83.1%±1.1%, p=0.805). There was no significant difference in postoperative functional class. There was no significant difference in periprocedural complication except vascular complication (0% [AVR] vs. 13.3% [TAVI], p=0.014). TAVI group had more moderate and severe paravalvular leakage.
Conclusion
In this study, both groups had similar periprocedural morbidity, and mortality. However, TAVI group had more greater than moderate paravalvular leakage, which can influence long-term outcome. Since more patients are treated with TAVI even in moderate risk, careful selection of the patients and appropriate guideline need to be established.
doi:10.5090/kjtcs.2013.46.5.346
PMCID: PMC3810556  PMID: 24175269
Aortic valve stenosis; Aortic valve, surgery; Transcatheter aortic valve implantation
22.  Preventive Effect of Pretreatment with Intravenous Nicorandil on Contrast-Induced Nephropathy in Patients with Renal Dysfunction Undergoing Coronary Angiography (PRINCIPLE Study) 
Yonsei Medical Journal  2013;54(4):957-964.
Purpose
To investigate the effect of pretreatment with intravenous nicorandil on the incidence of contrast-induced nephropathy (CIN) in patients with renal dysfunction undergoing coronary angiography.
Materials and Methods
This randomized controlled multicenter study enrolled a total of 166 patients (nicorandil n=81; control n=85) with an estimated glomerular filtration rate <60 mL/min. Nicorandil 12 mg dissolved in 100 mL of 0.9% saline was administered intravenously for 30 minutes just prior to coronary angiography in the nicorandil group. The same volume of only saline was given to the control group. The primary end-point was the incidence of CIN, defined as >0.5 mg/dL increase or >25% rise in serum creatinine (SCr) concentration within 48 hours of contrast exposure compared to baseline.
Results
The final analysis included 149 patients (nicorandil n=73; control n=76). The baseline characteristics and the total volume of the used contrast (Iodixanol, 125.6±69.1 mL vs. 126.9±74.6 mL, p=0.916) were similar between the two groups. The incidence of CIN also did not differ between the nicorandil and control groups (6.8% vs. 6.6%, p=0.794). There was no difference between the two groups in the relative change in SCr from baseline to peak level within 48 hours after coronary angiography (-1.58±24.07% vs. 0.96±17.49%, p=0.464), although the nicorandil group showed less absolute change in SCr than the control group (-0.01±0.43 mg/mL vs. 0.02±0.31 mg/mL, p=0.005).
Conclusion
Prophylactic intravenous infusion of nicorandil did not decrease the incidence of CIN in patients with renal dysfunction undergoing coronary angiography.
doi:10.3349/ymj.2013.54.4.957
PMCID: PMC3663233  PMID: 23709432
Contrast media; acute kidney injury; coronary artery disease
23.  Comparison of Early Clinical Outcomes Following Transcatheter Aortic Valve Implantation versus Surgical Aortic Valve Replacement versus Optimal Medical Therapy in Patients Older than 80 Years with Symptomatic Severe Aortic Stenosis 
Yonsei Medical Journal  2013;54(3):596-602.
Purpose
Transcatheter aortic valve implantation (TAVI) has become an attractive therapeutic strategy for severe aortic stenosis (AS) in elderly patients due to its minimally-invasive nature. Therefore, early results of its clinical outcomes in elderly Korean patients were evaluated.
Materials and Methods
We compared early clinical outcomes of TAVI, surgical aortic valve replacement (SAVR), and optimal medical therapy (OMT) in patients aged ≥80 years with symptomatic severe AS. Treatment groups were allocated as follows: TAVI (n=10), SAVR (n=14), and OMT (n=42).
Results
Baseline clinical characteristics including predicted operative mortality were similar among the three groups. However, patients with New York Heart Association functional class III or IV symptoms and smaller aortic valve area were treated with TAVI or SAVR rather than OMT. In-hospital combined safety endpoints (all-cause mortality, major stroke, peri-procedural myocardial infarction, life-threatening bleeding, major vascular complication, and acute kidney injury) after TAVI or SAVR were significantly lower in the TAVI group than in the SAVR group (10.0% vs. 71.4%, respectively, p=0.005), along with an acceptable rate of symptom improvement and device success. During the follow-up period, the TAVI group showed the lowest rate of 3-month major adverse cardiovascular and cerebrovascular events, a composite of all-cause mortality, myocardial infarction, major stroke, and re-hospitalization (TAVI 0.0% vs. SAVR 50.0% vs. OMT 42.9%, p=0.017).
Conclusion
Treatment with TAVI was associated with lower event rates compared to SAVR or OMT. Therefore, TAVI may be considered as the first therapeutic strategy in selected patients aged ≥80 years with symptomatic severe AS.
doi:10.3349/ymj.2013.54.3.596
PMCID: PMC3635628  PMID: 23549802
Aortic stenosis; transcatheter aortic valve implantation; treatment outcome
24.  Dorsal-Plantar Loop Technique Using Chronic Total Occlusion Devices via Anterior Tibial Artery 
Yonsei Medical Journal  2013;54(2):534-537.
The effectiveness of below-the-knee (BTK) percutaneous transluminal angioplasty to obtain successful revascularization in patients with critical limb ischemia has been well established, and many of these patients with chronic lower-extremity disease have been treated by endovascular intervention as the firstline treatment. Dorsal-plantaer loop technique is one of the new BTK interventional techiniques, and includes recanalization of both pedal and plantar arteries and their anatomical anastomoses. This method generally needs two approaches simultaneously, including antegrade and retrograde. In this report, however, we describe a case in which dorsal-plantar loop technique with only one antegrade approach, using chronic total occlusion devices via anterior tibial artery, was used to successfully recanalize BTK arteries. We think that this new technique, which may represent a safe and feasible endovascular option to avoid more invasive, time-consuming, and riskier surgical procedures, especially in end-stage renal disease and diabetes, should be considered whenever the foot is at risk, and results of above-the-ankle percutaneous transluminal angioplasty remain unsatisfactory or insufficient to achieve limb salvage.
doi:10.3349/ymj.2013.54.2.534
PMCID: PMC3575960  PMID: 23364993
Ischemia; peripheral arterial disease; angioplasty
25.  Relationship between Angiographic Late Loss and 5-Year Clinical Outcome after Drug-Eluting Stent Implantation 
Yonsei Medical Journal  2012;54(1):41-47.
Purpose
Currently, insufficient data exist to evaluate the relationship between angiographic late loss (LL) and long-term clinical outcome after drug-eluting stent (DES) implantation. In this study, we hypothesized that angiographic LL between 0.3 and 0.6 mm correlate with favorable long-term clinical outcomes.
Materials and Methods
Patients were enrolled in the present study if they had undergone both DES implantation in single coronary vessel and a subsequent follow-up angiogram (n=634). These individuals were then subdivided into three groups based on their relative angiographic LL: group I (angiographic LL <0.3 mm, n=378), group II (angiographic LL between 0.3 and 0.6 mm, n=124), and group III (angiographic LL >0.6 mm, n=134). During a 5-year follow-up period, all subjects were tracked for critical events, defined as any cause of death or myocardial infarction, which were then compared among the three groups.
Results
Mean follow-up duration was 63.0±10.0 months. Critical events occurred in 25 subjects in group I (6.6%), 5 in group II (4.0%), and 17 in group III (12.7%), (p=0.020; group I vs. group II, p=0.293; group II vs. group III, p=0.013). In a subsequent multivariate logistic regression analysis, chronic renal failure [odds ratio (OR)=3.29, 95% confidence interval (CI): 1.48-7.31, p=0.003] and long lesion length, defined as lesion length >28 mm (OR=1.88, 95% CI: 1.02-3.46, p=0.042) were independent predictors of long-term critical events.
Conclusion
This retrospective analysis fails to demonstrate that post-DES implantation angiographic LL between 0.3 and 0.6 mm is protective against future critical events.
doi:10.3349/ymj.2013.54.1.41
PMCID: PMC3521267  PMID: 23225797
Coronary artery disease; stents; outcome assessment

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