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The retrograde approach through a collateral artery is now thought to improve the success rate of percutaneous coronary intervention (PCI) for coronary chronic total occlusion (CTO), and different kinds of strategies for this technique have been developed. However, the basic principles of PCI for CTO, such as firm back-up support with a guiding catheter and fine control of the guide wire, should be adhered to more strictly to succeed with this complex procedure. We present a case in which a CTO of the proximal left anterior descending artery was successfully opened by the retrograde approach through a collateral from the left circumflex artery, during which two guiding catheters were simultaneously used in the same coronary artery for the purpose of strong back up support for the retrograde device and fine control for the antegrade device. The retrograde approach through a collateral artery is now thought to improve the success rate of percutaneous coronary intervention (PCI) for coronary chronic total occlusion (CTO), and different kinds of strategies for this technique have been developed. However, the basic principles of PCI for CTO, such as firm back-up support with a guiding catheter and fine control of the guide wire, should be adhered to more strictly to succeed with this complex procedure. We present a case in which a CTO of the proximal left anterior descending artery was successfully opened by the retrograde approach through a collateral from the left circumflex artery, during which two guiding catheters were simultaneously used in the same coronary artery for the purpose of strong back up support for the retrograde device and fine control for the antegrade device.
경피적관상동맥확장술은 상대적으로 안전한 시술이나 비록 협착병소가 단순병변일지라도 부작용의 위험성을 항상 내포한다. 저자들은 완전폐쇄를 동반한 다혈관 질환의 경피적관상동맥확장술도중 동시다발적으로 생긴 합병증을 수술없이 경피적 방법으로 치료하여 만족할만한 결과를 얻었기에 문헌고찰과 함께 이에 보고하는 바이다.
관상동맥 완전폐색병변은 관상동맥시술분야에 있어서 과거 성공률이나 예후면에서 비완전폐색병변에 비해서 성적이 좋지 않았으나 최근 시술도구와 기술의 발달로 인해 비약적인 발전을 보이고 있다. 그러나 고위험군 환자에서의 완전폐색병변의 혈관개통술은 그렇지 않은 경우에 비해 훨씬 높은 실패율과 부작용 때문에 상대적으로 금기 시 되어왔다. 이에 저저는 좌심실구혈율이 14%인 심한 좌심실기능 저하와 관상동맥 완전폐색병변을 보이는 만성신부전 환자에서 합병증 없이 성공적으로 경피적관동맥확장술을 시행하였기에 문헌 고찰과 함께 보고하는 바이다.
Intravascular ultrasonography (IVUS) imaging is a user-friendly technique widely used during coronary interventions. An 80-year-old man was admitted with chest pain, and successful percutaneous coronary intervention was performed with stent implantation. One week later, the patient complained of further chest pain. Urgent coronary angiography showed total occlusion of the middle left anterior descending artery and the aspiration of thrombi was high. IVUS imaging showed inadequate stent strut apposition and distal dissection. We attempted another stent implantation but the IVUS catheter was stuck on the 0.014 inch wire. Therefore, we tried to pass the wire across the lateral side. After the wire was successfully passaged, the sprinter balloon was passed through the crushed stent to expand it. After 4 days later, the patient was discharged with no symptoms or electrocardiographic change.
Objective: Metabolic syndrome (MS) is associated with increased left ventricular (LV) mass and diastolic dysfunction. This study uses relatively load-independent Doppler tissue echocardiography to examine whether MS is associated with decreased longitudinal contractile reserve during dynamic exercise. Methods: A total of 112 patients with relatively well-controlled, treated hypertension who complained of exertional dyspnea were enrolled (average age, 56.7±10.5 years). Fifty-six were non-diabetic patients with MS (group 1), and 56 were age-sex matched hypertensive patients without MS (group 2). Exercise stress echo was performed using a symptom-limited, multistage, supine bicycle exercise test. Multiple Doppler parameters were obtained at baseline, at each stage of exercise. Results: There was no significant difference between the two groups in terms of age, gender, and hemodynamic variables. E/E’, an index of LV filling pressure, was significantly higher in the MS group at rest and during exercise. The longitudinal contractile reserve,the change in S’ (longitudinal tissue velocity) from baseline to peak exercise, was significantly lower in the MS group (2.00±1.65 vs. 2.90±1.66, P=0.015). Multiple regression analysis showed independent association of MS with longitudinal contractile reserve when controlled for confounding factors, such as LV mass index, gender, blood pressure, and age (β=-0.235, P=0.035). Conclusion: Longitudinal contractile reserve was reduced in MS patients compared to others, although both groups demonstrated similar longitudinal contractile function at rest. We present the first demonstration that metabolic syndrome is independently associated with LV systolic dysfunction during exercise in hypertensive patients.
The diagnosis and assessment of pulmonary arterial hypertension (PAH) is a rapidly evolving area, with changes occurring in the definition of the disease, screening and diagnostic techniques, and staging and follow-up assessment. After 4th World Symposium on pulmonary hypertension (PH) which took place in Dana Point in early 2008, the definition of PH has been simplified (mean pulmonary artery pressure ≥25 mmHg) based on currently available evidences. The diagnosis of PH involves two stages: detection (determining the cause of a patient`s symptoms, or to detect the presence of PAH in a high-risk patient) and characterization (determining the specific clinical context of the PH, including causal factors, associated diseases or substrates and hemodynamic perturbations). Echocardiography and right heart catheterization have been main diagnostic method in PAH. Also, there has been progress in imaging techniques and biomarkers used to screen patients for the disease and to follow up their response to therapy. Useful tools to predict outcome include functional class, exercise capacity, pulmonary hemodynamics, acute vasoreactivity, right ventricular function, as well as brain natriuretic peptide, endothelin-1, and so on. As new therapies have been developed for PAH, screening, prompt diagnosis, and accurate assessment of disease severity have become increasingly important. A clear definition of PH and the development of a rational approach to diagnostic assessment and follow-up using both conventional and new tools will be essential to advance proper treatment of patients. (Korean J Med 78:5-13, 2010)