• Journal of Chest Surgery
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• v.56 no.6
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• pp.394-402
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• 2023

Background: The optimal choice of valve substitute for aortic valve replacement (AVR) in pediatric patients remains a matter of debate. This study investigated the outcomes following AVR using mechanical prostheses in children. Methods: Forty-four patients younger than 15 years who underwent mechanical AVR from March 1990 through March 2023 were included. The outcomes of interest were death or transplantation, hemorrhagic or thromboembolic events, and reoperation after mechanical AVR. Adverse events included any death, transplant, aortic valve reoperation, and major thromboembolic or hemorrhagic event. Results: The median age and weight at AVR were 139 months and 32 kg, respectively. The median follow-up duration was 56 months. The most commonly used valve size was 21 mm (14 [31.8%]). There were 2 in-hospital deaths, 1 in-hospital transplant, and 1 late death. The overall survival rates at 1 and 10 years post-AVR were 92.9% and 90.0%, respectively. Aortic valve reoperation was required in 4 patients at a median of 70 months post-AVR. No major hemorrhagic or thromboembolic events occurred. The 5- and 10-year adverse event-free survival rates were 81.8% and 72.2%, respectively. In univariable analysis, younger age, longer cardiopulmonary bypass time, and smaller valve size were associated with adverse events. The cut-off values for age and prosthetic valve size to minimize the risk of adverse events were 71 months and 20 mm, respectively. Conclusion: Mechanical AVR could be performed safely in children. Younger age, longer cardiopulmonary bypass time and smaller valve size were associated with adverse events. Thromboembolic or hemorrhagic complications might rarely occur.

• Korean Journal of Radiology
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• v.22 no.3
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• pp.324-333
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• 2021

Objective: The clinical course of an individual patient with heart failure is unpredictable with left ventricle ejection fraction (LVEF) only. We aimed to evaluate the prognostic value of cardiac magnetic resonance (CMR)-derived myocardial fibrosis extent and to determine the cutoff value for event-free survival in patients with non-ischemic cardiomyopathy (NICM) who had severely reduced LVEF. Materials and Methods: Our prospective cohort study included 78 NICM patients with significantly reduced LV systolic function (LVEF < 35%). CMR images were analyzed for the presence and extent of late gadolinium enhancement (LGE). The primary outcome was major adverse cardiac events (MACEs), defined as a composite of cardiac death, heart transplantation, implantable cardioverter-defibrillator discharge for major arrhythmia, and hospitalization for congestive heart failure within 5 years after enrollment. Results: A total of 80.8% (n = 63) of enrolled patients had LGE, with the median LVEF of 25.4% (19.8-32.4%). The extent of myocardial scarring was significantly higher in patients who experienced MACE than in those without any cardiac events (22.0 [5.5-46.1] %LV vs. 6.7 [0-17.1] %LV, respectively, p = 0.008). During follow-up, 51.4% of patients with LGE ≥ 12.0 %LV experienced MACE, along with 20.9% of those with LGE ≤ 12.0 %LV (log-rank p = 0.001). According to multivariate analysis, LGE extent more than 12.0 %LV was independently associated with MACE (adjusted hazard ratio, 6.71; 95% confidence interval, 2.54-17.74; p < 0.001). Conclusion: In NICM patients with significantly reduced LV systolic function, the extent of LGE is a strong predictor for long-term adverse cardiac outcomes. Event-free survival was well discriminated with an LGE cutoff value of 12.0 %LV in these patients.

• Korean Journal of Radiology
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• v.24 no.6
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• pp.512-521
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• 2023

Objective: There is increasing recognition that left atrial (LA) strain can be a prognostic marker of various cardiac diseases. However, its prognostic value in acute myocarditis remains unclear. Therefore, this study aimed to evaluate whether cardiovascular magnetic resonance (CMR)-derived parameters of LA strain can predict outcomes in patients with acute myocarditis. Materials and Methods: We retrospectively analyzed the data of 47 consecutive patients (44.2 ± 18.3 years; 29 males) with acute myocarditis who underwent CMR in 13.5 ± 9.7 days (range, 0-31 days) of symptom onset. Various parameters, including feature-tracked CMR-derived LA strain, were measured using CMR. The composite endpoints included cardiac death, heart transplantation, implantable cardioverter-defibrillator or pacemaker implantation, rehospitalization following a cardiac event, atrial fibrillation, or embolic stroke. The Cox regression analysis was performed to identify associations between the variables derived from CMR and the composite endpoints. Results: After a median follow-up of 37 months, 20 of the 47 (42.6%) patients experienced the composite events. In the multivariable Cox regression analysis, LA reservoir and conduit strains were independent predictors of the composite endpoints, with an adjusted hazard ratio per 1% increase of 0.90 (95% confidence interval [CI], 0.84-0.96; P = 0.002) and 0.91 (95% CI, 0.84-0.98; P = 0.013), respectively. Conclusion: LA reservoir and conduit strains derived from CMR are independent predictors of adverse clinical outcomes in patients with acute myocarditis.

• Korean Journal of Clinical Pharmacy
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• v.22 no.2
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• pp.113-122
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• 2012

ACC/AHA/SCAI Guideline recommends for administration dual antiplatelet therapy after drug-eluting stent (DES) to prevent restenosis and stent thrombosis in patients with percutaneous coronary intervention (PCI). Recently triple antiplatelet therapy including cilostazol is known to reduce restenosis and stent thrombosis significantly after DES implantation. However, there is lack of data providing the efficacy of triple antiplatelet therapy. The purpose of this study is to evaluate the clinical effects of the triple therapy after DES implantation compared with the dual therapy. This retrospective study collected data from medical charts of 251 patients who received DES implantation between Jul 2006 and Jun 2008. They received either dual antiplatelet therapy (N = 154 clopidogrel and aspirin; Dual group) or triple antiplatelet therapy (N = 97 cliostazol, clopidogrel and aspirin; Triple group). Major adverse cardiac event rates (MACE, included total death, myocardial infarction, target lesion revascularization) at 12 months, 24 months, stent thrombosis, rates of bleeding complications and adverse drug reactions were compared between these two groups. Compared with the dual group, the triple group had a similar incidence of the MACE rates at 24months (12.3% vs. 12.4%, p = 0.99). There is no difference in overall stent thrombosis between two groups (Dual group 2.6% vs. Triple group 4.1%, p = 0.5). Subgroup analysis showed that diabetic patients got more benefit in reducing MACE rates but, there is no statistical difference. Bleeding complications and adverse drug effects were not different significantly. As compared with dual antiplatelet therapy, triple antiplatelet therapy did not reduce the 12-months, 24-months MACE rates and stent thrombosis. Bleeding complications and adverse drug effects were not different.

• Journal of Chest Surgery
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• v.43 no.3
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• pp.246-253
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• 2010

Background: Our objective was to review the long-term prognosis of patients with preoperative mild to moderate ischemic mitral regurgitation who underwent off-pump coronary artery bypass grafting. Material and Method: We prospectively followed 1,000 consecutive and systematic off-pump coronary artery bypass grafting patients who were operated on between September 1996 and March 2004; follow-up was achieved for 97%. Sixty-seven patients (6.7%) had mild to moderate ischemic mitral regurgitation at the time of surgery. Operative mortality, actuarial survival and major adverse cardiac event free survival were compared to assess the effect of ischemic mitral regurgitation. Result: Average follow-up was $66{\pm}22$ months. Patients with ischemic mitral regurgitation were older (p<0.001), had lower ejection fractions (p<0.001) and more comorbidities. Significantly more female patients presented with ischemic mitral regurgitation (p=0.002). There was no significant difference in operative mortality and perioperative myocardial infarction in ischemic mitral regurgitation patients (p=0.25). Eight-year survival was decreased in ischemic mitral regurgitation patients ($39.6{\pm}11.8%$ vs $76.7{\pm}2.2$, p<0.001). However, after correcting for risk factors, mild to moderate ischemic mitral regurgitation was not found to be a significant independent risk factor for long-term mortality (p=0.42). Major adverse cardiac event free survival at 8 years was significantly lower in ischemic mitral regurgitation patients ($53.12{\pm}12%$ vs $77{\pm}2%$, p<0.001). After correction for risk factors, ischemic mitral regurgitation remained a significant independent cause of major adverse cardiac events (HR: 2.31), especially congestive heart failure and recurrent myocardial infarction. Conclusion: In our series, patients with preoperative mild to moderate ischemic mitral regurgitation had a higher prevalence of preoperative risk factors than patients without ischemic mitral regurgitation. They had comparable perioperative mortality and morbidity, but, in the long term, were found to be at elevated risk for recurrent cardiac events.

• Journal of Preventive Medicine and Public Health
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• v.55 no.4
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• pp.351-359
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• 2022

Objectives: The Regional CardioCerebroVascular Center (RCCVC) project was initiated to improve clinical outcomes for patients with acute myocardial infarction or stroke in non-capital areas of Korea. The purpose of this study was to evaluate the outcomes and issues identified by the Busan RCCVC project in the treatment of ST-segment elevation myocardial infarction (STEMI). Methods: Among the patients who were registered in the Korean Registry of Acute Myocardial Infarction for the RCCVC project between 2007 and 2019, those who underwent percutaneous coronary intervention (PCI) for STEMI at the Busan RCCVC were selected, and their medical data were compared with a historical cohort. Results: In total, 1161 patients were selected for the analysis. Ten years after the implementation of the Busan RCCVC project, the median door-to-balloon time was reduced from 86 (interquartile range [IQR], 64-116) to 54 (IQR, 44-61) minutes, and the median symptom-to-balloon time was reduced from 256 (IQR, 180-407) to 189 (IQR, 118-305) minutes (p<0.001). Inversely, the false-positive PCI team activation rate increased from 0.6% to 21.4% (p<0.001). However, the 1-year cardiovascular death and major adverse cardiac event rates did not change. Even after 10 years, approximately 75% of the patients had a symptom-to-balloon time over 120 minutes, and approximately 50% of the patients underwent inter-hospital transfer for primary PCI. Conclusions: A decade after the implementation of the Busan RCCVC project, although time parameters for early reperfusion therapy for STEMI improved, at the cost of an increased false-positive PCI team activation rate, survival outcomes were unchanged.

• Korean Circulation Journal
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• v.53 no.9
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• pp.635-644
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• 2023

Background and Objectives: The History, Electrocardiography, Age, Risk factors, and Troponin (HEART) pathway was developed to identify patients at low risk of a major adverse cardiac event (MACE) among patients presenting with chest pain to the emergency department. Methods: We modified the HEART pathway by replacing the Korean cut-off of 25 kg/m² with the conventional threshold of 30 kg/m² in the definition of obesity among risk factors. The primary outcome was a MACE within 30 days, which included acute myocardial infarction, primary coronary intervention, coronary artery bypass grafting, and all-cause death. Results: Of the 1,304 patients prospectively enrolled, MACE occurred in 320 (24.5%). The modified HEART pathway identified 37.3% of patients as low-risk compared with 38.3% using the HEART pathway. Of the 500 patients classified as low-risk with HEART pathway, 8 (1.6%) experienced MACE, and of the 486 low-risk patients with modified HEART pathway, 4 (0.8%) experienced MACE. The modified HEART pathway had a sensitivity of 98.8%, a negative predictive value (NPV) of 99.2%, a specificity of 49.0%, and a positive predictive value (PPV) of 38.6%, compared with the original HEART pathway, with a sensitivity of 97.5%, a NPV of 98.4%, a specificity of 50.0%, and a PPV of 38.8%. Conclusions: When applied to Korean population, modified HEART pathway could identify patients safe for early discharge more accurately by using body mass index cut-off levels suggested for Koreans.

• Journal of Chest Surgery
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• v.39 no.7 s.264
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• pp.534-543
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• 2006

Background: There are a lot of debates regarding the optimal timing of operation of acute myocardial infarction (AMI). Off pump coronary artery bypass grafting (OPCAB) has benefits by avoiding the adverse effects of the cardio-pulmonary bypass, but its efficacy in AMI has not been confirmed yet. The purpose of this study is to evaluate retrospectively early and mid-term results of OPCAB in patients with AMI according to transmurality and timing of operation. Material and Method: Data were collected in 126 AMI patients who underwent OPCAB between January 2002 and July 2005, Mean age of patients were 61.2 years. Male was 92 (73.0%) and female was 34 (27.2%). 106 patients (85.7%) had 3 vessel coronary artery disease or left main disease. Urgent or emergent operations were performed in 25 patients (19.8%). 72 patients (57.1%) had non-transmural myocardial infarction (group 1) and 52 patients (42.9%) had transmural myocardial infarction (group 2). The incidence of cardiogenic shock and insertion of intra-aortic balloon pump (IABP) was higher in group 2. The time between occurrence of AMI and operation was divided in 4 subgroups (<1 day, $1{\sim}3\;days,\;4{\sim}7\;days$, >8 days). OPCAB was performed a mean of $5.3{\pm}7.1$ days after AMI in total, which was $4.2{\pm}5.9$ days in group 1, and $6,6{\pm}8.3$ days in group 2. Result: Mean distal an-astomoses were 3.21 and postoperative IABP was inserted in 3 patients. There was 1 perioperative death in group 1 due to low cardiac output syndrome, but no perioperative new MI occurred in this study. There was no difference in postoperative major complication between two groups and according to the timing of operation. Mean follow-up time was 21.3 months ($4{\sim}42$ months). The 42 months actuarial survival rate was $94.9{\pm}2.4%$, which was $91.4{\pm}4.7%$ in group 1 and $98.0{\pm}2.0%$ in group 2 (p=0.26). The 42 months freedom rate from cardiac death was $97.6{\pm}1.4%$ which was $97.0{\pm}2.0%$ in group 1 and $98.0{\pm}2.0%$ in group 2 (p=0.74). The 42 months freedom rate from cardiac event was $95.4{\pm}2.0%$ which was $94.8{\pm}2.9%$ in group 1 and $95.9{\pm}2.9%$ in group 2 (p=0.89). Conclusion: OPCAB in AMI not only reduces morbidity but also favors hospital outcomes irrespective of timing of operation. The transmurality of myocardial infarction did not affect the surgical and midterm outcomes of OPCAB. Therefore, there may be no need to delay the surgical off-pump revascularization of the patients with AMI if surgical revascularization is indicated.

• Korean Circulation Journal
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• v.54 no.4
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• pp.189-200
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• 2024

Background and Objectives: Concerns remain that early aspirin cessation may be associated with potential harm in subsets at high risk of ischemic events. This study aimed to assess the effects of P2Y12 inhibitor monotherapy after 3-month dual antiplatelet therapy (DAPT) vs. prolonged DAPT (12-month or longer) based on the ischemic risk stratification, the CHADS-P2A2RC, after percutaneous coronary intervention (PCI). Methods: This was a sub-study of the SMART-CHOICE trial. The effect of the randomized antiplatelet strategies was assessed across 3 CHADS-P2A2RC risk score categories. The primary outcome was a major adverse cardiac and cerebral event (MACCE), a composite of all-cause death, myocardial infarction, or stroke. Results: Up to 3 years, the high CHADS-P2A2RC risk score group had the highest incidence of MACCE (105 [12.1%], adjusted hazard ratio [HR], 2.927; 95% confidence interval [CI], 1.358-6.309; p=0.006) followed by moderate-risk (40 [1.4%], adjusted HR, 1.786; 95% CI, 0.868-3.674; p=0.115) and low-risk (9 [0.5%], reference). In secondary analyses, P2Y12 inhibitor monotherapy reduced the Bleeding Academic Research Consortium (BARC) types 2, 3, or 5 bleeding without increasing the risk of MACCE as compared with prolonged DAPT across the 3 CHADS-P2A2RC risk strata without significant interaction term (interaction p for MACCE=0.705 and interaction p for BARC types 2, 3, or 5 bleeding=0.055). Conclusions: The CHADS-P2A2RC risk score is valuable in discriminating high-ischemic-risk patients. Even in such patients with a high risk of ischemic events, P2Y12 inhibitor monotherapy was associated with a lower incidence of bleeding without increased risk of ischemic events compared with prolonged DAPT.