Publications by authors named "Hyoung-Seob Park"

83 Publications

Coil Embolization for Supra-annular Rupture during Transcatheter Aortic Valve Replacement under Extracorporeal Membrane Oxygenation Support.

Korean Circ J 2021 Nov 29. Epub 2021 Nov 29.

Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Daegu, Korea.

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http://dx.doi.org/10.4070/kcj.2021.0327DOI Listing
November 2021

Artificial intelligence predicts clinically relevant atrial high-rate episodes in patients with cardiac implantable electronic devices.

Sci Rep 2022 Jan 7;12(1):37. Epub 2022 Jan 7.

Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.

To assess the utility of machine learning (ML) algorithms in predicting clinically relevant atrial high-rate episodes (AHREs), which can be recorded by a pacemaker. We aimed to develop ML-based models to predict clinically relevant AHREs based on the clinical parameters of patients with implanted pacemakers in comparison to logistic regression (LR). We included 721 patients without known atrial fibrillation or atrial flutter from a prospective multicenter (11 tertiary hospitals) registry comprising all geographical regions of Korea from September 2017 to July 2020. Predictive models of clinically relevant AHREs were developed using the random forest (RF) algorithm, support vector machine (SVM) algorithm, and extreme gradient boosting (XGB) algorithm. Model prediction training was conducted by seven hospitals, and model performance was evaluated using data from four hospitals. During a median follow-up of 18 months, clinically relevant AHREs were noted in 104 patients (14.4%). The three ML-based models improved the discrimination of the AHREs (area under the receiver operating characteristic curve: RF: 0.742, SVM: 0.675, and XGB: 0.745 vs. LR: 0.669). The XGB model had a greater resolution in the Brier score (RF: 0.008, SVM: 0.008, and XGB: 0.021 vs. LR: 0.013) than the other models. The use of the ML-based models in patient classification was associated with improved prediction of clinically relevant AHREs after pacemaker implantation.
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http://dx.doi.org/10.1038/s41598-021-03914-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8741914PMC
January 2022

Clinical impact of left atrial enlargement in Korean patients with atrial fibrillation.

Sci Rep 2021 12 10;11(1):23808. Epub 2021 Dec 10.

Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro, 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.

We sought to evaluate the clinical implication of LAE based on left atrial anterior-posterior (LA AP) dimension or LA volume index (LAVI) in Korean patients with atrial fibrillation (AF). We enrolled 8159 AF patients from the CODE-AF registry. The primary outcome was rate of stroke or systemic embolism (SSE). The prevalence of mild, moderate, and severe LAE by LA AP dimension was 30.6%, 18.5%, and 21.4%, and by LAVI (available in 5808 patients) was 15.7%, 12.5% and 37.8%, respectively. Compared with no or mild LAE, patients with significant LAE (moderate to severe LAE, n = 3258, 39.9%) were associated with a higher rate of SSE (2.5% vs. 1.4%, P = 0.001). Multivariable analysis suggested presence of significant LAE by LA AP dimension was associated with a higher risk of SSE in the overall population (HR 1.57, 95% CI: 1.14-2.17, P = 0.005) and in patients using anticoagulants (n = 5836, HR 1.79, 95% CI: 1.23-2.63, P = 0.002). Patients with significant LAE by LAVI were also at higher risk of SSE (HR 1.58, 95% CI: 1.09-2.29, P = 0.017). In conclusion, significant LAE by LA dimension or LAVI was present in 39.9% and 50.2% of AF patients, respectively, and was associated with a higher rate of SSE.
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http://dx.doi.org/10.1038/s41598-021-03266-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8664956PMC
December 2021

Acute and long-term efficacy of ablation index-guided higher power shorter duration ablation in patients with atrial fibrillation: A prospective registry.

J Arrhythm 2021 Oct 21;37(5):1250-1259. Epub 2021 Jul 21.

Department of Internal Medicine Seoul National University Hospital Seoul Republic of Korea.

Background: Theoretically, targeting the same ablation index (AI) using higher power may achieve the same lesion size with a shorter ablation time. We evaluated the acute and long-term efficacy of higher-powered ablation guided by ablation index (HPAI) compared with conventional-powered ablation guided by AI (CPAI) for pulmonary vein isolation (PVI) in patients with atrial fibrillation (AF).

Methods: Drug refractory symptomatic AF patients who had been ablated with 40 W on the anterior/roof segments and 30 W on the posterior/inferior/carina segments were enrolled (HPAI group). We compared the HPAI group with the CPAI group who were ablated with 30 W on the anterior/roof segments and 25 W on the posterior/inferior/carina segments. The same AI was targeted (≥450 on the anterior/roof segments and ≥350 on the posterior/inferior/carina segments). We compared ablation time, acute pulmonary vein reconnection (PVR) and 1-year AF recurrence between the two groups.

Results: A total of 118 patients were included (86 in the HPAI group and 32 in the CPAI group, paroxysmal AF, 73%). There was no significant difference in the acute PVR rate between the HPAI and the CPAI groups (3.7% vs. 4.2%,  = .580) with a 41% reduction in ablation time for PVI (38.7 ± 8.3 vs. 65.8 ± 13.7 minutes,  < .001). The 1-year AF recurrence rate was not significantly different between HPAI and CPAI groups (12.8% vs. 21.9%, Log-rank  = .242). There were no major complications in either group.

Conclusions: Increased power during AF ablation, using the same AI targets, reduced the procedure and ablation times, and showed a comparable acute and long-term outcome without compromising safety.

Clinical Trial Registration: https://www.clinicaltrials.gov. Unique identifier: NCT04379557.
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http://dx.doi.org/10.1002/joa3.12605DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8485805PMC
October 2021

Electrocardiographic Manifestations in Patients with COVID-19: Daegu in South Korea.

Korean Circ J 2021 Oct;51(10):851-862

Division of Cardiology, Daegu Catholic University College of Medicine, Daegu, Korea.

Background And Objectives: As the coronavirus disease 2019 (COVID-19) spreads worldwide, cardiac injury in patients infected with COVID-19 becomes a significant concern. Thus, this study investigates the impact of several electrocardiogram (ECG) parameters and disease severity in COVID-19 patients.

Methods: Seven medical centers in Daegu admitted 822 patients with COVID-19 between February and April 2020. This study examined 267 patients among them who underwent an ECG test and evaluated their biochemical parameters like C-reactive protein (CRP), log N-terminal pro-B-type Natriuretic Peptide (NT-proBNP), cardiac enzyme, and ECG parameters (heart rate, PR interval, QRS interval, T inversion, QT interval, and Tpe [the interval between peak to end in a T wave]).

Results: Those patients were divided into 3 groups of mild (100 patients), moderate (89 patients), and severe (78 patients) according to clinical severity score. The level of CRP, log NT-proBNP, and creatinine kinase-myocardial band were significantly increased in severe patients. Meanwhile, severe patients exhibited prolonged QT intervals (QTc) and Tpe (Tpe-c) compared to mild or moderate patients. Moreover, deceased patients (58; 21.7%) showed increased dispersion of QTc and Tpe-c compared with surviving patients (78.2±41.1 vs. 40.8±24.6 ms and 60.2±37.3 vs. 40.8±24.5 ms, both p<0.05, respectively). The QTc dispersion of more than 56.1 ms could predict the mortality in multivariate analysis (odd ratio, 11.55; 95% confidence interval, 3.746-42.306).

Conclusions: COVID-19 infections could involve cardiac injuries, especially cardiac repolarization abnormalities. A prolonged QTc dispersion could be an independent predictable factor of mortality.
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http://dx.doi.org/10.4070/kcj.2021.0116DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8484995PMC
October 2021

High density mapping guided partial antral ablation for a pulmonary vein isolation.

Sci Rep 2021 08 16;11(1):16563. Epub 2021 Aug 16.

Department of Thoracic and Cardiovascular Surgery, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Republic of Korea.

The muscular discontinuities at the pulmonary vein (PV)-left atrial (LA) junction are known. The high-density mapping may help to find the muscular discontinuity. This study evaluated the efficacy of a partial antral ablation for a pulmonary vein (PV) isolation using high density (HD) mapping. A total of 60 drug-refractory atrial fibrillation (AF) patients undergoing catheter ablation were enrolled. The detailed activation mapping of each PV and LA junction was performed using an HD mapping system, and each PV segment's activation pattern was classified into a "directly-activated from the LA" or "passively-activated from an adjacent PV segment" pattern. The antral ablations were performed at the directly-activated PV segments only when the PV had "passively-activated segments". If the PV did not contain passively-activated segments, a circumferential antral ablation was performed on those PVs. A "successful partial antral ablation" was designated if the electrical isolation of targeted PV was achieved by ablation at the directly-activated segments only. If the isolation was not achieved even though all directly-activated segments were ablated, a "failed partial antral ablation" was designated, and then a circumferential ablation was performed. Among 240 PVs, passively-activated segments were observed in 140 (58.3%) PVs. Both inferior PVs had more passively-activated segments than superior PVs, and the posteroinferior segments had the highest proportion of passive activation. The overall rate of successful partial antral ablation was 85%. The atrial tachyarrhythmia recurrence was observed in 10 patients (16.7%) at 1-year. HD mapping allowed the evaluation of the detailed activation patterns of the PVs, and passively-activated segments may represent muscular discontinuity. Partial antral ablation of directly-activated antral segments only was feasible and effective for a PVI.
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http://dx.doi.org/10.1038/s41598-021-96004-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8367962PMC
August 2021

Ablation of persistent atrial fibrillation based on high density voltage mapping and complex fractionated atrial electrograms: A randomized controlled trial.

Medicine (Baltimore) 2021 Aug;100(31):e26702

Department of Thoracic and Cardiovascular surgery, Keimyung University School of Medicine, Keimyung University Dongsan Hospital, Daegu, Republic of Korea.

Introduction: Pulmonary vein isolation (PVI) is the cornerstone of atrial fibrillation (AF) catheter ablation. However, a PVI alone has been considered insufficient for persistent AF. This study aimed to evaluate the efficacy of persistent AF ablation targeting complex fractionated atrial electrogram (CFAE) areas within low voltage zones identified by high-resolution mapping in addition to the PVI.

Methods: We randomized 50 patients (mean age 58.4 ± 9.5 years old, 86.0% males) with persistent AF to a PVI + CFAE group and PVI only group in a 1:1 ratio. CFAE and voltage mapping was performed simultaneously using a Pentaray Catheter with the CARTO3 CONFIDENSE module (Biosense Webster, CA, USA). The PVI + CFAE group, in addition to the PVI, underwent ablation targeting low voltage areas (<0.5 mV during AF) containing CFAEs.

Results: The mean persistent AF duration was 24.0 ± 23.1 months and mean left atrial dimension 4.9 ± 0.5 cm. In the PVI + CFAE group, AF converted to atrial tachycardia (AT) or sinus rhythm in 15 patients (60%) during the procedure. The PVI + CFAE group had a higher 1-year AF free survival (84.0% PVI + CFAE vs 44.0 PVI only, P = .006) without antiarrhythmic drugs. However, there was no difference in the AF/AT free survival (60.0% PVI + CFAE vs 40.0% PVI only, P = .329).

Conclusion: Persistent AF ablation targeting CFAE areas within low voltage zones using high-density voltage mapping had a higher AF free survival than a PVI only. Although recurrence with AT was frequent in the PVI+CFAE group, the sinus rhythm maintenance rate after redo procedures was 76%.
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http://dx.doi.org/10.1097/MD.0000000000026702DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8341227PMC
August 2021

Features and implications of higher systolic central than peripheral blood pressure in patients at very high risk of atherosclerotic cardiovascular disease.

J Hum Hypertens 2021 11 6;35(11):994-1002. Epub 2021 Jan 6.

Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Medical Center, Daegu, Republic of Korea.

Peripheral blood pressure (PBP) is usually higher than central blood pressure (CBP) due to pulse amplification; however, it is not well understood why cuff-measured PBP can be lower than CBP estimated by the late systolic pressure of radial pulse waves. We explored the implications of systolic PBP-CBP (P-CBP) differences for cardiovascular (CV) prognosis. In total, 335 patients at very high risk of atherosclerotic cardiovascular disease (ASCVD) underwent automated applanation tonometry and brachial-ankle pulse wave velocity (baPWV), and they were classified into groups according to positive or negative systolic P-CBP differences. Between-group characteristics and clinical outcomes (the composite of coronary revascularization, stroke, heart failure hospitalization, and CV death) were evaluated. Patients with negative differences had significantly higher frequency of hypertension, coronary artery disease, higher ASCVD risk burden, and elevated N-terminal pro b-type natriuretic peptide. They had higher left atrial volume index (LAVI) and lower systolic mitral septal tissue velocity (TVI-s') than those with a positive difference. These patients showed higher systolic PBP and CBP, and a higher baPWV. Multivariable analysis indicated that TVI-s', LAVI, and ASCVD risk burden were independent determinants of such systolic P-CBP differences. During a median follow-up of 12.6 months, clinical outcomes were significantly related to a negative difference (11.5% vs. 3.4%, p = 0.014), and a systolic P-CBP difference ≤ -8 mmHg was associated with a threefold higher likelihood of poor prognosis. In patients at very high risk of ASCVD, systolic P-CBP difference was associated with cardiac dysfunction and ASCVD risk burden, allowing further risk stratification.
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http://dx.doi.org/10.1038/s41371-020-00472-6DOI Listing
November 2021

The Implication of Cardiac Injury Score on In-hospital Mortality of Coronavirus Disease 2019.

J Korean Med Sci 2020 Oct 12;35(39):e349. Epub 2020 Oct 12.

Division of Cardiology, Department of Internal Medicine, Cardiovascular Center, Keimyung University Dongsan Hospital, Keimyung University College of Medicine, Daegu, Korea.

Backgrounds: The severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) has spread worldwide. Cardiac injury after SARS-CoV-2 infection is a major concern. The present study investigated impact of the biomarkers indicating cardiac injury in coronavirus disease 2019 (COVID-19) on patients' outcomes.

Methods: This study enrolled patients who were confirmed to have COVID-19 and admitted at a tertiary university referral hospital between February 19, 2020 and March 15, 2020. Cardiac injury was defined as an abnormality in one of the following result markers: 1) myocardial damage marker (creatine kinase-MB or troponin-I), 2) heart failure marker (N-terminal-pro B-type natriuretic peptide), and 3) electrical abnormality marker (electrocardiography). The relationship between each cardiac injury marker and mortality was evaluated. Survival analysis of mortality according to the scoring by numbers of cardiac injury markers was also performed.

Results: A total of 38 patients with COVID-19 were enrolled. Twenty-two patients (57.9%) had at least one of cardiac injury markers. The patients with cardiac injuries were older (69.6 ± 14.9 vs. 58.6 ± 13.9 years old, = 0.026), and were more male (59.1% vs. 18.8%, = 0.013). They showed lower initial oxygen saturation (92.8 vs. 97.1%, = 0.002) and a trend toward higher mortality (27.3 vs. 6.3%, = 0.099). The increased number of cardiac injury markers was significantly related to a higher incidence of in-hospital mortality which was also evidenced by Kaplan-Meier survival analysis ( = 0.008).

Conclusion: The increased number of cardiac injury markers is related to in-hospital mortality in patients with COVID-19.
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http://dx.doi.org/10.3346/jkms.2020.35.e349DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7550234PMC
October 2020

Cardiogenic vertigo: characteristics and proposed diagnostic criteria.

J Neurol 2021 Mar 6;268(3):1070-1075. Epub 2020 Oct 6.

Department of Neurology, Pusan National University Hospital, Pusan National University School of Medicine and Biomedical Research Institute, Pusan, South Korea.

Early identification of cardiogenic vertigo (CV) is necessary to prevent serious complications of cardiovascular diseases. However, the literature is limited to case reports without detailed clinical features or diagnostic criteria. The aim of this study was to define characteristics of CV and propose diagnostic criteria. This study included patients with CV diagnosed at Pusan National University and Keimyung University Hospitals. Demographic, clinical, laboratory, and treatment data were analyzed. Of 72 patients with clinically suspicious CV, 27 were finally included. The age ranged from 63 to 88 years (75.1 ± 7.2 years). Recurrent vertigo occurred without syncopal attacks in 52% [95% CI, 32-71], while it preceded (37% [19-58]) or followed (11% [2-29]) syncope. The patients with recurrent isolated vertigo had suffered from symptoms from 15 days to 5 years until final diagnosis (median 122 days). The vertigo lasted only for a few seconds (93% [76-99]) or a few minutes (7% [1-24]). Fourteen patients presented with spinning vertigo, and one of them showed spontaneous downbeat nystagmus during the attack. Accompanying symptoms including chest discomfort, palpitation, headache, arm twitching, and lightheadedness were found in 70% [50-86]. Between patients with and without syncope, there was no difference in clinical parameters and results of cardiac function tests. The most common cardiac abnormality during the attacks of vertigo was bradyarrhythmia (89% [71-98]). Cardiovascular diseases can develop recurrent isolated vertigo without or preceding syncope. Onset age, duration of vertigo, accompanying symptoms, and underlying cardiac diseases can aid in differentiation from other vestibular disorders. Early identification of CV would reduce morbidity and mortality associated with cardiac syncope.
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http://dx.doi.org/10.1007/s00415-020-10252-4DOI Listing
March 2021

Right bundle branch block-type wide QRS complex tachycardia with a reversed R/S complex in lead V: Development and validation of electrocardiographic differentiation criteria.

Heart Rhythm 2021 02 11;18(2):181-188. Epub 2020 Sep 11.

Heart Institute, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea. Electronic address:

Background: Differentiation of supraventricular tachycardia (SVT) with a right bundle branch block (RBBB) pattern from ventricular tachycardia (VT) is difficult, particularly when the R/S ratio in lead V is below 1.0.

Objective: We sought to investigate the electrocardiographic criteria for distinguishing between these arrhythmias.

Methods: We investigated electrocardiographic parameters from 111 consecutive patients who had RBBB pattern wide QRS complex tachycardia with a reversed R/S ratio in lead V (72 VTs, 39 SVTs). Diagnostic criteria from the previous algorithms were compared with our new criterion, the RS/QRS ratio, which was defined as the ratio of the interval from the onset of the QRS complex to the nadir of the S wave, divided by the QRS width in lead V. The RS/QRS ratio was further tested in a prospective population (31 fascicular VTs, 29 SVTs).

Results: The diagnostic accuracy of previous criteria (Brugada algorithm, Vereckei algorithm, and R-wave peak time criterion) was only modest. However, the RS/QRS ratio in lead V was significantly lower in SVT than in VT (0.36 ± 0.04 vs 0.50 ± 0.08; P < .001). A cutoff value of the RS/QRS ratio >0.41 differentiated VT from SVT with a high diagnostic accuracy (sensitivity 97.2%; specificity 89.7%). When tested in a prospective population with fascicular VT, the diagnostic accuracy of the criteria was maintained (sensitivity 90.3%; specificity 86.2%).

Conclusion: The RS/QRS ratio >0.41 in lead V is a simple and reliable index for distinguishing VT from SVT in RBBB pattern wide QRS complex tachycardia with a reversed R/S complex in lead V. This criterion was particularly useful for the differential diagnosis of fascicular VT from RBBB pattern SVT.
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http://dx.doi.org/10.1016/j.hrthm.2020.08.023DOI Listing
February 2021

Influence of Anatomical and Clinical Characteristics on Long-Term Prognosis of FFR-Guided Deferred Coronary Lesions.

JACC Cardiovasc Interv 2020 08;13(16):1907-1916

Department of Cariology, Keimyung University Dongsan Hospital, Daegu, Korea. Electronic address:

Objectives: The aim of this study was to evaluate the clinical and anatomical features to predict the long-term outcomes in patients with fractional flow reserve (FFR)-guided deferred lesions, verified by intravascular ultrasound (IVUS).

Background: Deferral of nonsignificant lesion by FFR is associated with a low risk of clinical events. However, the impact of combined information on clinical and anatomical factors is not well known.

Methods: The study included 459 patients with 552 intermediate lesions who had deferred revascularization on the basis of a nonischemic FFR (>0.80). Grayscale IVUS was examined simultaneously. The primary endpoint was patient-oriented composite outcome (POCO) (a composite of all-cause death, myocardial infarction, and any revascularization) during 5-year follow-up.

Results: The rate of 5-year POCO was 9.8%. Diabetes mellitus (hazard ratio: 3.50; 95% confidence interval [CI]: 1.86 to 6.57; p < 0.001), left ventricular ejection fraction ≤40% (hazard ratio: 4.80; 95% CI: 1.57 to 14.63; p = 0.006), and positive remodeling (hazard ratio: 2.04; 95% CI: 1.03 to 4.03; p = 0.041) were independent predictors for POCO. When the lesions were classified according to the presence of the adverse clinical characteristics (diabetes, left ventricular ejection fraction ≤40%) or adverse plaque characteristics (positive remodeling, plaque burden ≥70%), the risk of POCO was incrementally increased (4.3%, 13.6%, and 21.3%, respectively; p < 0.001).

Conclusions: In patients with FFR-guided deferred lesions, 5-year clinical outcomes were excellent. Lesion-related anatomical factors from intravascular imaging as well as patient-related clinical factors could provide incremental information about future clinical risks.
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http://dx.doi.org/10.1016/j.jcin.2020.05.040DOI Listing
August 2020

Adherence to dabigatran and the influence of dabigatran-induced gastrointestinal discomfort in the real-world practice.

Int J Cardiol 2021 01 14;323:77-82. Epub 2020 Aug 14.

Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Daegu, Republic of Korea. Electronic address:

Background: Dabigatran-induced gastrointestinal discomfort (DGID) is an important factor influencing the adherence to dabigatran. We investigated the incidence and risk factors of DGID and its impact on the adherence and persistence to dabigatran.

Methods: We prospectively enrolled the patients prescribed with dabigatran in 10 tertiary hospitals of the South Korea. The adherence was assessed using the percentage of the prescribed doses of the medication presumably taken by the patient (PDT by pill count). We evaluated the relationship between DGID and the baseline GI symptoms or the previous GI disease history using a questionnaire.

Results: A total of 474 patients (mean age 67.8 ± 9.3 years, male 68.6%, and mean CHADS-VASc score 2.2 ± 1.2) were enrolled. The adherence assessed by the PDT was 93.5 ± 5.5% at 1-month and 96.4 ± 8.4% at 6-months among the persistent patients. During the 6-month follow-up, 82 (18.1%) patients discontinued dabigatran, and the most common reason for dabigatran discontinuation was DGID (49, 59.8%). Sixty-eight (14.3%) patients experienced DGID, and there was no difference in the clinical factors between those with or without DGID. Among the patients who experienced DGID, 42 discontinued dabigatran (61.8%). In a multivariate analysis, DGID was the only predictor of dabigatran discontinuation and a low adherence.

Conclusion: Overall adherence of dabigatran was excellent, but those with DGID showed low adherence and persistence. Furthermore, it was challenging to predict DGID by clinical parameters. Therefore, it is recommended to follow the patients closely to check for DGID when prescribing dabigatran.
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http://dx.doi.org/10.1016/j.ijcard.2020.08.032DOI Listing
January 2021

Clinical impact of diabetes mellitus on 2-year clinical outcomes following PCI with second-generation drug-eluting stents; Landmark analysis findings from patient registry: Pooled analysis of the Korean multicenter drug-eluting stent registry.

PLoS One 2020 10;15(6):e0234362. Epub 2020 Jun 10.

Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Daegu, South Korea.

Background: Patients with diabetes mellitus are at an increased risk for adverse clinical events following percutaneous coronary interventions (PCI). However, the clinical impact of diabetes mellitus (DM) on second-generation drug-eluting stent (DES) implantation is not well-known. The aim of the current analysis was to examine the clinical impact of DM on clinical outcomes and the time sequence of associated risks in patients treated with second-generation DES.

Methods: Using patient-level data from two stent-specific, all-comer, prospective DES registries, we evaluated 1,913 patients who underwent PCI with second-generation DES between Feb 2009 and Dec 2013. The primary outcomes assessed were two-year major cardiac adverse events (MACE), composite endpoints of death from any cause, myocardial infarction (MI), and any repeat revascularization. We classified 0-1 year as the early period and 1-2 years as the late period. Landmark analyses were performed according to diabetes mellitus status.

Results: There were 1,913 patients with 2,614 lesions included in the pooled dataset. The median duration of clinical follow-up in the overall population was 2.0 years (interquartile range 1.9-2.1). Patients with DM had more cardiovascular risk factors than patients without DM. In multivariate analyses, the presence of DM and renal failure were strong predictors of MACE and target-vessel revascularization (TVR). After inverse probability of treatment weighting (IPTW) analyses, patients with DM had significantly increased rates of 2-year MACE (HR 2.07, 95% CI; 1.50-2.86; P <0.001). In landmark analyses, patients with DM had significantly higher rates of MACE in the early period (0-1 year) (HR 3.04, 95% CI; 1.97-4.68; P < 0.001) after IPTW adjustment, but these findings or trends were not observed in the late period (1-2 year) (HR 1.24, 95% CI; 0.74-2.07; P = 0.41).

Conclusions: In the second-generation DES era, the clinical impact of DM significantly increased the 2-year event rate of MACE, mainly caused by clinical events in the early period (0-1 year). Careful observation of patients with DM is advised in the early period following PCI with second-generation DES.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0234362PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7286514PMC
August 2020

Myocardial Contrast Uptake in Relation to Coronary Artery Disease and Prognosis.

Ultrasound Med Biol 2020 08 18;46(8):1880-1888. Epub 2020 May 18.

Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Medical Center, Daegu, Republic of Korea.

During left ventricular opacification (LVO), myocardial contrast uptake (MCU) is frequently observed, but its clinical implication is uncertain. We aimed to investigate the diagnostic performance of MCU and its prognostic value in known or suspected coronary artery disease (CAD). Contrast echocardiography was retrospectively analyzed in 457 patients who had previous coronary angiography <12 mo before LVO. MCU was classified into replacement or interstitial patterns. Subendocardial patterns were further inspected. Events were defined as a primary composite of the occurrence of acute coronary syndrome, heart failure hospitalization, sustained ventricular tachycardia and all-cause mortality. MCU had an 87.6% sensitivity, 75.5% specificity, 73.0% positive predictive value and 87.7% negative predictive value in detecting CAD. After a median follow-up of 17.3 mo, 52 events occurred. Replacement, interstitial and subendocardial MCU patterns were associated with events. In conclusion, the presence of MCU was useful in identifying CAD and provided incremental prognostic value for clinical outcomes.
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http://dx.doi.org/10.1016/j.ultrasmedbio.2020.04.012DOI Listing
August 2020

Contact Force-Guided Ablation Reduced Poor Contact Segments and Improved Acute Reconnection in Patients with Atrial Fibrillation.

J Atr Fibrillation 2020 Feb-Mar;12(5):2185. Epub 2020 Feb 28.

Division of Cardiology, Department of Internal Medicine, Keimyung University, Dongsan Medical Center, Daegu, Republic of Korea.

Background: There is a paucity of information regarding whether contact force (CF)-guided ablation improves the outcomes of pulmonary vein isolation (PVI) in patients with atrial fibrillation (AF) by achieving more optimal contact. We sought to assess whether real time CF-guided ablation has an impact on ablation parameters and acute pulmonary vein reconnection (PVR).

Methods: Left or right PVs were randomized to either CF-guided or blinded groups, and the order of CF blindness: CF-guided left PV/CF-blinded right PV, CF-blinded left PV/CF-guided right PV, CF-guided right PV/CF-blinded left PV, and CF-blinded right PV/CF-guided left PV groups. We compared CF parameters and acute PVR between segments ablated by CF-guided and CF-blinded strategies.

Results: Sixty patients with drug refractory symptomatic AF were included (paroxysmal AF 73%). CF-guided segments did not show significant differences in CF parameters compared to CF-blinded segments. However, CF-guided segments showed fewer segments with mean CF value <5 g than CF-blinded segments (4.3% vs. 12.4%, p<0.001). Forty-two patients showed acute PVR in 92 segments (8.5%). CF-guided PV segments showed lower acute PVR rate than CF-blinded segments (5.9% vs. 11.1%, p=0.011).

Conclusions: CF-guided ablation could reduce acute PVR after PVI by decreasing the number of segments with poor contact rather than increasing the mean CF during ablation. Better contact guided by CF information might help in improving the results of PVI. Further investigation will be needed to identify the association between the difference in acute reconnection and the long-term outcomes.
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http://dx.doi.org/10.4022/jafib.2185DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7237089PMC
February 2020

Paroxysmal and persistent atrial fibrillation ablation outcomes with the pulmonary vein ablation catheter GOLD duty-cycled phased radiofrequency ablation catheter: quality of life and 12-month efficacy results from the GOLD Atrial Fibrillation Registry.

Europace 2020 06;22(6):888-896

Cardiology Department, St. Vincenz-Krankenhaus Paderborn, Medizinische Klinik II, Paderborn, Germany.

Aims: The GOLD AF Registry has been designed to prospectively assess the population, indications, and outcomes using second-generation phased radiofrequency (RF) ablation (pulmonary vein ablation catheter GOLD) in a global examination of standard-of-care use for the treatment of paroxysmal and persistent atrial fibrillation (AF).

Methods And Results: GOLD AF (NCT02433613) is a prospective, observational, multi-centre registry designed to characterize efficacy and safety of phased RF ablation in patients with AF. The primary endpoint was freedom from AF recurrence at 12-month follow-up after a 90-day blanking period. Ancillary objectives include safety, procedural efficiency, and quality of life (QoL). The QoL assessment using the Atrial Fibrillation Effect on QualiTy-of-Life (AFEQT) and the European Heart Rhythm Association (EHRA) Score of AF-related symptoms was collected at baseline and 12 months. In total, 1054 patients were included in this analysis (age 60.6, 67.6% male, 26.5% PersAF). Kaplan-Meier estimate of freedom from AF recurrence was 77.7% at 12 months. Peri-procedural device or procedure-related complications were observed in 26 (2.5%) patients, with a low stroke rate of 0.3%. One-year post-ablation, the EHRA AF Symptom score decreased in 68% of patients. The AFEQT score improvement was observed in 88.4% and 90.4% of patients who completed the questionnaire in-person or interviewed by phone at 12 month follow-up, respectively.

Conclusion: Phased RF ablation for the treatment of paroxysmal and persistent AF demonstrated a 77.7% freedom from AF recurrence at 12 months in addition to a significant reduction in arrhythmia symptoms and clinically meaningful improved QoL. Low peri-procedural complication rate of <3% was reported.
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http://dx.doi.org/10.1093/europace/euaa042DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7273334PMC
June 2020

Clinical Impact of Implantable Cardioverter-Defibrillator Therapy and Mortality Prediction Model for Effective Primary Prevention in Korean Patients.

J Korean Med Sci 2020 Mar 9;35(9):e49. Epub 2020 Mar 9.

Department of Internal Medicine, Yeungnam University Medical Center, Daegu, Korea.

Background: Studies on the efficacy of implantable cardioverter-defibrillator (ICD) therapy for primary prevention in Asian patients are relatively lacking compared to those for secondary prevention. Also, it is important to stratify which patients will benefit from ICD therapy for primary prevention.

Methods: Of 483 consecutive patients who received new implantation of ICD in 9 centers in Korea, 305 patients with reduced left ventricular systolic function and/or documented ventricular fibrillation/tachycardia were enrolled and divided into primary (n = 167) and secondary prevention groups (n = 138).

Results: During mean follow-up duration of 2.6 ± 1.6 years, appropriate ICD therapy occurred in 78 patients (25.6%), and appropriate ICD shock and anti-tachycardia pacing occurred in 15.1% and 15.1% of patients, respectively. Appropriate ICD shock rate was not different between the two groups (primary 12% vs. secondary 18.8%, = 0.118). However, appropriate ICD therapy rate including shock and anti-tachycardia pacing was significantly higher (primary 18% vs. secondary 34.8%, = 0.001) in the secondary prevention group. Type of prevention and etiology, appropriate and inappropriate ICD shock did not affect all-cause death. High levels of N-terminal pro-B-type natriuretic peptide, New York Heart Association functional class, low levels of estimated glomerular filtration ratio, and body mass index were associated with death before appropriate ICD shock in the primary prevention group. When patients were categorized in 5 risk score groups according to the sum of values defined by each cut-off level, significant differences in death rate before appropriate ICD shock were observed among risk 0 (0%), 1 (3.6%), 2 (3%), 3 (26.5%), and 4 (40%) ( < 0.001).

Conclusion: In this multicenter regional registry, the frequency of appropriate ICD therapy is not low in the primary prevention group. In addition, combination of poor prognostic factors of heart failure is useful in risk stratification of patients who are not benefiting from ICD therapy for primary prevention.
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http://dx.doi.org/10.3346/jkms.2020.35.e49DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7061144PMC
March 2020

The impact of catheter ablation of atrial fibrillation on the left atrial volume and function: study using three-dimensional echocardiography.

J Interv Card Electrophysiol 2020 Jan 30;57(1):87-95. Epub 2019 Dec 30.

Cardiovascular Center, Keimyung University Dongsan Hospital, 1035, Dalgubeol-daero, Daegu, Dalseo-gu,, 42601, South Korea.

Purpose: The exact correlation between the baseline left atrial (LA) volume (LAV) and atrial fibrillation (AF) radiofrequency catheter ablation (RFCA) outcomes and changes to the LA after AF RFCA has not yet been fully understood. We sought to evaluate the serial changes in the LAV and LA function after RFCA using 3D echocardiography.

Methods: Consecutive patients who received RFCA of paroxysmal (PAF) or persistent AF (PeAF) at our center between January 2013 and March 2016 were included. Real-time 3D apical full-volume images were acquired, and a 3D volumetric assessment was performed using an automated three-beat averaging method. The LAV index (LAVI) was calculated and the LA ejection fraction (LAEF) was calculated as [LAVmax - LAVmin]/LAVmax.

Results: Ninety-nine total patients were enrolled, and the mean age was 58.0 ± 8.2 years and 75 (74.7%) were male. There were 59 (59.6%) PAF patients and the remaining 40 (40.4%) had PeAF. AF recurred in 5 of 59 (8.5%) PAF and in 10 of 40 (25%) PeAF patients. The LAVImax increased on 1 day, decreased at 3 months, and then increased again at 1 year but was lower than that at baseline. The LAEF changes were similar to the volume changes but were more prominent in PeAF than PAF patients. The baseline 3D LAVImax was an independent predictor of AF recurrence after RFCA and the cut-off value was 44.13 ml/m.

Conclusion: In our study, even after 3 months of scar formation due to ablation, structural remodeling of the LA continued. The changes were more prominent in the non-recurrent, PeAF patients.
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http://dx.doi.org/10.1007/s10840-019-00696-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7036070PMC
January 2020

NOAC Adherence of Patients with Atrial Fibrillation in the Real World: Dosing Frequency Matters?

Thromb Haemost 2020 Feb 28;120(2):306-313. Epub 2019 Oct 28.

Division of Cardiology, Department of Internal Medicine, SM Christianity Hospital, Pohang, South Korea.

Background And Objectives:  Nonvitamin K antagonist oral anticoagulants (NOACs) require stricter medication adherence. We investigated the NOACs adherence in real-world practice.

Methods:  We screened all patients in our cardiology department the day before their outpatient appointment, over a 5-month period. We enrolled 719 consecutive patients who were taking NOACs for atrial fibrillation. The patients were contacted by phone or text to bring the remnant pills with them without any information why. Adherence was measured by the percentage of prescribed doses taken (PDT) (number of doses taken/number of doses expected to be taken from the last prescription × 100 [%]) and the Morisky Medication Adherence Scale (MMAS)-8.

Results:  All 4 NOACs (apixaban 47.8%, dabigatran 21.2%, rivaroxaban 18.4%, and edoxaban 12.6%) were prescribed. The mean duration that the patients had been taking NOACs was 7.2 ± 5.7 months. The PDT was 95.4 ± 9.1% in the once-daily dosing group and 93.4 ± 12.7% in the twice-daily group, and the difference was statistically significant ( = 0.017). The mean MMAS was 2.6 ± 0.8. The proportion of patients with a PDT < 80% was 7.8%. They had a significantly higher MMAS than the PDT ≥ 80% group (3.4 vs. 2.5;  = 0.000).

Conclusion:  Most patients who were taking NOACs had excellent adherence regardless of the dosing frequency. An MMAS ≥ 3 could be used as a simple screening tool for a poor NOAC adherence.
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http://dx.doi.org/10.1055/s-0039-1697954DOI Listing
February 2020

Early efficacy and safety of statin therapy in Korean patients with hypercholesterolemia: Daegu and Gyeongbuk Statin Registry.

Korean J Intern Med 2020 03 19;35(2):342-350. Epub 2019 Aug 19.

Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Daegu, Korea.

Background/aims: To date, prospective data are limited on efficacy and safety profiles of statin therapy in Korean hypercholesterolemic patients. Hence, the aim of this study was to evaluate the practice patterns of statin therapy and its efficacy and safety through the prospective Daegu and Gyeongbuk statin registry.

Methods: Statin naïve patients who were prescribed statins according to the criteria of Korean Guidelines for Management of Dyslipidemia were enrolled. Clinical and laboratory evaluations were performed at baseline and at week 8, where the efficacy was assessed with the same guidelines.

Results: Of 908 patients, atorvastatin and rosuvastatin were most frequently prescribed statins (63.1% and 29.3%, respectively). High intensity statins (atorvastatin 40 mg or rosuvastatin 20 mg) were prescribed in 24.7% of all patients and in 79.5% of high and very high risk groups. The total and low density lipoprotein (LDL) cholesterol levels decreased from 203.7 ± 43.0 to 140.6 ± 28.6 mg/dL and 134.4 ± 35.7 to 79.5 ± 21.3 mg/dL, respectively. The achievement rate of the LDL target goal was 98.6% in low risk, 95.0% in moderate risk, 88.1% in high risk, and 42.1% in very high risk patients (59.7% in overall). There was no significant difference in the efficacy between atorvastatin and rosuvastatin. Adverse events were observed in 12.0% of patients and led to 1.4% of treatment cessation.

Conclusion: The efficacy of the usual starting dose of statins in daily practice was relatively insufficient for Korean hypercholesterolemic patients with high or very high risks. Short-term adverse events of statin therapy were not common in Korean patients with a low discontinuation rate.
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http://dx.doi.org/10.3904/kjim.2018.272DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7060999PMC
March 2020

Status of international normalized ratio control and treatment patterns in patients with nonvalvular atrial fibrillation taking vitamin K antagonist with or without antiplatelet therapy: Results from KORAFII registry.

J Arrhythm 2019 Aug 17;35(4):593-601. Epub 2019 Jun 17.

Department of Biostatistics College of Medicine Korea University Seoul Korea.

Background: Studies have shown that the concomitant use of a vitamin K antagonist (VKA) and an antiplatelet (APL) drug increased the bleeding risk and was less effective at preventing ischemic events. This study aimed to investigate the control status of international normalized ratio (INR) and the discontinuation rate of a VKA in patients taking VKA plus an APL drug compared with those taking a VKA alone.

Methods: Data were extracted from the KORean Atrial Fibrillation Investigation II registry, a multicenter noninterventional prospective observational study. Nonvalvular atrial fibrillation (NVAF) patients with CHADS scores ≥ 1 who newly started (within 3 months) a VKA were enrolled and followed up for 1 year.

Results: A total of 866 NVAF patients (mean age, 67.7 years; 60.3% men) without a bleeding history were divided into the VKA+APL (n = 229) and VKA alone (n = 637) groups. During follow-up, mean INR level was lower in the VKA+APL group than in the VKA alone group (1.7 ± 0.8 vs 1.9 ± 0.9,  = 0.0005). INR levels were poorly controlled in both groups (66.1% and 64.7%, respectively). Patients in the VKA+APL group more frequently discontinued VKA than patients in the VKA alone group (28.8% vs 24.2%,  = 0.045). Major causes of VKA discontinuation were uncontrolled INR level and patient dissatisfaction or concerns.

Conclusions: The conditions of NVAF patients were inadequately controlled with VKA with or without an APL. These findings suggest that other antithrombotic treatment options are warranted in NVAF patients to achieve INR control.
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http://dx.doi.org/10.1002/joa3.12183DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6686287PMC
August 2019

5-Year Outcomes According to FFR of Left Circumflex Coronary Artery After Left Main Crossover Stenting.

JACC Cardiovasc Interv 2019 05;12(9):847-855

Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Daegu, South Korea. Electronic address:

Objectives: The aim of the current study was to evaluate the long-term clinical impact of fractional flow reserve (FFR) in jailed left circumflex coronary artery (LCx) after left main coronary artery (LM) simple crossover stenting.

Background: Although the provisional side-branch intervention with FFR guidance has been validated for non-LM bifurcation lesions, the outcome of such a strategy in LM bifurcation disease is not well-known.

Methods: Patients who underwent LM-to-left anterior descending coronary artery simple crossover stenting and who had FFR measurements in the LCx thereafter were enrolled. A low FFR was defined as ≤0.80. The clinical outcomes were assessed by the 5-year rate of target lesion failure (TLF) (a composite of cardiac death, target-vessel myocardial infarction, or target lesion revascularization).

Results: In 83 patients, the mean FFR of the LCx after LM stenting was 0.87 ± 0.08, and 14 patients (16.9%) had a low FFR. There was no correlation between the FFR and angiographic % diameter stenosis in jailed LCx (R = 0.039; p = 0.071) and there was no difference in the angiographic % diameter stenosis in the high and low FFR groups. At 5 years, the low FFR group had a significantly higher rate of TLF than the high FFR group (33.4% vs. 10.7%; hazard ratio: 4.09, 95% confidence interval: 1.15 to 14.52; p = 0.029). However, there was no difference in the clinical outcomes according to the angiographic % diameter stenosis. In a multivariate analysis, a low FFR was an independent predictor of the risk for a 5-year TLF (hazard ratio: 6.49; 95% confidence interval: 1.37 to 30.73; p = 0.018).

Conclusions: The patients with a high FFR in jailed LCx had better 5-year outcomes than those with a low FFR. The FFR measurement in jailed LCx can be helpful in selecting an adequate treatment strategy and may reduce unnecessary complex procedures.
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http://dx.doi.org/10.1016/j.jcin.2019.02.037DOI Listing
May 2019

Novel method for the prediction of para-Hisian premature ventricular complexes from the electrocardiogram.

J Arrhythm 2019 Feb 21;35(1):92-98. Epub 2018 Nov 21.

Cardiology Revere Health Provo Utah.

Background: Catheter ablation of para-Hisian (PH) premature ventricular complexes (PVCs) has a high risk of heart block. This study aimed to find the electrocardiographic (ECG) predictors of PH-PVCs.

Methods: We enrolled 47 patients who underwent an electrophysiologic study for catheter ablation of PVCs and analyzed the ECG characteristics, retrospectively.

Results: The PVC locations were the PH in 14, right ventricular (RV) outflow tract (OT) in 11, left ventricular (LV) OT in 16, LV septum in 5, and LV summit in 1. The QRS width of the PH-PVCs was significantly narrower than that of the rest of PVCs (140.9 ± 17.1 ms vs. 158.9 ± 19.4 ms,  = 0.004). Precordial transition of the PH-PVCs related to sinus rhythm was not helpful in predicting the location. Lead I had monophasic R waves in 100% and lead aVR QS waves in 100%. In aVL, 13 of 14 patients had monophasic R waves, and 1 had biphasic (rS) waves with an initial positive polarity. Among the study cohort, 15 patients had a QS in aVR and R in aVL, including 13 PH-PVCs and 2 PVCs coming from the RVOT septum and LVOT septum, respectively. The QS in aVR and monophasic R in aVL had a sensitivity of 92.8%, specificity of 93.9%, positive predictive value of 86.7%, and negative predictive value of 96.9% for localizing PH-PVCs.

Conclusions: A PVC morphology with a QS in aVR and monophasic R in aVL and QRS width <143 msec, could be used as a reliable parameter for predicting the PH location.
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http://dx.doi.org/10.1002/joa3.12139DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6373644PMC
February 2019

Rationale, design, and endpoints of the 'DEvice-Detected CArdiac Tachyarrhythmic Events and Sleep-disordered Breathing (DEDiCATES)' study: Prospective multicenter observational study of device-detected tachyarrhythmia and sleep-disordered breathing.

Int J Cardiol 2019 04 15;280:69-73. Epub 2019 Jan 15.

Division of Cardiology, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea. Electronic address:

Background: Few studies have investigated the prognostic value of cardiac implantable electronic device (CIED)-detection of sleep-disordered breathing (SDB) for risk stratification of cardiovascular events. In the Device-Detected CArdiac Tachyarrhythmic events and Sleep-disordered breathing (DEDiCATES) study, we aim to determine whether device-detected SDB events are associated with increased risk of cardiac arrhythmias or other cardiovascular outcomes.

Methods And Design: Six-hundred patients (300 patients with low-voltage pacing devices and 300 with high-voltage defibrillator devices) who have dual chamber CIEDs with AP Scan™ function (Boston Scientific Inc., Marlborough, MA, USA) are planned to be enrolled in this study. AP Scan reports the average number of sleep disturbance events per hour per night in the form of a Respiratory Disturbance Index (RDI). The daily RDI values are to be used for quantitative measurement of the severity and burden of SDB. CIED-detected atrial high rate episodes (AHREs) and clinical atrial tachyarrhythmia will be assessed as the primary outcomes over a follow-up period of 2 years. Correlations between CIED-detected SDB and AHRE burdens will be analyzed. The secondary outcomes are CIED-detected or clinical ventricular arrhythmic events, stroke, heart failure hospitalization, mortality, and quality of life.

Conclusion: This study will determine the prognostic value of automated diagnostic function of CIED for SDB, which will help to improve the cardiovascular prognoses of CIED patients by enabling convenient and accurate assessments of SDB events.
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http://dx.doi.org/10.1016/j.ijcard.2019.01.045DOI Listing
April 2019

The incidence of left atrial appendage thrombi on transesophageal echocardiography after pretreatment with apixaban for cardioversion in the real-world practice.

PLoS One 2018 7;13(12):e0208734. Epub 2018 Dec 7.

Department of internal medicine, Division of Cardiology, Keimyung University Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Republic of Korea.

The risk of thromboembolisms during the post-cardioversion period is high. For patients with persistent atrial fibrillation (AF), anticoagulation with warfarin (INR 2.0~3.0) is recommended for at least three weeks prior and four weeks after cardioversion. We aimed to evaluate the efficacy of apixaban in preventing thromboembolic events during post-cardioversion. We enrolled 127 consecutive persistent AF patients (83 persistent, 44 longstanding persistent AF), scheduled to undergo cardioversion and were pretreated with apixaban. All patients underwent transesophageal echocardiography (TEE) to rule out thrombi in the left atrium (LA) or LA appendage (LAA) after anticoagulation with apixaban. The median duration of anticoagulation before the TEE was 37 (interquartile range [IQR] 34, 50) days. There were 7 patients (5.5%) with visible thrombi in the LAA. A spontaneous echo contrast was noted in 24 (18.9%) patients. Cardioversion was attempted in 117 patients, and they were prescribed amiodarone before the elective DC cardioversion. Sinus rhythm was achieved in 37 patients (31.6%) by amiodarone itself. DC cardioversion was attempted in 80 patients and was successful in 73 (91.3%). None of the cardioverted patients had any thromboembolic events within one month. Transient ischemic attacks were observed in one patient during a median follow up period of 202 days (IQR 143, 294). In conclusion, apixaban could be used as an anticoagulant for patients scheduled for cardioversion. However, the incidence of thrombi was not negligible. TEE or other imaging modalities should be considered before cardioversion or other invasive procedures.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0208734PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6285970PMC
May 2019

Quality of Anticoagulation and Treatment Satisfaction in Patients with Non-Valvular Atrial Fibrillation Treated with Vitamin K Antagonist: Result from the KORean Atrial Fibrillation Investigation II.

J Korean Med Sci 2018 Dec 21;33(49):e323. Epub 2018 Nov 21.

Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea.

Background: Vitamin K antagonist (VKA) to prevent thromboembolism in non-valvular atrial fibrillation (NVAF) patients has limitations such as drug interaction. This study investigated the clinical characteristics of Korean patients treated with VKA for stroke prevention and assessed quality of VKA therapy and treatment satisfaction.

Methods: We conducted a multicenter, prospective, non-interventional study. Patients with CHADS ≥ 1 and treated with VKA (started within the last 3 months) were enrolled from April 2013 to March 2014. Demographic and clinical features including risk factors of stroke and VKA treatment information was collected at baseline. Treatment patterns and international normalized ratio (INR) level were evaluated during follow-up. Time in therapeutic range (TTR) > 60% indicated well-controlled INR. Treatment satisfaction on the VKA use was measured by Treatment Satisfaction Questionnaire for Medication (TSQM) after 3 months of follow-up.

Results: A total of 877 patients (age, 67; male, 60%) were enrolled and followed up for one year. More than half of patients (56%) had CHADS ≥ 2 and 83.6% had CHADS-VASc ≥ 2. A total of 852 patients had one or more INR measurement during their follow-up period. Among those patients, 25.5% discontinued VKA treatment during follow-up. Of all patients, 626 patients (73%) had poor-controlled INR (TTR < 60%) measure. Patients' treatment satisfaction measured with TSQM was 55.6 in global satisfaction domain.

Conclusion: INR was poorly controlled in Korean NVAF patients treated with VKA. VKA users also showed low treatment satisfaction.
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http://dx.doi.org/10.3346/jkms.2018.33.e323DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6262187PMC
December 2018

Implication of ultrasound contrast-enhancement of carotid plaques in prevalence of acute coronary syndrome and occurrence of cardiovascular outcomes.

J Clin Ultrasound 2018 Sep;46(7):461-466

Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Medical Center, Daegu, Republic of Korea.

Purpose: Ultrasonographic contrast enhancement of carotid plaque (CECP) has been used to detect neovascularization of vasa vasorum and plaque. However, it is uncertain whether CECP can provide risk stratification of coronary artery disease (CAD). This study aimed to evaluate the relationship between CECP and manifestations of acute coronary syndrome (ACS) in established CAD patients and to explore the prognostic implication of CECP for cardiovascular (CV) clinical outcomes.

Methods: A medical record review revealed that contrast-enhanced ultrasonography was performed to evaluate carotid atherosclerosis in 209 coronary artery-stented and 105 non-stented patients. The rate of ACS manifestations was compared depending on contrast uptake patterns: grade 0, absent; grade 1, dot; and grade 2, diffuse pattern. CV primary outcomes were assessed during a mean 7.6 months of follow-up.

Results: Male sex, smoking, history of old myocardial infarction, intensive medications, and a favorable lipid profile were common in the stented versus non-stented group. Patients with grade 2 CECP had a higher rate of ACS, greater plaque thickness, and class I-II of Gray-Weale plaque echogenicity. During follow-up, 10 coronary revascularizations (nine ACSs), six strokes, and four heart failures occurred. Grade 2 CECP was more closely related with CV primary outcomes and showed a tendency toward more acute CV outcomes.

Conclusion: ACS manifestations were proportionate to CECP grade. Diffuse CECP uptake could be a risk factor for acute CV outcomes.
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http://dx.doi.org/10.1002/jcu.22638DOI Listing
September 2018

Comparison of the efficacy between impedance-guided and contact force-guided atrial fibrillation ablation using an automated annotation system.

J Arrhythm 2018 Jun 11;34(3):239-246. Epub 2018 Apr 11.

Division of Cardiology Dongsan Medical Center Keimyung University Daegu Korea.

Background: This study compared the efficacy of catheter ablation of atrial fibrillation (AF) between impedance (IMP)-guided and contact force (CF)-guided annotation using the automated annotation system (VisiTag™).

Methods: Fifty patients undergoing pulmonary vein isolation (PVI) for AF were randomized to the IMP-guided or CF-guided groups. The annotation criteria for VisiTag™ were a 10 second minimum ablation time and 2 mm maximum catheter movement range. A minimum CF of 10 g was added to the criteria in the CF-guided group. In the IMP-guided group, a minimum IMP drop of over 5 Ω was added to the criteria.

Results: The rates of successful PVI after an initial ablation line were higher in the CF-guided group (80% vs 48%, =.018). Although average CF was similar between two groups, the average force-time integral (FTI) was significantly higher in the CF-guided group (298.3 ± 65. 2 g·s vs 255.1 ± 38.3 g·s, =.007). The atrial arrhythmia-free survival at 1 year demonstrated no difference between the two groups (84.0% in the IMP-guided group vs 80.0% in the CF-guided group, =.737). If the use of any antiarrhythmic drug beyond the blanking period was considered as a failure, the clinical success rate at 1 year was 52.0% for the CF-guided group vs 56.0% for the IMP-guided group (=.813).

Conclusions: Atrial fibrillation ablation using an automated annotation system guided by CF improved the success rate of PVI after the initial circumferential ablation. An IMP-guided annotation combined with catheter stability criteria showed similar clinical outcomes as compared to the CF-guided annotation.
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http://dx.doi.org/10.1002/joa3.12054DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6010015PMC
June 2018

Prognostic Usefulness of Tricuspid Annular Diameter for Cardiovascular Events in Patients With Tricuspid Regurgitation of Moderate to Severe Degree.

Am J Cardiol 2018 06 2;121(11):1343-1350. Epub 2018 Mar 2.

Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Medical Center, Daegu, Republic of Korea.

Functional tricuspid regurgitation (TR) is frequently encountered. Current guidelines recommend the surgical correction of severe TR only at the time of left valve surgery despite emphasizing the enlarged tricuspid annulus (TA) dimension. We attempted to evaluate the relation between TA dimension and clinical outcomes of moderate or severe TR. A total of 213 patients (mean age 68 years, women 68%) with moderate or severe TR secondary to left-sided valve surgery, nonvalvular disease, or isolated primary TR were retrospectively identified and classified into tertiles of TA dimension. Cardiovascular (CV) outcomes were defined as a composite of hospitalization for worsening heart failure (HF), stroke, and CV death over a median follow-up of 3.4 years. Upper and lower tertiles of TA dimension had high frequencies of left-sided valve surgery and isolated primary TR, respectively. TA dimension was correlated with TR severity assigned as color Doppler grade and systolic tissue Doppler imaging of the tricuspid valve (TDI s'). During follow-up, there were 87 (41%) occurrences of primary outcomes: 65 HFs (31%), 13 CV deaths (6%), and 9 strokes (4%). There was a high frequency of adverse outcomes in the upper tertile. TA dimension and TDI s' were independently related to outcomes. An enlarged TA dimension was associated with outcomes irrespective of subgroups according to type or severity of TR and TDI s' (p = 0.21, p = 0.77, p = 0.15 for interaction). A cut-off value of 4.0 cm for TA dimension was best for CV event occurrence. When assessing clinical CV outcomes, TA dimension should be considered, even in moderate TR.
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http://dx.doi.org/10.1016/j.amjcard.2018.02.013DOI Listing
June 2018
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