Publications by authors named "Woo Jin Jang"

41 Publications

Association between polyvascular disease and clinical outcomes in patients with cardiogenic shock: Results from the RESCUE registry.

Int J Cardiol 2021 Jul 8. Epub 2021 Jul 8.

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

Background: Clinical implications of systemic atherosclerosis in patients with cardiogenic shock (CS) remain unclear. This study investigated the association between polyvascular disease (PVD) and clinical outcome in CS patients.

Methods: A total of 1247 CS patients was enrolled from the RESCUE registry, a multicenter, observational cohort between January 2014 and December 2018. They were divided into two groups according to presence of PVD, defined as ≥2 coexistence of coronary artery disease, peripheral arterial disease, or cerebrovascular disease. Primary outcome was all-cause death during 12 months of follow-up.

Results: 136 (10.9%) patients were diagnosed with PVD. The risk of 12-month all-cause death was significantly higher in the PVD group than in the non-PVD group (54.4% versus 40.4%, adjusted hazard ratio [HR] 1.31, 95% confidence interval [CI] 1.02-1.69, p = 0.034). There was a significant interaction between PVD and vasoactive inotropic score (VIS) (p for interaction = 0.014). Among the 945 patients with VIS <84, PVD was associated with a higher risk of 12-month all-cause death (unadjusted HR 1.77, 95% CI 1.30-2.41, p = 0.030); among the 302 patients with VIS ≥84, the incidence of 12-month all-cause death was similar between the PVD and non-PVD groups (unadjusted HR 1.03, 95% CI 0.68-1.56, p = 0.301).

Conclusions: Presence of PVD was associated with 12-month all-cause mortality in patients with CS, especially for less severe forms of CS patients with VIS <84. Clinicaltrials.govnumber:NCT02985008.
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http://dx.doi.org/10.1016/j.ijcard.2021.07.008DOI Listing
July 2021

Comparison of in-hospital outcomes of patients with vs. without ischaemic cardiomyopathy undergoing veno-arterial-extracorporeal membrane oxygenation.

ESC Heart Fail 2021 Jun 18. Epub 2021 Jun 18.

Division of Cardiology, Department of Internal Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon, 35015, Republic of Korea.

Aims: This study aimed to investigate differences in baseline and treatment characteristics, and in-hospital mortality according to the aetiologies of cardiogenic shock in patients undergoing veno-arterial-extracorporeal membrane oxygenation (VA-ECMO).

Methods And Results: The RESCUE registry is a multicentre, observational cohort that includes 1247 patients with cardiogenic shock from 12 centres. A total of 496 patients requiring VA-ECMO were finally selected, and the study population was stratified by cardiogenic shock aetiology [ischaemic cardiomyopathy (ICM, n = 342) and non-ICM (NICM, n = 154)]. The primary outcome of interest was in-hospital mortality. Sensitivity analyses including propensity-score matching adjustments were performed. Mean age of the entire population was 61.8 ± 14.2, and 30.8% were women. There were significant differences in baseline characteristics; notable differences included the older age of patients with ICM (65.1 ± 13.7 vs. 58.2 ± 13.8, P < 0.001), preponderance of males [258 (75.4%) vs. 85 (55.2%), P < 0.001], and higher prevalence of diabetes mellitus [140 (40.9%) vs. 39 (25.3%), P = 0.001] compared with patients in the NICM aetiology group. Patients with ischaemic cardiogenic shock were more likely to have longer shock duration before VA-ECMO implantation (518.7 ± 941.4 min vs. 292.4 ± 707.8 min, P = 0.003) and were less likely to undergo distal limb perfusion than those with NICM [108 (31.6%) vs. 79 (51.3%), P < 0.001]. In-hospital mortality in the overall cohort was 52.2%; patients with ICM had a higher unadjusted risk of in-hospital mortality [203 (59.4%) vs. 56 (36.4%); unadjusted hazard ratio, 2.295; 95% confidence interval, 1.698-3.100; P < 0.001]. There were no significant differences in the primary outcome between the two aetiologies following propensity-score matching multiple adjustments (adjusted hazard ratio, 1.265; 95% confidence interval, 0.840-1.906; P = 0.260).

Conclusions: Results of the current study indicated among patients with cardiogenic shock undergoing VA-ECMO, ischaemic aetiology does not seem to impact in-hospital mortality. These findings underline that early initiation and appropriate treatment strategies of VA-ECMO for patients with ICM shock are required.
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http://dx.doi.org/10.1002/ehf2.13481DOI Listing
June 2021

Clinical Characteristics and Predictors of In-Hospital Mortality in Patients With Cardiogenic Shock: Results From the RESCUE Registry.

Circ Heart Fail 2021 Jun 15;14(6):e008141. Epub 2021 Jun 15.

Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center (J.H.Y., K.H.C., T.K.P., J.M.L., Y.B.S., J.-Y.H., S.-H.C., H.-C.G.), Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.

Background: In the current era of mechanical circulatory support, limited data are available on prognosis of cardiogenic shock (CS) caused by various diseases. We investigated the characteristics and predictors of in-hospital mortality in Korean patients with CS.

Methods: The RESCUE study (Retrospective and Prospective Observational Study to Investigate Clinical Outcomes and Efficacy of Left Ventricular Assist Device for Korean Patients With CS) is a multicenter, retrospective, and prospective registry of patients that presented with CS. Between January 2014 and December 2018, 1247 patients with CS were enrolled from 12 major centers in Korea. The primary outcome was in-hospital mortality.

Results: In-hospital mortality rate was 33.6%. The main causes of shock were ischemic heart disease (80.7%), dilated cardiomyopathy (6.1%), myocarditis (3.2%), and nonischemic ventricular arrhythmia (2.5%). Vasopressors were used in 1081 patients (86.7%). The most frequently used vasopressor was dopamine (63.4%) followed by norepinephrine (57.3%). An intraaortic balloon pump was used in 314 patients (25.2%) and extracorporeal membrane oxygenator in 496 patients (39.8%). In multivariable analysis, age ≥70years (odds ratio [OR], 2.73 [95% CI, 1.89-3.94], <0.001), body mass index <25 kg/m (OR, 1.52 [95% CI, 1.08-2.16], =0.017), cardiac arrest at presentation (OR, 2.16 [95% CI, 1.44-3.23], <0.001), vasoactive-inotrope score >80 (OR, 3.55 [95% CI, 2.54-4.95], <0.001), requiring continuous renal replacement therapy (OR, 4.14 [95% CI, 2.88-5.95], <0.001), mechanical ventilator (OR, 3.17 [95% CI, 2.16-4.63], <0.001), intraaortic balloon pump (OR, 1.55 [95% CI, 1.07-2.24], =0.020), and extracorporeal membrane oxygenator (OR, 1.85 [95% CI, 1.25-2.76], =0.002) were independent predictors for in-hospital mortality.

Conclusions: The in-hospital mortality of patients with CS remains high despite the high utilization of mechanical circulatory support. Age, low body mass index, cardiac arrest at presentation, amount of vasopressor, and advanced organ failure requiring various support devices were poor prognostic factors for in-hospital mortality. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02985008.
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http://dx.doi.org/10.1161/CIRCHEARTFAILURE.120.008141DOI Listing
June 2021

P2Y12 inhibitor monotherapy after coronary stenting according to type of P2Y12 inhibitor.

Heart 2021 Mar 23. Epub 2021 Mar 23.

Department of Cardiology, Korea University Guro Hospital, Seoul, Korea (the Republic of).

Objective: To compare P2Y12 inhibitor monotherapy after 3-month dual antiplatelet therapy (DAPT) with 12-month DAPT according to the type of P2Y12 inhibitor in patients undergoing percutaneous coronary intervention (PCI).

Methods: The Smart Angioplasty Research Team: Comparison Between P2Y12 Antagonist Monotherapy vs Dual Antiplatelet Therapy in Patients Undergoing Implantation of Coronary Drug-Eluting Stents (SMART-CHOICE) randomised trial compared 3-month DAPT followed by P2Y12 inhibitor monotherapy with 12-month DAPT. In this trial, 2993 patients undergoing successful PCI with drug-eluting stent were enrolled in Korea. As a prespecified analysis, P2Y12 inhibitor monotherapy after 3-month DAPT versus 12-month DAPT were compared among patients receiving clopidogrel and those receiving potent P2Y12 inhibitor (ticagrelor or prasugrel), respectively. The primary endpoint was a composite of all-cause death, myocardial infarction or stroke at 12 months after the index procedure.

Results: Among 2993 patients (mean age 64 years), 58.2% presented with acute coronary syndrome. Clopidogrel was prescribed in 2312 patients (77.2%) and a potent P2Y12 inhibitor in 681 (22.8%). There were no significant differences in the primary endpoint between the P2Y12 inhibitor monotherapy group and the DAPT group among patients receiving clopidogrel (3.0% vs 3.0%; HR: 1.02; 95% CI 0.64 to 1.65; p=0.93) as well as among patients receiving potent P2Y12 inhibitors (2.4% vs 0.7%; HR: 3.37; 95% CI 0.77 to 14.78; p=0.11; interaction p=0.1). Among patients receiving clopidogrel, P2Y12 inhibitor monotherapy compared with DAPT showed consistent treatment effects across various subgroups for the primary endpoint. Among patients receiving potent P2Y12 inhibitors, the rate of bleeding (Bleeding Academic Research Consortium types 2- 5) was significantly lower in the P2Y12 inhibitor monotherapy group than in the DAPT group (1.5% vs 5.0%; HR: 0.33; 95% CI 0.12 to 0.87; p=0.03).

Conclusions: Compared with 12-month DAPT, clopidogrel monotherapy after 3-month DAPT showed comparable cardiovascular outcomes in patients undergoing PCI.

Trial Registration Number: NCT02079194.
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http://dx.doi.org/10.1136/heartjnl-2020-318821DOI Listing
March 2021

Differential Prognostic Implications of Vasoactive Inotropic Score for Patients With Acute Myocardial Infarction Complicated by Cardiogenic Shock According to Use of Mechanical Circulatory Support.

Crit Care Med 2021 May;49(5):770-780

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

Objectives: To identify whether the prognostic implications of Vasoactive Inotropic Score according to use of mechanical circulatory support differ in the treatment of acute myocardial infarction complicated by cardiogenic shock.

Design: A multicenter retrospective and prospective observational cohort study.

Setting/patient: The REtrospective and prospective observational Study to investigate Clinical oUtcomes and Efficacy registry includes 1,247 patients with cardiogenic shock from 12 centers in Korea. A total of 836 patients with acute myocardial infarction complicated by cardiogenic shock were finally selected, and the study population was stratified by quartiles of Vasoactive Inotropic Score (< 10, 10-30, 30-90, and > 90) for the present study.

Interventions: None.

Measurements And Main Results: Primary endpoint was in-hospital mortality and secondary endpoint was follow-up mortality. Among the study population, 326 patients (39.0%) received medical treatment alone, 218 (26.1%) received intra-aortic balloon pump, and 292 (34.9%) received extracorporeal membrane oxygenation. In-hospital mortality occurred in 305 patients (36.5%) and was significantly higher in patients with higher Vasoactive Inotropic Score (15.6%, 20.8%, 40.2%, and 67.3%, for < 10, 10-30, 30-90, and > 90; p < 0.001). Vasoactive Inotropic Score showed better ability to predict in-hospital mortality in acute myocardial infarction patients with cardiogenic shock who received medical treatment alone (area under the curve: 0.797; 95% CI, 0.728-0.865) than in those who received intra-aortic balloon pump (area under the curve, 0.704; 95% CI, 0.625-0.783) or extracorporeal membrane oxygenation (area under the curve, 0.644; 95% CI, 0.580-0.709). The best cutoff value of Vasoactive Inotropic Score for the prediction of in-hospital mortality also differed according to the use of mechanical circulatory support (16.5, 40.1, and 84.0 for medical treatment alone, intra-aortic balloon pump, and extracorporeal membrane oxygenation, respectively). There was a significant interaction between Vasoactive Inotropic Score as a continuous value and the use of mechanical circulatory support including intra-aortic balloon pump (interaction-p = 0.006) and extracorporeal membrane oxygenation (interaction-p < 0.001) for all-cause mortality during follow-up.

Conclusions: High Vasoactive Inotropic Score was associated with significantly higher in-hospital and follow-up mortality in patients with acute myocardial infarction complicated by cardiogenic shock. The predictive value of Vasoactive Inotropic Score for mortality was significantly higher in acute myocardial infarction patients with cardiogenic shock treated by medical treatment alone than in those treated by mechanical circulatory support such as intra-aortic balloon pump or extracorporeal membrane oxygenation.
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http://dx.doi.org/10.1097/CCM.0000000000004815DOI Listing
May 2021

Improved RRT-Connect Algorithm Based on Triangular Inequality for Robot Path Planning.

Sensors (Basel) 2021 Jan 6;21(2). Epub 2021 Jan 6.

Department of Computer Science and Engineering, Dongguk University, Seoul 04620, Korea.

This paper proposed a triangular inequality-based rewiring method for the rapidly exploring random tree (RRT)-Connect robot path-planning algorithm that guarantees the planning time compared to the RRT algorithm, to bring it closer to the optimum. To check the proposed algorithm's performance, this paper compared the RRT and RRT-Connect algorithms in various environments through simulation. From these experimental results, the proposed algorithm shows both quicker planning time and shorter path length than the RRT algorithm and shorter path length than the RRT-Connect algorithm with a similar number of samples and planning time.
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http://dx.doi.org/10.3390/s21020333DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7825297PMC
January 2021

Safety of 3-Month Dual Antiplatelet Therapy After Implantation of Ultrathin Sirolimus-Eluting Stents With Biodegradable Polymer (Orsiro): Results From the SMART-CHOICE Trial.

J Am Heart Assoc 2021 01 21;10(1):e018366. Epub 2020 Dec 21.

Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Korea.

Background This study sought to investigate the safety of 3-month dual antiplatelet therapy (DAPT) in patients receiving ultrathin sirolimus-eluting stents with biodegradable polymer (Orsiro). Methods and Results The SMART-CHOICE (Smart Angioplasty Research Team: Comparison Between P2Y12 Antagonist Monotherapy vs Dual Anti- platelet Therapy in Patients Undergoing Implantation of Coronary Drug-Eluting Stents) randomized trial compared 3-month DAPT followed by P2Y12 inhibitor monotherapy with 12-month DAPT in 2993 patients undergoing percutaneous coronary intervention. The present analysis was a prespecified subgroup analysis for patients receiving Orsiro stents. As a post hoc analysis, comparisons between Orsiro and everolimus-eluting stents were also done among patients receiving 3-month DAPT. Of 972 patients receiving Orsiro stents, 481 patients were randomly assigned to 3-month DAPT and 491 to 12-month DAPT. At 12 months, the target vessel failure, defined as a composite of cardiac death, target vessel-related myocardial infarction, or target vessel revascularization, occurred in 8 patients (1.7%) in the 3-month DAPT group and in 14 patients (2.9%) in the 12-month DAPT group (hazard ratio [HR], 0.58; 95% CI, 0.24-1.39; =0.22). In whole population who were randomly assigned to receive 3-month DAPT (n=1495), there was no significant difference in the target vessel failure between the Orsiro group and the everolimus-eluting stent group (n=1014) (1.7% versus 1.8%; HR, 0.96; 95% CI, 0.41-2.22; =0.92). Conclusions In patients receiving Orsiro stents, clinical outcomes at 1 year were similar between the 3-month DAPT followed by P2Y12 inhibitor monotherapy and 12-month DAPT strategies. With 3-month DAPT, there was no significant difference in target vessel failure between Orsiro and everolimus-eluting stents. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02079194.
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http://dx.doi.org/10.1161/JAHA.120.018366DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7955499PMC
January 2021

Echocardiographic Predictors of Successful Extracorporeal Membrane Oxygenation Weaning After Refractory Cardiogenic Shock.

J Am Soc Echocardiogr 2021 Apr 13;34(4):414-422.e4. Epub 2020 Dec 13.

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

Background: Limited data are available regarding echocardiographic predictors for successful weaning from venoarterial (VA) extracorporeal membrane oxygenation (ECMO). We sought to determine whether echocardiographic parameters during ECMO flow study could predict successful weaning from ECMO.

Methods: A total of 92 ECMO patients from a multicenter ECMO registry underwent VA-ECMO flow study with transthoracic echocardiography before a weaning trial. During VA-ECMO flow study, flow was decreased by 30%-50% of the initial flow for 15 minutes, and echocardiography was performed both at baseline and after flow reduction. Changes of echocardiographic parameters were compared between the successful and failed weaning group.

Results: Sixty-four of the 92 patients were able to be weaned from VA-ECMO successfully. During VA-ECMO flow study, both lateral e' and tricuspid annular S' velocity improved significantly in the successful weaning group, while such findings were not observed in the failed weaning group. From univariable analysis, left heart decompression, improvement of lateral e' velocity, and improvement of tricuspid annular S' velocity showed significant association with successful VA-ECMO weaning. Predictability of the model with the change of lateral e' and tricuspid annular S' according to the reduction of ECMO flow for successful weaning from VA-ECMO is much higher than that of the model with conventional echocardiographic predictors from previous studies (left ventricular ejection fraction > 20%-25%, left ventricular time-velocity integral ≥ 10 cm, mitral annulus S' ≥ 6 cm/sec).

Conclusions: Improvement of lateral e' velocity and tricuspid annular S' velocity during VA-ECMO flow study may better represent cardiac reserve from a recovering heart than conventional echocardiographic parameters at minimal flow. Assessment of tissue Doppler parameters during ECMO flow study is a simple and feasible method to guide physicians on the optimal time to wean from ECMO.
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http://dx.doi.org/10.1016/j.echo.2020.12.002DOI Listing
April 2021

Clinical Significance of Low-Flow Time in Patients Undergoing Extracorporeal Cardiopulmonary Resuscitation: Results from the RESCUE Registry.

J Clin Med 2020 Nov 7;9(11). Epub 2020 Nov 7.

Division of Cardiology, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea.

Limited data are available on the association between low-flow time and survival in patients with in-hospital cardiac arrest (IHCA) who undergo extracorporeal cardiopulmonary resuscitation (ECPR). We evaluated data from 183 IHCA patients who underwent ECPR as a rescue procedure. Patients were divided into two groups: patients undergoing extracorporeal membrane oxygenation as an adjunct to standard cardiopulmonary resuscitation for less than 38 min ( = 110) or for longer than 38 min ( = 73). The ECPR ≤ 38 min group had a significantly greater incidence of survival to discharge compared to the ECPR > 38 min group (40.0% versus 24.7%, = 0.032). The incidence of good neurologic outcomes at discharge tended to be greater in the ECPR ≤ 38 min group than in the ECPR > 38 min group (35.5% versus 24.7%, = 0.102). The incidences of limb ischemia ( = 0.354) and stroke ( = 0.805) were similar between the two groups, but major bleeding occurred less frequently in the ECPR ≤ 38 min group compared to the ECPR > 38 min group ( = 0.002). Low-flow time ≤ 38 min may reduce the risk of mortality and fatal neurologic damage and could be a measure of optimal management in patients with IHCA.
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http://dx.doi.org/10.3390/jcm9113588DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7695027PMC
November 2020

A randomized comparison of Coronary Stents according to Short or Prolonged durations of Dual Antiplatelet Therapy in patients with Acute Coronary Syndromes: a pre-specified analysis of the SMART-DATE trial.

EuroIntervention 2020 Nov 3. Epub 2020 Nov 3.

Ewha Womans University College of medicine, Seoul Hospital, Seoul, Korea.

Aims: We sought to compare biodegradable-polymer biolimus-eluting stents(BP-BES) with durable-polymer everolimus-eluting(DP-EES) and zotarolimus-eluting stents(DP-ZES) in patients with acute coronary syndrome(ACS) according to different duration of dual antiplatelet therapy(DAPT).

Methods And Results: In the SMART-DATE trial, 2712 patients with ACS underwent randomization for allocation of DAPT (6-month [n=1357] or 12-month or longer [n=1355]) and type of stents (BP-BES [n=901]), DP-EES [n=904], or DP-ZES [n=907]). At 18 months, primary endpoint (a composite of cardiac death, myocardial infarction, or stent thrombosis) was 2.6% with BP-BES, 2.0% with DP-EES, and 2.1% with DP-ZES (HR 1.29, 95% CI 0.70-2.39, p =0.42 for BP-BES vs. DP-EES and HR 1.23, 95% CI 0.67-2.26, p =0.50 for BP-BES vs. DP-ZES). The treatment effect of BP-BES for the primary endpoint was consistent among patients receiving 6-month DAPT as well as those receiving 12-month or longer DAPT (BP-BES vs. DP-EES, p interaction =0.48 and BP-BES vs. DP-ZES, p interaction =0.87). After excluding 179 patients (101 in the BP-BES group) who did not receive allocated DES, per-protocol analysis showed similar results.

Conclusions: The risk of a composite of cardiac death, myocardial infarction, or stent thrombosis was not significantly different between patients receiving BP-BES vs. DP-EES or DP-ZES across short or prolonged duration of DAPT after ACS.
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http://dx.doi.org/10.4244/EIJ-D-20-00556DOI Listing
November 2020

Wirelessly controlled, bioresorbable drug delivery device with active valves that exploit electrochemically triggered crevice corrosion.

Sci Adv 2020 Aug 28;6(35):eabb1093. Epub 2020 Aug 28.

Weldon School of Biomedical Engineering and School of Mechanical Engineering, Purdue University, West Lafayette, IN 47907, USA.

Implantable drug release platforms that offer wirelessly programmable control over pharmacokinetics have potential in advanced treatment protocols for hormone imbalances, malignant cancers, diabetic conditions, and others. We present a system with this type of functionality in which the constituent materials undergo complete bioresorption to eliminate device load from the patient after completing the final stage of the release process. Here, bioresorbable polyanhydride reservoirs store drugs in defined reservoirs without leakage until wirelessly triggered valve structures open to allow release. These valves operate through an electrochemical mechanism of geometrically accelerated corrosion induced by passage of electrical current from a wireless, bioresorbable power-harvesting unit. Evaluations in cell cultures demonstrate the efficacy of this technology for the treatment of cancerous tissues by release of the drug doxorubicin. Complete in vivo studies of platforms with multiple, independently controlled release events in live-animal models illustrate capabilities for control of blood glucose levels by timed delivery of insulin.
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http://dx.doi.org/10.1126/sciadv.abb1093DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7455185PMC
August 2020

Impact of stent designs of second-generation drug-eluting stents on long-term outcomes in coronary bifurcation lesions.

Catheter Cardiovasc Interv 2020 Jul 30. Epub 2020 Jul 30.

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

Objectives: We compared the long-term clinical outcomes of four different types of second-generation drug-eluting stents (DESs) in coronary bifurcation lesions.

Background: Clinical outcomes of different designs of second-generation DESs are not well known in bifurcation lesions.

Methods: Patients who underwent percutaneous coronary intervention with second-generation DESs for coronary bifurcation lesion were enrolled from 21 centers in South Korea. A total of 2,526 patients was evaluated and divided into four treatment groups according to DES type: bioabsorbable polymer biolimus-eluting stent (BP-BES group, n = 514), platinum chromium everolimus-eluting stent (PtCr-EES group, n = 473), cobalt nickel zotarolimus-eluting stent (CoNi-ZES group, n = 736), or cobalt chromium everolimus-eluting stent (CoCr-EES group, n = 803). Primary outcome was target lesion failure (TLF, defined as a composite of cardiac death, target vessel myocardial infarction, or target lesion revascularization). Inverse probability of treatment weighting (IPTW) was performed to reduce selection bias and potential confounding factors.

Results: For 5 years of follow-up, the rates of TLF among the four DES groups were not significantly different (6.2% for BP-BES group, 8.2% for PtCr-EES group, 6.5% for CoNi-ZES group, and 8.6% for CoCr-EES group, p = .434). The results were consistent after IPTW adjustment (6.8, 8.4, 6.0, and 7.5%, respectively, p = .554). In subgroup analysis, the similarity of long-term outcomes among the four different types of second-generation DES was consistent across subgroups regardless of side branch treatment (p for interaction = .691).

Conclusion: There seems to be no significant difference in long-term clinical outcomes among patients who received different types of second-generation DES for coronary bifurcation lesion.
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http://dx.doi.org/10.1002/ccd.29137DOI Listing
July 2020

Effect of P2Y12 Inhibitor Monotherapy vs Dual Antiplatelet Therapy on Cardiovascular Events in Patients Undergoing Percutaneous Coronary Intervention: The SMART-CHOICE Randomized Clinical Trial.

JAMA 2019 06;321(24):2428-2437

Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.

Importance: Data on P2Y12 inhibitor monotherapy after short-duration dual antiplatelet therapy (DAPT) in patients undergoing percutaneous coronary intervention are limited.

Objective: To determine whether P2Y12 inhibitor monotherapy after 3 months of DAPT is noninferior to 12 months of DAPT in patients undergoing PCI.

Design, Setting, And Participants: The SMART-CHOICE trial was an open-label, noninferiority, randomized study that was conducted in 33 hospitals in Korea and included 2993 patients undergoing PCI with drug-eluting stents. Enrollment began March 18, 2014, and follow-up was completed July 19, 2018.

Interventions: Patients were randomly assigned to receive aspirin plus a P2Y12 inhibitor for 3 months and thereafter P2Y12 inhibitor alone (n = 1495) or DAPT for 12 months (n = 1498).

Main Outcomes And Measures: The primary end point was major adverse cardiac and cerebrovascular events (a composite of all-cause death, myocardial infarction, or stroke) at 12 months after the index procedure. Secondary end points included the components of the primary end point and bleeding defined as Bleeding Academic Research Consortium type 2 to 5. The noninferiority margin was 1.8%.

Results: Among 2993 patients who were randomized (mean age, 64 years; 795 women [26.6%]), 2912 (97.3%) completed the trial. Adherence to the study protocol was 79.3% of the P2Y12 inhibitor monotherapy group and 95.2% of the DAPT group. At 12 months, major adverse cardiac and cerebrovascular events occurred in 42 patients in the P2Y12 inhibitor monotherapy group and in 36 patients in the DAPT group (2.9% vs 2.5%; difference, 0.4% [1-sided 95% CI, -∞% to 1.3%]; P = .007 for noninferiority). There were no significant differences in all-cause death (21 [1.4%] vs 18 [1.2%]; hazard ratio [HR], 1.18; 95% CI, 0.63-2.21; P = .61), myocardial infarction (11 [0.8%] vs 17 [1.2%]; HR, 0.66; 95% CI, 0.31-1.40; P = .28), or stroke (11 [0.8%] vs 5 [0.3%]; HR, 2.23; 95% CI, 0.78-6.43; P = .14) between the 2 groups. The rate of bleeding was significantly lower in the P2Y12 inhibitor monotherapy group than in the DAPT group (2.0% vs 3.4%; HR, 0.58; 95% CI, 0.36-0.92; P = .02).

Conclusions And Relevance: Among patients undergoing percutaneous coronary intervention, P2Y12 inhibitor monotherapy after 3 months of DAPT compared with prolonged DAPT resulted in noninferior rates of major adverse cardiac and cerebrovascular events. Because of limitations in the study population and adherence, further research is needed in other populations.

Trial Registration: ClinicalTrials.gov Identifier: NCT02079194.
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http://dx.doi.org/10.1001/jama.2019.8146DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6593635PMC
June 2019

Multimodal Sensing with a Three-Dimensional Piezoresistive Structure.

ACS Nano 2019 10 24;13(10):10972-10979. Epub 2019 May 24.

Center for Bio-Integrated Electronics, Departments of Materials Science and Engineering, Biomedical Engineering, Chemistry, Mechanical Engineering, Electrical Engineering and Computer Science, and Neurological Surgery, Simpson Querrey Institute for Nano/biotechnology, McCormick School of Engineering and Feinberg School of Medicine , Northwestern University , Evanston , Illinois 60208 , United States.

Sensors that reproduce the complex characteristics of cutaneous receptors in the skin have important potential in the context of artificial systems for controlled interactions with the physical environment. Multimodal responses with high sensitivity and wide dynamic range are essential for many such applications. This report introduces a simple, three-dimensional type of microelectromechanical sensor that incorporates monocrystalline silicon nanomembranes as piezoresistive elements in a configuration that enables separate, simultaneous measurements of multiple mechanical stimuli, such as normal force, shear force, and bending, along with temperature. The technology provides high sensitivity measurements with millisecond response times, as supported by quantitative simulations. The fabrication and assembly processes allow scalable production of interconnected arrays of such devices with capabilities in spatiotemporal mapping. Integration with wireless data recording and transmission electronics allows operation with standard consumer devices.
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http://dx.doi.org/10.1021/acsnano.9b02030DOI Listing
October 2019

Season and myocardial injury in patients with ST-segment elevation myocardial infarction: A cardiac magnetic resonance imaging study.

PLoS One 2019 8;14(2):e0211807. Epub 2019 Feb 8.

Department of Radiology, Cardiovascular Imaging Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.

Background: Little is known about the causality and pathological mechanism underlying the association of seasonal variation with myocardial injury in patients with ST-segment elevation myocardial infarction (STEMI).

Objective: We evaluated the association of seasonal effect with myocardial injury using cardiovascular magnetic resonance (CMR) imaging in STEMI patients undergoing primary percutaneous coronary intervention (PCI).

Methods: In 279 patients undergoing primary PCI for STEMI, CMR was performed for a median of 3.3 days after the index procedure. Of these, STEMI occurred in 56 patients in the winter (Winter group), 80 patients in the spring (Spring group), 76 patients in the summer (Summer group), and 67 patients in the autumn (Autumn group), respectively. We compared myocardial infarct size, extent of area at risk (AAR), myocardial salvage index (MSI) and microvascular obstruction (MVO) area as assessed by CMR according to the season in which STEMI occurred.

Results: In the CMR analysis, the myocardial infarct size was not significantly different among the Winter group (21.0 ± 10.5%), the Spring group (19.6 ± 11.5%), the Summer group (18.6 ± 10.6%), and the Autumn group (21.1 ± 11.3%) (P = 0.475). The extent of AAR, MSI, and MVO areas were similar among the four groups. In the subgroup analysis, myocardial infarct size, extent of AAR, MSI, and MVO were not significantly different between the Harsh climate (winter + summer) and the Mild climate (spring + autumn) groups.

Conclusions: Seasonal influences may not affect advanced myocardial injury in STEMI patients undergoing primary PCI.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0211807PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6368377PMC
November 2019

Second-generation drug-eluting stenting versus coronary artery bypass grafting for treatment of coronary chronic total occlusion.

J Cardiol 2019 05 2;73(5):432-437. Epub 2019 Jan 2.

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

Background: Limited data are available regarding the long-term clinical outcomes of percutaneous coronary intervention (PCI) using second-generation drug-eluting stents (DESs) versus coronary artery bypass grafting (CABG) for the treatment of coronary artery disease (CAD) with chronic total occlusion (CTO). We compared the clinical outcomes of patients with multivessel CAD including CTO lesions treated with PCI using DESs versus CABG.

Methods: We analyzed data from 423 consecutive patients who underwent successful revascularization for CTO between March 2008 and February 2012. Death or myocardial infarction (MI) and major adverse cardiac and cerebrovascular events (MACCE) were compared between patients treated with PCI using second-generation DESs (n=232, 2nd DES group) versus those treated with CABG (n=191, CABG group). To reduce selection bias according to treatment strategy and other potential confounding factors, inverse probability of treatment weighting (IPTW) was also performed.

Results: During a median follow-up duration of 32 months, there was no significant difference in death or MI [hazard ratio (HR): 0.69; 95% confidence interval (CI): 0.29-1.63; p=0.399] or MACCE (HR: 1.32; 95% CI: 0.74-2.35; p=0.341) between the 2nd DES group and the CABG group based on multivariable analysis. After IPTW adjustment, the incidences of death or MI (HR: 0.72; 95% CI: 0.26-1.95; p=0.518) and MACCE (HR: 1.49; 95% CI: 0.76-2.91; p=0.244) remained similar in the two groups. In subgroup analysis, the effect of second-generation drug-eluting stenting was comparable to that of CABG across various subgroups without a significant p-value for the interaction.

Conclusions: The efficacy of PCI using second-generation DES was comparable to that of CABG in CTO patients with multivessel CAD.
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http://dx.doi.org/10.1016/j.jjcc.2018.12.008DOI Listing
May 2019

Fluoroscopy-guided simultaneous distal perfusion as a preventive strategy of limb ischemia in patients undergoing extracorporeal membrane oxygenation.

Ann Intensive Care 2018 Oct 29;8(1):101. Epub 2018 Oct 29.

Division of Cardiology, Department of Critical Care Medicine and Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81, Irwon-dong, Gangnam-gu, Seoul, 135-710, Republic of Korea.

Background: Limited data are available regarding prevention of limb ischemia in femorally cannulated patients on venoarterial extracorporeal membrane oxygenation (VA-ECMO). We investigated the association between strategy of distal perfusion catheter (DPC) insertion and vascular complications like limb ischemia in patients undergoing VA-ECMO.

Methods: We evaluated 230 patients from two tertiary hospitals who received VA-ECMO via femoral cannulation between August 2014 and July 2017. The patients were divided into two groups according to DPC insertion strategy: patients who underwent DPC insertion at the time of primary cannulation (DPC group, n = 96) and patients who were provisionally treated with DPC (No-DPC group, n = 134). The primary outcome was limb ischemia.

Results: Of the 96 patients in the DPC group, 61 (63.5%) underwent insertion under fluoroscopic guidance. The DPC group had a significantly lower incidence of limb ischemia (2.1% vs. 8.2%, p = 0.047) and a lower tendency of in-hospital mortality (38.5% vs. 50.7%, p = 0.067) than the No-DPC group. In the multivariable analysis, fluoroscopy-guided simultaneous insertion of the DPC (odds ratio 0.11; 95% confidence interval 0.01-0.98; p = 0.048) was a significant predictor of reduction of limb ischemia.

Conclusions: Simultaneous insertion of a DPC, particularly under fluoroscopy guidance, can be considered as a preventive strategy for limb ischemia in femorally cannulated patients on VA-ECMO.
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http://dx.doi.org/10.1186/s13613-018-0445-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6206319PMC
October 2018

Benefit of Prolonged Dual Antiplatelet Therapy After Implantation of Drug-Eluting Stent for Coronary Bifurcation Lesions: Results From the Coronary Bifurcation Stenting Registry II.

Circ Cardiovasc Interv 2018 07;11(7):e005849

Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea (Y.B.S., S.-H.C., S.W.C., B.S.K., H.-C.G., J.-Y.H.).

Background: Whether prolonged dual antiplatelet therapy (DAPT) improves clinical outcomes after percutaneous coronary intervention for coronary bifurcation lesion is uncertain.

Methods And Results: We evaluated 2082 patients who were treated with drug-eluting stent for bifurcation lesions and were event free (no death, myocardial infarction [MI], cerebrovascular accident, stent thrombosis, or any revascularization) at 12 months after the index procedure. Patients were divided into 2 groups: DAPT ≥12-month group (n=1776) and DAPT <12-month group (n=306). Primary outcome was all-cause death or MI. At 4 years after the index procedure, death or MI occurred less frequently in the DAPT ≥12-month group than the DAPT <12-month group (2.8% versus 12.3%; adjusted hazard ratio, 0.21; 95% confidence interval, 0.13-0.35; <0.001). After propensity score matching, incidence of death or MI was still lower in the DAPT ≥12-month group than the DAPT <12-month group (2.6% versus 12.3%; adjusted hazard ratio, 0.22; 95% confidence interval, 0.12-0.38; <0.001). In subgroup analysis, the treatment effect of prolonged DAPT was consistent across subgroups regardless of lesion location, stenting technique, or type of used drug-eluting stent.

Conclusions: The risk of all-cause death or MI was significantly lower in the ≥12-month DAPT group than the <12-month DAPT group after percutaneous coronary intervention for bifurcation lesion using drug-eluting stent. Our results suggest that prolonged DAPT may improve long-term clinical outcomes after percutaneous coronary intervention for bifurcation lesions.

Clinical Trial Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01642992.
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http://dx.doi.org/10.1161/CIRCINTERVENTIONS.117.005849DOI Listing
July 2018

Long-term Survival Benefit of Statin in Patients with Coronary Chronic Total Occlusion without Revascularization.

J Korean Med Sci 2018 Apr 13;33(18):e134. Epub 2018 Apr 13.

Division of Cardiology, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.

Background: Limited data are available on the efficacy of statin therapy in stable ischemic heart disease with chronic total occlusion (CTO) without revascularization. We investigated whether statin therapy could be beneficial in stable patients with CTO without revascularization.

Methods: From March 2003 to February 2012, 2,024 patients with at least one CTO were enrolled in a retrospective, single-center registry; 664 of these patients were managed conservatively without an initial revascularization strategy. Among them, we excluded CTO cases involving acute coronary syndrome, in-hospital death or incomplete data and classified 551 patients into statin (n = 369) and non-statin (n = 182) groups according to use of statin at discharge. Propensity score matching analysis was also performed in 148 pairs. The primary outcome was cardiac death.

Results: The median overall follow-up duration was 45.7 months (interquartile range: 19.9-70.5 months). Cardiac death occurred in 22 patients (6.0%) in the statin group vs. 24 patients (13.2%) in the non-statin group ( < 0.001). In propensity score matching analysis, statin therapy was associated with a low risk of cardiac death (adjusted hazard ratio [HR], 0.39; 95% confidence interval [CI], 0.18-0.85; = 0.022) and major adverse cardiac events (adjusted HR, 0.66; 95% CI, 0.43-0.98; = 0.043). On multivariate analysis, independent predictors for cardiac death were age > 70 years, renal insufficiency, prior myocardial infarction, left ventricular ejection fraction < 40%, proximal-to-mid CTO location, and no use of statin in CTO patients.

Conclusion: Statin therapy at discharge may be associated with a reduction in long-term cardiac mortality in stable CTO patients without revascularization.
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http://dx.doi.org/10.3346/jkms.2018.33.e134DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5920123PMC
April 2018

Clinical Significance of Reciprocal ST-segment Changes in Patients With STEMI: A Cardiac Magnetic Resonance Imaging Study.

Rev Esp Cardiol (Engl Ed) 2019 Feb 23;72(2):120-129. Epub 2018 Feb 23.

Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.

Introduction And Objectives: We sought to determine the association of reciprocal change in the ST-segment with myocardial injury assessed by cardiac magnetic resonance (CMR) in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI).

Methods: We performed CMR imaging in 244 patients who underwent primary PCI for their first STEMI; CMR was performed a median 3 days after primary PCI. The first electrocardiogram was analyzed, and patients were stratified according to the presence of reciprocal change. The primary outcome was infarct size measured by CMR. Secondary outcomes were area at risk and myocardial salvage index.

Results: Patients with reciprocal change (n=133, 54.5%) had a lower incidence of anterior infarction (27.8% vs 71.2%, P < .001) and shorter symptom onset to balloon time (221.5±169.8 vs 289.7±337.3min, P=.042). Using a multiple linear regression model, we found that patients with reciprocal change had a larger area at risk (P=.002) and a greater myocardial salvage index (P=.04) than patients without reciprocal change. Consequently, myocardial infarct size was not significantly different between the 2 groups (P=.14). The rate of major adverse cardiovascular events, including all-cause death, myocardial infarction, and repeat coronary revascularization, was similar between the 2 groups after 2 years of follow-up (P=.92).

Conclusions: Reciprocal ST-segment change was associated with larger extent of ischemic myocardium at risk and more myocardial salvage but not with final infarct size or adverse clinical outcomes in STEMI patients undergoing primary PCI.
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http://dx.doi.org/10.1016/j.rec.2018.01.005DOI Listing
February 2019

Duration of dual antiplatelet therapy in patients treated with percutaneous coronary intervention for coronary chronic total occlusion.

PLoS One 2017 5;12(5):e0176737. Epub 2017 May 5.

Division of Cardiology, Department of Medicine, Heart, Stroke and Vascular Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.

Background: The duration of dual antiplatelet therapy (DAPT) after drug-eluting stent implantation in coronary chronic total occlusion (CTO) remains unclear.

Methods: We retrospectively analyzed a total of 512 patients treated with percutaneous coronary intervention (PCI) in the Samsung Medical Center CTO registry. Patients were separated into ≤ 12-month (199, 38.9%) vs. > 12 month (313, 61.1%) based on DAPT duration with aspirin and clopidogrel. The primary outcome was major adverse cardiac and cerebrovascular event (MACCE) during follow-up.

Results: Median follow-up duration was 67 (interquartile range: 51-84) months. MACCE occurred in 43 patients (21.6%) in the ≤ 12-month and 55 patients (17.6%) in the > 12-month groups. In the propensity-matched population, the rate of MACCE did not differ significantly between the ≤ 12-month and > 12-month group (19.4% vs. 18.8%; hazard ratio [HR], 0.95; 95% confidential interval [CI], 0.52-1.76, p = 0.88). Moreover, moderate or severe bleeding according to BARC criteria (type 2, 3 or 5) was also similar between the ≤ 12-month and > 12-month group (2.5% vs. 1.9%; HR, 1.00; 95% CI, 0.20-4.96, p = 0.99).

Conclusion: Among patients treated with PCI for CTO, DAPT with durations of ≤ 12-month showed similar long-term clinical outcomes compared to > 12-month DAPT.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0176737PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5419557PMC
September 2017

Clinical Significance of Postinfarct Fever in ST-Segment Elevation Myocardial Infarction: A Cardiac Magnetic Resonance Imaging Study.

J Am Heart Assoc 2017 Apr 24;6(4). Epub 2017 Apr 24.

Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.

Background: Little is known about causality and pathological mechanism underlying association of postinfarct fever with myocardial injury in patients with ST-segment elevation myocardial infarction.

Methods And Results: In 276 patients undergoing primary percutaneous coronary intervention for ST-segment elevation myocardial infarction, cardiac magnetic resonance imaging was performed a median of 3.4 days after the index procedure. Forty-five patients had postinfarct fever (peak body temperature within 4 days after primary percutaneous coronary intervention ≥37.7°C; Fever group) whereas 231 did not (no-Fever group). Primary outcome was myocardial infarct size as assessed by cardiac magnetic resonance imaging. Secondary outcomes were extent of area at risk, myocardial salvage index, and microvascular obstruction area. In cardiac magnetic resonance imaging analysis, myocardial infarct size (25.6% [19.7-32.4] in the Fever group versus 17.2% [11.8-25.4] in the no-Fever group; <0.01), extent of area at risk (43.7% [31.9-54.9] versus 35.3% [24.0-43.7]; <0.01), and microvascular obstruction area (4.4% [0.0-13.2] versus 1.2% [0.0-5.1]; =0.02) were greater in the Fever group than in the no-Fever group. Myocardial salvage index tended to be lower in the Fever group compared to the no-Fever group (37.7 [28.5-56.1] versus 47.0 [34.1-56.8]; =0.13). In multivariate analysis, postinfarct fever was associated with larger myocardial infarct (odds ratio, 3.48; 95% CI, 1.71-7.07; <0.01) and lower MSI (odds ratio, 2.10; 95% CI, 1.01-4.08; =0.03).

Conclusions: Postinfarct fever could predict advanced myocardial injury and less salvaged myocardium in ST-segment elevation myocardial infarction patients undergoing primary percutaneous coronary intervention.
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http://dx.doi.org/10.1161/JAHA.117.005687DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5533041PMC
April 2017

Cardioprotective Effects of Intracoronary Morphine in ST-Segment Elevation Myocardial Infarction Patients Undergoing Primary Percutaneous Coronary Intervention: A Prospective, Randomized Trial.

J Am Heart Assoc 2017 Apr 3;6(4). Epub 2017 Apr 3.

Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea

Background: A cardioprotective role of morphine acting via opioid receptors has been demonstrated, and previous preclinical studies have reported that morphine could reduce reperfusion injury and myocardial infarct size in a way similar to that of ischemic periconditioning. This study aimed to evaluate the effect of intracoronary morphine on myocardial infarct size in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention.

Methods And Results: This study was designed as a 2-center, prospective, randomized, open-label, blinded end point trial. A total of 91 ST-elevation myocardial infarction patients with thrombolysis in myocardial infarction flow grade of 0 to 1 undergoing primary percutaneous coronary intervention were randomly assigned to a morphine or control group at a 1:1 ratio. The morphine group received 3 mg of morphine sulfate diluted with 3 mL of normal saline, and the control group received 3 mL of normal saline into a coronary artery immediately after restoration of coronary flow. The primary end point was myocardial infarct size assessed by cardiac magnetic resonance imaging The cardiac magnetic resonance images were evaluated for 42 and 38 patients in the morphine and control groups, respectively. Myocardial infarct size was not different between the 2 groups (25.6±11.2% versus 24.6±10.5%, =0.77), nor was the extent of microvascular obstruction or myocardial salvage index (6.0±6.3% versus 5.1±4.6%, =0.91; 31.1±15.2% versus 30.3±10.9%, =0.75, respectively). There was no difference in peak creatine kinase-MB level, final thrombolysis in myocardial infarction flow, myocardial brush grade, or complete resolution of ST-segment.

Conclusions: Intracoronary morphine administration could not reduce myocardial infarct size in ST-elevation myocardial infarction patients undergoing primary percutaneous coronary intervention.

Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01738100.
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http://dx.doi.org/10.1161/JAHA.116.005426DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5533032PMC
April 2017

Clinical implications of residual SYNTAX score after percutaneous coronary intervention in patients with chronic total occlusion and multivessel coronary artery disease: a comparison with coronary artery bypass grafting.

EuroIntervention 2017 May;13(1):97-105

Division of Cardiology, Department of Internal Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Republic of Korea.

Aims: In this study we sought to evaluate the clinical impact of the residual SYNTAX score (rSS) after percutaneous coronary intervention (PCI) in patients with chronic total occlusion (CTO) and multivessel coronary artery disease (CAD).

Methods And Results: We analysed data from 1,043 patients with CTO and multivessel CAD who were treated with PCI or coronary artery bypass grafting (CABG). Patients were divided into three groups: patients with rSS≤12 after PCI (rSS≤12 group, n=445), patients with rSS>12 after PCI (rSS>12 group, n=150), and patients who underwent CABG (CABG group, n=448). We compared the incidence of cardiac death among the three groups. During a median follow-up period of 42 months, cardiac death occurred in 14 patients (3.1%) in the rSS≤12 group, 14 patients (9.3%) in the rSS>12 group, and 29 patients (6.5%) in the CABG group. On multivariate analysis, the rSS≤12 group had a significantly lower incidence of cardiac death than the rSS>12 group (hazard ratio [HR] 0.35, 95% confidence interval [CI]: 0.16 to 0.75; p=0.01), but had an incidence of cardiac death similar to that of the CABG group (HR 0.63, 95% CI: 0.32 to 1.23; p=0.17).

Conclusions: An rSS≤12 after PCI may reduce the risk of cardiac mortality and could be a measure of reasonable incomplete revascularisation in patients with CTO and multivessel CAD.
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http://dx.doi.org/10.4244/EIJ-D-16-00421DOI Listing
May 2017

Morphine Does Not Affect Myocardial Salvage in ST-Segment Elevation Myocardial Infarction.

PLoS One 2017 12;12(1):e0170115. Epub 2017 Jan 12.

Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.

Recent studies have proposed intravenous (IV) morphine is associated with delayed action of antiplatelet agents in acute myocardial infarction. However, it is unknown whether morphine results in increased myocardial damage in ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI). We investigated myocardial salvage index (MSI) to determine whether IV morphine affects myocardial injury adversely in STEMI patients undergoing primary PCI. 299 STEMI patients underwent contrast-enhanced magnetic resonance imaging a median of 3 days after PCI. Infarct size was measured on delayed-enhancement imaging, and area at risk was quantified on T2-weighted imaging. MSI was calculated as '[area at risk-infarct size] X 100 / area at risk'. IV morphine was administrated in 32.1% of patients. Patients treated with morphine had shorter symptom to balloon time and higher prevalence of Thrombolysis in Myocardial Infarction flow grade 0 or 1. The morphine group showed a trend toward larger MSI and infarct size and significantly greater area at risk than the non-morphine group. After propensity score matching (90 pairs), MSI was similar between the morphine and non-morphine group (46.1% versus 43.5%, P = .11), and infarct size and area at risk showed no difference. In propensity score-matched analysis, IV morphine prior to primary PCI in STEMI patients did not cause adverse impacts on myocardial salvage.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0170115PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5231339PMC
August 2017

Shock Index as a Predictor of Myocardial Injury in ST-segment Elevation Myocardial Infarction.

Am J Med Sci 2016 Dec 20;352(6):574-581. Epub 2016 Sep 20.

Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.

Background: Little is known about the association between shock index and myocardial injury in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI).

Methods: We analyzed cardiac magnetic resonance imaging from 306 consecutive patients treated with primary PCI for STEMI. The patients were divided into the following 2 groups: initial shock index >0.7 (n = 88) and ≤0.7 (n = 218). Shock index was calculated as the ratio of heart rate to systolic blood pressure based on the first recorded vital signs upon arrival. The primary end point was myocardial infarct size.

Results: The shock index >0.7 group, exhibited a lower baseline left ventricular ejection fraction (P = 0.01), higher N-terminal prohormone of brain natriuretic peptide level (P = 0.01), higher Killip class (P < 0.01) and higher prevalence of diabetes (P = 0.02) than the shock index ≤0.7 group. There were no significant differences in the angiographic or procedural characteristics between the 2 groups. In cardiac magnetic resonance imaging analysis, the shock index >0.7 group had a larger infarct size than did the shock index ≤0.7 group (22.9 ± 11.2% versus 19.2 ± 11.5%, P < 0.01). According to multivariate analysis, shock index >0.7 was associated with large myocardial infarctions (odds ratio = 3.02; 95% CI: 1.62-5.65; P < 0.01).

Conclusions: Initial shock index is a potentially reliable predictor of myocardial injury in patients with STEMI undergoing primary PCI.
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http://dx.doi.org/10.1016/j.amjms.2016.09.003DOI Listing
December 2016

D-Dimer Levels Predict Myocardial Injury in ST-Segment Elevation Myocardial Infarction: A Cardiac Magnetic Resonance Imaging Study.

PLoS One 2016 11;11(8):e0160955. Epub 2016 Aug 11.

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

Objectives: Elevated D-dimer levels on admission predict prognosis in patients undergoing primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI), but the association of D-dimer levels with structural markers of myocardial injury in these patients is unknown.

Methods: We performed cardiac magnetic resonance (CMR) imaging in 208 patients treated with primary PCI for STEMI. CMR was performed a median of 3 days after the index procedure. Of the 208 patients studied, 75 patients had D-dimer levels above the normal range on admission (>0.5 μg/mL; high D-dimer group) while 133 had normal levels (≤0.5 μg/mL; low D-dimer group). The primary outcome was myocardial infarct size assessed by CMR. Secondary outcomes included area at risk (AAR), microvascular obstruction (MVO) area, and myocardial salvage index (MSI).

Results: In CMR analysis, myocardial infarct size was larger in the high D-dimer group than in the low D-dimer group (22.3% [16.2-30.5] versus 18.8% [10.7-26.7]; p = 0.02). Compared to the low D-dimer group, the high D-dimer group also had a larger AAR (38.1% [31.7-46.9] versus 35.8% [24.2-45.3]; p = 0.04) and a smaller MSI (37.7 [28.2-46.9] versus 47.1 [33.2-57.0]; p = 0.01). In multivariate analysis, high D-dimer levels were significantly associated with larger myocardial infarct (OR 2.59; 95% CI 1.37-4.87; p<0.01) and lower MSI (OR 2.62; 95% CI 1.44-4.78; p<0.01).

Conclusions: In STEMI patients undergoing primary PCI, high D-dimer levels on admission were associated with a larger myocardial infarct size, a greater extent of AAR, and lower MSI, as assessed by CMR data. Elevated initial D-dimer level may be a marker of advanced myocardial injury in patients treated with primary PCI for STEMI.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0160955PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4981325PMC
August 2017

Association of β-blocker therapy with long-term clinical outcomes in patients with coronary chronic total occlusion.

Medicine (Baltimore) 2016 Jul;95(30):e4300

Division of Cardiology, Department of Medicine, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul Division of Cardiology, Department of Internal Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Republic of Korea.

There are limited data regarding the efficacy of β-blockers for secondary prevention in patients with coronary chronic total occlusion (CTO). Therefore, we investigated the association of β-blocker therapy with long-term clinical outcomes in CTO patients. From March 2003 to February 2012, a total of 2024 CTO patients treated with either medical therapy alone or revascularization were enrolled in the study. We assessed 1596 patients with stable ischemic heart disease and divided them into the β-blocker group (n = 932) and the no-β-blocker group (n = 664). The primary outcome was all-cause death. The median follow-up duration was 3.9 (interquartile range: 2.0-6.2) years. All-cause death occurred in 11.6% patients in the β-blocker group and 13.6% patients in the no-β-blocker group (hazard ratio [HR]: 0.81, 95% confidence interval [CI]: 0.61-1.08; P = 0.15). In the propensity score-matched population (570 pairs), all-cause death occurred in 12.3% patients in the β-blocker group and 12.8% patients in the no-β-blocker group (HR: 0.93, 95% CI: 0.67-1.29; P = 0.66). In subgroup analysis, β-blocker therapy was associated with better outcome, in terms of all-cause death, in patients with CTO of the left anterior descending coronary artery and Synergy Between PCI with Taxus and Cardiac Surgery (SYNTAX) score ≥23 (P for interaction = 0.01 and 0.02, respectively). In conclusion, β-blocker therapy was not associated with favorable long-term clinical outcomes in stable CTO patients, regardless of treatment strategy. However, β-blocker therapy might be beneficial in a highly selective group of CTO patients with a high ischemic burden.
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http://dx.doi.org/10.1097/MD.0000000000004300DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5265841PMC
July 2016

Differential effect of side branch intervention on long-term clinical outcomes according to side branch stenosis after main vessel stenting: Results from the COBIS (Coronary Bifurcation Stenting) Registry II.

Int J Cardiol 2016 Oct 6;221:471-7. Epub 2016 Jul 6.

Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.

Background: Indication of side branch (SB) intervention after main vessel (MV) stenting is not established for coronary bifurcation lesions.

Methods: We evaluated 2017 patients who were treated with 1-stent technique or MV stenting as a first strategy. Patients undergoing SB intervention after MV stenting (SB intervention group, n=929) were compared to those treated with MV stenting only (no-SB intervention group, n=1088).

Results: During a median follow-up of 37months, cardiac death or myocardial infarction (MI) tended to occur less frequently in the SB intervention group than in the no-SB intervention group (1.8% versus 2.9%; adjusted hazard ratio [HR] 0.53; 95% confidence interval [CI] 0.25-1.11; P=0.09). There was a significant interaction between SB intervention and SB stenosis after MV stenting (P for interaction <0.01). Among 1077 patients with diameter stenosis of SB ≥50% after MV stenting, SB intervention was associated with a lower risk of cardiac death or MI (1.2% versus 4.2%; adjusted HR 0.22; 95% CI 0.09-0.52; P<0.01). However, among 940 patients with diameter stenosis of SB <50%, there was no significant difference in cardiac death or MI between the SB intervention group and the no-SB intervention group (3.5% versus 2.2%; adjusted HR 1.36; 95% CI 0.58-3.20; P=0.48).

Conclusions: The effect of SB intervention differed according to SB stenosis after MV stenting. SB intervention may reduce cardiac death or MI in bifurcation lesions with diameter stenosis of SB ≥50% after MV stenting.
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http://dx.doi.org/10.1016/j.ijcard.2016.07.045DOI Listing
October 2016

Clinical and Echocardiographic Characteristics of Acute Cardiac Dysfunction Associated With Acute Brain Hemorrhage - Difference From Takotsubo Cardiomyopathy.

Circ J 2016 Aug 5;80(9):2026-32. Epub 2016 Jul 5.

Division of Cardiology, Department of Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine.

Background: Cardiac dysfunction (CD) associated with brain hemorrhage is similar to that with takotsubo cardiomyopathy but still not well understood. We aimed to investigate the clinical and echocardiographic findings of acute CD (ACD) related to brain hemorrhage.

Methods and results: Between 2013 and 2014, consecutive patients diagnosed with spontaneous and traumatic brain hemorrhage were prospectively enrolled. Electrocardiography, cardiac enzymes, and echocardiography were performed. Left ventricular (LV) systolic dysfunction on echocardiography was defined as ACD related to brain hemorrhage when all the following conditions were satisfied: abnormal ECG and cardiac troponin level, LV wall motion abnormality or decreased LV systolic function on echocardiography, and no previous history of cardiac disease. Otherwise, LV dysfunction was considered to be other CD unrelated to brain hemorrhage. In a total of 208 patients, 15 (7.2%) showed ACD. Of them, 8 patients were men and 8 showed apex-sparing LV hypokinesia and 9 died in hospital. Other cardiac abnormalities observed in the study patients were NT-proBNP elevation (n=123), QT interval prolongation (n=95), LV hypertrophy (n=89), and troponin I elevation (n=47). There were 36 in-hospital deaths (17.3%). Glasgow coma score and ACD were independently associated with in-hospital death.

Conclusions: ACD was observed in patients with various brain hemorrhages. Unlike takotsubo cardiomyopathy, high proportions of male sex, apex-sparing LV dysfunction, and in-hospital death were observed for ACD associated with brain hemorrhage. (Circ J 2016; 80: 2026-2032).
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http://dx.doi.org/10.1253/circj.CJ-16-0395DOI Listing
August 2016
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