• Korean Circulation Journal
• /
• v.53 no.7
• /
• pp.425-451
• /
• 2023

Most patients with heart failure (HF) have multiple comorbidities, which impact their quality of life, aggravate HF, and increase mortality. Cardiovascular comorbidities include systemic and pulmonary hypertension, ischemic and valvular heart diseases, and atrial fibrillation. Non-cardiovascular comorbidities include diabetes mellitus (DM), chronic kidney and pulmonary diseases, iron deficiency and anemia, and sleep apnea. In patients with HF with hypertension and left ventricular hypertrophy, renin-angiotensin system inhibitors combined with calcium channel blockers and/or diuretics is an effective treatment regimen. Measurement of pulmonary vascular resistance via right heart catheterization is recommended for patients with HF considered suitable for implantation of mechanical circulatory support devices or as heart transplantation candidates. Coronary angiography remains the gold standard for the diagnosis and reperfusion in patients with HF and angina pectoris refractory to antianginal medications. In patients with HF and atrial fibrillation, longterm anticoagulants are recommended according to the CHA₂DS₂-VASc scores. Valvular heart diseases should be treated medically and/or surgically. In patients with HF and DM, metformin is relatively safer; thiazolidinediones cause fluid retention and should be avoided in patients with HF and dyspnea. In renal insufficiency, both volume status and cardiac performance are important for therapy guidance. In patients with HF and pulmonary disease, beta-blockers are underused, which may be related to increased mortality. In patients with HF and anemia, iron supplementation can help improve symptoms. In obstructive sleep apnea, continuous positive airway pressure therapy helps avoid severe nocturnal hypoxia. Appropriate management of comorbidities is important for improving clinical outcomes in patients with HF.

• Korean Journal of Radiology
• /
• v.24 no.4
• /
• pp.349-361
• /
• 2023

Objective: To quantitatively assess the pulmonary vasculature using non-contrast computed tomography (CT) in patients with chronic thromboembolic pulmonary hypertension (CTEPH) pre- and post-treatment and correlate CT-based parameters with right heart catheterization (RHC) hemodynamic and clinical parameters. Materials and Methods: A total of 30 patients with CTEPH (mean age, 57.9 years; 53% female) who received multimodal treatment, including riociguat for ≥ 16 weeks with or without balloon pulmonary angioplasty and underwent both non-contrast CT for pulmonary vasculature analysis and RHC pre- and post-treatment were included. The radiographic analysis included subpleural perfusion parameters, including blood volume in small vessels with a cross-sectional area ≤ 5 mm² (BV5) and total blood vessel volume (TBV) in the lungs. The RHC parameters included mean pulmonary artery pressure (mPAP), pulmonary vascular resistance (PVR), and cardiac index (CI). Clinical parameters included the World Health Organization (WHO) functional class and 6-minute walking distance (6MWD). Results: The number, area, and density of the subpleural small vessels increased after treatment by 35.7% (P < 0.001), 13.3% (P = 0.028), and 39.3% (P < 0.001), respectively. The blood volume shifted from larger to smaller vessels, as indicated by an 11.3% increase in the BV5/TBV ratio (P = 0.042). The BV5/TBV ratio was negatively correlated with PVR (r = -0.26; P = 0.035) and positively correlated with CI (r = 0.33; P = 0.009). The percent change across treatment in the BV5/TBV ratio correlated with the percent change in mPAP (r = -0.56; P = 0.001), PVR (r = -0.64; P < 0.001), and CI (r = 0.28; P = 0.049). Furthermore, the BV5/TBV ratio was inversely associated with the WHO functional classes I-IV (P = 0.004) and positively associated with 6MWD (P = 0.013). Conclusion: Non-contrast CT measures could quantitatively assess changes in the pulmonary vasculature in response to treatment and were correlated with hemodynamic and clinical parameters.

• Korean Circulation Journal
• /
• v.54 no.7
• /
• pp.409-421
• /
• 2024

Background and Objectives: The recent developments in chronic thromboembolic pulmonary hypertension (CTEPH) are emphasizing the multidisciplinary team. We report on the changes in clinical practice following the development of a multidisciplinary team, based on our 7 years of experience. Methods: Multidisciplinary team was established in 2015 offering both balloon pulmonary angioplasty (BPA) and pulmonary endarterectomy (PEA) with technical upgrades by internal and external expertise. For operable cases, PEA was recommended as the primary treatment modality, followed by pulmonary angiography and right heart catheterization after 6 months to evaluate treatment effect and identify patients requiring further BPA. For patients with inoperable anatomy or high surgical risk, BPA was recommended as the initial treatment modality. Patient data and clinical outcomes were closely monitored. Results: The number of CTEPH treatments rapidly increased and postoperative survival improved after team development. Before the team, 38 patients were treated by PEA for 18 years; however, 125 patients were treated by PEA or BPA after the team for 7 years. The number of PEA performed was 64 and that of BPA 342 sessions. World Health Organization functional class I or II was achieved in 93% of patients. The patients treated with PEA was younger, male dominant, higher pulmonary artery pressure, and smaller cardiac index, than BPA-only patients. In-hospital death after PEA was only 1 case and none after BPA. Conclusions: The balanced development of BPA and PEA through a multidisciplinary team approach proved synergistic in increasing the number of actively treated CTEPH patients and improving clinical outcomes.

• Journal of Chest Surgery
• /
• v.32 no.5
• /
• pp.422-427
• /
• 1999

Background: Tachycardia induced heart failure model would be the model of choice for the dilated cardiomyopathy. This more closely resembles the clinical syndrome and does not require major surgical trauma, myocardial ischemia and pharmacological or toxic depression of cardiac function. When heart failure is progressive, application of new surgical procedures to the faling heart is highly risky. It has been shown that recovery trajectory from heart failure is a new method in decreasing animal mortality. The purpose is to establish the control datas for recovery trajectory in the canine heart failure model. Material and Method: 21 mongrel dogs were studied at 4 stages(baseline, at the heart failure, 4 and 8 weeks after recovery). Heart failure was induced during 4 weeks of continuous rapid pacing using a pacemaker. Eight weeks of trajectory of recovery period was allowed. Indices of left ventricular function and dimension were measured every 2 weeks and the hemodynamics were measured by use of Swan-Ganz catheterization and thermodilution method every 4 weeks. Values were expressed as mean${\pm}$standard deviation. Result: 4(20%) dogs died due to heart failure. Left ventricular end-diastolic volume at the 4 stages were 40.8${\pm}$7.4, 82.1${\pm}$21.1, 59.9${\pm}$7.7 and 46.5${\pm}$6.5ml. Left ventricular end-systolic volume showed the same trend. Ejection fractions were 50.6${\pm}$4.1, 17.5${\pm}$5.8, 36.3${\pm}$7.3, and 41.5${\pm}$2.4%. Blood pressure and heart rate showed no significant changes. Pressures of central vein, right ventricle, pulmonary artery, and pulmonary capillary wedge showed significant increase during the heart failure period, normalizing at the end of recovery period. Stroke volumes were 21.5${\pm}$8.2, 12.3${\pm}$3.5, 17.9${\pm}$4.6, and 15.5${\pm}$3.4ml. Blood norepinephrine level was 133.3${\pm}$60.0pg/dL at the baseline and 479.4${\pm}$327.3pg/dL at the heart failure stage(p=0.008). Conclusion: Development of tachycardia induced heart failure model is of high priority due to ready availability and reasonable amenability to measurements. Recovery trajectory after cessation of tachycardia showed reduction of cardiac dilatation and heart function. Application of new surgical procedures during the recovery period could decrease animal mortality.

• Journal of Chest Surgery
• /
• v.37 no.9
• /
• pp.755-761
• /
• 2004

We evaluated the efficacy of Dor procedure in patients with ischemic left ventricular dysfunction. Material and Method: Between April 1998 and December 2002, 45 patients underwent the Dor procedure con-comitant with coronary artery bypass grafting (CABG). Left ventricular ejection fraction (LVEF) and left ventricular end-diastolic/end-systolic volumes (LVEDV/LVESV) were measured by echocardiography, myocardial SPECT, and cardiac catheterization and angiography performed at the sequence of preoperative, early postoperative, and one year postoperative stage. Result: Cardiopulmonary bypass and aortic clamp times were mean 141$\pm$64, 69$\pm$24 minutes, respectively. Intraaortic balloon pump (IABP) therapy was required in 19 patients (42%; 7 preoperatively, 9 intraoperatively, 3 postoperatively). Operative mortality rate was 2.2% (1/45). Postoperative morbidities were low cardiac output syndrome (12), atrial fibrillation (5), acute renal failure (4), and postoperative bleeding (4). Functional class (NYHA) was improved from classes 2.8 to 1.1 (p < 0,01). When we compared between the preoperative and early postoperative values, LVEF was improved from 32$\pm$9% to 52$\pm$11% (p<0.01). The asynergy portion decreased from 57$\pm$12% to 22$\pm$9%, and LVEDV/LVESV indexes improved from 125$\pm$39 mL/$m^2$, 85$\pm$30 mL/$m^2$ to 66$\pm$23 mL/$m^2$, 32$\pm$16 mL/$m^2$ (p<0.01). Although these changes in volumes were relatively preserved at postoperative one year, the left ventricular volumes showed a tendency to increase. Conclusion: After the Dor procedure for ischemic left ventricular dysfunction, LVEF improvement and left ventricular volume reduction were maintained till postoperative one year. The tendency for left ventricular volume to increase at postoperative one year suggested the requirement of strict medical management.

• Tuberculosis and Respiratory Diseases
• /
• v.42 no.5
• /
• pp.752-759
• /
• 1995

Background: Bronchial asthma is characterized by noctunal dyspnea, cough and wheezing because of airway hyperresponsiveness to nonspecific stimuli. These symptoms and signs are also observed in patients with congestive heart failure. Therefore, this is so called "cardiac asthma". There are lots of experimental and clinical datas to suggest that airway dysfunctions occur in acute and chronic congestive heart failure. However, it is still controversial whether bronchial hyperresponsiveness is present in patients with congestive heart failure. To assess whether bronchial hyperresponsiveness is present in patients with congestive heart failure and to demonstrate the relationship between bronchial responsiveness and vascular pressure, we performed methacholine provocation test in 11 patients with mitral valvular heart disease. Methods: All patients were in the New York Heart Association functional class II and treated continuously with digoxin and/or dichlozid and/or angiotensin converting enzyme inhibitor except one patient. All patients were undergone right and left side heart catheterization for hemodynamic measurements. A 20 percent fall of peak expiratory flow rate were considered as positive response to methacholine provocation test. Results: 1) Only one patient who has normal pulmonary artery pressure, pulmonary capillary wedge pressure, cardiac index was positive in methacholine provocation test. 2) Their mean pulmonary artery pressure, pulmonary capillary wedge pressure were $21.72{\pm}9.70mmHg$, $15.45{\pm}8.69mmHg$ respectively which were significantly higher. Conclusion: It is speculated that in stable congestive heart failure patients, bronchial responsiveness as assessed by methacholine provocation test may not be increased.

• Clinical and Experimental Pediatrics
• /
• v.52 no.4
• /
• pp.488-493
• /
• 2009

Purpose : The aim of this study was to assess the efficacy and safety of recent-generation patent ductus arteriosus (PDA) closure devices applied by a new selection strategy according to the characteristics of each PDA. Methods : From February 2003 to January 2006, 138 patients underwent transcatheter closure of PDA (study group). According to the size and morphology of each ductus, a COOK Detachable Coil or 'flex' PFM Nit-Occlud was used for a small ductus (group 1, n=43); 'medium' PFM Nit-Occlud (group 2, n=49) for a moderate ductus; and an Amplatzer Duct Occluder (group 3, n=46) for a large ductus. The 83 patients who underwent transcatheter closure of PDA from February 2000 to January 2003 were defined as the comparison group. The Qp/Qs ratio, pulmonary/aorta pressure ratio, and MD of the ductus were compared. Immediate and follow-up results including residual shunts and complications were also evaluated and compared among groups. Results : In all 138 patients, complete occlusions were confirmed without major complications, while procedure failure (n=2, 2.2%), device embolization (n=1, 1.1%), and persistent residual shunt (n=4, 4.5%) were documented in the comparison group. Total complication rates were lower in the study group than in the comparison group (study group, 1.4%; comparison group, 9.0%; P<0.05). Conclusion : A novel strategy adopting the merits of various recent-generation devices for transcatheter closure of PDA provides excellent clinical results with minimal risk.

• Journal of Chest Surgery
• /
• v.36 no.7
• /
• pp.510-513
• /
• 2003

Annuloaortic ectasia, aortic regurgitation(AR), and ventricular septal defect(VSD) in patients with right ventricular hypoplasia is a very rare condition. We report a patient who underwent aortic root replacement with a composite graft for annuloaortic ectasia associated with VSD and AR in right ventricular hypoplasia. The patient was a 19 year-old male. Transthoraic echocardiogram and cardiac catheterization revealed a perimembranous VSD (2 cm in diameter), severe AR, annuloaortic ectasia, bipartite right ventricle with hapoplasia, and hypoplastic tricuspid valve. Operative findings showed that free margins of the right and noncoronary cusps were markedly elongated, thickened, and retracted, and commissure between the right coronary cusp and the noncoronary cusp was fused and calcified. VSD was closed with an autologous pericardial patch and composite graft aortic root replacement using direct coronary button reimplantation was performed, and the hypertrophic muscle of the right ventricular outflow tract was resected. The patient had transient weaning failure of cardiopulmonary bypass and was discharged at the postoperative 14 days without any problems.

• Clinical and Experimental Pediatrics
• /
• v.45 no.2
• /
• pp.199-207
• /
• 2002

Purpose : Since the successful application of total atrio-pulmonary connection(TAPC) to patients with various types of physiologic single ventricles in 1971, post-operative survival rates have reached more than 90%. However some patients have been shown to present with late complications such as right atrial thrombosis, atrial fibrillation and protein losing enteropathy eventually leading to re-operation to control the long-term complications. The aim of this study is to review the results of total cavo-pulmonary connection(TCPC) in cases with late complications after TAPC. Methods : Between Jan. 1995 and Dec. 2000, 6 patients(5 males and 1 female) underwent cardiac catheterization $11{\pm}3$ months after conversion of previous TAPC to TCPC. We compared the hemodynamic and morphologic parameters before and after TCPC and also assessed the clinical outcomes. The indications for TAPC were tricuspid atresia in 4 cases and complex double-outlet right ventricle with single ventricle physiology in 2 cases. Results : There was no peri-operative mortality and all patients were clinically and hemodynamically improved at a mean follow-up of 11 months(range : 4 to 13). However, protein losing enteropathy recurred in 2 patients; this was were successfully treated with subcutaneous administration of heparin. Right atrial pressure before TCPC was $18.0{\pm}3.6mmHg$, but baffle pressure, corresponding to right atrial pressure decreased to $14.8{\pm}3.6mmHg$ after TCPC. The size of the pulmonary arteries did not regress after TCPC. Conclusion : The conversion of TAPC to TCPC improves clinical and hemodynamic status by decreasing the right atrial pressure and by providing a laminar cavo-pulmonary flow which enhances the effective pulmonary circulation in the so-called Fontan circulation.

• Journal of Chest Surgery
• /
• v.30 no.7
• /
• pp.656-662
• /
• 1997

Aortic valvuloplasty has recently gained attention as an attractive alternative procedure for aortic valvular disease. Between March 1995 to August 1996, 14 patients with pure aortic regurgitation(AR) underwent aortic alvuloplasty using leaflet extension with glutaraldehydepreserved autologous pericardium. There were 11 males and 3 females, and the mean age was 34.8 $\pm$ 15.3 years. Preoperative echocardiography and cardiac catheterization revealed that the degree of AR was mean 3.4$\pm$0.65, and more than moderate degree of mitral regurgitation(MR) were detected in 4 patients. In 12 patients, 3 leaflets were extended and in another 2 patients only one deformed leaflet was extended. Concomitant mitral valvuloplasty (MVP) was performed in 4 patients. The competency of the aortic valve after completion of repair was evaluated by the transesophageal echocardiography in operating theater, and there was no aortic and mitral stenosis or regurgitation. In an early postoperative echocardiography, trivial AR was detected in 3 patients and mild MR in 1 patient. The end-systolic and end-diastolic dimensions of the left ventricle were decreased significantly(p<0.05) as compared with those of preoperative values. T ere was no mortality and no significant postoperative complication encountered. Late complication developed in 2 patients during the follow-up period(mean 7.9$\pm$ 5.9 months). One patient underwent AVR on postoperative 7th month due to endocarditis, and the another patient with Behcet's disease underwent Ross operation at postoperative 4th month. In conclusion, AVP of leaflet extension technique offers an excellent early clinical result and represents a good alterna!ivy surgical treatment for the pure AR especially in young age group, although long-term follow-up is necessary to determine the durability of glutaraldehyde-preserved autologous pericardium as a valve leaflet.