Objectives This study sought to investigate the predictors and outcomes of side branch (SB) occlusion after main vessel (MV) stenting in coronary bifurcation lesions. Background SB occlusion is a ...serious complication that occurs during percutaneous coronary intervention (PCI) for bifurcation lesions. Methods Consecutive patients undergoing PCI using drug-eluting stents for bifurcation lesions with SB ≥2.3 mm were enrolled. We selected patients treated with the 1-stent technique or MV stenting first strategy. SB occlusion after MV stenting was defined as Thrombolysis in Myocardial Infarction flow grade <3. Results SB occlusion occurred in 187 (8.4%) of 2,227 bifurcation lesions. In multivariate analysis, independent predictors of SB occlusion were pre-procedural percent diameter stenosis of the SB ≥50% (odds ratio OR: 2.34; 95% confidence interval CI: 1.59 to 3.43; p < 0.001) and the proximal MV ≥50% (OR: 2.34; 95% CI: 1.57 to 3.50; p < 0.001), SB lesion length (OR: 1.03; 95% CI: 1.003 to 1.06; p = 0.03), and acute coronary syndrome (OR: 1.53; 95% CI: 1.06 to 2.19; p = 0.02). Of 187 occluded SBs, flow was restored spontaneously in 26 (13.9%) and by SB intervention in 103 (55.1%) but not in 58 (31.0%). Jailed wire in the SB was associated with flow recovery (74.8% vs. 57.8%, p = 0.02). Cardiac death or myocardial infarction occurred more frequently in patients with SB occlusion than in those without SB occlusion (adjusted hazard ratio: 2.34; 95% CI: 1.15 to 4.77; p = 0.02). Conclusions Angiographic findings of SB, proximal MV stenosis, and clinical presentation are predictive of SB occlusion after MV stenting. Occlusion of sizable SB is associated with adverse clinical outcomes. (Korean Coronary Bifurcation Stenting Registry II COBIS; NCT01642992 )
Background α-Klotho is reported to have protective effects against kidney injury, and its renal expression is decreased in many experimental models of kidney disease. However, circulating α-klotho ...levels in human chronic kidney disease (CKD) and the relationship to progression are unknown. Study Design Post hoc analysis of a prospective cohort study. Setting & Participants 243 of 301 participants from a CKD cohort at our institution between January 2006 and December 2011 were eligible for the study. Predictor Baseline α-klotho levels. Outcomes Primary outcome was the composite of doubling of baseline serum creatinine concentration, end-stage renal disease, or death. End-stage renal disease was defined as onset of treatment by renal replacement therapy. Measurements Serum α-klotho and fibroblast growth factor 23 (FGF-23) were measured using enzyme-linked immunosorbent assay. Results Lower serum α-klotho levels were associated with more severe CKD stage in the cross-sectional analysis of the baseline data ( P for trend < 0.001). In the adjusted multivariable linear regression model, log(α-klotho) was associated independently with estimated glomerular filtration rate (β = 0.154; P = 0.001). Cox regression analysis showed that baseline α-klotho level independently predicted the composite outcome after adjustment for age, diabetes, blood pressure, estimated glomerular filtration rate, proteinuria, parathyroid hormone level, and FGF-23 level (HR per 10-pg/mL increase, 0.96; 95% CI, 0.94-0.98; P < 0.001). When patients were categorized into 2 groups according to baseline median α-klotho value, 43 (35.2%) patients with α-klotho levels ≤396.3 pg/mL reached the primary composite outcome compared with 19 (15.7%) with α-klotho levels >396.3 pg/mL (HR, 2.03; 95% CI, 1.07-3.85; P = 0.03). Limitations Uncontrolled dietary phosphorus intake and use of frozen samples. Conclusions This observational study showed that low circulating α-klotho levels were associated with adverse kidney disease outcome, suggesting that α-klotho is a novel biomarker for CKD progression. More data from larger prospective longitudinal studies are required to validate our findings.
Background Because there is a controversy regarding the management of papillary thyroid microcarcinoma, the purpose of this study was to compare lobectomy with total thyroidectomy as a primary ...operative treatment for papillary thyroid microcarcinoma. Loco-regional recurrence in the contralateral remnant lobe can be managed safely by completion thyroidectomy via the previous scar. However, reoperation for operation bed (thyroidectomy site) or regional lymph node (central or lateral) recurrence generally is associated with morbidity. Therefore, we analyzed overall loco-regional recurrence and loco-regional recurrence outside of the contralateral remnant lobe separately. Methods We retrospectively reviewed 8,676 conventional patients with papillary thyroid microcarcinoma who underwent thyroidectomy. Results Lobectomy was performed in 3,289 (37.9%) patients, and total thyroidectomy was performed in 5,387 (62.1%) patients. Total thyroidectomy significantly decreased the risk of overall loco-regional recurrence (adjusted hazard ratio 0.398, P < .001). However, total thyroidectomy did not significantly decrease the risk of loco-regional recurrence outside of the contralateral remnant lobe (adjusted hazard ratio 0.880, P = .640). Particularly in conventional papillary thyroid microcarcinoma patients with multifocality, total thyroidectomy significantly decreased the risk of overall loco-regional recurrence (adjusted hazard ratio 0.284, P = .002) and loco-regional recurrence outside of the contralateral remnant lobe (adjusted hazard ratio 0.342, P = .020). Conclusion Although lobectomy is associated with contralateral remnant lobe recurrence, lobectomy did not increase the risk of loco-regional recurrence outside of the contralateral remnant lobe in patients with papillary thyroid microcarcinoma, except in those with multifocality. Because recurrence in the contralateral remnant lobe can be managed safely by completion thyroidectomy, lobectomy may be a safe operative option for select patients with papillary thyroid microcarcinoma without multifocality.
Objectives We investigated whether statin therapy could be beneficial in patients with acute myocardial infarction (AMI) who have baseline low-density lipoprotein cholesterol (LDL-C) levels below 70 ...mg/dl. Background Intensive lipid-lowering therapy with a target LDL-C value <70 mg/dl is recommended in patients with very high cardiovascular risk. However, whether to use statin therapy in patients with baseline LDL-C levels below 70 mg/dl is controversial. Methods We analyzed 1,054 patients with AMI who had baseline LDL-C levels below 70 mg/dl and survived at discharge from the Korean Acute MI Registry between November 2005 and December 2007. They were divided into 2 groups according to the prescribing of statins at discharge (statin group n = 607; nonstatin group n = 447). The primary endpoint was the composite of 1-year major adverse cardiac events, including death, recurrent MI, target vessel revascularization, and coronary artery bypass grafting. Results Statin therapy significantly reduced the risk of the composite primary endpoint (adjusted hazard ratio HR: 0.56; 95% confidence interval CI: 0.34 to 0.89; p = 0.015). Statin therapy reduced the risk of cardiac death (HR: 0.47; 95% CI: 0.23 to 0.93; p = 0.031) and coronary revascularization (HR: 0.45, 95% CI: 0.24 to 0.85; p = 0.013). However, there were no differences in the risk of the composite of all-cause death, recurrent MI, and repeated percutaneous coronary intervention rate. Conclusions Statin therapy in patients with AMI with LDL-C levels below 70 mg/dl was associated with improved clinical outcome.
Despite the usefulness of intravascular ultrasound (IVUS) in percutaneous coronary intervention (PCI), the impact of IVUS guidance on clinical outcomes, particularly for chronic total occlusion (CTO) ...intervention, has rarely been studied. We sought to investigate the clinical usefulness of IVUS-guided CTO intervention with second-generation drug-eluting stent implantation. From 2007 to 2009, a total of 2,568 patients were enrolled in the Korean-CTO registry and 534 patients with successful implantation of second-generation drug-eluting stents were analyzed. IVUS-guided PCI was performed on 206 patients (39%). Clinical outcomes at 2 years were compared between the IVUS-guidance group and the angiography-guidance group in 201 propensity score–matched pairs. The primary end point was the occurrence of definite or probable stent thrombosis. Clinical characteristics were similar between both groups after matching. At 2 years, the IVUS-guidance group showed significantly less stent thrombosis than the angiography-guidance group (0% vs 3.0%, p = 0.014) and a lesser trend toward myocardial infarction (1.0% vs 4.0%, p = 0.058). Target lesion revascularization (TLR) and major adverse cardiovascular event rates were similar. However, a significant interaction was observed between the use of IVUS and lesion length for predicting the TLR (p = 0.037), suggesting usefulness of IVUS in long-lesion (≥3 cm) relative to short-lesion CTO. In conclusion, although IVUS-guided CTO PCI was not associated with a reduction in overall major adverse cardiovascular events, IVUS guidance appears to be associated with a reduction of stent thrombosis and myocardial infarction compared with angiography-guided CTO PCI. Additionally, TLR occurred less frequently in the IVUS-guidance group, especially for long lesions.
Background Current guidelines for endoscopic management such as EMR and endoscopic submucosal dissection (ESD) in early gastric cancer (EGC) are in evolution, with broader indication criteria. ...Objective To determine the clinical outcomes of endoscopic treatment, based on absolute indication and extended indication criteria and endoscopic methods. Design Retrospective study. Setting Tertiary-care, academic medical center. Patients EMR or ESD was performed on 1627 cases of EGC in 1447 patients from July 1994 to January 2009. Intervention EMR and ESD. Main Outcome Measurements Clinical outcomes of EGC after EMR or ESD, based on the indication criteria. Results Although the complete resection rate was higher (95.9% vs 88.4%; P < .001), and the complication rate was lower (6.8% vs 9.8%; P = .054) in the absolute than in the extended indication group, there was no between-group difference in the local recurrence rate (0.9% vs 1.1%; P = .783) at a median follow-up period of 32 months (interquartile range 22-48 months). In the extended indication group, ESD resulted in a significantly higher complete resection rate than EMR (83.0% vs 91.1%; P = .006). Limitations Retrospective study. Conclusion ESD in the extended indication group showed acceptable clinical outcomes with a relatively high complete resection rate and a low local recurrence rate.
Background Although focal ground-glass opacity (GGO) lung nodules are generally reported to grow slowly, their natural course is unclear. The purpose of this study was to elucidate the natural course ...of screening-detected pure GGO lung nodules in patients with no history of malignancy. Methods We retrospectively reviewed the database of subjects who had undergone screenings involving low-dose CT scans. We included patients with pure GGO lung nodules who were followed for > 2 years after the initial screening. Results Between June 1997 and September 2006, 122 pure GGO nodules were found in 89 patients. The median nodule size was 5.5 mm (range, 3-20 mm) in the largest diameter on initial low-dose CT scan. The median follow-up period per patient was 59 months. On a per-person basis, the frequency of growth was 13.5% (12 of 89 patients). On a per-nodule basis, the frequency of growth was 9.8% (12 of 122 nodules). Nodule growth was significantly associated with initial size and new development of an internal solid portion. The median volume doubling time was 769 days for growing pure GGO nodules. A total of 11 growing nodules were surgically validated, and all lesions were confirmed as primary lung cancer. Conclusions About 90% of the screening-detected pure GGO lung nodules did not grow during long-term follow-up in subjects with no history of malignancy and most growing nodules had an indolent clinical course. A strategy of long-term follow-up and selective surgery for growing nodules should be considered for pure GGO lung nodules.
Abstract Objective Conduction disturbances are common in patients with aortic stenosis (AS). We investigated the incidence, reversibility, and prognosis of conduction disorders requiring permanent ...pacemaker (PPM) implantation in patients with degenerative AS after isolated aortic valve replacement (AVR). Methods This was a retrospective study conducted at a tertiary care center. We evaluated the incidence of conduction disturbances in patients who underwent isolated surgical AVR for AS between January 2005 and May 2015. Relevant clinical information was obtained from the patients’ medical records. Results We reviewed results of 663 patients with pathologically proven degenerative AS bicuspid aortic valve, n=285 (43.0%) who underwent isolated AVR mechanical valve, n=310 (46.8%). Patients’ mean age was 67.1±8.1 years, and 362 were male (54.6%). Immediate postoperative intraventricular conduction disorders occurred in 56 patients (8.4%), and atrioventricular block (AVB) occurred in 68 patients (10.3%). Ten patients with symptomatic second-degree or third- degree AVB underwent PPM implantation within 30 days of AVR. During the mean follow-up period of 1288 ± 1122 days, 64 patients (9.7%) developed irreversible conduction disorders (bundle branch block (BBB), n=24; and first degree AVB, n=42). Of the 10 patients requiring PPM, four remained PPM-dependent during follow-up. Beyond 30 days after AVR, one patient underwent PPM implantation for de novo conduction disturbance 44 months post-operatively. Conclusions After isolated AVR, PPM implantation for conduction disturbance is rare (n = 10/663, 1.5%). Isolated AVR for degenerative AS has a low risk of conduction disturbances during long-term follow-up.
Background The extent of surgery for papillary thyroid carcinoma (PTC) is associated strongly with disease persistence, recurrence, and mortality. It is difficult, however, to determine the optimal ...extent for surgery. The BRAF mutation is well known for its diagnostic and prognostic value in PTC. Among the variants of PTC, the clinical importance of the BRAF mutation has been associated particularly with conventional PTC. The goal of this study was to clarify the role of the BRAF mutation as a determinant for the operative extent in conventional PTC. Methods Histopathology and BRAF mutation status of 3,019 patients with conventional PTC were analyzed. With regard to the extent of surgery in PTC, focus was given to the factors of tumor bilaterality, central lymph node metastasis (CLNM), and lateral lymph node metastasis. In addition, the prognostic impact of BRAF mutation on loco-regional recurrence was investigated. Results The BRAF mutation was found to be an independent indicator of tumor bilaterality (odds ratio OR 1.484, P = .010); however, it was not an independent indicator of CLNM (OR 1.167, P = .254) or lateral lymph node metastasis (OR 0.647, P = .384). Moreover, it was not an independent indicator of CLNM in either the therapeutic or prophylactic central neck dissection. Finally, BRAF mutation positivity did not increase the risk of loco-regional recurrence (adjusted hazard ratio = 0.829, P = .523). Conclusion The BRAF mutation is a possible indicator for determining the extent of thyroidectomy required but not for the extent of lymph node dissection and prognosis in patients with conventional PTC.
Although video-assisted thoracic surgery (VATS) pleural drainage and decortication have been proven to be effective treatments in the early stages of empyema, the optimal timing of VATS is still not ...clear. To assess the effectiveness of early VATS drainage and decortication, we reviewed the records of patients who underwent VATS and open decortication for empyema.
One hundred twenty-eight patients with empyema were treated with VATS and open decortication over 8 years at Korea University Anam Hospital. The VATS patients (120 patients) were divided into 3 groups based on the interval between the onset of chest symptoms and the time of operation (group 1: <2 weeks; group 2: 2 to 4 weeks; group 3: >4 weeks). Additional 8 open decortication patients with symptom durations greater than 4 weeks were compared with group 3 patients.
Groups 1 and 2 showed shorter chest tube duration, postoperative hospital stay, surgical procedure time, and fewer prolonged air leaks than group 3. No significant difference was noted between groups 1 and 2; and no difference was noted in the length of postoperative intensive care unit stays or the reintervention and reoperation rates among the 3 groups. In chronic empyema patients, group 3 showed shorter chest tube duration than the open decortication group.
Patients with symptom durations of less than 4 weeks showed better early results than those with symptom durations greater than 4 weeks. Thus, symptom duration can be considered a reliable preoperative factor in deciding the surgical management of empyema or cases involving loculated pleural effusion.