Prognostic implications of late gadolinium enhancement at the right ventricular insertion point in patients with non-ischemic dilated cardiomyopathy: A multicenter retrospective cohort study

INTRODUCTION: The presence of late gadolinium enhancement (LGE) at the right ventricular insertion point (RVIP) on cardiac magnetic resonance (CMR) is generally believed to be nonspecific, but the clinical implication of this unique LGE pattern in patients with non-ischemic dilated cardiomyopathy (NICM) has not been elucidated. OBJECTIVES: We investigated the prognostic significance of RVIP-LGE in NICM patients. METHODS: A total of 360 consecutive NICM patients referred for CMR (102 with no LGE, 50 with RVIP-LGE, 121 with left ventricular [LV]-LGE, and 87 with both an LV and RVIP-LGE) were studied. The primary endpoint was a composite of the all-cause death, hospitalization due to worsening of heart failure, and major arrhythmic events. RESULTS: During a mean follow-up of 45.2 ± 36.5 months, 149 (41.4%) patients (22 [21.6%] no LGE vs. 16 [32.0%] RVIP-LGE vs. 62 [51.2%] LV-LGE vs. 49 [56.3%] both LV and RVIP-LGE, P < 0.0001) reached the primary endpoint. A Kaplan Meier curve demonstrated that RVIP-LGE patients had an intermediate trend of an event free survival rate for the composite endpoint (log-rank P < 0.0001). In a multivariable Cox regression model, LV-LGE (P = 0.008) and both LV and RVIP-LGE (P = 0.003) were significantly associated with a worse outcome, whereas RVIP-LGE was not (P = 0.101). In addition, RVIP-LGE patients (n = 32) had a more favorable outcome compared to LV-LGE patients (n = 32) even after matching the extent of the LGE (median 3.4% [interquartile range, 3.1-3.8], 8 [25.0%] RVIP-LGE vs. 20 [62.5%] LV-LGE, P = 0.002). CONCLUSIONS: LGE confined to the RVIP among NICM patients did not significantly increase the risk of adverse cardiac events, and also showed a better outcome than the same extent of LGE located in the LV. Identification of this unique LGE distribution may help refine the current risk stratification.ope

Cardiovascular Events of Electrical Cardioversion Under Optimal Anticoagulation in Atrial Fibrillation: The Multicenter Analysis

PURPOSE: Electric cardioversion has been successfully used in terminating symptomatic atrial fibrillation (AF). Nevertheless, largescale study about the acute cardiovascular events following electrical cardioversion of AF is lacking. This study was performed to evaluate the incidence, risk factors, and clinical consequences of acute cardiovascular events following electrical cardioversion of AF. MATERIALS AND METHODS: The study enrolled 1100 AF patients (mean age 60±11 years) who received cardioversion at four tertiary hospitals. Hospitalizations for stroke/transient ischemic attack, major bleedings, and arrhythmic events during 30 days post electric cardioversion were assessed. RESULTS: The mean duration of anticoagulation before cardioversion was 95.8±51.6 days. The mean International Normalized Ratio at the time of cardioversion was 2.4±0.9. The antiarrhythmic drugs at the time of cardioversion were class I (45%), amiodarone (40%), beta-blocker (53%), calcium-channel blocker (21%), and other medication (11%). The success rate of terminating AF via cardioversion was 87% (n=947). Following cardioversion, 5 strokes and 5 major bleedings occurred. The history of stroke/transient ischemic attack (OR 6.23, 95% CI 1.69-22.90) and heart failure (OR 6.40, 95% CI 1.77-23.14) were among predictors of thromboembolic or bleeding events. Eight patients were hospitalized for bradyarrhythmia. These patients were more likely to have had a lower heart rate prior to the procedure (p=0.045). Consequently, 3 of these patients were implanted with a permanent pacemaker. CONCLUSION: Cardioversion appears as a safe procedure with a reasonably acceptable cardiovascular event rate. However, to prevent the cardiovascular events, several risk factors should be considered before cardioversion.ope

Early Experience of Novel Oral Anticoagulants in Catheter Ablation for Atrial Fibrillation: Efficacy and Safety Comparison to Warfarin

PURPOSE: Compared with warfarin, novel oral anticoagulants (NOACs) are convenient to use, although they require a blanking period immediately before radiofrequency catheter ablation for atrial fibrillation (AF). We compared NOACs and uninterrupted warfarin in the peri-procedural period of AF ablation. MATERIALS AND METHODS: We compared 141 patients treated with peri-procedural NOACs (72% men; 58 ± 11 years old; 71% with paroxysmal AF) and 281 age-, sex-, AF type-, and history of stroke-matched patients treated with uninterrupted warfarin. NOACs were stopped 24 hours before the procedure and restarted on the same procedure day after hemostasis was achieved. RESULTS: We found no difference in the CHA₂DS₂-VASc (p=0.376) and HAS-BLED scores (p=0.175) between the groups. The preprocedural anticoagulation duration was significantly shorter in the NOAC group (76.3 ± 110.7 days) than in the warfarin group (274.7 ± 582.7 days, p<0.001). The intra-procedural total heparin requirement was higher (p<0.001), although mean activated clotting time was shorter (350.0 ± 25.0 s vs. 367.4 ± 42.9 s, p<0.001), in the NOAC group than in the warfarin group. There was no significant difference in thromboembolic events (1.4% vs. 0%, p=0.111) or major bleeding (1.4% vs. 3.9%, p=0.235) between the NOAC and warfarin groups. Minor stroke occurred in two cases within 10 hours of the procedure (underlying CHA₂DS₂-VASc scores 0 and 1) in the NOAC group. CONCLUSION: Pre-procedural anticoagulation duration was shorter and intra-procedural heparin requirement was higher with NOAC than with uninterrupted warfarin during AF ablation. Although the peri-procedural thromboembolism and bleeding incidences did not differ, minor stroke occurred in two cases in the NOAC group.ope

Long-Term Prognosis of Patients with an Implantable Cardioverter-Defibrillator in Korea

PURPOSE: The objective of this study was to elucidate the long-term prognosis of patients with implantable cardioverter-defibrillators (ICDs) in Korea. MATERIALS AND METHODS: We enrolled 405 patients (age, 57.7±16.7 years; 311 men) who had undergone ICD implantation. The patients were divided into three groups: heart failure (HF) and ICD for primary (group 1, n=118) and secondary prevention (group 2, n=93) and non-HF (group 3, n=194). We compared appropriate and inappropriate ICD therapy delivery among the groups and between high- (heart rate ≥200 /min) and low-rate (<200 /min) ICD therapy zones. RESULTS: During the follow-up period (58.9±49.8 months), the annual appropriate ICD therapy rate was higher in group 2 (10.4%) than in groups 1 and 3 (6.1% and 5.9%, respectively, p<0.001). There were no significant differences in annual inappropriate ICD therapy rate among the three groups. In group 1, the annual appropriate ICD therapy rate was significantly lower in patients with a high-rate versus a low-rate therapy zone (4.5% and 9.6%, respectively, p=0.026). In group 3, the annual inappropriate ICD therapy rate was significantly lower in patients with a high-rate versus a low-rate therapy zone (3.1% and 4.0%, respectively, p=0.048). CONCLUSION: Appropriate ICD therapy rates are not low in Korean patients with ICD, relative to prior large-scale studies in Western countries. Appropriate and inappropriate ICD therapy could be reduced by a high-rate therapy zone in patients with HF and ICD for primary prevention, as well as non-HF patients, respectively.ope

교수설계 이론. 모형에 관한 연구

On the 20th century, the industrial society has changed to the information society, and we become to need a new methodology to solve the educational difficulties effectively. In this situation, educational technology which can meet these needs has developed rapidly. Various Instructional Design theories and models were developed, and applied. But their effects were not dominent. There are movements for finding out the main problems to improve educational process practically. So, the purpose of this study are to understand the historical development of Instructional Design field and to look into them about their functions, characteristics, and applications. Through these investigations, a survey research was performed about the attitude, knowledge, and application problems of Instructional Designers and Educational Technologists about Instructional Design theories and models in our country. The major findings of this research can be summarised as follows. In surveying about Instructional Design theories and models: 1. Most of Instructional Designers recognized the importance of application of Instructional Design. 2. The most important limitation of Instructional Design theories and models were pointed out as they were not prescriptive. 3. Gegne´ and Briggs&amp;apos;s ID theory is known to the most popular theory. 4. The most important difficulty for appling Instructional Design theories and models were the short information about ID. There can be some suggestions about these findings. 1. There must be more investigations about Instructional Design field in educational technology. 2. It is requested to develop and supply practical ID models which can be easily applied in the field. 3. There must be more education and training opportunities for understanding and application skills of ID theories and models. 4. A professional organization which can offer guides and materials about ID theories and models is demanded.;20세기 이후, 현대 산업사회는 정보화 사회로의 대전환기를 맞게 되었고, 교육의 문제를 효과적으로 해결하기 위한 새로운 방법론을 모색하게 되었다. 이러한 사회적 요구를 충족시켜주기 위하여 대두된 교육공학은 특히 체제적 접근의 교수설계의 개념을 중심으로 발전되어왔다. 교수설계 분야는 교육공학에 있어서 핵심적인 영역으로서, 다양한 학문 분야로부터의 이론과 원리를 받아들여 질적, 양적으로 팽창해왔다. 보다 효과적인 교육을 위한 교수설계의 중요성은 끊임없이 강조되어 왔으나, 실제 교육 현장에 있어서 교수설계이론 및 모형이 어떻게 적용될 수 있으며, 어떠한 역할을 할 수 있는지에 대한 반성의 소리도 계속 되어왔다. 이러한 시점에서 이제까지의 교수 설계 이론 및 모형에 관해 다각적으로 고찰해보고, 이들 교수설계 이론 및 모형이 우리의 교육현실에 있어서 실질적으로 도움이 될 수 있으려면, 어떻게 되어야 하는가에 대한 가능성을 모색해볼 필요가 있을 것이다. 따라서 본 연구는 교수설계의 역사적 발달과정을 살펴보고, 교수설계 이론 및 모형들을 그것들의 기능, 특성 및 적용을 중심으로 고찰하며, 이러한 논의를 바탕으로 우리나라 교육현실에서의 교수설계에 관한 전반적 이해 및 적용 정도와 적용에 따르는 문제점을 조사하기 위한 목적으로 실시되었다. 연구의 목적과 관련하여, 다음과 같은 연구가 행해졌다. 첫째, 행동주의 심리학, 인지주의 심리학, 구성주의 등이 교수설계에 미친 영향을 중심으로 교수설계의 발달과정을 살펴보고, 기존 교수설계 이론 및 모형들의 기능, 특성 및 적용을 중심으로 고찰하였다. 둘째, 우리나라 교육공학 분야를 중심으로 교수설계 이론. 모형에 대한 전반적인 이해와 이론모형의 실제 적용상황 및 문제점 등을 설문조사를 통해 살펴보았다. 연구는 다음과 같은 방법으로 행해졌다. 첫째, 교수설계이론. 모형과 관련된 국내외 문헌을 고찰하였다. 둘째, 한국 교육공학연구회 회원 및 교수설계와 관련된 직업에 종사하고 있는 전문가 215명을 대상으로 질문지 조사를 실시하였다. 이러한 연구를 통해서 다음과 같은 결론을 얻을 수 있었다. 1. 교수설계 관련자들의 교수설계의 중요성 및 연구의 필요성에 대한 인식은 매우 높으며, 모든 교수 프로그램 개발영역에 있어서 이론. 모형의 적용이 이루어지는 것이 바람직하다고 보았다. 2. 현재의 교수설계이론. 모형이 갖고 있는 한계점으로 가장 중요하게 지적될 수 있는 것은 이 이론 및 모형들이 보다 구체적이고, 처방적인 특성을 갖추어야 한다는 점이다. 3. 가장 폭넓게 알려져 있고, 선호되며, 광범위하게 적용되는 교수설계 이론 모형은 Gagne′와 Briggs의 교수설계이론이라고 볼 수 있으며, 그 이유는 그들의 이론이 일반적으로 손쉽게 여러 경우에 적용될 수 있으면서도, 이론적 설득력을 갖추고 있다고 여겨지기 때문이다. 4 교수설계이론. 모형의 적용에 있어서 가장 큰 문제점으로 지적되는 것은 교수설계이론. 모형에 관한 인식의 부족이며, 이를 극복하기 위해서는 우리의 현실에 보다 알맞는 이론. 모형의 개발과 보급이 요청된다. 이와 같은 결론을 바탕으로 다음과 같이 제언하고자 한다. 1. 교육공학에서 교수설계 분야에 관한 연구가 더욱 활발히 전개되어야 한다. 2. 현장에서 손쉽게 적용될 수 있는 교수설계 모형의 개발, 보급이 요청된다. 3. 교육, 연수, 강습회 등을 통해 교수설계이론. 모형에 관한 인식을 높이고, 실제적인 적용의 기회를 제공해야 한다. 4, 교수설계 및 관련 분야 전문가로 구성된 교재개발 전문기관 등의 조직이 요구되며, 이를 통해 교수설계이론. 모형을 실제로 적용한 구체적인 지침서 및 자료를 제공해주어야 한다.목차 = ⅲ 논문개요 = ⅷ Ⅰ. 서론 = 1 A. 연구의 필요성 및 목적 = 1 B. 연구의 내용 및 방법 = 4 1. 연구의 내용 = 4 2. 연구의 방법 = 4 C. 연구의 제한점 = 5 D. 용어의 정의 = 6 Ⅱ. 교수설계(Ingtructional Design)의 고찰 = 9 A. 교수설계의 개념 및 정의 = 9 1. 교수설계의 개념 = 9 2. 교수설계의 정의 = 13 B. 교수설계의 의의 = 17 C. 교수설계의 발달 = 20 1. 교수설계 개념의 발전 = 21 2. 행동주의 심리학과 교수설계 = 27 3. 인지주의 심리학과 교수설계 = 28 4. 구성주의(Constructivism)와 미래의 교수설계 = 32 Ⅲ. 교수설계 이론.모형의 고찰 = 42 A. 교수설계 이론.모형의 개념 = 42 B. 교수설계 이론.모형의 발달 및 특징 = 44 C. 교수설계의 이론.모형의 분석 = 50 1. 교수설계 이론.모형 분석의 필요성 = 50 2. 교수설계 이론.모형의 구성요소 = 52 3. 교수설계 이론.모형의 유형 = 63 D. 교수설계 이론.모형의 적용 = 79 1. 교수설계 이론.모형의 적용과 문제점 = 80 2. 우리나라에서의 교수설계 이론.모형의 적용 = 85 E. 교수설계 이론.모형의 인식 및 적용에 관한 선행 연구 = 89 Ⅳ. 교수설계 이론.모형에 대한 전반적 이해 및 적용 현황과 문제점에 관한 조사 = 92 A. 조사연구의 목적 = 92 B. 조사연구의 방법 및 절차 = 93 1. 조사대상 = 93 2. 조사도구 = 93 3. 조사절차 및 자료처리 = 94 C. 조사결과 분석 및 해석 = 95 1. 일반적 사항 = 95 2. 교수설계 이론.모형에 관한 전반적 이해 = 98 3. 교수설계이론.모형의 실제 적용 및 문제점 = 113 Ⅴ. 결론 및 제언 = 118 참고문헌 = 121 ** 부록 ** = 133 Abstract = 14

The effect of transesophageal echocardiography on the incidence of thromboembolism after electrical cardioversion in atrial fibrillation: A multicenter analysis

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Clinical features of familial hypercholesterolemia in Korea: Predictors of pathogenic mutations and coronary artery disease - A study supported by the Korean Society of Lipidology and Atherosclerosis

BACKGROUND: Proper screening and diagnosis of familial hypercholesterolemia (FH) is of critical importance for cardiovascular prevention. However, the clinical diagnosis of FH remains difficult partly because its phenotype can vary between different ethnicities. The aim of this study was to determine the clinical features and the best diagnostic approach in Korean FH patients. The predictors of putative pathogenic mutations and coronary artery disease (CAD) were also identified. METHODS AND RESULTS: Ninety-seven patients with low-density lipoprotein-cholesterol >190 mg/dL and xanthoma or FH-compatible family history were included. Putative pathogenic mutations in LDLR, APOB, or PCSK9 genes were identified in 32% of the enrolled patients. The subjects were classified according to four sets of clinical criteria (Simon Broome, Dutch, MEDPED, Japanese). The mutation rates in definite type FH of Simon Broome or Dutch criteria were 35%-37% and lower in our patients than in those of other countries. The mutation detection rate by MEDPED criteria was 67%-75% and higher than those based on other criteria. The best low-density lipoprotein-cholesterol (LDL-C) threshold for predicting mutations was 225 mg/dL. LDL-C was found to be the only independent predictor of mutation carriers, while hypertension and low high-density lipoprotein-cholesterol were predictive of CAD. CONCLUSIONS: The conventional clinical criteria showed limited mutation detection power and low specificities in Korean FH patients, in whom the best LDL-C threshold for putative mutation was 225 mg/dL. Traditional cardiovascular risk factors were also significantly associated with CAD risk in this population.ope

Transient apical wall thickening in patients with stress cardiomyopathy: Prevalence, profile, and impact on clinical course

BACKGROUND: Transient apical wall thickening (TAWT), mimicking apical hypertrophic cardiomyopathy during recovery from stress cardiomyopathy (SCM), has recently been reported. However, the clinical significance of this phenomenon has not yet been assessed. We aimed to explore the prevalence, profiles, and impact on the clinical course of TAWT in patients with SCM. METHODS: We retrospectively analyzed the SCM registry from January 2009 to December 2013. Of 429 patients with SCM, 124 patients who had typical features of transient apical ballooning were included. We identified patients who showed evidence of TAWT, which became normalized on serial echocardiograms. Clinical characteristics, incidence of cardiac complications (arrhythmia, pulmonary edema, cardiogenic shock, or left ventricular thrombus), and in-hospital mortality were compared between patients with and without TAWT. RESULTS: Among 124 patients, 17 (14%) patients showed TAWT. During the follow-up period, TAWT was observed 14.6 ± 10.3 days after the initial SCM diagnosis. Patients with TAWT showed a higher prevalence of septic shock as a triggering factor of SCM than those without TAWT (41.2% vs. 19.6%, p=0.048). Furthermore, cardiac complications were more prevalent in patients with TAWT compared to patients without (64.7% vs. 33.6%, p=0.03). Finally, in-hospital mortality was significantly higher in patients with TAWT group during the clinical course of SCM (p=0.009). CONCLUSION: TAWT in patients with SCM is not uncommon. Patients with SCM and systemic inflammation with hemodynamic instability might be susceptible to TAWT, which is often associated with cardiac complications. These patients showed worse prognosis compared to those without TAWT during recovery from SCM.ope

Pattern of late gadolinium enhancement predicts arrhythmic events in patients with non-ischemic cardiomyopathy

BACKGROUND: Left ventricular late gadolinium enhancement (LV-LGE) by cardiac magnetic resonance (CMR) imaging has been associated with adverse clinical outcomes in patients with non-ischemic cardiomyopathy (NICM). However, an association between the characteristics of the LGE and arrhythmic risk has not been demonstrated consistently. This study evaluated the impact of the LV-LGE characteristics on the arrhythmia risk in patients with NICM. METHODS: This study enrolled 365 consecutive patients (54±15years) with NICM who underwent CMR imaging. All patients were monitored for the following outcomes: major arrhythmic events (MA), including sustained ventricular tachycardia, an appropriate implantable cardioverter-defibrillator intervention, ventricular fibrillation and sudden cardiac death. RESULTS: During 44.3±36.4months of follow-up, 44 (12.1%) patients experienced MA. LV-LGE was observed in 40 (90.9%) and 221 (68.8%) patients with and without MA, respectively. LV-LGE was more frequently observed in the MA group (p=0.002). The age- and sex-adjusted hazard ratio (HR) of MA was increased in patients with LGE extent≥8% (HR 8.45, 95% confidence interval (CI) 2.91-24.6), and those with subendocardial (HR 6.98, 95% CI 1.74-28.0) and subepicardial LGE patterns (HR 7.2, 95% CI 1.61-35.6). In multivariable models adjusted for other clinical variables, only the subepicardial LGE pattern had 7.2 (95% CI, 1.61-32.6, p=0.01) time increase in the MA risk. CONCLUSIONS: LV-LGE in patients with NICM is not uncommon. The subepicardial pattern of the LV-LGE was an independent predictor of MA, suggesting that specific patterns of the LV-LGE are closely related to the severity of arrhythmic events.restrictio