Chiaki Obara

Onset heart rate and microvolt t-wave alternans during atrial pacing.

patient subgroup based on our a priori suspicion that these patients would benefit from an ICD and based on their high risk for death. These data, however, suggest that patients with severe heart failure should be considered for randomized trials, similar to patients with functional class II and III congestive heart failure. This risk for death may be reduced similarly in the functional class IV heart failure patients, but these patients, especially those with a history of ventricular arrhythmias, will remain a high-risk group, and will continue to be at risk for several forms of sudden death, including bradyarrhythmic and tachyarrhythmic death. It is possible that some patients did benefit from the ICD based on its backup bradycardia pacing capabilities. Although this cannot be excluded, it could still indicate the potential benefits of the ICD. These data indicate that early death is not inevitable in patients with functional class IV heart failure with malignant ventricular arrhythmias and an ICD implant. Important selection biases cannot be excluded. Patients who appeared to stabilize on medical therapy were more likely to be included. Exclusion of patients with functional class IV heart failure from future arrhythmia trials should be reconsidered.

Association between increased epicardial adipose tissue volume and coronary plaque composition

To assess the relationship between epicardial adipose tissue volume (EATV) and plaque vulnerability in significant coronary stenosis using a 40-MHz intravascular ultrasound (IVUS) imaging system (iMap-IVUS), we analyzed 130 consecutive patients with coronary stenosis who underwent dual-source computed tomography (CT) and cardiac catheterization. Culprit lesions were imaged by iMap-IVUS before stenting. The iMAP-IVUS system classified coronary plaque components as fibrous, lipid, necrotic, or calcified tissue, based on the radiofrequency spectrum. Epicardial adipose tissue was measured as the tissue ranging from −190 to −30 Hounsfield units. EATV, calculated as the sum of the fat areas on short-axis images, was 85.0 ± 34.0 cm3. There was a positive correlation between EATV and the percentage of necrotic plaque tissue (R2 = 0.34, P < 0.01), while there was a negative correlation between EATV and the percentage of fibrous tissue (R2 = 0.24, P < 0.01). Multivariate analysis revealed that an increased low-density lipoprotein cholesterol level (β = 0.15, P = 0.03) and EATV (β = 0.14, P = 0.02) were independently associated with the percentage of necrotic plaque tissue. An increase in EATV was associated with the development of coronary atherosclerosis and, potentially, with the most dangerous type of plaque.

Local injection of tissue-plasminogen activator using a pulse spray catheter as a treatment option for proximal deep vein thrombosis: A case report

A 24-year-old woman was admitted to our hospital with the diagnosis of pulmonary thromboembolism (PTE) and left common iliac vein thrombosis. She had used low-dose contraceptive pill for dysmenorrhea. Otherwise, her laboratory data did not show any other thrombotic risk factors. Thrombus in the common iliac vein usually requires a permanent inferior vena cava (IVC) filter. However, the use of long-term warfarin should have been avoided for her potential future pregnancy. A retrievable IVC filter was placed and catheter directed thrombolysis was performed for her deep vein thrombosis (DVT). Local injection of monteplase from a pulse spray catheter was performed for 4 days. After the catheter-based treatment, the thrombus resolved and the IVC filter was successfully removed on day 19. The patient was discharged on day 21. Warfarin therapy was discontinued 6 months after discharge. <Learning objective: Urokinase is recommended in the guideline of the Japanese Circulation Society. But the dose is much less than those stated in guidelines overseas. Several studies have shown that tissue-plasminogen activator (t-PA) might be more effective than urokinase. We report a case in which local injection of monteplase, a type of long acting t-PA, for DVT was effective in treating PTE and DVT.>.

Hypersensitivity of cerebral artery response to catecholamine in patients with neurally mediated syncope induced by isoproterenol.

N mediated syncope is a frequent cause of syncope not resulting from organic dysfunction.1 The head-up tilt test (HUT) is useful for diagnosing syncope and investigating the pathophysiologic mechanisms involved in this syndrome.1–3 Cerebral circulation during syncope has been largely unexplored. We studied cerebral circulation during the HUT by measurement of cerebral blood flow velocity (CBFV) using transcranial Doppler ultrasonography that has emerged as a reliable technique for assessing both blood flow and cerebral vasoreactivity.4,5 • • • The subjects were 10 patients (6 men and 4 women, aged 33 6 15 years) with a history of recurrent syncope of unknown origin (Table I). The HUT was performed in the fasting state. All cardioactive medications were discontinued at least 3 days before the study. Subjects were connected to a standard electrocardiographic monitor for continuous evaluation of heart rate and rhythm. Blood flow velocity of the middle cerebral artery was monitored at a mean depth of 55 mm via the transtemporal approach with a 2-MHz pulsed-wave transcranial Doppler apparatus (LOGIQ 500 MD, GE Yokogawa Medical Systems Inc., Tokyo, Japan). Transcranial Doppler sonography was used to assess CBFV (cm/s) in the middle cerebral artery during the HUT as frequently as possible with the following indexes: systolic, diastolic, and mean velocity. Gosling’s pulsatility index ([(systolic velocity) 2 (diastolic velocity)]/mean velocity) and resistance index ([(systolic velocity) 2 (diastolic velocity)]/systolic velocity) in the supine position and on presyncope were obtained, and the rate of change (D[(presyncope/supine position) 2 1] 3 100) was calculated. In the HUT, the subject was positioned at an angle 180° from the horizontal position on a tilt table until syncope was induced or for a maximum of 30 minutes. If syncope did not occur during the HUT, the subject was lowered to the horizontal position for 10 minutes, and isoproterenol (0.01, 0.02 mg/kg/min) was administered intravenously according to our previous report.6 The HUT was then continued as before for 15 minutes. Values of CBFV and pulsatility and resistance indexes were compared using the paired t test to determine if CBFV changed significantly during the HUT. All results are expressed as mean 6 SD, and a p value ,0.05 was considered statistically significant. None of the subjects had structural heart disease or a cerebral disease as assessed with a conventional, noninvasive evaluation. Syncope occurred in 5 of 10 subjects. One subject (no. 1) experienced syncope with the HUT alone. Four subjects experienced syncope by the HUT with isoproterenol provocation. Only subject 5 (among the 4 subjects) experienced syncope without hypotension and bradycardia (Table II). In 4 of 5 subjects with induced syncope, blood pressure and all CBFV indexes decreased, and pulsatility and resistance indexes increased with presyncope. In the remaining subject (no. 5) with induced syncope, pulsatility and resistance indexes and CBFV decreased without hypotension. On the other hand, syncope did not occur in 5 of 10 subjects. Blood pressure, heart rate, systolic velocity, mean velocity, and pulsatility and resistance indexes increased when subjects were in the supine and upright positions with and without isoproterenol provocation. Only the change in heart rate was significant. In the upright position, pulsatility and resistance indexes increased when blood pressure increased and these decreased when blood pressure decreased. This occurred with and without isoproterenol provocation. In 4 of 5 subjects with induced syncope using isoproterenol provocation, systolic velocity and pulFrom the Third Department of Internal Medicine, Showa University School of Medicine, Tokyo, Japan. Dr. Kobayashi’s address is: 142– 8600, 1–5-8 Hatanodai, Shinagawa-ku, Tokyo, Japan. Manuscript received June 28, 1999; revised manuscript received and accepted December 20, 1999. TABLE I Response to Head-Up Tilt Test

Serial 3-Vessel Optical Coherence Tomography and Intravascular Ultrasound Analysis of Changing Morphologies Associated With Lesion Progression in Patients With Stable Angina PectorisCLINICAL PERSPECTIVE

Background— Optical coherence tomographic (OCT) morphologies associated with lesion progression are not well studied. The aim of this study was to determine the morphological change for untreated lesion progression using both OCT and intravascular ultrasound (IVUS). Methods and Results— We used baseline and 8-month follow-up 3-vessel OCT and IVUS to assess 127 nonculprit lesions (IVUS plaque burden ≥40%) in 45 patients with stable angina after target lesion treatment. Lesion progression was defined as an IVUS lumen area decrease >0.5 mm2. A layered pattern was identified as a superficial layer that had a different optical intensity and a clear demarcation from underlying plaque. Lesion progression was observed in 19% (24/127) lesions, and its pattern was characterized into 3 types: type I, new superficial layered pattern at follow-up that was not present at baseline (n=9); type II, a layered pattern at baseline whose layer thickness increased at follow-up (n=7); or type III, no layered pattern at baseline or follow-up (n=8). The increase of IVUS plaque+media area was largest in type I and least in type III (1.9 mm2 [1.6–2.1], 1.1 mm2 [0.9–1.4], and 0.3 mm2 [−0.2 to 0.8], respectively; P=0.002). Type III, but not types I or II, showed negative remodeling during follow-up (IVUS vessel area; from 14.3 mm2 [11.4–17.2] to 13.5 mm2 [10.4–16.7]; P=0.02). OCT lipidic plaque was associated with lesion progression (odds ratio, 13.6; 95% confidence interval, 3.7–50.6; P<0.001). Conclusions— Lesion progression was categorized to distinct OCT morphologies that were related to changes in plaque mass or vessel remodeling.

TCT-73 Serial Three-Vessel Optical Coherence Tomography and Intravascular Ultrasound Analysis of Changing Morphologies Associated of Plaque Progression in Patients With Stable Angina Pectoris

nos: 73 76 TCT-73 Serial Three-Vessel Optical Coherence Tomography and Intravascular Ultrasound Analysis of Changing Morphologies Associated of Plaque Progression in Patients With Stable Angina Pectoris Myong Hwa Yamamoto, kennosuke yamashita, Mitsuaki Matsumura, Seitarou Ebara, Toshitaka Okabe, Shigeo Saito, Koichi Hoshimoto, Kisaki Amemiya, Tadayuki Yakushiji, Naoei Isomura, Hiroshi Araki, Chiaki Obara, Masahiko Ochiai, Gary Mintz, Akiko Maehara Cardiovascular Research Foundation, New York, New York, United States; Showa University Northern Yokohama Hospital, Yokohama, Japan; Cardiovascular Research Foundation, New York, New York, United States; NorthPoint Solutions, LLC; Showa University Northern Yokohama Hospital, Tokyo, Japan; Showa University Northern Yokohama Hospital, Yokohama, Japan; CRF; Showa universty yohohama northern hospital, Yokohama, Japan; Showa University Northern Yokohama Hospital, Yokohama, Japan; Showa University Northern Yokohama Hospital, Yokohama, Japan; Showa Univ. Northern Yokohama Hospital, Yokohama, Japan; Ospedale Sacco Vialba; Showa University Northern Yokohama Hospital, Kanagawa, Japan; Cardiovascular Research Foundation, Washington, District of Columbia, United States; Cardiovascular Research Foundation, New York, New York, United States BACKGROUND OCT morphologies associated with plaque progression are not well-studied. METHODS We used baseline and 8-mo follow-up 3-vessel OCT and IVUS to assess 124 non-culprit lesions (IVUS plaque burden 40%) in 45 pts with stable angina after culprit lesion percutaneous coronary intervention. Plaque progression was defined as IVUS minimum lumen area decrease >0.5mm2. Lipid plaques by OCT were defined as signal-poor regions with diffuse borders. RESULTS Overall, 24/124 plaques progressed and were characterized by OCT as plaque rupture (n1⁄44), new layer appearance (n1⁄47), thickening of fibrous cap (n1⁄47), or no OCT morphological change with negative remodeling by IVUS (n1⁄46, vessel area at baseline 12.2 [9.9, 18.7]mm2 to follow-up; 10.2 [8.0, 18.5]mm2, p1⁄40.17) (Figure). Pts with plaque progression (n1⁄416) reported less statin use (31.3% vs. 72.4%, p1⁄40.007) and higher baseline LDL-C (110.0 vs. 87.0 mg/dL, p1⁄40.007) and hs-CRP (0.097 vs. 0.051 mg/dL, p1⁄40.004). Multivariable logistic regression analysis showed that lipid plaque by OCT was an independent predictor of plaque progression (OR: 10.2, p1⁄40.001). Progression (n[24) Non-progression

THE ASSOCIATION BETWEEN EPICARDIAL FAT VOLUME AND CORONARY ARTERY PLAQUE CHARACTERIZATION

The aim of this study is to assess the relationship of EFV and plaque vulnerability using a 40MHz IVUS imaging system (iMap-IVUS) in significant coronary stenotic lesion. We analysed consecutive 130patients (94men and 36women) with suspected coronary artery disease who underwent dual-source CT (

Histopathology of the Posterolateral Myocardium in a Responder to Cardiac Resynchronization Therapy

We present a 72‐year‐old man with idiopathic dilated cardiomyopathy, who was in New York Heart Association class III and had left ventricular (LV) dyssynchrony on tissue Doppler imaging. Cardiac resynchronization therapy (CRT) was performed for his heart failure, which improved to class I. Two years later, ventricular arrhythmias recurred, resulting in death. The LV posterior vein containing a pacing lead showed half‐circumferential fibrous thickening. The LV myocardium of this region was relatively well preserved, and interstitial fibrosis due to cardiomyopathy was mild. Absence of a massive fibrotic scar on the LV posterior wall and positioning of the pacing lead in the optimal coronary vein (a posterolateral vein) might have been positive factors determining this patients response to CRT.