Hiroyuki Yoshitomi

Relationship Between Progressive Microvascular Damage and Intramyocardial Hemorrhage in Patients With Reperfused Anterior Myocardial Infarction Myocardial Contrast Echocardiographic Study

BACKGROUND Recent studies indicated that ischemic microvascular damage may be reversible or progressive after coronary reflow. Intramyocardial hemorrhage is a phenomenon that reflects severe microvascular injury. We examined the relationship between temporal changes in microvascular perfusion patterns detected by myocardial contrast echocardiography (MCE) and intramyocardial hemorrhage detected by magnetic resonance imaging (MRI) in patients with acute myocardial infarction (AMI). METHODS AND RESULTS The study population consisted of 24 patients with anterior AMI. All patients underwent MCE shortly after reflow and in the chronic stage (a mean of 31 days after reflow). Wall motion score (WMS) was determined as the sum of 16 segmental scores (dyskinetic/akinetic=3 to normal=0) at days 1 and 31. Gradient-echo acquisition and gadolinium-DTPA-enhanced spin-echo MRI were performed within 10 days after reflow. In MCE shortly after reflow, 16 patients (67%) showed contrast enhancement and the other 8 patients (33%) showed a sizable contrast defect. In the chronic stage, a persistent contrast defect was observed in 7 of 8 patients with a contrast defect shortly after reflow. Consistent contrast enhancement was observed in 12 of 16 patients (75%) with contrast enhancement shortly after reflow, indicating that a contrast defect newly appeared in 4 patients (25%). Intramyocardial hemorrhage was detected in 9 patients (38%): 5 of 7 patients with a persistent contrast defect and in all 4 patients with a new appearance of a contrast defect during the chronic stage. The patients without hemorrhage showed a significant improvement in WMS compared with patients with hemorrhage at day 31 (5+/-5 versus 19+/-6, P<.0005). CONCLUSIONS These results suggest that irreversible microvascular damage to the ischemic myocardium may cause intramyocardial hemorrhage after reflow, associated with impaired recovery of left ventricular function. Contrast enhancement within the risk area shortly after reflow does not necessarily indicate long-term microvascular salvage.

Effects of long-term nicorandil administration on endothelial function, inflammation, and oxidative stress in patients without coronary artery disease.

Long-term administration of nicorandil has been shown to improve outcomes through cardioprotective effects in patients with coronary artery disease. To identify the mechanisms responsible for these effects, this study examined the impact of long-term nicorandil administration on endothelial function, systemic inflammatory markers, and oxidative stress in patients with cardiovascular risk factors. Fifty-three patients were assigned to receive either nicorandil therapy (15 mg/day; n = 26) (nicorandil group) or usual care (n = 27) (nonnicorandil group). All study participants underwent flow-mediated vasodilatation (FMD) of the brachial artery 1 month before treatment, just before treatment, and at 3, 6, and 12 months following treatment. At identical time points, serum levels of malondialdehyde-modified low-density lipoprotein (MDA-LDL) and high-sensitivity C-reactive protein (hs-CRP) were collected. Compared with the nonnicorandil group, the nicorandil group demonstrated significantly increased FMD at 12 months, a finding not replicated for endothelium-independent vasodilatation with nitroglycerine. Analysis of biochemical markers revealed significantly reduced MAD-LDL levels in the nicorandil group at 12 months, as compared to slightly increased MAD-LDL levels in the nonnicorandil group. Significant reductions in hs-CRP levels were also noted at 6 and 12 months in the nicorandil group, while no change was found in the nonnicorandil group. Results demonstrated that long-term nicorandil therapy is associated with gradual improvements in endothelial function. Our findings also suggest that nicorandil treatment may result in cardiovascular protection through pleiotropic effects including reductions in oxidative injury and systemic inflammation.

Effects of supine and lateral recumbent positions on pulmonary venous flow in healthy subjects evaluated by transesophageal Doppler echocardiography

OBJECTIVES This study attempted to evaluate the effects of supine and lateral recumbent positions on pulmonary venous flow by transesophageal Doppler echocardiography in healthy subjects. BACKGROUND Although transesophageal echocardiographic examination is usually performed with the patient lying in the left lateral decubitus or supine position, little attention has been paid to the effects of these positions on pulmonary venous flow. METHODS We performed pulsed Doppler transesophageal echocardiography of the left and right pulmonary veins in 16 normal subjects as they lay in the left and right lateral decubitus and supine positions. RESULTS Data are reported as mean value +/- SD. Adequate recordings were obtained in 12 subjects (75%). In the left pulmonary vein, peak systolic velocity and time-velocity integral of systolic flow increased significantly in the left compared with the right lateral decubitus position (56 +/- 12 vs. 44 +/- 13 cm/s, p < 0.05, and 15 +/- 4 vs. 9 +/- 4 cm, p < 0.05, respectively). In the right pulmonary vein, peak systolic velocity and time-velocity integral of systolic flow decreased significantly in the left compared with the right lateral decubitus position (38 +/- 10 vs. 48 +/- 9 cm/s, p < 0.05, and 9 +/- 2 vs. 12 +/- 2 cm, p < 0.05, respectively). There were no significant differences between positions in peak diastolic flow velocity, time-velocity integral of diastolic flow or peak velocity of flow reversal at atrial contraction. CONCLUSIONS Pulmonary venous systolic peak velocities and time-velocity integrals of systolic flow increase when the pulmonary venous recording is from the recumbent subjects lower side. Therefore, the effects of position should be considered in evaluating left ventricular diastolic function by transesophageal Doppler echocardiography.

Association between Takayasu arteritis and ulcerative colitis – case report and review of serological HLA analysis

Summary Background Takayasu arteritis and ulcerative colitis are immune-mediated inflammatory diseases; genetic factors are assumed to play an important role in the pathogenesis of these 2 diseases. However, the coexistence of these 2 diseases has rarely been reported. Case Report In this report, we present a rare case of a 29-year-old man with a 4 years history of ulcerative colitis who developed Takayasu arteritis. He was found to carry the following human leukocyte antigens (HLA): A11, A24, B52, B62, DR4, and DR9. Conclusions We present a case report and review of the pertinent literature on serological analysis of HLA haplotype of the patients who exhibit both these diseases. In patients with both Takayasu arteritis and ulcerative colitis, high frequency of HLA-A24, B52, and DR 2 is observed. The pathological relevance of HLA-A24, B52, and DR2 to concomitant Takayasu arteritis and ulcerative colitis requires further investigation.

Activation of Inducible NOS in Peripheral Vessels and Outcomes in Heart Failure Patients

BACKGROUND Activation of inducible nitric oxide synthase (iNOS) has been reported in congestive heart failure (CHF) conditions. However, it is unknown whether activation of iNOS affects prognosis of CHF patients. We prospectively studied the influence of activation of iNOS in the forearm on the outcome of CHF patients. METHODS AND RESULTS Forearm blood flow (FBF) responses to 3 doses of acetylcholine (ACh) and nitroglycerin (NTG), and 4 doses of a selective iNOS inhibitor (aminoguanidine: Amn) and a nonselective NOS inhibitor (L-NMMA) were examined using plethysmography in 68 patients with CHF from idiopathic dilated cardiomyopathy. Plasma brain natriuretic peptide (BNP) and tumor necrosis factor-alpha (TNF-alpha) were also measured in all patients. During the mean follow-up period of 3.8 years, 25 patients were hospitalized for worsening heart failure and 9 of these patients died. Patients with adverse events had a diminished vasodilator response to ACh (P < .001) compared to patients without adverse events. Amn significantly decreased FBF (P < .001) in patients with adverse events, but not in patients without adverse events. FBF responses to NTG and L-NMMA were not significantly different between the 2 groups. When grouped by maximum FBF responses to each drug above and below the median value, multivariate Cox proportional hazards model analyses for cardiac event showed a significance in the FBF response to Amn (adjusted hazard ratio 5.89, P < .001). FBF responses to maximum dose of Amn significantly correlated with BNP and TNF-alpha levels (both P < .001). CONCLUSIONS CHF patients with vascular iNOS activation, as demonstrated by a greater vasoconstrictor response to Amn, had poor outcomes. Activation of iNOS in peripheral vessels, associated with proinflammatory cytokines in accordance to the severity of heart failure, is a marker for, or contributes to, adverse events in patients with CHF.

SUBLINGUAL NIFEDIPINE IN ELDERLY PATIENTS : EVEN A LOW DOSE INDUCES MYOCARDIAL ISCHAEMIA

1. Low doses of sublingual nifedipine are still used for the treatment of hypertensive crises, although recent studies have raised concerns that sublingual nifedipine may cause serious dose‐dependent adverse effects. The present study was performed to test the safety of low‐dose sublingual nifedipine administered to elderly hypertensive patients.

Doppler estimation of pulmonary artery end-diastolic pressure using contrast enhancement of pulmonary regurgitant signals

Pulmonary artery (PA) end-diastolic pressure is used as an estimate of PA wedge pressure. We evaluated contrast enhanced pulmonary regurgitant signals in the assessment of PA end-diastolic pressure in 24 patients in a critical care unit. Right atrial pressure was estimated by the percent decrease of the inferior vena caval diameter with inspiration. Weak or absent pulmonary regurgitant signals were enhanced by sonicated albumin (Albunex) in 23 patients (96%). The Doppler-determined PA end-diastolic pressure (the sum of the pulmonary regurgitant pressure gradient at end-diastole and the right atrial pressure) was significantly correlated with the catheter-determined PA end-diastolic pressure (y = 0.85x + 1.72, r = 0.93). Compared with invasive hemodynamic monitoring, the contrast-enhanced Doppler technique using Albunex is effective for measuring PA end-diastolic pressure, even in critically ill patients.

Steroid-induced crisis and rhabdomyolysis in a patient with pheochromocytoma: A case report and review

A 66-year-old Japanese woman was urgently referred to our hospital. Two days prior to admission, her general practitioner began to administer prednisolone for treatment of a diagnosis of polymyalgia rheumatica. At the time of admission, laboratory results indicated multiorgan failure with rhabdomyolysis. Abdominal ultrasonography and computed tomography revealed a tumor in the right adrenal gland. On the same day, we measured serum and urine cathecholamines, which were markedly elevated. Additionally, magnetic resonance imaging revealed an adrenal mass and metaiodobenzylguanidine scintigraphy showed labeling of the tumor. Then, the patient underwent surgical resection of the tumor via laparoscopy. Histological examination confirmed the diagnosis of pheochromocytoma. One week after the operation, serum and urinary catecholamine levels returned to normal. The patient was discharged 10 days after the operation, and has remained stable at home. This report indicates that steroid should be avoided if possible in patients with pheochromocytoma. Furthermore, pheochromocytoma should be recalled as a differential diagnosis whenever patients take a sudden turn for the worse, or have acute uncontrollable hypertension following steroid administration and/or whenever patients present with unexplained rhabdomyolysis.

The pitfall of coagulase-negative staphylococci: A case of Staphylococcus lugdunensis endocarditis

We report a case of a 60-year-old woman. She was transferred from a local hospital to our cardiovascular medicine department with a diagnosis of infectious endocarditis due to Staphylococcus lugdunensis. Transthoracic echocardiograph confirmed the presence of large vegetations on the native aortic and mitral valve, and subsequent severe regurgitation due to the aortic and mitral valve destruction. Emergent operation was performed and patients life was barely rescued. However, S. lugdunensis belongs to coagulase-negative staphylococci, which are generally regarded as relatively avirulent bacterium, the endocarditis caused by S. lugdunensis can be invasive and often resembles endocarditis due to Staphylococcus aureus. Therefore, whenever this organism is found in patients with endocarditis, early surgical treatment of the infected valve should be considered.

Factors influencing left atrial volume in treated hypertension

BACKGROUND Left atrial (LA) enlargement has been documented to occur in hypertension (HT), and has been an index for evaluating the diastolic function of the left ventricle. Enlargement of the LA is one of the vital factors that induce heart failure and atrial fibrillation (AF) in patients with HT. METHODS AND SUBJECTS 130 treated hypertensive patients were enrolled. All recruits participated in an echocardiogram, electrocardiogram, a routine blood examination including brain natriuretic peptide (BNP), and physical examinations. RESULTS Left ventricular mass (LVM) indexed to height(2.7) had a significant positive correlation with left atrial volume index (LAVI) (p<0.0001), as well as natural logarithm BNP (p<0.001). Blood pressure levels were not associated with LAVI, neither body mass index nor age. LAVI had a positive correlation with factors involving the left ventricle volume, LVM, and right ventricle systolic pressure (RVSP) (r=0.687, p<0.0001). The parameters of LV diastolic function were positively but weakly associated with LA size. In the subgroup of LAVI, the evidence of paroxysmal atrial fibrillation (PAF): LAVI<32 ml/m(2) had no PAF, whereas the incidence of PAF was 7.5%, 11.4%, and 15.2%, respectively in the LAVI>32 ml/m(2) group. Of anti-hypertension drugs, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers had a tendency to reduce LAVI; however, there was no statistical significance within the groups. CONCLUSIONS Left ventricular volume and mass are independent factors affecting LAVI in treated HT. The incidence of PAF is associated with LA size. In patients with treated HT, LA size may be a useful surrogate marker for monitoring the effectiveness of medical therapy and occurrence of AF.