Jun Nakazato

Electrocardiographic changes in patients with type A acute aortic dissection. Incidence, patterns and underlying mechanisms in 159 cases.

BACKGROUND Not only symptoms but electrocardiographic (ECG) changes mimicking acute coronary syndrome as well have been known to develop in acute aortic dissection (AAD). However, detailed information is lacking. OBJECTIVE We sought to evaluate incidence, patterns, and underlying mechanisms for acute ECG changes in type A AAD. METHODS Retrospective study in a single tertiary care hospital. A total of 159 cases (mean age 65.1±14.8 years, male/female=67/92) that presented within 12 h from the onset were included. Shift of the ST segment ≥0.1 mV or changes of the T wave were considered acute ECG changes. RESULTS Acute and chronic ECG changes were observed in 49.7% and 36.5% cases, respectively. ECG was normal only in 27.0% cases. ST elevation was observed in 8.2% cases and was closely related to direct coronary involvement. ST depression and T wave changes were observed in 34.0% and 21.4% cases, respectively. Cases with ST depression or T wave changes had higher incidence of shock (65.2% vs. 28.8%, p<0.001) and cardiac tamponade (51.2% vs. 15.0%, p<0.001) compared with those without changes. CONCLUSION Acute ECG changes were common in type A AAD. Physicians taking care of patients with chest pain and acute ECG changes should consider the possibility of AAD before performing thrombolysis or percutaneous catheter intervention.

Clinical Predictors for Delayed or Inappropriate Initial Diagnosis of Type A Acute Aortic Dissection in the Emergency Room

Background Initial diagnosis of acute aortic dissection (AAD) in the emergency room (ER) is sometimes difficult or delayed. The aim of this study is to define clinical predictors related to inappropriate or delayed diagnosis of Stanford type A AAD. Methods We conducted a retrospective analysis of 127 consecutive patients with type A AAD who presented to the ER within 12 h of symptom onset (age: 69.0 ± 15.4 years, male/female = 49/78). An inappropriate initial diagnosis (IID) was considered if AAD was not included in the differential diagnosis or if chest computed tomography or echocardiography was not performed as initial imaging tests. Clinical variables were compared between IID and appropriate diagnosis group. The time to final diagnosis (TFD) was also evaluated. Delayed diagnosis (DD) was defined as TFD > third quartile. Clinical factors predicting DD were evaluated in comparison with early diagnosis (defined as TFD within the third quartile). In addition, TFD was compared with respect to each clinical variable using a rank sum test. Results An IID was determined for 37% of patients. Walk-in (WI) visit to the ER [odds ratio (OR) 2.6, 95% confidence interval (CI) = 1.01–6.72, P = 0.048] and coronary malperfusion (CM, OR = 6.48, 95% CI = 1.14–36.82, P = 0.035) were predictors for IID. Overall, the median TFD was 1.5 h (first/third quartiles = 0.5/4.0 h). DD (>4.5 h) was observed in 27 cases (21.3%). TFD was significantly longer in WI patients (median and first/third quartiles = 1.0 and 0.5/2.85 h for the ambulance group vs. 3.0 and 1.0/8.0 h for the WI group, respectively; P = 0.003). Multivariate analysis revealed that WI visit was the only predictor for DD (OR = 3.72, 95% CI = 1.39–9.9, P = 0.009). TFD was significantly shorter for appropriate diagnoses than for IIDs (1.0 vs. 6.0 h, respectively; P < 0.0001). Conclusions WI visit to the ER and CM were predictors for IID, and WI was the only predictor for DD in acute type A AAD in the community hospital.

Coronary spasm as the cause of myocardial ischaemia in a patient with anomalous origin of the left anterior descending artery from the proximal right coronary artery.

A 49-year-old woman developed angina at rest. A CT of the coronary artery revealed that the left anterior descending artery arose from the right coronary artery, and traversed between the aorta and pulmonary trunk. An exercise stress myocardial scintigraphy did not reproduce myocardial ischaemia or anginal symptoms. A coronary angiography did not show any atherosclerotic changes. Finally, an ergotamine provocation test for vasospasm revealed diffuse severe spasm in the right coronary artery and the left anterior descending artery. Surgical correction of the anomaly was deferred and the patient was managed with medications to control spasm with good clinical outcome.

A case of arrhythmogenic right ventricular cardiomyopathy presenting with progressive right ventricular failure and recurrent multifocal monomorphic ventricular tachycardia during 15 years of follow-up

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a multigenic form of cardiomyopathy characterized by myocardial loss and fibrofatty replacement mainly in the right ventricle. Progressive right ventricular dysfunction, ventricular arrhythmias, and sudden cardiac death are the clinical picture of this disease. Despite its clinical importance as a cause of sudden death, ARVC is likely to be under-recognized. In case reports about ARVC, disease characteristics such as arrhythmias, images, and genes are described in fragments. Little is reported about the long-term course of ARVC in the same patient. In this report, we present a case of a 68-year-old male who was diagnosed with ARVC after his first episode of ventricular tachycardia. Both mechanical and electrical progression were seen during the 15 years of follow-up, requiring the modification of disease management. This report could help improve the understanding of this rare disease, and the way of its management. <Learning objective: Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a multigenic form of cardiomyopathy characterized by fibrofatty degeneration mostly in right ventricular myocardium. Despite its importance as a cause of sudden death, ARVC is likely to be under-recognized. This paper describes the progressive course of ARVC confirmed both clinically and pathologically during 15 years of follow-up, which could help improve understanding of this disease.>.

Left ventricular pseudoaneurysm as a complication of prosthetic mitral valve infective endocarditis

We report a case of infective endocarditis complicated with left ventricular pseudoaneurysm originating from the posterior annulus of the prosthetic mitral valve in a 56-year-old woman. Despite prolonged antibiotic treatment, transesophageal echocardiography (TEE) showed partial detachment of the prosthesis from the posterior mitral annulus. Three-dimensional rotational computed tomography clearly demonstrated a pseudoaneurysm toward the posterolateral portion of the mitral prosthetic valve, which was not evident by TEE. Valve replacement and repair of the pseudoaneurysm were performed 83 days after initiation of antibiotic therapy. Left ventricular pseudoaneurysm is a rare but serious complication of mitral prosthetic valve endocarditis. It requires prompt diagnosis and early surgical intervention. <Learning objective: We present a case of infective endocarditis (IE) complicated with left ventricular pseudoaneurysm originating from the prosthetic mitral valve. Repeated transesophageal echocardiography is recommended for all IE patients when perivalvular extension is suspected. Electrocardiography-gated three-dimensional-computed tomography is useful for detection and evaluation of pseudoaneurysm, especially in planning surgical procedures.>.

Primary chylopericardium treated by surgery: Report of two cases

Primary chylopericardium is a rare condition. The etiology and the treatment remain unclear. We report two cases of primary chylopericardium successfully treated by surgery. Both cases were asymptomatic young women and were found to have cardiomegaly on chest X-ray at a routine annual health examination. An echocardiography demonstrated massive pericardial effusion and chylous fluid was obtained with pericardiocentesis. Lymphoscintigraphy demonstrated abnormal communication between the pericardial sac and the thoracic duct. Because of reaccumulation of chylous pericardial effusion after conservative treatment, we performed surgical ligation of thoracic duct and partial pericardectomy by video-assisted thoracic surgery (VATS) in one case and by thoracotomy in another case. After surgery, both patients are doing well without recurrence of pericardial effusion. Surgical treatment including VATS is effective and should be performed in case of primary chylopericardium.