Kaori Hisazaki

Amniotic Fluid Embolism Triggered By Hypertensive Crisis Due to Undiagnosed Pheochromocytoma in a Pregnant Subject With Neurofibromatosis Type 1

ABSTRACT Objective: To report an unusual case of amniotic fluid embolism (AFE) caused by undiagnosed pheochromocytoma in a pregnant subject with neurofibromatosis type 1 (NF-1). Methods: We describe the clinical course and discuss the management of AFE in a patient with pheochromocytoma complicating NF-1 and present a review of relevant literature. Results: A 29-year-old female with a history of NF-1 presented with hypertension but no neurologic abnormalities. Pre-eclampsia and fetal dysfunction were diagnosed, and a cesarean section was performed. After it was completed, her oxygen saturation suddenly dropped, and an endotracheal intubation was performed. A watery discharge gushed out of the endotracheal tube. Whole-body computed tomography showed a left adrenal tumor (5-cm diameter). Two hours after admission to the intensive care unit, she developed ventricular fibrillation with cardiac shock. Direct current cardioversion, percutaneous cardiopulmonary support, and intra-aortic balloon pumping were imme...

Atrial tachycardia with a short PQ interval: Focal atrial tachycardia originating from the vicinity of the block line

A 64-year-old woman underwent catheter ablation of longstanding persistent atrial fibrillation. Despite electrical cardioversion after achieving a pulmonary vein antrum isolation, atrial fibrillation /unstable atrial tachycardia (AT) persisted and sinus rhythm could not be maintained. Thus, a left atrial (LA) roof and mitral isthmus linear ablation were added. However, electrical cardioversion reproducibly produced significant sinus pauses followed by a slow AT, which was not terminated by pacing. The procedure ended with placement of a temporary pacing catheter. The 12-lead electrogram on the next day (Figure 1A) showed a stable slow AT (96 bpm) with a short PQ interval. One month later, she underwent a second procedure for the persistent AT with the Rhythmia mapping system (Boston Scientific, Natick, MA, USA). During the second procedure, the tachycardia cycle length was 607 milliseconds and Wenckebach atrioventricular conduction was observed. Ultra-high resolution LA mapping (>4000 points/LA) revealed that the activation map fulfilled only 190 milliseconds (31% of the tachycardia cycle length), and that the AT originated from the low lateral LA in the vicinity of the previously created mitral isthmus line (Figure 1B, Supplementary video), and both the roof and mitral isthmus lines were blocked. A single radiofrequency application at that site (Figure 1B, white tag) terminated the AT (Figure 1C), and sinus rhythm was restored. Both the LA roof and mitral isthmus block lines were confirmed by pacing techniques. The patient has been free from any recurrent arrhythmias for 3 months of follow-up. It is well known that LA linear ablation predisposes to iatrogenic ATs, such as macroreentrant AT via a conduction gap and localized reentrant AT; however, focal AT originating from the vicinity of a complete block line is rare. Because of the conduction block across the roof and mitral isthmus lines, the wavefront passed transversely through the posterior LA, then the atrial septum followed by the anterior LA circuitously. Generally, mitral isthmus lines on the lateral LA do not produce LA conduction delays because the lateral LA is the latest activation area during sinus rhythm. In the present case, the activation of the right atrium was delayed (far from the AT origin) and created the terminal component of the P-wave, and therefore the PQ interval was apparently short during the AT. Indeed, as shown in Figure 1C, the coronary sinus activated much earlier than the right atrium and P-wave. Based on the observation that the AT was not terminated by pacing and was initiated soon after cardioversion, automaticity seems to have been a more likely mechanism than microreentry in the scar of the block line. In the present case, a concealed slow focal AT was manifested after the AF ablation, and a focal source close to the complete block line produced a significant conduction delay in the LA.

IMPACT OF SERUM MATRIX METALLOPROTEINASE-2 LEVELS ON PULMONARY VASCULAR RESISTANCE ELEVATION

Pulmonary vascular resistance (PVR) is an important hemodynamic measurement used in the management of patients with heart failure and pulmonary hypertension. The mechanisms of PVR increase are incompletely understood, although pulmonary vasculature remodeling implicated. We evaluated the