Keiji Hirooka

Right atrial spontaneous echo contrast indicates a high incidence of perfusion defects in pulmonary scintigraphy in patients with atrial fibrillation

This study investigated the relationship between right atrial SEC (RA-SEC) and silent pulmonary embolism (PE) in patients with nonvalvular atrial fibrillation (NVAF). Spontaneous echo contrast (SEC) within the cardiac chambers is associated with an increased risk of thromboembolism. However, most studies have examined the relationship between left atrial SEC and systemic thromboembolic disease. Transesophageal echocardiography (TEE) was performed in 210 patients with NVAF to assess a risk of thromboembolism. Right atrial SEC was detected in 37 patients, and 35 of these patients with RA-SEC and 29 patients without RA-SEC were enrolled in this study. However, patients with a history of symptomatic PE or deep vein thrombosis were excluded. Spontaneous echo contrast was diagnosed by TEE as the presence of smokelike echoes that swirled in a circular pattern. PE was diagnosed by pulmonary scintigraphy. Thrombotic and thrombolytic parameters, including serum concentrations of plasmin-α-plasmin inhibitor complex (PIC), thrombin-antithrombin complex (TAT), D-dimer, and fibrinogen were measured in all patients. Left ventricular dimension, cardiac function, and hematologic parameters were similar in the two groups. Nevertheless, the incidence of perfusion defects in pulmonary scintigraphy was significantly higher in the group with RA-SEC (40%) than in the group without RA-SEC (7%; chi-square, P = 0.006). The increased incidence of perfusion defects in pulmonary scintigraphy in patients with RA-SEC indicates that right atrial SEC may be a predictable factor at a high risk of PE.

Successful catheter ablation to accessory atrioventricular pathway as cardiac resynchronization therapy in a patient with dilated cardiomyopathy

A 55-year-old man was admitted to our hospital for further examination of the abnormalities of chest X-ray and electrocardiogram. He was diagnosed with type B Wolff-Parkinson-White syndrome concomitant with dilated cardiomyopathy. Despite the medical therapy using enalapril and carvedilol for 20 months, his cardiac performance and brain natriuretic peptide (BNP) were not so improved. Because asynchronous septal motion caused by pre-excitation through a right-sided accessory pathway (AP) might deteriorate his cardiac performance, catheter ablation to the AP was performed. Successful procedure after 17 months improved left ventricular (LV) contraction, reduced LV volume, and decreased mitral regurgitation and BNP.

Quantitative Assessment of Fluid Accumulation Using Bioelectrical Impedance Analysis in Patients With Acute Decompensated Heart Failure

BACKGROUND Acute decompensated heart failure (ADHF) is generally considered to be a problem of fluid volume overload, therefore accurately quantifying the degree of fluid accumulation is of critical importance in assessing whether adequate decongestion has been achieved. The aim of this study was to develop and validate a method to quantify the degree of fluid accumulation in patients with ADHF. METHODSANDRESULTS Using multi-frequency bioelectrical impedance analysis (BIA), we measured extracellular water (ECW) volume in 130 ADHF patients on admission and at discharge. We also predicted optimal ECW volume using original equations based on data from 60 control subjects without the signs of HF. Measured/predicted (M/P) ratio of ECW in ADHF patients was observed to decrease from 1.26±0.25 to 1.04±0.17 during hospitalization (P<0.001). The amount of ECW volume reduction was significantly correlated with reduction in body weight (r=0.766, P<0.001). On multivariate analysis, higher M/P ratio of ECW at discharge was associated with increased risk of ADHF readmission or cardiac death within 6 months after discharge. CONCLUSIONS Multi-frequency BIA-measured ECW was found to offer valuable information for analyzing the pathophysiology of ADHF, and may be a useful guide in the management of this disease.

An enhanced method for left ventricular volume and ejection fraction by triggered harmonic contrast echocardiography

To elucidate the validity and reproducibility of the use of intravenous echo-contrast agent in the evaluation of left ventricular (LV) performance, we measured LV volume and ejection fraction (EF) in 42 patients with triggered harmonic contrast imaging (THCI), compared with continuous harmonic imaging without contrast agent (CHI) and with cineventriculography (CVG). In 10 of 42 patients, THCI improved LV border delineation which could not be obtained even with CHI. LV end-diastolic, end-systolic volumes and EF by both CHI and THCI correlated well with those by CVG. Although LV volumes are underestimated, THCI lessened the mean differences to about in half, compared with CHI. The observer variabilities obtained using THCI were smaller than those by CHI. These results indicate the validity of LV enhancement and the measurement of EF using THCI. We suggest that this method noninvasively provides more accurate LV systolic function with the acceptable reproducibility.

Chinese herbal drug natural indigo may cause pulmonary artery hypertension

A 45-year-old woman was admitted due to increasing dyspnoea, chest oppression, and leg oedema in December 2015. She had a 5-year history of ulcerative colitis (UC) and had been taking the herbal medicine natural indigo (NI) at 2 g/day for 6 months. No abnormalities had been detected at a medical check-up …

Twice-Daily Administration of a Long-Acting Angiotensin-Converting Enzyme Inhibitor Has Greater Effects on Neurohumoral Factors than a Once-Daily Regimen in Patients with Chronic Congestive Heart Failure

Although many clinical trials have evaluated the use of long-acting angiotensin-converting enzyme (ACE) inhibitors in patients with chronic congestive heart failure (CHF), there are no data regarding whether a once-daily or twice-daily regimen is preferable with respect to effects on the neuroendocrine system. To address this issue, the authors evaluated the comparative effects of the administration schedule on neurohumoral factors and autonomic nervous activity in patients with CHF. Thirty-two patients with mild compensated CHF received lisinopril (5–20 mg/d) orally either once a day (n = 17) or twice a day (n = 15) for more than 3 months. After this initial therapy, patients receiving a once-daily regimen switched to a twice-daily regimen and vice-versa, and patients were followed for an additional 3 months. Neurohumoral factors and the coefficient of variance in the electrocardiographic R-R interval (CVRR) were measured. Hemodynamic parameters, renal function, plasma concentrations of brain natriuretic peptide and aldosterone, and CVRR did not differ between the two regimens. However, the plasma concentration of norepinephrine was significantly lower, and plasma renin activity tended to be lower with the twice-daily regimen. These findings suggest that twice-daily administration of long-acting ACE inhibitors may have better effects on the neuroendocrine system than a once-daily regimen in patients with mild CHF.

Images in cardiovascular medicine. ST elevation during open heart surgery: floating air bubble in saphenous vein graft.

A 58-year-old man with severe mitral regurgitation and silent myocardial ischemia underwent mitral valvuloplasty and CABG. Preoperative coronary angiography revealed a total occlusion of the left circumflex coronary artery. The right coronary artery supplied the collateral flow to the posterior descending branch of the left circumflex coronary artery. The saphenous vein graft (SVG) was anastomosed to this branch after valvuloplasty. Just before closure of the chest wall, the ECG showed severe ST-segment elevation in leads II, III, and aVF (Figure 1 …A 58-year-old man with severe mitral regurgitation and silent myocardial ischemia underwent mitral valvuloplasty and CABG. Preoperative coronary angiography revealed a total occlusion of the left circumflex coronary artery. The right coronary artery supplied the collateral flow to the posterior descending branch of the left circumflex coronary artery. The saphenous vein graft (SVG) was anastomosed to this branch after valvuloplasty. Just before closure of the chest wall, the ECG showed severe ST-segment elevation in leads II, III, and aVF (Figure 1 …

ST Elevation During Open Heart Surgery Floating Air Bubble in Saphenous Vein Graft

A 58-year-old man with severe mitral regurgitation and silent myocardial ischemia underwent mitral valvuloplasty and CABG. Preoperative coronary angiography revealed a total occlusion of the left circumflex coronary artery. The right coronary artery supplied the collateral flow to the posterior descending branch of the left circumflex coronary artery. The saphenous vein graft (SVG) was anastomosed to this branch after valvuloplasty. Just before closure of the chest wall, the ECG showed severe ST-segment elevation in leads II, III, and aVF (Figure 1 …A 58-year-old man with severe mitral regurgitation and silent myocardial ischemia underwent mitral valvuloplasty and CABG. Preoperative coronary angiography revealed a total occlusion of the left circumflex coronary artery. The right coronary artery supplied the collateral flow to the posterior descending branch of the left circumflex coronary artery. The saphenous vein graft (SVG) was anastomosed to this branch after valvuloplasty. Just before closure of the chest wall, the ECG showed severe ST-segment elevation in leads II, III, and aVF (Figure 1 …

Intracoronary Positive and Negative Contrast Jets at a ‘Napkin Ring’ Coronary Stenosis

A very short coronary stenosis is somewhat difficult to correctly evaluate by conventional coronary angiography. The demonstration of positive and negative contrast jets observed just distal to the lesion is helpful in identifying the severity of the disease causing this disorder. In the present case, intravascular ultrasound confirmed the presence of a very short stenosis and membranous disease at the site of the lesion. The presence of intracoronary contrast jets reflects the morphology and severity of disease of the membranous type, although the reason for the appearance of contrast jets with this type of lesion should be sought.

Differences in amiodarone efficacy in relation to ejection fraction and basal rhythm in patients with implantable cardioverter defibrillators

BACKGROUND Atrial fibrillation (AF) and ventricular arrhythmias (VAs) are associated with increased morbidity and mortality. However, data are lacking concerning the association of AF and VAs. This study aimed to clarify the association between AF and VAs and to investigate the effect of amiodarone on the incidence of VAs in patients with implantable cardioverter defibrillators (ICDs). METHODS AND RESULTS We enrolled 612 patients who had ICDs or who underwent cardiac resynchronization therapy with a defibrillator (CRT-D) and classified them into two groups (sinus rhythm [SR] group, n = 427; AF group, n = 185) according to their basal rhythm at enrollment. Patients with paroxysmal AF were grouped into the AF group. The incidence of VAs, i.e., ventricular tachycardia (VT) and ventricular fibrillation (VF), was significantly lower in the AF group than in the SR group (0.54 vs 0.95 episodes/person/year, P = 0.032). Furthermore, amiodarone use was significantly higher in the AF group than in the SR group (P = 0.003). Non-use of amiodarone was associated with a significant increase in the occurrence of VT/VF in the two groups. This beneficial suppressive effect of amiodarone on the incidence of VT/VF was present in the AF group regardless of left ventricular ejection fraction (LVEF). However, this effect of amiodarone was present only in patients with LVEF ≥ 40% in the SR group. CONCLUSIONS Amiodarone was negatively associated with VT/VF occurrence and was frequently used in ICD/CRT-D patients with AF. VT/VF was controlled by amiodarone in all cases in the AF group but only in patients with an LVEF ≥ 40% in the SR group.