Kimio Kamimori

Parathyroid hormone and systolic blood pressure accelerate the progression of aortic valve stenosis in chronic hemodialysis patients

BACKGROUND Aortic valve stenosis (AS) is a frequent complication contributing to poor prognosis in chronic hemodialysis (CHD) patients. However, little is known regarding the risk factors affecting AS progression. The purpose of this study was to define risk factors affecting AS progression in CHD patients. METHODS We retrospectively investigated 34 consecutive CHD patients with asymptomatic AS (mild in 9, moderate in 20, severe in 5; aortic valve area (AVA), 1.31±0.31cm(2); mean age, 69±8years) who underwent followed-up paired transthoracic echocardiography with period of at least six months apart (22±9months). AS progression was evaluated using the absolute reduction in AVA per year. RESULTS CHD patients were divided into 20 patients with rapid progression (AVA reduction, >0.1cm(2) per year) and 14 with slow progression (AVA reduction, ≤ 0.1cm(2) per year). Serum parathyroid hormone (PTH) level was significantly higher in patients with rapid progression than in those with slow progression [343±489pg/ml vs. 76±80pg/ml, P<0.05]. In univariate analysis, AS progression by absolute AVA reduction per year was associated with age, PTH level, initial AVA, systolic blood pressure (SBP), diastolic blood pressure, total cholesterol, and left ventricular diameter at end-diastole and end-systole. Multiple regression analysis indicated that serum PTH level and SBP remained independently associated with AS progression. CONCLUSIONS AS progression was accelerated in the presence of high PTH and SBP. Careful monitoring and intensive treatment of these parameters may have a beneficial effect on secondary prevention in CHD patients.

Left ventricular remodeling after myocardial infarction in antecedent hypertensive patients.

Antecedent hypertension adversely affects mortality and heart failure after myocardial infarction (MI). In addition, accelerated ventricular remodeling is a contributor to the increased mortality observed after MI. The purpose of this study was to assess the relationship of antecedent hypertension to ventricular remodeling after MI. Ninety-four patients presenting with a first acute MI who were treated with reperfusion therapy within 12 h of their symptom onset were enrolled in this study. All of them underwent left ventriculography immediately after reperfusion therapy and again at 6 months after the occurrence of MI. Patients were divided into two groups: a hypertensive group and a normotensive group. End-diastolic volume index (EDVI), end-systolic volume index (ESVI), and ejection fraction (EF) values in the acute phase were compared to those at 6 months after acute MI in either group. The hypertensive group showed a significant increase in both EDVI and ESVI after 6 months, whereas the normotensive group did not. In addition, there was no change in EF in the hypertensive group, whereas EF increased significantly after 6 months in the normotensive group. As a result, the percent changes in ESVI and EF were significantly different between the hypertensive group and normotensive group. The results demonstrated that antecedent hypertension interacts with ventricular cavity dilatation after MI.

Left ventricular–right atrial communication by perforation of the atrioventricular portion of the membranous septum and severe aortic valve regurgitation caused by infective endocarditis

We report the case of acquired left ventricle (LV) to right atrial (RA) communication through an aneurysm of the atrioventricular septum caused by infectious endocarditis. A severe aortic valve regurgitation and destruction of the aortic valve was detected by echocardiography. Transesophageal echocardiography revealed a flail aortic valve with vegetation and abnormal shunt flow from the LV to RA with ruptured aneurysm of the membranous septum. An abscess cavity of the aortic ring was introduced. Because of worsening congestive heart failure, the patient underwent emergency aortic valve replacement and patch closure of the communication of the membranous septum. The patient’s postoperative course was uneventful.

Cor triatriatum dexter with atrial septal defect evaluated by real-time three-dimensional transesophageal echocardiography.

An 82-year-old woman presented with palpitation chest oppression and exertional dyspnea. Medical history included systemic hypertension treated by a nearby clinic. On admission, chest X-ray revealed increased cardiothoracic ratio of 64 % and vascular congestion. ECG showed atrial fibrillation with about 92 bpm. On examination, she had blood pressure of 164/66 mmHg and oxygen saturation of 96 % on room air. At physical examination, a soft systolic murmur was present on 4LSB (Levine 3/6) and pitting edema at lower extremities. Laboratory investigation showed elevated BNP (791 pg/ml). Transthoracic echocardiography (TTE) demonstrated the dilated right heart with volume overload and left ventricular function was normal. The morphology of the tricuspid valve (TV) looked normal but systolic pressure gradient over the TV was 46 mmHg. The size of the inferior vena cava (IVC) was 22 mm. TTE revealed a large band in the right atrium (RA) dividing into two chambers (Fig. 1a, b). However, Doppler analysis revealed no gradient between the two chambers and, accordingly, absence of obstruction in the RA. TTE showed a secundum atrial septal defect (ASD) with left-to-right shunt by color-flow imaging and pulmonary to systemic flow ratio was estimated to be about 1.8 (Fig. 1a). An anomalous membrane in the RA is shown with cardiac CT. These findings were compatible with persistence of valve of sinus venosus [1, 2]. To confirm the diagnosis and to image the front view of the membrane, real-time 3D-TEE was performed with iE33 (Philips Ltd., Netherlands) and analyzed online and offline. The 3D image was displayed as a volumetric data set and with the ability to manipulate the direction of the view and two-dimensional (2D) images of any section. 3D-TEE showed a large hole in the center of the membrane (32 9 27 mm) allowing communication between the two chambers of the RA (Fig. 1c, d) [3]. During the procedure, a contrast study using agitated saline injected from the left brachial vein (Fig. 2a) revealed partitioning of the RA into two chambers by the membrane. IVC flow was not obstructed, but restricted. The patient was diagnosed as having cor triatriatum dexter and successfully treated with diuretics, vasodilator, and antiplatelet medicine. She was discharged without surgical treatment.

The usefulness of right ventriculography to aid anchoring a pacing lead to the right ventricular septum

Aims Although right ventricular septal pacing is thought to be more effective in minimizing pacing-induced left ventricular dysfunction, the accurate way to anchor the lead to the right ventricular septum (RVS) has not been established. Our aim was to clarify the usefulness of right ventriculography (RVG) to aid accurate anchoring of the lead to the RVS. Methods and results Eighty-four patients who underwent pacemaker implantation were enrolled. We anchored the lead to the RVS by using an RVG image obtained at a 30° right anterior oblique view as a reference. We confirmed the actual lead position by performing computed tomography after the procedure and examined the characteristics of the paced QRS complex. Of the 81 patients, except 3 patients whose leads were anchored to the apex due to high pacing thresholds in the RVS, the leads were successfully anchored to the RVS in the 79 (98%) patients, and the number of leads placed in the high-, mid-, and low-RVS was 3 (4%), 58 (73%), and 18 (23%), respectively. The paced QRS duration in these 79 patients was 140 ± 13 ms. The paced QRS duration from mid-RVS was considerably narrower than that from high- or low-RVS (137 ± 12 ms vs. 146 ± 12 ms; P = 0.012). Conclusion Right ventriculography was very useful in aiding accurate anchoring of the lead to the RVS. Further, pacing from mid-RVS may be more effective in minimizing the QRS duration than pacing from other RVS sites.

Pheochromocytoma Multisystem Crisis Behaving Like Interstitial Pneumonia: An Autopsy Case.

Pheochromocytoma multisystem crisis is a rare and life-threatening disease that is associated with numerous symptoms and which is also difficult to diagnose. We herein report an autopsy case of a 61-year-old man who died due to pheochromocytoma multisystem crisis. The patient complained of vomiting and breathlessness. Computed tomography showed a shadow-like region with a similar appearance to interstitial pneumonia. The patient was diagnosed with takotsubo cardiomyopathy induced by severe lung disease based on the results of echocardiography and coronary angiography. The patient was treated for interstitial pneumonia. However, his condition rapidly deteriorated and he died 6 hours after arrival. We were later informed of his extremely high catecholamine serum levels. We found pheochromocytoma with hemorrhage at autopsy. The patients lungs showed acute passive congestion with edema and extravasation.