Kohei Fujimoto

Percutaneous Transcatheter Balloon Valvuloplasty for Bioprosthetic Tricuspid Valve Stenosis

A 59-year-old woman was admitted to our hospital because of exertional dyspnea, abdominal distension, and leg edema over the past 2 weeks. She had a history of rheumatic fever at the age of 12 years. In 1983, at the age of 37, she had undergone tricuspid valve replacement with a Carpentier-Edwards bioprosthesis for tricuspid stenosis and mitral valve replacement with a mechanical valve for mitral stenosis. The physical examination on admission revealed marked edema in both legs. There was also presystolic pulsation of the liver, which was palpable 4 cm below the right costal margin. A Levine grade III/VI, rough, diastolic rumble at the lower left sternal border was accentuated during inspiration. Echocardiography revealed severe tricuspid stenosis and a large amount of ascites. The leaflets were thickened, …

Long RP' Tachycardia With Unusual Entrainment Responses: What Is the Mechanism?

A 71-year-old man with palpitation was referred for electrophysiological study and radiofrequency ablation. Baseline findings of 12-lead electrocardiogram during sinus rhythm and echocardiography were normal. Atrio-His (AH) and His-ventricular (HV) intervals were measured as 113 and 40 milliseconds, respectively. Dual atrioventricular (AV) nodal physiology was observed during programmed atrial stimulation. The earliest atrial activation during ventricular constant pacing was recorded at His bundle region, and para-Hisian pacing showed an AV nodal pattern. Short RP’ tachycardia (SVT 1) accompanied by a jump-up in the AH interval was induced by atrial extrastimulation or atrial constant pacing (Fig. 1). During SVT 1, the AH and HV intervals were measured as 453 and 40 milliseconds, respectively, and the earliest atrial activation was recorded at the His bundle region. Ventricular extrastimuli delivered during SVT 1 when the His bundle is refractory did not reset the atrial cycle. Figure 2A shows a transition from SVT 1 to long RP’ tachycardia (SVT 2) with a true atrial–atrial-ventricular (AAV) response after cessation of ventricular entrainment pacing (VEP) during SVT 1. During SVT 2, the AH and HV intervals were measured as 125 and 42 milliseconds, respectively, and the earliest atrial activation was recorded at the coronary sinus (CS) ostium. Ventricular extrastimuli delivered during SVT 2 did not reset the atrial cycle, and VEP during SVT2 was performed (Fig. 2B). What is the mechanism underlying the 2 entrainment responses?

Hereditary Hemorrhagic Telangiectasia With Pulmonary Arteriovenous Fistulas

A 65-year-old woman presented with exertional dyspnea and general fatigue that began 1 week ago. She had a family history of hereditary hemorrhagic telangiectasia manifesting as telangiectasia of gastrointestinal (GI) tract and nasal mucosa and of pulmonary arteriovenous fistulas (PAVFs). Her first PAVF was diagnosed in 1999 but was untreated at that time. Her medical history was significant for multiple GI bleeds, mild to moderate nosebleeds, and a minor cerebral stroke probably due …