Mahoto Kato

Unusual Appearance of Mitral Annular Calcification Mimicking Intracardiac Tumor Prompting Early Surgery

Although mitral annular calcification (MAC) is usually easy to diagnose by transthoracic echocardiography, we experienced a rare case with MAC which looked like an intracardiac tumor. The patient who had been on chronic hemodialysis for 20 years was admitted to our hospital because of dyspnea. Transthoracic echocardiography showed a mass with severe calcification on the anterior mitral annulus and mean mitral gradient of 20 mm Hg. Because of the suspicion of the intracardiac calcified tumor that restricted mitral valve motion causing mitral obstruction, she underwent resection of the mass and mitral valve replacement. Pathological findings showed that the mass had a calcified envelope containing liquefied necrotic eosinophilic material with lympocytic infiltrate inside consistent with MAC. We should consider a possibility of MAC when we see a severe calcified mass attached to the mitral annulus in a patient on long-term hemodialysis.

Impaired heart rate responses and exercise capacity in heart failure patients with paced baseline rhythms.

BACKGROUND Conduction system disease and beta-blocker therapy are both common among heart failure (HF) patients and contribute to increasing reliance on paced rhythms. We hypothesized that many HF patients dependent on pacing have suboptimal heart rate responses and associated limitations in exercise capacity. METHODS AND RESULTS We studied 122 HF patients (left ventricular ejection fractions ≤40%) referred for cardiopulmonary exercise testing, comparing those with pacing at baseline with those with native rhythms. The paced group (PG) had lower resting (71 ± 9 vs 75 ± 15 beats/min; P = .048) and peak heart rates (103 ± 22 vs 127 ± 27 beats/min; P < .0001). Although beta-blockers were prescribed with similar frequency in both groups (90% vs 85%), average dose was higher in the PG. Inotropic reserve (oxygen pulse) was similar in both groups (11.1 ± 3.3 vs 11.1 ± 3.4 mL/beat; P = .94), consistent with equivalent stroke volumes, but chronotropic incompetence was higher (95% vs 71%, P = .001) and peak VO(2) was lower (12.2 ± 3.4 vs 14.2 ± 4.1 mL/kg/min; P = .004) in the PG. CONCLUSIONS Chronotropic incompetence and exercise capacity are worse in HF patients depending on paced heart rate responses. This has implications for quality of life as well as advanced therapy choices based on exercise capacity. Reevaluating beta-blocker dosing and optimizing pacemaker programming may therefore benefit the growing population of HF patients with device-dependent rhythms.

Expression of cell division cycle 2 kinase transcription in chronically rejected cardiac allografts of nonhuman primates.

SummaryAccurate diagnosis and prevention of graft arteriosclerosis, known as chronic rejection, is critical to the success of cardiac transplantation, but often is difficult to attain. Expression of cell division cycle (cdc) 2 kinase, which plays a critical role in cell transition through the G2/M phase, is critical to the proliferation of vascular smooth muscle cells. To evaluate the usefulness of cdc2 kinase expression for pathophysiological analysis of chronic rejection, heterotopic cardiac transplantation was performed in Japanese monkeys (n=7). Standard reverse transcriptase-polymerase chain reaction (RT-PCR) and in situ RT-PCR were performed to evaluate the expression. In the coronary arteries of chronically rejected allografts, enhanced cdc2 kinase expression was observed in thickened intima and media, while none was expressed in native hearts. The cdc2 kinase was also expressed before the intimal thickening occurred. These results indicate that enhanced expression of cdc2 kinase is a sensitive indicator for chronic cardiac rejection; targeting cdc2 kinase may be a viable gene therapy for prevention of this vasculopathy.

Should We Use Outpatient Dobutamine or Milrinone

The risks associated with both acute and chronic use of intravenous inotropic agents are widely recognized.1 However, for some patients with severe hypotension or inadequate diuretic response, inotropic therapy is initiated during hospitalization and continued as an outpatient if weaning attempts are unsuccessful. Use of intravenous inotropic agents for refractory symptoms in stage D heart failure has received a class IIb indication.2 Related article on p 320 The phosphodiesterase III inhibitor milrinone increases cardiac output and reduces systemic vascular resistance and pulmonary capillary wedge pressures in patients with advanced heart failure.3 The drug has been described to exert these hemodynamic effects with …

Calcified Amorphous Tumor-Induced Acute Cerebral Infarction: A Case Report and Histopathologic Comparison of Calcified Amorphous Tumor and Mitral Annular Calcification

We report the case of a 38-year-old woman who was admitted for acute cerebral infarction linked to a cardiac calcified amorphous tumor (CAT) and related mitral annular calcification (MAC). The cardiac mass was removed, and mitral valve replacement surgery was performed. Pathological examination revealed an amorphous accumulation of degenerating material within both lesions, indicating that build-up of calcium along the mitral annulus and subsequent rupture of the fibrotic tissue may be involved in the initiation and progression of CAT.

A Case of Calcified Amorphous Tumor Found with Cerebral Infarction

A 47-year-old man with cerebral infarction and end-stage of kidney disease on hemodialysis was transferred to our hospital because of a suspicion of infective endocarditis. Although echocardiography revealed a high echoic mass on the mitral leaflet mimicking of vegetation, we finally diagnosed Calcified Amorphous Tumor (CAT) by clinical course and image findings. Because of lacking of prospective investigations despite lots of case reports, epidemiology, prognosis and appropriate treatment including surgical resection of CAT are still controversy.

The Impact of Bronchodilator Therapy on Systolic Heart Failure with Concomitant Mild to Moderate COPD

In older adults, chronic obstructive pulmonary disease (COPD) is commonly associated with heart failure with reduced ejection fraction (HFrEF), and the high prevalence of this combination suggests that customized treatment is highly necessary in patients with COPD and HFrEF. To investigate whether the treatment of COPD with tiotropium, an anticholinergic bronchodilator, reduces the severity of heart failure in patients with HFrEF complicated by mild to moderate COPD, forty consecutive participants were randomly divided into two groups and enrolled in a crossover design study. Group A inhaled 18 μg tiotropium daily for 28 days and underwent observation for another 28 days. Group B completed the 28-day observation period first and then received tiotropium inhalation therapy for 28 days. Pulmonary and cardiac functions were measured on days 1, 29, and 56. In both groups, 28 days of tiotropium inhalation therapy substantially improved the left ventricular ejection fraction (from 36.3 ± 2.4% to 41.8 ± 5.9%, p < 0.01, in group A; from 35.7 ± 3.8% to 41.6 ± 3.8%, p < 0.01, in group B) and plasma brain natriuretic peptide levels (from 374 ± 94 to 263 ± 92 pg/mL, p < 0.01, in group A; from 358 ± 110 to 246 ± 101 pg/mL, p < 0.01, in group B). Tiotropium inhalation therapy improves pulmonary function as well as cardiac function, and reduces the severity of heart failure in patients with compensated HFrEF with concomitant mild to moderate COPD.

IMPACT OF EXERCISE CAPACITY BEYOND ANAEROBIC THRESHOLD

Methods: To study this question in a population prior to recommended use of beta blockers which variably limit peak heart rate, we examined data collected in 142 Pts with LVEF < 40% after myocardial infarction (MI) who participated in a randomized trial of the use of captopril for secondary prevention. Maximal bicycle exercise testing with continuous gas exchange measurement was performed 3-6 months after MI. The increase in VO2 beyond VAT was defined as BAT-VO2. Cox proportional hazards regression analysis was used and hazard ratios (HR) for PVO2 and BAT-VO2 were calculated for increments of 10 ml/min.