Makoto Kumakura

Limited role of coronary angioplasty and stentingin coronary spastic angina with organic stenosis

OBJECTIVES We investigated the efficacy of percutaneous coronary intervention (PCI) in patients with coronary spastic angina (CSA) and severe organic stenosis. BACKGROUND Coronary spasm occurs at the site of organic stenosis in most patients with CSA and severe stenosis, whereas multivessel spasm occurs frequently in those with normal coronary arteries. The incidence of multivessel spasm and the efficacy of PCI in patients with CSA and severe stenosis have not been fully elucidated. METHODS Forty-five patients with CSA and severe stenosis underwent spasm provocative testing with intracoronary acetylcholine before and 7 +/- 3 months after PCI (20 patients had angioplasty and 25 patients had stenting), when all patients were free of restenosis. RESULTS Spasm was induced at the site of severe stenosis in 30 patients (66.7%) with (n = 12) or without (n = 18) spasm induced in another vessel. In the remaining 15 patients, spasm was induced at a different site in the stenotic vessel and/or in another vessel. Repeat provocative tests were performed in 43 of 45 patients. Although spasm was never induced at exactly the same site of the initial stenosis that had been dilated, spasm was induced at a different site in the dilated vessel and/or in another vessel, in 33 (76.7%) of 43 patients. Multivessel spasm occurred in 28 (62.2%) of 45 patients on one or both provocations. CONCLUSIONS Spasm was frequently induced at a site different from the initial stenosis, even in the absence of restenosis after PCI. Calcium antagonists should be continued in most patients with CSA who show no restenosis after PCI.

A Case of Effusive-Constrictive Pericarditis After Cardiac Surgery

A 60-year-old woman who had undergone repair of an atrial septal defect was readmitted to the hospital with dyspnea, abdominal distention, and leg edema 31 months after surgery. An echocardiogram demonstrated massive pericardial effusion. Cardiac catheterization revealed elevation and equilibrium of the 4-chamber diastolic pressure and a dip-and-plateau pattern in the right and the left ventricular pressures. Despite removal of pericardial fluid by pericardiocentesis, the findings and symptoms did not improve. The patient underwent both parietal and visceral pericardiectomy after which striking hemodynamic and symptomatic improvement occurred. Effusive-constrictive pericarditis is uncommon but should be considered in patients with refractory heart failure and massive pericardial effusion showing no improvement after removal of pericardial fluid.

A case of giant cell myocarditis with evidence of cardiac autoimmunity

A 45-year-old-woman with giant cell myocarditis showing high titer of circulating antiheart antibodies is reported. She experienced two recurrences of myocarditis and repeatedly responded to immunosuppressive therapy using prednisolone. The titer of antiheart antibodies went up and down appropriately according to the clinical responses to immunosuppressive therapy. This case suggested that giant cell myocarditis might be related to autoimmunity.