Masanao Toma

Coronary angiography by 64-detector row computed tomography using low dose of contrast material with saline chaser: influence of total injection volume on vessel attenuation.

Objective: To assess the influence of total injection volume on thoracic great vessels and coronary arteries enhancement in 64-detecter row computed tomography (CT) coronary angiography using low dose of contrast material. Methods: Sixty patients underwent cardiac CT (64 × 0.5 mm, 0.4 rot/s) using 40 mL of contrast material (350 mg of Iodine per milliliter) in 30 patients and 50 mL in 30 patients. Computed tomography densities (Hounsfield units) in ascending aorta, descending aorta, and main pulmonary artery were measured at every second with the time of CT data acquisition recorded in each reconstructed image. Computed tomography densities of proximal and distal coronary arteries were also measured. Differences in CT densities between 40 and 50 mL contrast material were assessed with the Student t test. In addition, the relation between the injection volume (mL) of contrast material per kilogram body weight and contrast enhancement in coronary arteries was studied. Results: The average attenuations in the ascending and descending aorta and coronary arteries were significantly lower in 40-mL group than in 50-mL group (<0.05). In addition, the average attenuations in the pulmonary artery were significantly lower in 40-mL group than 50-mL group (<0.01). Every patient with the total injection volume of more than 0.9 mL/kg body weight showed a contrast enhancement more than 250 Hounsfield units. Conclusions: The reduction of total injection volume lowered the enhancement of thoracic great vessels and coronary arteries in 64-detector row cardiac CT. The injection volume of at least 0.9 mL/kg body weight was necessary for a steady contrast enhancement in coronary arteries.

Long-Term Outcomes of Coronary-Artery Bypass Graft Surgery Versus Percutaneous Coronary Intervention for Multivessel Coronary Artery Disease in the Bare-Metal Stent Era

Background— Observational registries comparing coronary artery bypass graft (CABG) surgery and percutaneous coronary intervention (PCI) have reported long-term survival results that are discordant with those of randomized trials. Methods and Results— We conducted a multicenter study in Japan enrolling consecutive patients undergoing first CABG or PCI between January 2000 and December 2002. Among 9877 patients enrolled, 5420 (PCI: 3712, CABG: 1708) had multivessel disease without left main involvement. Because age is an important determinant when choosing revascularization strategies, survival analysis was stratified by either age ≥75 or <75 years. Analyses were also performed in other relevant subgroups. Median follow-up interval was 1284 days with 95% follow-up rate at 2 years. At 3 years, unadjusted survival rates were 91.7% and 89.6% in the CABG and PCI groups, respectively (log rank P=0.26). After adjustment for baseline characteristics, survival outcome tended to be better after CABG (hazard ratio for death after PCI versus CABG [HR], 95% confidence interval [CI]: 1.23 [0.99-1.53], P=0.06). Adjusted survival outcomes also tended to be better for CABG among elderly patients (HR [95%CI]: 1.37 [0.98-1.92] P=0.07), but not among nonelderly patients (HR [95% CI]: 1.09 [0.82-1.46], P=0.55). Unadjusted and adjusted survival outcome for CABG and PCI were not significantly different in any subgroups when elderly patients were excluded from analysis. Conclusions— In the CREDO-Kyoto registry, survival outcomes among patients <75 years of age were similar after PCI and CABG, a result that is consistent with those of randomized trials.

Left Ventricular Functional Analysis Using 64-Slice Multidetector Row Computed Tomography: Comparison with Left Ventriculography and Cardiovascular Magnetic Resonance

Objective: The progress in computed tomography (CT) has improved temporal resolution and shortened the acquisition time. We compared cardiac function using 64-slice CT with left ventriculography (LVG) and cardiovascular magnetic resonance (CMR). Methods: A head-to-head comparison between CT, LVG and CMR was performed in 41 patients. In global LV function, CMR served as the reference. Regional wall motion was compared in a 5-point scoring system. Results: CT had excellent intra- and interobserver reproducibility. Ejection fraction, end-diastolic and end-systolic volumes by CT were closely correlated with CMR (r = 0.95, 0.96 and 0.98, respectively), while LVG underestimated LV volumes (p < 0.01). The standard deviation of ejection fraction difference between CT and CMR was significantly lower than that between LVG and CMR (p = 0.0015). In regional function, there were good agreements of 94.8% (ĸ = 0.82) between CT and LVG and 94.5% (ĸ = 0.84) between CT and CMR. The intermethod agreements in mild hypokinesis using CT tended to be lower. Conclusion: An excellent correlation was observed between CT and CMR in the LV function over a wide range of heart rates. However, even though 64-slice CT tended to be less sensitive in detecting mild hypokinesis, it still showed excellent concordance in advanced regional abnormalities.

Endovascular Treatment of a Giant Aortic Arch Aneurysm With a Triple-Branched Stent Graft

An 86-year-old woman was referred for treatment of a rapidly enlarging aortic arch aneurysm, which had been monitored for 2 years with serial computed tomography (CT) scans. The size of the aneurysm had been 65 mm 2 years previously, but it had enlarged to 110 mm at the most recent examination (Figure 1). The patient complained of hemosputum and back pain. The risk of rupture was considered very high if the aneurysm was left untreated; however, thoracotomy was considered high risk because of the patient’s age. After obtaining the informed …

Intermittent infusions of carperitide or inotoropes in out-patients with advanced heart failure

BACKGROUND The ambulatory treatment of advanced heart failure (HF) with intermittent infusions of inotropes or natriuretic peptide chosen immediately before each infusion has not been described. METHODS Between May 2005 and July 2009, we treated 11 patients presenting with advanced HF, who received a total of 369 infusions of carperitide, olprinone, dopamine, or dobutamine, once or twice weekly. The pharmaceutical was selected before each infusion based on the systolic blood pressure (BP). RESULTS Carperitide, olprinone, and catecholamines were administered to 8 (73 infusions of 0.030±0.004μg/kg/min for 3.3±0.8h), 4 (18 infusions of 0.070±0.017μg/kg/min for 3.3±0.5h), and 6 patients (278 infusions of 3.6±1.9μg/kg/min for 2.8±1.0h), respectively. No adverse effect requiring cessation of infusion was observed. Over a mean follow-up of 29.3±28.8months (range 2-104), 4 patients died, all from cardiac causes. The Kaplan-Meier cumulative survival rate was 69.3% at 20 months (median follow-up). Compared with the pre-infusion period, the duration and number of hospitalizations for management of HF were decreased by 73.9% (p=0.017), and 51.9% (p=0.007), respectively, during the treatment period, and the overall medical costs by 56.9% (p=0.021). CONCLUSIONS In this study population, intermittent drug infusions selected from inotropes or natriuretic peptide based on the baseline systolic BP significantly decreased the length and number of hospitalizations and costs, without increasing mortality. These results indicate that intermittent infusions might be one of the therapeutic options in advanced HF.

Angio-Embolization of Renal Artery Pseudoaneurysm after Renal Biopsy: A Case Report

Renal artery pseudoaneurysm is a rare clinical entity that has been reported after renal biopsy, percutaneous renal surgery, penetrating trauma, and rarely blunt renal trauma. We present the case of a 37-year-old man with ruptured renal artery pseudoaneurysm accompanied by massive gross hematuria, urinary clot retention, and bladder tamponade, which were the presenting signs seven hours after renal biopsy. Abdominal CT scan showed a large perinephric, intracapsular hematoma of left kidney. His angiogram revealed a left renal segmental artery pseudoaneurysm that measured 1 cm × 1 cm. He was successfully treated by selective embolization of the arterial branch supplying the pseudoaneurysm.

Thoracic endovascular aortic repair with branched Inoue Stent Graft for arch aortic aneurysms

Background Thoracic endovascular aortic repair (TEVAR) for thoracic aortic aneurysms (TAAs) is in rapid expansion due to its minimal invasiveness. However, TEVAR for an arch aneurysm with a straight stent graft needs surgical reconstruction for supra‐aortic vessels. A branched stent graft pioneered by Inoue (branched Inoue Stent Graft [ISG]) has been expected to resolve this problem, but its utility remains to be established in the real clinical setting. This study evaluated the long‐term clinical outcome of branched ISGs for TAAs. Methods Among 217 consecutive patients who underwent TEVAR with ISGs between March 2003 and September 2013, 89 patients with TAAs were treated with implantation of the branched ISG (single branch: n = 64; double branch: n = 18; triple branch: n = 7). The primary end point was freedom from aneurysm‐related death. Secondary end points included periprocedural adverse events, freedom from all‐cause death and major adverse events (composite of aneurysm‐related death, surgical conversion, aneurysm rapture, persistent type I or III endoleak, graft infection, graft occlusion, graft migration, and aneurysm expansion), changes of aneurysm diameter, stroke, and any endovascular reintervention during follow‐up. Results All deployments of branched ISGs were successful. The 30‐day mortality was 4.5% (single branch, 3.1%; double branch, 0%; triple branch, 29%), and periprocedural stroke was 16% (single branch, 7.8%; double branch, 33%; triple branch, 42%). At 1 and 5 years, freedom from aneurysm‐related death was 93% and 93%, respectively, and freedom from all‐cause death was 85% and 59%, respectively. Survival free of major adverse events was 76% at 5 years. The cumulative incidence of stroke was 11% at 5 years. Three patients underwent surgical conversion because of persistent type I endoleak. One branch graft occlusion was observed at the left subclavian artery in a patient who received a double‐branched graft. Conclusions Periprocedural outcome of the single‐branched ISG was acceptable, and long‐term safety and efficacy were demonstrated. However, the procedural complications of the multibranched ISG leave room for improvement.

The deeper the pouch is, the longer the radiofrequency duration and higher the radiofrequency energy needed-Cavotricuspid isthmus ablation using intracardiac echocardiography

The aim of this study was to explore whether the pouch depth influenced the radiofrequency (RF) duration and total delivered RF energy for cavotricuspid isthmus (CTI) ablation and define the cutoff value for a deep pouch‐specified ablation strategy.

Ruptured Abdominal Aortic Aneurysm Treated by Double-Balloon Technique and Endovascular Strategy: Case Series

Purpose: Mortality in patients with ruptured abdominal aortic aneurysms (rAAAs) has remained high despite advances in interventions. Endovascular aneurysm repair (EVAR) was recently developed for treatment of rAAAs. In this study, we assessed our endovascular strategy including a double-balloon technique for rAAA. Methods: We analyzed 12 consecutive patients with rAAAs who were treated by our double-balloon technique and endovascular strategy from March 2013 to July 2016. Results: The 30-day and 1-year mortality rates were both 17%. The mean times from admission to arrival at the hybrid operating room, from admission to aortic occlusion, and from admission to completion of EVAR were 46.8, 63.5, and 110.0 minutes, respectively. Conclusion: This study indicates that the herein-described double-balloon endovascular technique is feasible for use in the management of rAAA.

MYOCARDIAL INJURY IN HYPERTENSIVE HEART

Background: It has been reported that slight elevation of N-terminal Pro-brain natriuretic peptide (NT-proBNP) is a predictor of cardiovascular events. In patients with heart failure, biomarkers of myocyte injury are elevated. However, the correlation between these markers in patients with essential hypertension has not been elucidated. We evaluated the relationship between NT-proBNP and heart-type fatty acid-binding protein (H-FABP) in hypertensive patients.