Nobuyuki Masaki

Association between brachial-ankle pulse wave velocity and the ratio of l-arginine to asymmetric dimethylarginine in patients undergoing coronary angiography

BACKGROUND Endothelial dysfunction causes vasomotor dysregulation and vascular stiffening in addition to structural changes. By influencing NO synthesis, deficiency of l-arginine relative to asymmetric dimethylarginine (ADMA), which is an l-arginine derivative that acts as a competitive NO synthase inhibitor, may lead to the promotion of arterial stiffness. This study investigated the relationship between the l-arginine/ADMA ratio and brachial-ankle pulse wave velocity (baPWV), an indicator of arterial stiffness. METHODS AND RESULTS This cross-sectional study enrolled 74 patients (62 men, 12 women; mean age, 67±10 years) undergoing elective coronary angiography. A total of 54 (73%) patients had coronary artery disease. Serum l-arginine and ADMA were measured by high-performance liquid chromatography with fluorescence detection. The ratio of l-arginine to ADMA and the serum l-arginine level was associated with baPWV in univariate regression analysis (l-arginine/ADMA ratio: β=-0.323, p=0.005; l-arginine: β=-0.247, p=0.034). In addition, baPWV was related to blood hemoglobin concentration, hematocrit, brain natriuretic peptide level, symmetric dimethylarginine, renal function, blood pressure, and heart rate. In multivariate analysis, the l-arginine/ADMA ratio was a significant predictor of baPWV (β=-0.310, p<0.001). In subgroup analyses, the l-arginine/ADMA ratio was associated with baPWV in elderly patients (n=46, β=-0.359, p=0.004), and in younger patients (n=28, β=-0.412, p=0.006). CONCLUSION A low l-arginine/ADMA ratio may be associated with high baPWV in patients undergoing coronary angiography.

Three-dimensional echocardiography could distinguish a ventricular septal defect adjacent to asymptomatic ruptured sinus of Valsalva aneurysm

Sinus of Valsalva aneurysm (SVA) arises frequently in the right coronary sinus, and ventricular septal defect (VSD) is a prevalent coexistent cardiac abnormality. A 38-year-old asymptomatic male diagnosed with VSD on cardiac catheterization in his childhood, was referred to our hospital for the change in intensity of his cardiac murmur pointed out by his family physician. A grade V continuous murmur was auscultated with a thrill loudest at the forth left sternal border. Although, transthoracic and transesophageal echocardiography and cardiac catheterization have showed the ruptured right coronary sinus aneurysm, it was difficult to demonstrate coexistence of a doubly committed subarterial VSD. Three-dimensional echocardiography could provide clear images for diagnosis of the VSD closely adjacent to the ruptured SVA. The defect was confirmed at surgery.

Usefulness of the d-ROMs test for prediction of cardiovascular events

BACKGROUND d-ROMs test developed to determine the degree of individual oxidative stress may predict cardiovascular events. METHODS AND RESULTS 265 patients (204 men, 61 women; age, 65±13years) who had been treated for cardiovascular disease were divided evenly by quartile of baseline d-ROMs levels, and were followed up. During the observation periods of 2.66±1.47years, there were 14 (5%) deaths, 8 (3%) cardiovascular deaths, 13 (5%) major adverse cardiovascular events (MACEs), and 51 (19%) all cardiovascular events including heart failure, cardiovascular surgery, and revascularization. Log-rank tests demonstrated that the patients in the 4th quartile (d-ROMs≧395.00U.CARR) had a higher incidence rate of cardiovascular death than those in the 2nd quartile (d-ROMs 286.00-335.00, p=0.022). In multivariate Cox regression analysis, even after adjustment for age, sex, coronary risk factors, C-reactive protein, and renal function, high d-ROMs was a risk factor for all-cause death [adjusted HR of 4th vs. 1st quartile, 10.791 (95% confidence interval 1.032-112.805), p=0.047], and all cardiovascular events [HR of 4th vs. 1st quartile, 2.651 (95% confidence interval 1.138-6.177), p=0.024]. CONCLUSIONS Our results suggest that d-ROMs is a useful oxidative stress marker to assess prognosis and risk of further cardiovascular events.

Elevation of Derivatives of Reactive Oxygen Metabolites Elevated in Young "Disaster Responders" in Hypertension due to Great East Japan Earthquake

There have been very few studies on serum biomarkers associated with hypertension in disaster situations. We assessed biomarkers associated with disaster-related hypertension (DRH) due to the Great East Japan Earthquake of March 2011.We collected blood samples from members of the Japan Self Defense Forces (JSDF) (n = 77) after completing disaster relief operations. We divided them into two groups based on systolic blood pressure. We defined DRH as either systolic blood pressure greater than 140 mmHg or diastolic blood pressure greater than 90 mmHg at the time of completing missions.In subjects with DRH, the mean blood pressure was 143.5 ± 5.0/99.5 ± 2.4 mmHg. Height and body weight measurements were slightly greater in the DRH group but the differences were not significant, and age was significantly higher in the DRH group. There were no differences in serum biochemical tests including metabolic markers, sulfur-containing amino acids, and cytokines. Among nitric oxide-related amino acids, asymmetric dimethylarginine (ADMA) was lower in the DRH group than in the normotension group (0.40 ± 0.02 versus 0.31 ± 0.02 μmol/L P = 0.04). The serum oxidative stress metabolite levels (d-ROMs; indicators of active oxygen metabolite products) were significantly higher in the DRH group (273.6 ± 6.08 versus 313.5 ± 13.7 U.CARR P = 0.016). Using multivariable regression analysis, d-ROMs levels were particularly predictive for DRH.Oxidative stress is associated with DRH in responders to the disaster of the Great East Japan Earthquake.

Right Ventricular Wall Dissection With Ventricular Septal Rupture Following Myocardial Infarction Visualized on 3-Dimensional Transthoracic Echocardiography

hypotension. During treatment, shock and heart murmur suddenly appeared at 10 days after the onset of MI. On transthoracic echocardiography, ventricular septal rupture near the apex was suggested (Figure 2A, arrows), whereas 3-D transthoracic echocardiography, recorded on Vivid 7 (GE Healthcare UK, England), more clearly delineated the complication, which involved dissection of the RV inferior wall (Figure 2B, arrows; Movie S1) and a shunt flow through it into the RV cavity (Figure 2C). Furthermore, 3-D color Doppler echocardiography focusing on RV endocardium identified a shunt flow via a 1.8-cm slit (Figure 2D; Movie S2). Therefore, we diagnosed ventricular septal rupture communicating with the RV cavity via RV wall dissection. Intra-aortic balloon pump was promptly inserted, and emergency surgical repair planned, but the thrombocytopenia did not respond to any treatment including platelet transfusion, and the surgery was therefore delayed due to deteriorating thrombocytopenia (6,000/μl) and renal function. Cardiogenic 64-year-old woman was transferred to National Defense Medical College Hospital after percutaneous coronary intervention (PCI) following acute myocardial infarction (MI) of the right coronary artery (Figure 1). She had rheumatoid arthritis, lupus-like syndrome, and thrombocytopenia (20,000/μl), and had been taking prednisolone 10 mg/day for 1 month. Systolic blood pressure was 70–80 mmHg in the previous hospital, and the patient was diagnosed with right ventricular (RV) infarction based on echocardiography and the presence of hypotension. Onset-to-balloon time for PCI was 8 h in the previous hospital. Coronary flow at TIMI grade 3 was achieved after thrombus aspiration and implantation of a drug-eluting stent to segment 3 of the right coronary artery. Aspirin and clopidogrel had been administered only for 1 day and argatroban for 3 days considering the thrombocytopenia. In addition, noradrenaline, hydrocortisone, and immunoglobulin G had been administered i.v. on the present admission. Neither β-blocker, angiotensin-converting enzyme inhibitor, nor angiotensin receptor blocker was prescribed because of A

Provocation of Microvessel Spasm by Low-Dose Acetylcholine in Patients with Suspected Coronary Artery Disease Two Case Reports

Endothelial dysfunction plays an important role in the pathogenesis of cardiac syndrome X, and intracoronary low-dose acetylcholine infusion is a widely used diagnostic modality for studying the coronary artery endothelial function. The authors herein report 2 cases of cardiac syndrome X with coronary artery endothelial dysfunction and microvessel spasm. The findings of non invasive testing were positive for ischemia. Coronary angiograms appeared entirely normal in both cases. However, the intracoronary infusion of low-dose (1.5-15 µg/minute) acetylcholine demonstrated an impairment of the coronary blood flow response and consequently provoked an ST-segment elevation in an electrocardiogram. The coronary angiograms showed no spasm in the epicardial arteries. These patients are thus suggested to have cardiac syndrome X with microvessel spasms associated with coronary artery endothelial dysfunction.

A Rare Case of Rush Progression of Purulent Pericarditis by Escherichia coli in a Patient with Malignant Lymphoma

Purulent pericarditis is a rare disease in the antibiotic era. The common pathogens of purulent pericarditis are gram-positive species such as Staphylococcus aureus. Streptococcus pneumoniae, Salmonella, Haemophilus, fungal pathogens/tuberculosis can also result in purulent pericarditis. We report an old male case of purulent pericarditis by Escherichia coli. He came to our hospital suffering from leg edema for 3 months. Echocardiography revealed the large amount of pericardial effusion, and he was admitted to test the cause of pericardial effusion without high fever, tachycardia, and shock vital signs. On the third day, he suddenly presented vital shock. We performed emergency cardiopulmonary resuscitation and pericardiocentesis. Appearance of pericardial effusion was hemorrhagic and purulent. The gram stain revealed remarkable E. coli invasion to pericardial space. Antibiotic therapy was immediately started; however, he died on sixth day with septic shock. The cytological examination of pericardial effusion suggested the invasion of malignant lymphoma to pericardium. This case showed subacute or chronic process of pericarditis without severe clinical and laboratory sings before admission. Nevertheless, bacterial purulent pericarditis usually shows acute clinical manifestation; the first process of this case was very silent. Immunosuppression of malignant lymphoma might make E. coli translocation from gastrointestinal tract to pericardial space, and bacterial pericarditis was progressed to purulent pericarditis. In the latter process, this case showed unexpected rush progression to death by sepsis from purulent pericarditis. Immediate pericardiocentesis should be performed for a prompt diagnosis of purulent pericarditis, and it might have improved the outcome of this case.

Tranexamic Acid Controlled Chronic Disseminated Intravascular Coagulation Associated with Aortic Dissection and Patent False Lumen for Three Years

The management of chronic disseminated intravascular coagulation (DIC) caused by aortic dissection has not yet been established. Even in cases where surgical correction is performed, therapeutic control of systemic hemorrhaging is still required. We herein report the successful treatment of a case of aortic dissection with a patent false lumen using tranexamic acid for acute exacerbation of chronic DIC. Oral administration of 1,500 mg tranexamic acid per day stabilized the coagulative and fibrinolytic parameters and relieved bleeding tendencies with no side effects. Heparin was administered periodically for the management of hemodialysis. This favorable result continued for up to 3 years.

The dramatic 3D IVUS imaging demonstrating a dislodged coronary stent

A 78-year-old female underwent cardiac evaluation because she had presented with typical effort-induced chest pain. Coronary angiography revealed severe stenoses in the proximal left anterior descending coronary artery (LAD) and ostium of the diagonal branch. Then, a stent was deployed in the LAD covering the takeoff of the branch. Next, we tried to deploy an additional stent in the branch, but the new stent was stripped off the balloon platform. We demonstrate here the dramatic 3D intravascular ultrasound (IVUS) images of a dislodged stent, indicating that 3D IVUS imaging should allow the precise location and statement of lost stent.

Suppression of Ventricular Tachycardia Associated with Cardiac Sarcoidosis by Steroid Therapy

In patients with cardiac sarcoidosis, ventricular tachycardia (VT) is observed in some cases. However, effective therapies for the VT are still unknown.