Norio Higuma

Additional ST-segment elevation immediately after reperfusion and its effect on myocardial salvage in anterior wall acute myocardial infarction

Rapid resolution of ST-segment elevation is a reperfusion-associated electrocardiographic change in acute myocardial infarction. However, some patients have additional ST-segment elevation immediately after reperfusion before such resolution. The clinical significance and the effect on myocardial salvage of this electrocardiographic change are unknown. To examine this electrocardiographic feature and determine its clinical basis for occurrence and influence on left ventricular function, 58 consecutive patients with a first anterior wall acute myocardial infarction who had intracoronary thrombolysis or coronary angioplasty, or both, were assessed. With the use of frequent electrocardiographic procedures during reperfusion therapy, patients were divided in 2 groups: those with additional ST-segment elevation (n = 35; group A, > or = 0.5 mV increase in summed ST-segment elevation in lead V1-V6 within 15 minutes after reperfusion), and those without this phenomenon (n = 23; group B). Baseline characteristics, creatine kinase kinetics and left ventricular function were compared between both groups. Before reperfusion, group A had a greater summed ST-segment elevation (2.44 +/- 1.07 vs 1.57 +/- 0.98 mV; p = 0.003) and poorer collaterals (p = 0.001) than did group B. Peak creatine kinase was significantly higher in group A than in B (6,550 +/- 3,477 vs 4,310 +/- 1,880 IU/liter; p = 0.003). Group A had less improvement in ejection fraction (-4.2 +/- 9.9% vs 1.7 +/- 9.6%; p = 0.04) and regional wall motion (0.28 +/- 0.74 vs 0.76 +/- 0.79 SD/chord; p = 0.03) than did group B. It is thought that additional ST-segment elevation immediately after reperfusion occurred in myocardium with severe ischemic damage before reperfusion.(ABSTRACT TRUNCATED AT 250 WORDS)

Guidewire-induced coronary artery perforation treated with transcatheter delivery of subcutaneous tissue.

In three cases of small coronary artery perforation by guidewires during percutaneous coronary intervention, coronary leakage continued despite prolonged balloon inflation and reversal of heparin. Subcutaneous tissue was selectively delivered to perforated vessels by means of microcatheters in a successful attempt to stop leakage. This method appears to be extremely effective for treating guidewire‐induced perforations of distal coronary arteries.

Immediate effects of percutaneous transvenous mitral commissurotomy on pulmonary hemodynamics at rest and during exercise in mitral stenosis

Hemodynamics were evaluated during exercise in 33 patients with mitral stenosis who underwent percutaneous transvenous mitral commissurotomy (PTMC). PTMC was performed using an Inoue balloon. Each patient underwent a supine ergometer exercise test before and on the day after PTMC. Ergometer work load was started at 20 W and increased in increments of 20 W at 3-minute intervals until terminated by the patients fatigue or shortness of breath. Mitral valve area increased by 0.8 +/- 0.4 cm2 (1.1 +/- 0.3 to 1.9 +/- 0.4 cm2, p less than 0.001). Mean mitral pressure gradient decreased (12 +/- 5 to 6 +/- 2 mm Hg, p less than 0.001). Pulmonary arterial pressure significantly decreased and the cardiac index significantly increased both at rest and during exercise after PTMC. Before PTMC, the increases in pulmonary arterial pressure, total pulmonary resistance and pulmonary arteriolar resistance during exercise were greater in patients with a mitral valve area less than 1.0 cm2 than in patients with an area greater than or equal to 1.0 cm2. After PTMC, total pulmonary resistance still increased during exercise. However, pulmonary arteriolar resistance did not change during exercise in patients with a mitral valve area greater than or equal to 1.5 cm2, whereas it increased in patients with an area less than 1.5 cm2. An enlarged mitral valve area greater than or equal to 1.5 cm2, which may prevent pulmonary vasoconstriction and permits a greater increase in pulmonary blood flow during exercise, is considered a good result immediately after PTMC.

Obstinate thrombosis during percutaneous coronary intervention in a case with heparin-induced thrombocytopenia with thrombosis syndrome successfully treated by argatroban anticoagulant therapy

We describe a case of massive coronary thrombus after the coronary stenting due to heparin‐induced thrombocytopenia with thrombosis syndrome (HITTS). Only argatroban was able to resolve the thrombus. This is the first case in which argatroban successfully treated massive thrombus during percutaneous coronary intervention in a patient with HITTS. Cathet Cardiovasc Intervent 2003;59:351–354.

Exercise Induced Atrioventricular Block with Gap Phenomenon in Atrioventricular Conduction

A 54‐year‐old man with normal atrioventricuiar (AV) conduction at rest gave a 4‐year history of presyncope during exercise. Treadmill testing showed exercise induced AV block. Electrophysiological study demonstrated rate dependent infranodal AV block and abnormal refractory period of the His‐Purkinje system. The gap phenomenon in AV conduction occurred during the programmed stimulation. Supernormal conduction could be considered as the mechanism of the gap phenomenon in this patient.

Splenic Abscess in a Patient on Hemodialysis

Takamichi Nakamura, MD, The Second Department of Medicine, Yamanashi Medical School, Yamanashi 409-38 (Japan) Dear Sir, A splenic abscess is an unusual condition seen in immunocompromized patients or associated with intravenous drug abuse [1]. Several conditions including trauma, immunodeficiency, corticosteroid and/or immunosuppressive therapy and diabetes mellitus have been listed under the predisposing factors for a splenic abscess [1]. Splenic abscesses have not been reported in hemodialysis patients without any of these predisposing factors reported previously [1], although 2 hemodialysis patients with diabetes mellitus or immunosuppressive therapy were reported to develop splenic abscesses acquired through access site infection [2]. A 36-year-old man who had been on hemodialysis for 3 years was admitted with left hypochondralgia and fever. There was no history of trauma, blood access site infection, diabetes mellitus or immunosuppressive therapy. Nine years previously, he had had hematuria, proteinuria and hypertension. Renal biopsy confirmed mesangial proliferative glomerulonephritis. Over the next 6 years, he progressed to end-stage renal failure. After 3 years of maintenance hemodialysis, he had general fatigue and fever. He was treated with antibiotics (MINO, ENX, CXD, CEZ), since leukocytosis was found at the hemodialysis clinic. The symptoms did not respond to these antibiotics, and he was transferred to the renal unit in our hospital. On examination, there was tenderness in the left hypochondrium. There was no sign of hepatomegaly or ascites. There was no infected needle site related with A-V fistula. The white blood cell count was 26,300/mm3 with a severe left shift. Hb was 9.3 g/dl. ESR was 117/161 mm. CRP was 6 + . S-GOT, S-GPT, AI-P and LDH were normal. Chest X ray was normal. An ultrasound scan showed multiple hypoechoic lesions in the spleen (fig. la), and normal findings in liver, gallbladder and kidney. A computed tomography also showed multiple nonenhanced low density lesions in spleen (fig. lb), and normal findings in other intra-abdominal organs. No organism was grown from the blood. As shown in figure 2, he was treated with latamoxef (LMOX) for 8 days sequentially, and the fever resolved. Subsequently, he was treated with LMOX only after hemodialysis. An ultrasound scan examination revealed that the splenic abscess was getting smaller and finally resolved on the 30th hospital day. Antibiotic therapy was stopped when the ultrasound scan examination and

Assessment of a coronary artery fistula to the pulmonary artery by transesophageal echocardiography

ninen E, LInsimies E, Uusitupa M. Noninvasive detection of cardiac sympathetic nervous dysfunction in diabetes using ‘%metaiodobenzylguanidine. Diabetes 1992;41:1069 75. Mustonen J, Mlntysaari M, Kuikka J, Vanninen E, Vainio P. LBnsimies E, Uusitupa M. Decreased myocardial lz31-metaiodobenzylguanidine uptake is associated with disturbed left ventricular diastolic filling in diabetes. Ah/l HEART J 1992;123:804-5. Murakawa Y, Inoue H, Nozaki A, Sugimoto T. Role of sympathovagal interaction in diurnal variation of QT interval. Am J Cardiol 1992;69:339-43.

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.

Efficacy of Marker Wire for intracoronary stenting

The Marker Wire was used for Palmaz-Schatz coronary stent implantation. The Marker Wire is useful in estimating lesion length and in determining the number of stents required, in addition to facilitating stent positioning.