Rie Aoyama

Two Case Reports of Group B Streptococcal Infective Endocarditis Complicated by Embolism.

Streptococcus agalactiae (Group B streptococcus, GBS) is the major pathogen encountered in the perinatal period, although the incidence of GBS infection has recently increased among non-pregnant adults. Nevertheless, GBS infective endocarditis (IE) is uncommon and often accompanies aortic embolism. We experienced two cases of GBS IE. In Case 1, mobile vegetation of the aortic valve caused an infective cerebral aneurysm. In Case 2, the patient experienced an acute aortic embolic episode. Generally, early surgery for large mobile sites of vegetation is recommended as a class IIb therapy in the guidelines. GBS IE often exhibits a severe clinical course and specificity of vegetation. Therefore, early surgery should be considered in such cases.

Evaluation of myocardial glucose metabolism in hypertrophic cardiomyopathy using 18F-fluorodeoxyglucose positron emission tomography

Background The purposes of this study were to assess the usefulness of myocardial 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography (PET)/computed tomography (CT) for evaluating myocardial metabolic status in hypertrophic cardiomyopathy (HCM) and the therapeutic efficacy of alcohol septal ablation (ASA) in hypertrophic obstructive cardiomyopathy (HOCM). Methods Thirty HCM patients (64.4±10.5 years, 14 male, 12 hypertrophic non-obstructive cardiomyopathy [HNCM], 16 HOCM, and 2 dilated phase of HCM) underwent 18F-FDG-PET/CT. 18F-FDG uptake was semi-quantitatively evaluated using an uptake score in each 17 segment and the entire LV or regional standardized uptake value (SUV). Results 18F-FDG uptake was observed mostly in a hypertrophied myocardium in HNCM patients, whereas 18F-FDG was extensively accumulated beyond the hypertrophied myocardium in HOCM patients. There was a positive correlation between the summed uptake score of 18F-FDG and high-sensitive troponin T level in HNCM patients (r = 0.603, p = 0.049), whereas the score was positively correlated with brain natriuretic peptide level (r = 0.614, p = 0.011) in HOCM patients. In 10 patients who received ASA, the maximum SUV of the entire LV was significantly reduced from 5.6±2.6 to 3.2±2.1 (p = 0.040) after ASA. Reduction of that maximum SUV was particularly significant in the lateral region (from 5.5±2.6 to 2.9 ±2.2, p = 0.024) but not significant in the anteroseptal region (from 4.5±2.6 to 2.9±1.6, p = 0.12). Conclusion Extensive 18F-FDG uptake beyond the hypertrophied myocardium was observed in HOCM. ASA attenuates 18F-FDG uptake in a remote lateral myocardium.

The impact of blood pressure variability on coronary plaque vulnerability in stable angina: an analysis using optical coherence tomography

Background Blood pressure variability (BPV), especially visit-to-visit BPV, has been reported to be a risk factor for cardiovascular disease. The impact of BPV on coronary plaque vulnerability remains uncertain. The aim of this study was to investigate the relationship between BPV and coronary plaque vulnerability. Patients and methods From August 2013 to May 2014, 36 patients with both hypertension and stable angina pectoris who underwent a percutaneous coronary intervention guided by frequency-domain optical coherence tomography were investigated retrospectively. The size of the lipid cores and the thickness of the fibrous cap covering the lipid core were measured by frequency-domain optical coherence tomography, and we calculated the blood pressure coefficient of variation (CV) and SD as intraindividual visit-to-visit BPV. Results Both SD and CV of systolic blood pressure (SBP) correlated positively with lipid arc (SBP-SD: r=0.68, P<0.01; SBP-CV: r=0.64, P<0.01) as well as average SBP (r=0.48, P<0.01). Fibrous cap thickness did not correlate with blood pressure variables or BPV. Conclusion BPV is related to coronary plaque volume, but not to coronary plaque vulnerability. In addition to conventional coronary risk factors, BPV may be a therapeutic target for coronary atherosclerosis.

EVALUATION OF MYOCARDIAL GLUCOSE METABOLISM IN HYPERTROPHIC CARDIOMYOPATHY BY 18F-FLUORODEOXYGLUCOSE POSITRON EMISSION TOMOGRAPHY: IMPACT OF ALCOHOL SEPTAL ABLATION THERAPY

The significance of myocardial 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET)/computed tomography (CT) has not yet been determined in hypertrophic cardiomyopathy (HCM). Twenty-two HCM patients (61±11 years, 11 male) underwent FDG-PET/CT. We divided them into 2 groups according to

Transcatheter aortic valve implantation using Evolut R in quadricuspid aortic valve with severe stenosis and regurgitation

Transcatheter aortic valve implantation (TAVI) for aortic stenosis (AS) is widely spread but is controversial in bicuspid or quadricuspid aortic valve (QAV) because of calcification or raphes which may affect on device expansion [1]. We report TAVI for QAV with severe AS and aortic valve regurgitation (AR). An 83-year-old man was repeatedly hospitalized because of heart failure due to severe ASR. He had reduced left ventricular function due to coronary artery disease and rejected surgery. Echocardiogram showed that peak aortic velocity was 4.68 m/s and aortic valve area was 0.82 cm2 with severe AR (Fig. 1a). Cardiac computed tomography (CT) showed QAV of three equal cusps and one small cusp regarded as type B by the Hurwitz’s classification [2]. The accessory cusp was situated between right and non-coronary cusp (Fig. 1b). The longitudinal CT showed strong calcification of left coronary cusp (LCC) protruding to left ventricular outflow tract (Fig. 1c), so self-expandable valve is appropriate rather than the balloon-expandable one for fear of annulus rupture. The annular perimeter and its area was 79.1 mm and 483.7 mm2, so we selected 29 mm Evolut R. Coronary height was 11.8 mm in left coronary artery and 16.1 mm in right one, so we did not do coronary protection. The vascular diameters of femoral access sites were about 7 mm, so we could insert 18French sheath. Balloon valvuloplasty (BAV) using 20 mm balloon was done as preparation (Fig. 1d) and LCC was sufficiently spread. Then, Evolut R was deployed in the supra-annular position so that its distal end was put on the edge of the calcification of LCC (Fig. 1e). The mean pressure gradient decreased from 51.5 to 3.0 mmHg and diastolic blood pressure increased from 35 to 51 mmHg (Fig. 1f). There was trivial paravalvular leak after procedure (Fig. 1g). BAV made them possible to grasp how expandable calcified cusps are, to crimp Evolut R to the annulus properly and to minimize paravalvular leak. In TAVI for QAV, although insufficient valve expansion or paravalvular leak may be expected, it made possible to perform sufficient treatment in the proper preparation. TAVI could be a viable option for severe ASR of QAV.

Tuberculous pericarditis treated with steroid in a dialysis patient

Mycobacterium tuberculosis has spread worldwide and its mortality rate had been very high. The prevention technology and antituberculosis (TB) chemotherapy has improved its prognosis. However, immunocompromised patients, such as those who had HIV infection, older age and on haemodialysis, are still at high risk of TB infection. TB pericarditis is a common cause of constrictive pericarditis and its mortality remains high. Early diagnosis and initiation of appropriate therapy are critical to improve mortality. Additionally, detection of an elevation in the adenosine deaminase level in pericardial effusion is reported to be useful. We report the case of an immunocompromised patient with TB pericarditis, and steroid therapy could prevent him from progressing to constrictive pericarditis. The adenosine deaminase value of pericardial effusion was so helpful that we could promptly make clinical and therapeutic decisions.

Impact of age on left ventricular geometry and diastolic function in elderly patients with treated hypertension

Abstract Purpose: Left ventricular (LV) remodelling is observed in numerous patients with hypertension and is a principal cause of heart failure in elderly patients. The aim of this study was to determine the relationships between age and structural/functional LV remodelling observed in elderly hypertensive patients. Methods: A total of 557 elderly hypertensive patients (mean age: 74.0 ± 8.6 years) with preserved LV systolic function underwent echocardiography and 24-hour blood pressure (BP) measurement. Results: Overall, 41.1% of patients had LV hypertrophy, 77.9% had increased relative wall thickness (RWT) defined as RWT >0.42, and 31.8% had both. Logistic analysis of the entire study population showed that increased RWT was associated with both 24-hour systolic BP (odds ratio (OR) 1.38, 95% confidence interval (CI) 1.12 to 1.70) and age (OR 1.32, 95%CI 1.08 to 1.61), whereas increased RWT was associated only with age (OR 1.61, 95%CI 1.23 to 2.11) after excluding patients with LV hypertrophy. Univariate and multivariate linear regression analyses of all patients showed that LV diastolic echocardiographic parameters were consistently associated with age (p ≤ .001) alone, even considering LV structural changes. Conclusions: Age was independently correlated with LV concentric/functional changes regardless of LV hypertrophy, suggesting that ageing is independently involved in the progression of LV remodelling.

114 GRADE I HYPERTENSION IS ASSOCIATED WITH MYOCARDIAL INFARCTION, WHILE KIDNEY SIZE IS ASSOCIATED WITH CEREBRAL INFARCTION IN THE VERY ELDERLY PATIENTS; ANALYSIS FROM 3100 CONSECUTIVE AUTOPSY CASES

Purpose: Even after HYVET showed efficacy of antihypertensive treatment in octogenarians, target blood pressure (BP) remains to be examined. Methods: We studied 3100 autopsy cases (1589 men, median 81yrs) at a general geriatric hospital. We related BP to myocardial (MI) and cerebral infarction (CI). Results: Averaged BPs were 141±1/80±0mmHg. 21% of the cases had MI and 66% had CI. Ages of death, systolic BP, heart weight, and kidney weight were related to MI and CI. In logistic regression analysis, the hazard of MI after adjustment for age and sex was 1.67 (95%CI, 1.24 to 2.26, *p<0.001) for the highest (>156mmHg) versus the lowest systolic BP quartile (<119mmHg), and 1.53 (95%CI, 1.13 to 2.07; p=0.005) for the second highest (140–155mmHg) versus the lowest quartile. Among those who deceased >81 years old, the hazard of MI was 1.48 (95%CI, 0.97 to 2.27, p=0.07) for the highest quartile, and 1.59 (95%CI, 1.04 to 2.43, p<0.05) for the second highest quartile. In contrast, the hazard of CI was 2.42 (95%CI, 1.78 to 3.29*) for the highest versus the lowest BP quartile, and 1.69 (95%CI, 1.26 to 2.26*) for the second highest versus the lowest quartile. In octogenarians, CI was not significantly associated with systolic BP, while the hazard was 1.76 (95%CI, 1.22 to 2.55, p=0.003) for the lowest versus the highest tertile of kidney weight. Conclusion: Grade I hypertension was associated with MI and CI in the elderly. In octogenarians, grade I hypertension was associated with MI, while kidney atrophy was associated with CI.