Shioto Yasuda

Case of paroxysmal atrial fibrillation improved after the administration of proton pump inhibitor for associated reflux esophagitis.

A 64-year-old man had demonstrated palpitations caused by paroxysmal atrial fibrillation (AF) documented by ambulatory electrocardiographic monitoring. Effectiveness of antiarrhythmic agent (disopyramide: 300 mg/day) was limited. Based on the gastrointestinal endoscopic findings, proton pump inhibitor (PPI: rabeprazole, 10 mg/day) was administered to eliminate heart burn due to reflux esophagitis. Symptoms of paroxysmal AF and reflux esophagitis were confusing due to the anatomical proximity of the diseased organs and concomitant occurrence in the evening and when in a supine position. After the additional PPI therapy, not only was reflux esophagitis improved subjectively and endoscopically but also paroxysms of AF markedly reduced. Because esophagus is attached to left atrial posterior wall and the role of inflammatory process on the development of AF is highlighted, amelioration of reflux esophagitis by PPI may have been followed by the remarkable reduction of paroxysms of AF.

Relationship between amiodarone-induced subclinical lung toxicity and Th1/Th2 balance

BACKGROUND Although amiodarone is a potent antiarrhythmic agent, its clinical use is limited by serious lung toxicity. This study investigated the mechanisms of amiodarone-induced lung toxicity from an immunological perspective. Because interferon gamma (IFN-gamma: Th1 cytokine) inhibits pulmonary fibroblast proliferation whereas interleukin-4 (IL-4: Th2 cytokine) augments fibroblast growth and collagen production, we hypothesized that amiodarone lung toxicity is related to Th1/Th2 balance. METHODS Twenty-six consecutive Japanese patients with ventricular arrhythmias treated with amiodarone were enrolled in this study and were divided into two groups. Group A contained patients demonstrating amiodarone lung toxicity diagnosed by chest X-ray, KL-6 or D(LCO) (n=6), whereas group B included patients treated without any adverse effects (n=20). Th1/Th2 balance was investigated by the ratio of IFN-gamma and IL-4 produced by activated peripheral CD4(+) T cells. RESULTS Clinical baseline characteristics prior to oral amiodarone did not show any differences between group A and group B except for D(LCO) (82.0+/-5.2% vs. 90.8+/-9.0%, p=0.032) and Th1/Th2 balance (7.98+/-1.68 vs. 13.34+/-5.10, p=0.020). This balance was not altered three months after withdrawal of amiodarone in group A and under continued treatment in group B, suggesting patient-specific rather than amiodarone-induced. After starting amiodarone, serum concentration of desethylamiodarone was greater in group A than in group B (p=0.009) and was inversely proportional to Th1/Th2 ratio (p=0.013). Multilogistic regression analysis indicated that Th1/Th2 balance was the most powerful indicator of amiodarone lung toxicity (p=0.046, odds ratio of 0.424). CONCLUSIONS Although large cohort is required, the present study indicates that Th1/Th2 balance may influence amiodarone metabolism and may be a powerful indicator of amiodarone-induced subclinical lung toxicity at least in Japanese.

Influence of common cardiac drugs on gastroesophageal reflux disease: Multicenter questionnaire survey

BACKGROUND Although gastroesophageal reflux disease (GERD) causes noncardiac chest pain mimicking angina pectoris, systemic studies surveying the effects of common cardiac drugs on symptomatic GERD are rare. METHODS To investigate the drugrelated GERD, this multicenter trial enrolled 201 consecutive cardiac outpatients (69.7 ± 10.5 y) after obtaining written informed consent. They were assessed using the Frequency Scale for Symptoms of GERD (F-scale) to screen for GERD with a cut-off value of 8.0. Clinical background was obtained from medical records. Gastric medicine was empirically administered at the discretion of the attending physician. F-scale score and incidence of GERD were analyzed individually in relation to background and prescription. RESULTS The average F-scale score did not correlate with gender, age or underlying diseases. F-scale score was elevated significantly (p = 0.006) by administration of calcium channel blockers to the patients treated with gastric medicine, suggesting that calcium channel blockers exacerbate the possibly preexisting GERD. Incidence of GERD within 2 months after starting warfarin tended to be greater than that at other durations (p = 0.087). Patients showing a high score (≥ 8.0) suggestive of GERD showed a correlation with the combined administration of calcium channel blockers (OR = 3.19; 95% CI of 1.01 - 10.11; p = 0.049) and warfarin (OR = 3.05; 95% CI of 1.00 - 9.27; p = 0.049) in the best logistic model. CONCLUSION Although larger cohort is required, this survey demonstrates that the combination of calcium channel blockers and warfarin is an independent risk factor for GERD.

A family of hereditary long QT syndrome caused by Q738X HERG mutation

Abstract We report a family of type 2 long QT syndrome caused by a novel single nucleotide HERG mutation (c.C2212T, p.Q738X). A female complained of syncope and ECG showed long QT, flat T wave, lack of QT shortening during sinus tachycardia and subsequent Torsade de Pointes. After implantation of ICD, she has experienced no syncope. Her father exhibited advanced atrioventricular block and persistent atrial flutter, and her daughter showed long QT with broad-based, sharp T wave. A possible cause to show wide variety of ECG phenotypes under the same mutation in this family is discussed.

Open-loop, clockwise QT-RR hysteresis immediately before the onset of torsades de pointes in type 2 long QT syndrome

Delay of QT interval adaptation to sudden heart rate change causes hysteresis in dynamic QT-RR relationship. We analyzed QT-RR plotting during and after exercise in a patient with genetically identified type 2 long QT syndrome before and after starting oral propranolol. Blunted QT shortening by exercise and augmented postexercise QT prolongation resulted in an open-loop, clockwise QT-RR hysteresis immediately before the onset of torsades de pointes before propranolol. However, this hysteresis was eliminated by propranolol. QT-RR analysis provided insight into the mechanisms of the onset of torsades de pointes at least in this case of type 2 long QT syndrome.

Serum Polyunsaturated Fatty Acid Profile and Carotid Intima-media Thickness in Japanese Atherosclerotic Patients Hospitalized for Endovascular Therapy

Aims: Serum eicosapentaenoic acid (EPA) to arachidonic acid (AA) ratio (EPA/AA) in Japanese is rapidly changing according to the senescence and food westernization, and sonographic carotid artery intima-media thickness (IMT) is increasingly used as a surrogate of systemic atherosclerosis. However, the relationship between IMT and EPA/AA in Japanese remains unclear. Original Research Article

Successful Chemoradiotherapy for Undifferentiated Malignant Neoplasm Arising from the Left Pulmonary Artery

Undifferentiated malignant neoplasms, which occur primarily in the pulmonary artery, are extremely rare and associated with poor outcomes as there is no effective therapy. A 67-year-old woman visited our hospital with complaints of dry cough and dyspnea on exertion. A contrast-enhanced chest computed tomography revealed an intravascular tumor obstructing the left pulmonary artery and a pedunculated lesion extending to the main and right pulmonary artery. Multiple metastases in the lung, bones and bilateral adrenal glands were identified by fluorodeoxyglucose-positron emission tomography. A small sample was obtained by catheter aspiration biopsy of the intravascular tumor, and examination revealed undifferentiated small atypical cells. The tumor was diagnosed as an undifferentiated neoplasm arising from the pulmonary artery based on immunohistochemical findings, including the absence of expressions of organ-specific markers. Systemic chemotherapy (paclitaxel and carboplatin) and concurrent radiation were performed as treatment for the primary tumor. Marked shrinkage of the intravascular tumor was achieved, and no serious adverse events were observed during therapy. Chemotherapy was continued for 5 months, but the patient died because of tumor progression 9 months after the initial diagnosis. Chemoradiotherapy has efficacy against undifferentiated neoplasm of the pulmonary artery.

Pulmonary Venous Flow Pattern and Atrial Fibrillation: Fact and Controversy

The role of echocardiography in patients with atrial fibrillation (AF) has been changing gradually according with recent advance in echocardiographic instruments and better understanding for AF. Historically, M-mode echocardiography applied to AF patients has focused on the diagnosis of underlying organic heart diseases and on the detection of left atrial (LA) thrombi. These are not surprising because AF had been the highest risk of ischemic stroke in the era of incomplete anticoagulation therapy. Thereafter, LA size, volume and functions have been foci assessed by echocardiography. These echocardiographic procedures have been conducted for prediction and prevention of recurrence of AF paroxysms (Barbier et al, 1994; Verdecchia et al, 2003; Vasan et al, 2003). Spontaneous echo contrast has also been an established B-mode echocardiographic finding with highly predictive value of ischemic stroke. After the development of Doppler echocardiography, pulmonary venous flow (PVF) evaluation is a routine laboratory investigation for patients with and without AF. The usefulness of PVF evaluation is not limited to assess LA or left ventricular (LV) functions, but has expanded to investigation of various aspects of AF (Tabata et al., 2003). PVF recording increases its usefulness when it is combined with recordings of Doppler LV inflow pattern. This article reviews the established usefulness of PVF estimation in patients with permanent AF, and then focuses on the potential usefulness of PVF assessment in AF progression, i.e., during sinus rhythm (i.e., interval of paroxysms of AF), during ongoing paroxysmal AF, and further during the longterm AF management.

Case of atrial tachycardia originating from giant coronary sinus connected to persistent left superior vena cava: successful catheter ablation guided by noncontact mapping.

Radiofrequency (RF) catheter ablation is widely applied to tachyarrhythmia associated not only with structurally normal hearts but also with relatively mild cardiac anomalies. We present a case of 35 year-old female complaining of exercise-induced frequent palpitations caused by atrial tachycardia (AT) originating from giant coronary sinus (CS) connected to persistent left superior vena cava. AT was sensitive to intravenous ATP administration. Electrophysiological study partly using noncontact balloon of EnSite system clarified that two foci of AT were located at the orifice and the distal inner lumen of giant CS. After repetitive applications of RF energy to these origins, AT was not induced by drip infusion of isoproterenol. AT was not evoked by exercise without antiarrhythmic drugs 15 months after the RF ablation. This case indicates that RF ablation guided by noncontact mapping technique should be considered as a therapeutic regimen for AT associated with mild cardiac malformations.

Noncontact Mapping-Guided Catheter Ablation of Posterosuperior Right Atrial Tachycardia Associated with Sick Sinus Syndrome

Focal atrial tachycardia (AT) is sometimes associated with sick sinus syndrome. A 57‐year‐old female complained of palpitation, fatigue and presyncope. Ambulatory monitoring demonstrated frequent segments of AT and subsequent sinus arrests. P wave morphology of ectopic beats was similar to that of sinus rhythm. After obtaining diagnosis of bradycardia tachycardia syndrome, she underwent electrophysiologic study (EPS) and radiofrequency (RF) catheter ablation to eliminate AT.