Shiro Yanagi

Cardioprotective effect of the angiotensin II type 1 receptor antagonist TCV-116 on ischemia-reperfusion injury

We investigated the protective effect of angiotensin II (Ang II) type 1 receptor antagonist on myocardial ischemia-reperfusion injury and the role of exogenous Ang II to this injury in perfused hearts. We orally administered TCV-116 (Ang II type 1 receptor antagonist) and delapril (angiotensin converting enzyme inhibitor) to Wistar rats for 1 week and measured the immunoreactive cardiac Ang II. Immunoreactive cardiac Ang II (pg/gm tissue) was 14.3 +/- 2.0 in control group, 11.8 +/- 0.8 in TCV-116-treated group, and 7.3 +/- 0.6 in delapril-treated group (p < 0.05 compared to TCV-116-treated group; p < 0.01 compared to control group). The 15 hearts (five rats in each group) were perfused by a langendorff method and global ischemia was maintained for 30 min. Both TCV-116 and delapril were found to improve postischemic cardiac function and decrease reperfusion creatine kinase (CK) release. Ang II injection before ischemia worsened postischemic cardiac function and increased reperfusion CK release. Only TCV-116 prevented this injury. These data indicated that TCV-116 Ang II type 1 receptor antagonist was effective against myocardial ischemia-reperfusion injury, and exogenous Ang II accelerated this injury through Ang II type 1 receptor.

Circulating immunoreactive endothelin in patients undergoing percutaneous transluminal coronary angioplasty

Circulating immunoreactive endothelin (ir-ET) in the coronary sinus (CS) and the femoral artery (Ao) was measured in patients who underwent percutaneous transluminal coronary angioplasty (PTCA). Plasma ir-ET level in the CS was significantly increased from 1.6 +/- 0.8 pg/mL to 2.0 +/- 1.0 pg/mL after PTCA (P less than .05). Plasma ir-ET level in the Ao tended to increase after PTCA, but it was not significant. Plasma ir-ET level in the CS was not related to the plasma thromboglobulin level, plasma thrombin-antithrombin complex level, mean blood pressure, or heart rate. These results suggest that the increase of plasma ir-ET level in the CS may be associated with the coronary endothelial injury by PTCA.

A Prospective, Multicenter, Randomized Trial to Assess Efficacy of Pioglitazone on In-Stent Neointimal Suppression in Type 2 Diabetes : POPPS (Prevention of In-Stent Neointimal Proliferation by Pioglitazone Study)

OBJECTIVES The aim of this study was to clarify whether pioglitazone suppresses in-stent neointimal proliferation and reduces restenosis and target lesion revascularization (TLR) after percutaneous coronary intervention (PCI). BACKGROUND Previous single-center studies have demonstrated the anti-restenotic effect of a peroxisome proliferator-activated receptor gamma agonist, pioglitazone, after PCI. METHODS A total of 97 patients with type 2 diabetes mellitus (T2DM) undergoing PCI (bare-metal stents only) were enrolled. After PCI, patients were randomly assigned to either the pioglitazone group (n = 48) or the control group (n = 49). Angiographical and intravascular ultrasound (IVUS) imaging were performed at baseline and repeated at 6-month follow-up. Primary end points included angiographical restenosis and TLR at 6 months follow-up. Secondary end point was in-stent neointimal volume by IVUS. RESULTS Baseline glucose level and glycosylated hemoglobin (HbA1c) level were similar between the pioglitazone group and the control group. Angiographical restenosis rate was 17% in the pioglitazone group and 35% in control group (p = 0.06). The TLR was significantly lower in pioglitazone group than in control group (12.5% vs. 29.8%, p = 0.04). By IVUS (n = 56), in-stent neointimal volume at 6 months showed a trend toward smaller in the pioglitazone group than in the control group (48.0 +/- 30.2 mm(3) vs. 62.7 +/- 29.0 mm(3), p = 0.07). Neointimal index (neointimal volume/stent volume x 100) was significantly smaller in the pioglitazone group than in the control group (31.1 +/- 14.3% vs. 40.5 +/- 12.9%, p = 0.01). CONCLUSIONS Pioglitazone treatment might suppress in-stent neointimal proliferation and reduce incidence of TLR after PCI in patients with T2DM.

Prognostic value of Doppler transmitral flow patterns and cardiac natriuretic peptides in patients with chronic congestive heart failure admitted for episodes of acute decompensation

Abstract This study was designed to determine whether the restrictive filling transmitral flow velocity pattern is associated with increased plasma levels of atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP). It was also designed to evaluate the prognostic value of these parameters from patients with chronic congestive heart failure (CHF) admitted for episodes of acute decompensation. We performed Doppler echocardiography, measured plasma levels of ANP and BNP in 33 patients at the time of admission, and assessed the subsequent cardiac mortality for 3 months. Eleven patients (33%) had a restrictive filling pattern of deceleration time (DcT) <120 ms. Plasma ANP and BNP levels were markedly increased in all patients to 189 ± 145 pg/ml and 865 ± 559 pg/ml, respectively. Seventeen patients (52%) showed more than 700 pg/ml of plasma levels of BNP. There was a significant correlation of DcT with the plasma ANP level (r = −0.41, P = 0.017), and a better correlation of DcT with the plasma BNP level (r = −0.50, P = 0.003). The combined index of both shorter DcT (<120 ms) and higher plasma BNP levels (>700 pg/ml) was the best predictor of cardiac mortality by Cox univariate analysis (χ2 = 5.87, P = 0.015). Furthermore, the sensitivity and specificity of this index for the detection of cardiac mortality were 80% and 86%, respectively. In conclusion, the combined analysis of the Doppler transmitral flow velocity pattern and measurement of the plasma BNP level is noteworthy since it is noninvasive and convenient. Moreover, it is extremely useful in predicting the prognosis for patients with chronic CHF admitted for episodes of acute decompensation.

Coronary flow reserve correlates left ventricular diastolic dysfunction in patients with dilated cardiomyopathy.

The relationship between altered coronary circulation and left ventricular (LV) function in dilated cardiomyopathy (DCM) remains unclear. We used the Doppler guidewire and transthoracic echo Doppler in 24 DCM patients to investigate the relationship between coronary flow reserve (CFR) and LV systolic/diastolic function, trying to predict diastolic dysfunction and evaluate DCM severity with CFR. CFR correlated better with the deceleration time (DT) of the E‐wave and the ratio of E‐wave peak value to that of the A‐wave (E/A) than with LV ejection fraction (EF). The optimal CFR cutoff value for predicting the restrictive pattern of transmitral flow velocity (DT = 120 msec) was 2.6 (sensitivity 91%, specificity 100%). Dividing patients into two groups around the CFR = 2.6 cutoff, differences in DT and E/A between groups were more prominent than those for EF. CFR correlates better with LV diastolic than systolic function and may be useful for predicting diastolic dysfunction in DCM patients. Cathet Cardiovasc Intervent 2003;58:43–50.

Parathyroid hormone and systolic blood pressure accelerate the progression of aortic valve stenosis in chronic hemodialysis patients

BACKGROUND Aortic valve stenosis (AS) is a frequent complication contributing to poor prognosis in chronic hemodialysis (CHD) patients. However, little is known regarding the risk factors affecting AS progression. The purpose of this study was to define risk factors affecting AS progression in CHD patients. METHODS We retrospectively investigated 34 consecutive CHD patients with asymptomatic AS (mild in 9, moderate in 20, severe in 5; aortic valve area (AVA), 1.31±0.31cm(2); mean age, 69±8years) who underwent followed-up paired transthoracic echocardiography with period of at least six months apart (22±9months). AS progression was evaluated using the absolute reduction in AVA per year. RESULTS CHD patients were divided into 20 patients with rapid progression (AVA reduction, >0.1cm(2) per year) and 14 with slow progression (AVA reduction, ≤ 0.1cm(2) per year). Serum parathyroid hormone (PTH) level was significantly higher in patients with rapid progression than in those with slow progression [343±489pg/ml vs. 76±80pg/ml, P<0.05]. In univariate analysis, AS progression by absolute AVA reduction per year was associated with age, PTH level, initial AVA, systolic blood pressure (SBP), diastolic blood pressure, total cholesterol, and left ventricular diameter at end-diastole and end-systole. Multiple regression analysis indicated that serum PTH level and SBP remained independently associated with AS progression. CONCLUSIONS AS progression was accelerated in the presence of high PTH and SBP. Careful monitoring and intensive treatment of these parameters may have a beneficial effect on secondary prevention in CHD patients.

Left ventricular–right atrial communication by perforation of the atrioventricular portion of the membranous septum and severe aortic valve regurgitation caused by infective endocarditis

We report the case of acquired left ventricle (LV) to right atrial (RA) communication through an aneurysm of the atrioventricular septum caused by infectious endocarditis. A severe aortic valve regurgitation and destruction of the aortic valve was detected by echocardiography. Transesophageal echocardiography revealed a flail aortic valve with vegetation and abnormal shunt flow from the LV to RA with ruptured aneurysm of the membranous septum. An abscess cavity of the aortic ring was introduced. Because of worsening congestive heart failure, the patient underwent emergency aortic valve replacement and patch closure of the communication of the membranous septum. The patient’s postoperative course was uneventful.

Cor triatriatum dexter with atrial septal defect evaluated by real-time three-dimensional transesophageal echocardiography.

An 82-year-old woman presented with palpitation chest oppression and exertional dyspnea. Medical history included systemic hypertension treated by a nearby clinic. On admission, chest X-ray revealed increased cardiothoracic ratio of 64 % and vascular congestion. ECG showed atrial fibrillation with about 92 bpm. On examination, she had blood pressure of 164/66 mmHg and oxygen saturation of 96 % on room air. At physical examination, a soft systolic murmur was present on 4LSB (Levine 3/6) and pitting edema at lower extremities. Laboratory investigation showed elevated BNP (791 pg/ml). Transthoracic echocardiography (TTE) demonstrated the dilated right heart with volume overload and left ventricular function was normal. The morphology of the tricuspid valve (TV) looked normal but systolic pressure gradient over the TV was 46 mmHg. The size of the inferior vena cava (IVC) was 22 mm. TTE revealed a large band in the right atrium (RA) dividing into two chambers (Fig. 1a, b). However, Doppler analysis revealed no gradient between the two chambers and, accordingly, absence of obstruction in the RA. TTE showed a secundum atrial septal defect (ASD) with left-to-right shunt by color-flow imaging and pulmonary to systemic flow ratio was estimated to be about 1.8 (Fig. 1a). An anomalous membrane in the RA is shown with cardiac CT. These findings were compatible with persistence of valve of sinus venosus [1, 2]. To confirm the diagnosis and to image the front view of the membrane, real-time 3D-TEE was performed with iE33 (Philips Ltd., Netherlands) and analyzed online and offline. The 3D image was displayed as a volumetric data set and with the ability to manipulate the direction of the view and two-dimensional (2D) images of any section. 3D-TEE showed a large hole in the center of the membrane (32 9 27 mm) allowing communication between the two chambers of the RA (Fig. 1c, d) [3]. During the procedure, a contrast study using agitated saline injected from the left brachial vein (Fig. 2a) revealed partitioning of the RA into two chambers by the membrane. IVC flow was not obstructed, but restricted. The patient was diagnosed as having cor triatriatum dexter and successfully treated with diuretics, vasodilator, and antiplatelet medicine. She was discharged without surgical treatment.

Pheochromocytoma Multisystem Crisis Behaving Like Interstitial Pneumonia: An Autopsy Case.

Pheochromocytoma multisystem crisis is a rare and life-threatening disease that is associated with numerous symptoms and which is also difficult to diagnose. We herein report an autopsy case of a 61-year-old man who died due to pheochromocytoma multisystem crisis. The patient complained of vomiting and breathlessness. Computed tomography showed a shadow-like region with a similar appearance to interstitial pneumonia. The patient was diagnosed with takotsubo cardiomyopathy induced by severe lung disease based on the results of echocardiography and coronary angiography. The patient was treated for interstitial pneumonia. However, his condition rapidly deteriorated and he died 6 hours after arrival. We were later informed of his extremely high catecholamine serum levels. We found pheochromocytoma with hemorrhage at autopsy. The patients lungs showed acute passive congestion with edema and extravasation.

Usefulness of noninvasive assessment of coronary flow reserve using contrast enhanced transthoracic color doppler echocardiography for detecting left anterior descending stenosis with comparison of stress thallium-201 single-photon emission computed tomography

1117-39 Usefulness of Noninvasive Assessment of Coronary Flow Reserve Using Contrast Enhanced Transthoracic Color Doppler Echocardiography for Detecting Left Anterior Descending Stenosis With Comparison of Stress Thallium-201 Single-Photon Emission Computed Tomography 1117-41 Coronary Flow Velocity Reserve Using Transthoracic Color Doppler Echocardiography Is Influenced by Serum High-Density Lipoprotein and Low-Density Lipoprotein Cholesterol Level in Patients With Hyperlipidemia