Shu Inami

Left ventricular function in pulmonary hypertension

To elucidate left ventricular function in pulmonary hypertension, we measured parameters of left ventricular as well as right ventricular function by echocardiography in 11 patients with pulmonary hypertension (idiopathic pulmonary artery hypertension in 4, chronic thromboembolic pulmonary hypertension in 5, and other pulmonary hypertension in 2). The percent change in these parameters 6 months after treatment with pulmonary artery vasodilators (beraprost in 8 and sildenafil in 3) was assessed. There was a correlation between the relative change in right ventricular systolic pressure (RVSP) and the relative changes in left ventricular outflow tract velocity–time integral (r = −0.730, P = 0.011) and mitral valve velocity–time integral (r = −0.621, P = 0.041). However, there was no correlation between the relative change in RVSP and the relative changes in left ventricular ejection fraction, left ventricular diastolic dimension, and systolic blood pressure. The relative change in RVSP was also correlated with the relative change in early diastolic myocardial velocity at the medial mitral annulus (r = −0.675, P = 0.023). Reduction of RVSP by pulmonary artery vasodilators might increase left ventricular preload, leading to an increase in stroke volume. Right ventricular load reduction might improve left ventricular diastolic function in patients with pulmonary hypertension, possibly through altered interventricular septal performance.

Early Surgical Intervention and Optimal Medical Treatment for Candida parapsilosis Endocarditis

We herein report the case of a 72-year-old man with endocarditis of the aortic valve who underwent urgent aortic valve replacement 36 hours after admission due to an aggravation of aortic valve regurgitation. Postoperative cultures of the blood and site of valve vegetation identified Candida parapsilosis as a pathogen. Antifungal therapy with amphotericin B and fluconazole was initiated after surgical treatment. Thereafter, the patient displayed a favorable clinical course. Candida parapsilosis endocarditis involving the native valves is extremely rare and associated with a very high mortality rate. Prompt surgical treatment and the aggressive use of antifungal agents are required to save the patients life.

Choice of Antihypertensive Combination Therapy Based on Daily Salt Intake

Background:It is unclear whether thiazide diuretics (TZs) or calcium channel blockers (CCBs) are more effective as add-on therapy to angiotensin receptor blockers (ARBs) in controlling hypertension. Because TZs are a rational choice in salt-sensitive hypertension, patients with high salt intake might preferentially benefit from ARB/TZ over ARB/CCB combination therapy. Methods:Hypertensive patients who failed to reach blood pressure goals despite treatment with ARBs alone were randomly assigned to receive either ARB/TZ or ARB/CCB combination therapy. Estimated daily sodium intake was calculated from spot urine values of sodium and creatinine. Results:Blood pressure was measured at baseline, and at 4, 8 and 12 weeks after starting combination therapy. For all study patients (n = 87), diastolic blood pressure reduction was greater in patients receiving ARB/CCB treatment. However, in the 37 patients with a baseline estimated daily salt intake greater than 10 g and baseline systolic blood pressure (SBP) ranging from 150 to 200 mm Hg, SBP was lower (P < 0.05) and SBP reduction was greater (P < 0.05) 4 weeks after starting combination therapy in those receiving ARB/TZ treatment. In the 31 patients whose estimated daily salt intake increased at 12 weeks compared with baseline, SBP at 12 weeks was lower in those receiving ARB/TZ treatment (P < 0.05). Conclusions:Estimated daily salt intake is a useful tool for guiding antihypertensive therapy and should be measured repeatedly during the therapeutic course.

Hypopharyngeal perforation caused by intraoperative transesophageal echocardiography

Intraoperative transesophageal echocardiography (TEE) is an invaluable tool for cardiac surgical decision-making. TEE is considered reasonably noninvasive and safe, but insertion and manipulation of the TEE probe can lead to complications. Here, we report a patient with aortic stenosis who experienced TEE-associated hypopharyngeal perforation at the pyriform sinus complicated by esophageal trauma, pneumomediastinum and pneumoretroperitoneum. Based on this case, we suggest that rare complications be kept in mind when using TEE intraoperatively.

Cardiac paraganglioma with a novel germline mutation of succinate dehydrogenase gene D

A 58-year-old woman with a past medical history of a carotid body tumor, resected 4 months prior to presentation, was admitted to our hospital for treatment of a cardiac tumor that was identified on post-operative echocardiography and chest computed tomography. The cardiac tumor was surgically removed and identified pathologically as a paraganglioma, similarly to the carotid body tumor. Genetic analysis of both tumors identified a non-synonymous mutation in the succinate dehydrogenase (SDH) gene D, Exon4, c.320T>C, p.Leu107Pro showing co-segregation with paternal transmission and maternal imprinting among family members. This novel mutation appears to be the cause of familial paraganglioma in this patient.

Protective effects of bisoprolol against myocardial injury and pulmonary dysfunction in patients with chronic heart failure

OBJECTIVES This study was designed to elucidate differences in effects of 2 beta blockers, bisoprolol and carvedilol, in patients with chronic heart failure. BACKGROUND Although the beta blockers bisoprolol and carvedilol are commonly used in patients with chronic heart failure, differences in the efficacy and safety of these medications have not been established in this patient population. METHODS Patients with chronic systolic heart failure, defined as ≤45% ejection fraction, who had received intensive medical therapy with the exception of beta blockers, were randomly assigned to receive either bisoprolol or carvedilol for 24weeks. RESULTS A total of 67 patients were enrolled in the study (bisoprolol: 38 patients, carvedilol: 29 patients). No difference was observed in the improvement of NYHA class, ejection fraction, or N-terminal pro-brain-type natriuretic peptide level between groups. In contrast, the level of high sensitivity troponin T decreased in the bisoprolol group [-4.1±0.9 to -4.5±0.8 log (ng/ml), P=0.003], but did not change in the carvedilol group [-4.4±1.1 to -4.6±0.8 log (ng/ml), P=0.161]. Forced expiratory volume in the first second increased in the bisoprolol group [2.26±0.70 to 2.40±0.70 (L), P=0.014], but did not change in the carvedilol group [2.53±0.71 to 2.59±0.78 (L), P=0.127]. CONCLUSION Bisoprolol might be superior to carvedilol in providing protection from myocardial injury and preserving pulmonary function in patients with chronic systolic heart failure.

Radiation-Induced Coronary Artery Disease Manifested at Very Late Phase

We report the case of a 51-year-old female, in whom coronary artery disease such as occlusion of septal perforators was manifested, on the occasion of hospitalization with congestive heart failure. The patient had a history of radiation therapy for a mediastinal tumor 19 years previously. As she had no conventional coronary risk factors, the cause of the coronary artery disease is thought to have been related to the radiation therapy. As survival rates of cancer patients improve as a consequence of therapeutic advances, we should be aware of the possibility of coronary artery disease as a very late complication of radiation therapy, even in patients who have no coronary risk factors.

Effective Cibenzoline Treatment in a Patient With Midventricular Obstruction After Transcatheter Aortic Valve Implantation

An 80-year-old woman with severe aortic stenosis was admitted to our hospital for transcatheter aortic valve implantation (TAVI). She had New York Heart Association functional class III congestive heart failure. Her comorbidities included multiple myeloma, idiopathic thrombocytopenic purpura treated with chronic steroids, hypertension, diabetes mellitus, and persistent atrial fibrillation. Echocardiography demonstrated a calcified tricuspid aortic valve with leaflet restriction consistent with severe aortic stenosis (Figure 1A; Movie I in the Data Supplement). The instantaneous peak velocity across the aortic valve on Doppler imaging was 5.0 m/s, and the mean pressure gradient was 53 mm Hg (Figure 1B). The aortic valve area calculated by using the continuity equation was 0.49 cm2. A concentric left ventricular (LV) hypertrophy was observed in the septum, measuring 13 mm, and in the posterior wall, measuring 14 mm. The LV cavity was small, with an LV internal dimension of 39 mm at end diastole. LV ejection fraction was 80%. Late peaking of the midcavitary LV pressure gradient of 25 mm Hg at rest was observed, without LV outflow tract obstruction and systolic anterior motion of the mitral valve leaflet (Figure 1C). Coronary angiography revealed no significant coronary artery stenosis. Given her severe aortic stenosis and heart failure symptoms with comorbidities of severe …

Risk of heart failure due to a combination of mild mitral regurgitation and impaired distensibility of the left ventricle in patients with old myocardial infarction.

Ischemic mitral regurgitation (MR) is a serious complication after myocardial infarction, and the incidence of heart failure (HF) increases as the severity of MR increases. However, little is known about the relationship between mild MR and HF in the patients with old myocardial infarction (OMI) and a normal ejection fraction (EF).