Tadakatsu Yamada

Relation between collateral flow assessed by Doppler guide wire and angiographic collateral grades

We investigated the relation between the angiographic collateral grade (Rentrops classification) and the collateral flow velocity pattern in 43 patients with angina pectoris. Collateral flow velocity was measured with a Doppler guide wire during balloon occlusion in coronary angioplasty. Collateral flow was detected in 21 of the 43 patients. In 6 of the 21 patients, collateral vessels were not seen angiographically before angioplasty. The direction of collateral flow was classified as forward, backward, or bidirectional. Forward and backward collateral flows were seen in all angiographic grades. Bidirectional collateral flows were observed only in grades 0 to 2. The peak collateral flow velocity was not correlated with the angiographic grades, but the ratio of the collateral flow duration to a cardiac cycle length was correlated with them (grade 0, 44% +/- 15%; grade 1, 70% +/- 16%; grade 2, 84% +/- 11%; and grade 3, 93% +/- 3%; p < 0.0005, analysis of variance). The peak velocity integral was also correlated with the angiographic collateral grades (p < 0.05; analysis of variance). The peak velocity integral was also correlated with the angiographic collateral grades (p < 0.05; analysis of variance). Electrocardiographic signs of ischemia were less observed in patients with unidirection and longer duration of collateral flow pattern (p < 0.05, respectively). A Doppler guide wire may be useful in assessing collateral flow grade.

Beneficial effects of rapid introduction of adaptive servo-ventilation in the emergency room in patients with acute cardiogenic pulmonary edema

BACKGROUND Adaptive servo-ventilation (ASV) at home has been used for patients with chronic heart failure. However, its effect on acute cardiogenic pulmonary edema (ACPE) is not clear. The aim of this study was to elucidate the effect of ASV use in the emergency room in patients with ACPE. METHODS We enrolled 198 consecutive patients with ACPE. Eighty patients received standard therapies, such as oxygen inhalation and vasodilators (conventional therapy group), and 118 received ASV in addition to standard therapy (ASV therapy group). ASV was initiated in the emergency room immediately after diagnosis. The procedure was switched over from ASV to endotracheal intubation (ETI) when oxygenation was insufficient. RESULTS The ETI rate in the ASV therapy group was significantly lower than that in the conventional therapy group (3% vs. 21%, p<0.01). The intensive care unit and/or high care unit length of stay in the ASV therapy group was also significantly shorter than that in the conventional therapy group (1.9±2.1 days vs. 5.3±6.8 days, p<0.01). Consequently, the hospitalization period in the ASV therapy group was shorter than that in the conventional therapy group (19.3±11.0 days vs. 26.3±16.6 days, p<0.01). CONCLUSION In patients with ACPE, rapid introduction of ASV in the emergency room reduces the need for ETI and decreases the hospitalization period.

Ergonovine-Induced Alterations in Coronary Flow Velocity Preceding Onset of Occlusive Spasm in Patients Without Significant Coronary Artery Stenoses

This study examined serial changes in coronary flow velocity to elucidate the dynamic change of coronary circulation during coronary spasm. Twenty patients with variant angina and 27 control patients were studied. Coronary flow velocity was monitored using a Doppler guidewire following intracoronary ergonovine administration. In the control group, diastolic flow velocity either did not change or increased slightly in response to ergonovine. However, in patients with variant angina, 2 patterns of flow velocity alterations were observed. In the first pattern, flow initially increased and then suddenly decreased (16 of 20 patients). In the second pattern, flow gradually decreased (3 of 20 patients). In the remaining patient, the coronary flow alteration could not be detected because of branch spasm. When abnormally high flow velocity was defined as a 100% increase in flow after ergonovine administration within 1 minute, and abnormally low flow velocity was defined as a 50% decrease in flow to diagnose variant angina, sensitivities of 35%, 75%, and 85% were noted if flow was measured 1.0, 2.0, and 3.0 minutes after ergonovine administration, respectively. These abnormal flow velocities were observed before ischemic ST changes appeared. In conclusion, in patients with variant angina, characteristic serial changes in coronary flow velocity occur before occlusive spasm. Variant angina may be diagnosed earlier by monitoring flow velocity rather than by monitoring for ischemic electrocardiographic changes.

Time interval determination from left atrial appendage ejection flow in patients with mitral stenosis.

The feasibility of determining the time interval from left atrial appendage (LAA) flow was examined using transesophageal Doppler echocardiography. Time intervals were compared between LAA flow and mitral flow patterns during late diastole in 8 patients with mitral stenosis and in 12 controls. The start of ejection flow from the LAA was later than the initiation of mitral flow, but the termination was same in both flows, indicating the contribution of LAA ejection to the latter half of the left atrial booster pump function. The pre‐ejection time and the time interval from P‐wave to end‐ejection correlated significantly with left atrial dimensions (r = 0.55, and r = 0.70, respectively). The pre‐ejection time, duration of the ejection flow from the LAA, and duration of mitral flow in the atrial contraction phase were significantly longer in patients with mitral stenosis (126 ± 14 msec, 131 ± 36 msec, and 167 ± 28 msec, respectively) than in the controls (109 ± 13 msec, 108 ± 15 msec, and 141 ± 17 msec, respectively). These results indicate that electrical conduction time from the right atrium to LAA can be estimated from the LAA ejection flow, and the time is related to the left atrial size. In patients with mitral stenosis, LAA contraction may contribute to left ventricular filling in the latter half of the atrial contraction phase.

Vasomotility and Nitric Oxide Bioactivity of the Bridging Segments of the Left Anterior Descending Coronary Artery

We compared bridging and nonbridging coronary artery segments with respect to the vasoconstrictor effect of acetylcholine. Bridging segments were hypersensitive to the constrictor effect of acetylcholine, and results suggest that the effect of nitric oxide on the acetylcholine-stimulated condition is decreased, or that the smooth muscle sensitivity to acetylcholine is increased.

A calcified amorphous tumor that developed on both sides of the atrioventricular valve annulus.

We report a rare case of a hemodialysis patient with a calcified amorphous tumor (CAT) on both sides of the atrioventricular valve annulus. A 70-year-old female who had received hemodialysis for 23 years because of chronic glomerulonephritis presented to our hospital with acute heart failure. Echocardiography indicated the presence of mobile cardiac masses on the mitral valve and tricuspid valve annulus. We suspected the presence of a cardiac tumor or vegetation. The patient received 3 g/day sulbactam-ampicillin and 60 mg/day gentamicin. Surgery was performed on the 14th day after hospital admission. The patient underwent mitral valve replacement, tricuspid annuloplasty, and tumor resection. Based on the pathological findings, the cardiac tumor was diagnosed as a CAT.

Clinical Usefulness of Coronary Flow Reserve Ratio for the Detection of Significant Coronary Artery Disease on 13N-Ammonia Positron Emission Tomography

BACKGROUND This study aimed to evaluate the diagnostic performance of coronary flow reserve (CFR), hyperemic myocardial blood flow (hMBF), and CFR ratio for detecting significant coronary artery disease (CAD) on 13N-ammonia positron emission tomography (PET).Methods and Results:We analyzed 63 patients (mean age, 71±9 years; 43 males) with suspected CAD who underwent both pharmacological stress/rest 13N-ammonia PET and coronary angiography. CFR and hMBF for PET were calculated automatically using quantitative PET software, and the CFR ratio was defined as the ratio of per-vessel CFR to maximum CFR in a standard 17-segment model. We compared the diagnostic performance among the 3 quantitative values. In the per-vessel analysis, 55 vessels were diagnosed as significant CAD (≥70% stenosis and/or fraction flow reserve ≤0.8). CFR, hMBF, and CFR ratio of significant CAD were significantly lower than for non-significant CAD (1.85±0.69 vs. 2.38±0.69; P<0.01, 1.67±0.54 vs. 2.19±0.52 mL·min-1·g-1; P<0.01, and 0.66±0.15 vs. 0.82±0.09; P<0.01, respectively). In the receiver-operating characteristic curve analysis, CFR, hMBF, and CFR ratio had areas under the curve of 0.71, 0.75, and 0.85 respectively, and the CFR ratio was significantly higher than CFR and hMBF (P<0.05). The sensitivity, specificity, and accuracy of the CFR ratio with an optimal cutoff value of 0.75 were 75%, 85%, and 82%, respectively. CONCLUSIONS Clinically, the CFR ratio in 13N-ammonia PET was more effective in detecting significant CAD.

FAVORABLE EFFECTS OF EARLY ADMINISTRATION OF TOLVAPTAN IN ELDERLY PATIENTS WITH REPEAT HOSPITALIZATIONS FOR ACUTE DECOMPENSATED HEART FAILURE

Tolvaptan is an oral selective vasopressin 2 receptor antagonist that acts on the distal nephrons, causing a loss of electrolyte-free water. Thus far, its early administration in elderly patients who had repeat hospitalizations for acute decompensated heart failure (ADHF) despite receiving optimal

A Case of Isolated Left Atrial Infective Mural Endocarditis

A 52-year-old man presented with a fever and malaise. Transthoracic echocardiogram was performed because of a holosystolic murmur, which showed mitral valve prolapse and a regurgitation jet toward the posterior wall of the left atrium. There was no apparent vegetation at any valves. Blood cultures were positive for Streptococcus mitis/oralis. Transesophageal echocardiogram revealed vegetation only at the posterior wall of the left atrium exposed to the mitral regurgitant jet. We diagnosed this condition as infective mural endocarditis. This case highlighted the need for a detailed observation of the valves and the atrial wall when infective endocarditis is suspected.

Radiation-Induced Cardiomyopathy Incidentally Detected on Oncology 18 F-Fluorodeoxyglucose Positron Emission Tomography

therapy (RTx) with a total dose of 60 Gy for the tumor and lymph nodes, with 40 Gy and 20 Gy using anteriorposterior and parallel-oblique fields, respectively (Figure 1A). Before RTx, 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET)/computed tomography (CT) A 54-year-old man was referred to Ehime Prefectural Central Hospital because of dysphagia. After several examinations, he was diagnosed with unresectable stage IV esophageal cancer. The patient received chemotherapy (5-fluorouracil+cisplatin) and mediastinal radio-