Taiji Okada

Acute Myocardial Infarction due to Left Atrial Myxoma

Myxoma is a common benign cardiac tumor that may rarely cause an acute myocardial infarction. A 77-year-old woman was admitted to our hospital with chest pain. Electrocardiography showed an ST elevation in leads V3-6. Transthoracic echocardiography revealed an ovoid mass with fragmentation in the left atrium and hypokinesia of the left ventricular apex. Coronary angiography indicated the presence of a coronary embolism that was suspected to be from the left atrial mass. The mass was removed by emergency surgical resection to avoid a further systemic embolism and was diagnosed pathologically as a myxoma. The patient was discharged after 13 days with no complications.

A case of long QT syndrome having compound mutations of KCNH2 and SCN5A

Long QT syndrome (LQTS) is a hereditary ion channelopathy resulting in prolonged cardiac repolarization and abnormal prolongation of the QT interval on the electrocardiogram (ECG). The patients are likely to develop ventricular arrhythmias and sudden cardiac death. Molecular biology and basic electrophysiology studies revealed an approach to the management of patients with LQTS, which includes genotype-based risk stratification. A 16-year-old-woman with QT prolongation on ECG had frequent syncopal episodes and an attack of ventricular tachycardia followed by ventricular fibrillation. The SCN5A mutation (intravene sequence 4-1 c/t) in addition to the KCNH2 mutation (Arg56Gln) was identified. Her mother and older sister were also diagnosed as having LQTS, but had only a single mutation (KCNH2). Her older sister had an episode of syncope, but her mother did not. Genetic analysis sometimes reveals 2 or more mutations in LQTS patients with clinical phenotypes of the Romano-Ward syndrome. Compound mutations in different LQTS-related genes are likely to modify clinical characteristics. In addition, comprehensive screening of LQTS-related genes might be needed when facing family members with different clinical manifestations. <Learning objective: Molecular biology and basic electrophysiology studies revealed an approach to the management of patients with LQTS, which includes genotype-based risk stratification. We described a case of LQTS having compound mutations of KCNH2 and SCN5A who had frequent syncopal episodes and an attack of ventricular fibrillation. The mutations of 2 different genes were associated with a severe phenotype of LQTS. Comprehensive screening of LQTS-related genes might be needed for estimating the severity of LQTS.>.

A case of myocardial infarction and left ventricular pseudo-false aneurysm perforating the right ventricle

We describe a case of left ventricular (LV) pseudo-false aneurysm perforating the right ventricle (RV), which is a very uncommon complication of myocardial infarction (MI). An 88-year-old woman was referred to our hospital because of complete atrioventricular block. She was drowsy, her heart rate was 27 beats/min, and her blood pressure was 90/70 mmHg. A grade of II/VI pansystolic murmur was audible at the lower sternal border. Echocardiographic study revealed an aneurysm on the inferoseptum and a large (30 mm) defect between the inferoseptal wall and the aneurysm (Fig. 1a). A color Doppler image showed shunt flows passing from a large defect of inferoseptal myocardium and the aneurysmal pouch to the RV (Fig. 1b, c). Coronary arteriography was performed and the proximal right coronary artery (RCA) was occluded. The left coronary arteries were normal and percutaneous coronary intervention of the RCA was not performed. On the basis of the initial laboratory examination findings (creatine kinase 563 U/L, creatine kinase MB 29.1 ng/mL, troponin I 49.31 ng/mL), she was diagnosed with a perforation of an LV pseudo-false aneurysm into the RV following the subacute phase of an inferior MI. Temporary pacing and intra-aortic balloon pumping were started, and prompt surgical repair of the LV pseudo-false aneurysm was considered. However, her operative risk was high and her family desired conservative management. She died 10 days after admission as a result of multi-organ failure. An LV pseudo-false aneurysm, which was first reported by Stewart et al. [1], is a very uncommon complication of MI. It occurs when hemorrhagic dissection into the area of a transmural MI does not completely reach the epicardium and is contained within the area of the infarcted myocardium. Several authors described the perforation of an LV pseudo-false aneurysm into the RV following acute inferior MI [2, 3]. Although the hemodynamics of this condition are similar to those of postinfarction ventricular septal defect, the perforation usually develops in the subacute or chronic phase of MI. Although no pathology examination was performed, the present patient was diagnosed as having an LV pseudo-false aneurysm on the basis of echocardiographic findings of incompletely dissected myocardium and the aneurysmal pouch containing the area

Comparison of CTAC and prone imaging for the detection of coronary artery disease using CZT SPECT

BackgroundCadmium-zinc-telluride (CZT) cameras have improved the evaluation of patients with chest pain. However, inferior/inferolateral attenuation artifacts similar to those seen with conventional Anger cameras persist. We added prone acquisitions and CT attenuation correction (CTAC) to the standard supine image acquisition and analyzed the resulting examinations.Methods and resultsSeventy-two patients referred for invasive coronary angiography (CAG), and who also underwent rest/stress myocardial perfusion imaging (MPI) on a CZT camera in the supine and prone positions plus CTAC imaging, to examine known or suspected CAD between April 2013 and March 2014 were included. A sixteen-slice CT scan acquired on a SPECT/CT scanner between rest and stress imaging provided data for iterative reconstruction. Sensitivity, specificity, accuracy, and positive and negative likelihood ratios (LRs) were calculated to compare MPI with CAG on a per-patient basis. Per-patient sensitivity, specificity, and accuracy of supine images to predict coronary abnormalities on CAG were 35% [95% confidence interval (CI) 19–52], 86% (95% CI 80–92), and 74% (95% CI 66–82); those of prone imaging were 65% (95% CI 45–81), 82% (95% CI 76–87), and 78% (95% CI 68–85); and those of CTAC were 59% (95% CI 41–71), 93% (95% CI 87–97), and 85% (95% CI 76–91), respectively.ConclusionsProne acquisition and CTAC images improve the ability to assess the inferior/inferolateral area.

Myocardial Calcification with a Latent Risk of Congestive Heart Failure in a Patient with Apical Hypertrophic Cardiomyopathy.

Myocardial calcification is rare. An 88-year-old man who had previously been diagnosed with apical hypertrophic cardiomyopathy exhibited left ventricular asynergy on echocardiography before undergoing cholecystectomy. Computed tomography revealed severe calcification in the apical region of the left ventricular myocardium, although the coronary arteries were intact and the hemodynamics on right heart catheterization were normal. The cause of the left ventricular asynergy appeared to be myocardial calcification, thought to be the result of rheumatic fever based on the patients past history. Stress echocardiography showed a latent risk for the development of heart failure due to the distensibility of the calcified left ventricular myocardium.

A Case of Left Ventricular Thrombus with Superior Mesenteric Vein Thrombosis Due to Atopic Dermatitis

A 55-year-old man was presented to the emergency room because of abdominal pain for 4 days. He had a history of atopic dermatitis. Left ventricular (LV) asynergy and thrombus was detected on echocardiography, and superior mesenteric vein thrombosis was detected by computed tomography. There are no reported cases of this combination of thrombi. We hypothesized that the reason for this complication is the combination of coagulation disorder due to atopic dermatitis, silent myocardial infarction, and exacerbation of the coagulation abnormality due to bacteremia, leading to superior mesenteric vein and LV thrombosis. Atopic dermatitis that has potential risk factors of thrombus with sepsis could provoke thrombophilic state. Atopic dermatitis is a common disease, but continuous medical care is essential.

Improvement of the Left Ventricular Function after Tricuspid Valve Plasty for Traumatic Tricuspid Regurgitation

Traumatic tricuspid regurgitation (TR) is a rare cardiovascular complication in chest trauma. Changes in the left ventricle (LV) function after operation are unclear. A 61-year-old woman who had been involved in a traffic accident 1 month earlier presented with exertional dyspnea. Transthoracic echocardiography (TTE) showed severe tricuspid regurgitation (TR) accompanied by LV dysfunction due to anterior leaflet prolapse with papillary muscle rupture. After tricuspid plasty, the LV function improved, as evidenced by TTE and speckle tracking echocardiography. In conclusion, the early diagnosis of traumatic TR is important, and early surgical intervention might be effective for achieving ventricular function improvement.

Acute Coronary Syndrome in a Puerperal Patient with Coronary Artery Ectasia due to a Coronary Artery Fistula

Coronary artery fistulas are rare and the feeding artery is ectatic and tortuous. It is not well-known whether coronary artery ectasia (CAE) is a risk factor of acute coronary syndrome (ACS) in the puerperal periods. A 40-year-old woman with a coronary artery fistula and an ectatic right coronary artery (RCA) had delivered twins. A month later, she had chest pain and coronary angiography revealed thrombogenesis in the RCA. She had no risk factors of cardiovascular disease or thrombogenesis. We should recognize that CAE is a risk factor for ACS in women in the perinatal and puerperal periods.

Pneumococcal endocarditis complicating meningitis and arthritis in a previously healthy woman: A case report

Streptococcus pneumoniae is the most common cause of community-acquired bacterial meningitis in adults. Pneumococcal endocarditis coexisting with meningitis is rare, especially in healthy individuals. A 66-year-old woman was admitted with pneumococcal bacteremia, meningitis, and arthritis. She was in good condition before admission. Because of typical presentation of bacterial meningitis characteristics and normal echocardiographic findings, the patient was administered antibiotics for meningitis and arthritis. On hospitalization day 59, she developed a fever, and echocardiography showed severe aortic regurgitation, perforation, and vegetation of the aortic valve. She was diagnosed with pneumococcal endocarditis and underwent aortic valve replacement surgery. In general, invasive pneumococcal infections occur in debilitated middle-aged men with predisposing factors such as chronic alcoholism, chronic obstructive pulmonary disease, and immunosuppressive conditions. In this case, regardless of the appropriate treatment and no risk of invasive pneumococcal infections, infective endocarditis occurred. <Learning objective: This case suggested that invasive pneumococcal infections progressing to infective endocarditis can occur in healthy individuals and underscore the importance of careful observation in patients with pneumococcal meningitis, in particular, in the case of blood culture positive patients.>.