Takanao Ueyama

'Takotsubo' cardiomyopathy in a maintenance hemodialysis patient.

Abstract:  An 84‐year‐old woman undergoing maintenance hemodialysis presented with chest discomfort lasting several days and electrocardiographic abnormalities. She had stopped smoking 2 weeks earlier and was experiencing irritability. Upon admission, electrocardiography showed ST‐segment elevation in leads I, II, aVF, and V2‐6 and an abnormal Q wave in leads II, III, and aVF. Ultrasound cardiography showed left ventricular anteroapical akinesia and basal hyperkinesia. The chest discomfort disappeared without specific therapy. During hospital days 1–5, the ST‐segment elevation gradually improved. Giant negative T waves then developed. The left ventricular asynergy resolved by day 8. Radionuclide imaging with iodine‐123‐beta‐methyl‐p‐iodophenyl pentadecanoic acid, but not with technetium‐99 m‐sestamibi, showed an apical defect. Elective coronary angiography showed no stenosis. ‘Takotsubo’ cardiomyopathy was diagnosed. After discharge, the patient continued regular dialysis without cardiac symptoms. We concluded that endogenously activated sympathetic nerve action in hemodialysis patients, especially those under emotional or physical stress, might be a causative factor for Takotsubo cardiomyopathy.

Three-dimensional echocardiographic assessment of left ventricular function in takotsubo cardiomyopathy

We evaluated left ventricular (LV) function by three-dimensional echocardiography (3DE) in a patient with takotsubo cardiomyopathy (TC). An 82-year-old man was admitted to our hospital with a suspicion of acute myocardial infarction but was diagnosed as TC by coronary angiography and left ventriculography (LVG). Three-dimensional echocardiography showed circular asynergy from the midventricle to the apex associated with hyperkinesis of the base and volumetric data very close to those obtained by LVG. Thus, 3DE is a useful tool in evaluating regional wall motion abnormalities and LV volume in patients with TC.

Intracoronary followed by intravenous administration of the short-acting β-blocker landiolol prevents myocardial injury in the face of elective percutaneous coronary intervention

BACKGROUND Myocardial injury during elective percutaneous coronary intervention (PCI) is associated with higher subsequent cardiac events and mortality. β-Blockers have been used to reduce myocardial injury during ischemia and reperfusion. We investigated whether intracoronary followed by intravenous administration of the short-acting β-blocker landiolol prevents myocardial injury in the face of elective PCI. METHODS AND RESULTS Patients undergoing elective PCI (n=70) were randomly assigned to the landiolol (n=35) or control (n=35) group. Landiolol or saline was administered into target vessels through a balloon catheter for 1min before and after first balloon inflation followed by continuous intravenous administration for 6h after PCI. The incidence of myocardial injury defined by cardiac troponin-I (cTnI) >/=0.05 ng/ml was 79% of the patients in the control group compared to 56% in the landiolol group (p=0.04). The cTnI level at 24h after PCI tended to be lower in the landiolol group (0.57 ± 1.14 versus 1.27 ± 2.48 ng/ml; p=0.07), while the CK-MB level was not significantly different between the landiolol and control groups. The incidence of peri-procedural myocardial infarction defined by cTnI >/=0.12 ng/ml was significantly (p=0.02) lower in the landiolol group (41%) compared to the control group (70%). There was no incidence of coronary spasm, hypotension, bradycardia or heart failure during and after PCI in the two groups. CONCLUSIONS Brief intracoronary followed by continuous intravenous administration of landiolol is safe and effective for myocardial protection in the face of elective PCI.

Non-invasive detection of ischemic left ventricular dysfunction using rest gated SPECT: expectation of simultaneous evaluation of both myocardial perfusion and wall motion abnormality

ObjectiveAlthough the accurate detection of ischemic etiology is important in the management of patients with severe left ventricular (LV) dysfunction, it is difficult to determine using a non-invasive strategy. The present study investigates whether perfusion and regional functional abnormalities identified by quantitative electrocardiographic gated single-photon emission computed tomography (QGS) at rest can detect ischemic LV dysfunction in patients with severe LV dysfunction.MethodsRest QGS with 99mTc-tetrofosmin was performed on 54 consecutive patients with LV ejection fraction of ≤40%. Ischemic LV dysfunction (n = 32) was defined according to the established standard. Regional perfusion and wall motion were calculated using a 14-segment model (six mid-ventricular and eight apical segments) and compared with a normal control group.ResultsThe numbers of reduced [mean −1 standard deviation (SD) of normal individuals] and severely reduced (mean −2 SD) wall motion segments were similar between patients with ischemic and non-ischemic LV dysfunction (13.5 ± 1.1 vs. 13.6 ± 0.9 and 10.6 ± 2.0 vs. 9.9 ± 3.0 segments, respectively). The number of hypoperfused (mean −1 SD) segments was significantly greater in patients with ischemic LV dysfunction than in those with non-ischemic LV dysfunction (9.3 ± 3.8 vs. 2.0 ± 2.8 segments, P < 0.0001). The analysis of the receiver operating characteristics showed that a cut-off value of 4 hypoperfused segments among 14 segments provided the best separation between ischemic and non-ischemic LV dysfunction (sensitivity = 88% and specificity = 91%). Furthermore, patients with non-ischemic LV dysfunction had no severely hypoperfused (mean −2 SD) segments in any of the segments, whereas patients with ischemic LV dysfunction had 4.4 ± 0.2 segments.ConclusionsThe QGS strategy at rest can accurately differentiate patients with ischemic LV dysfunction from those with severe LV dysfunction by simultaneous regional evaluation of wall motion and myocardial perfusion.

Direct correlation between regional systolic function and regional washout rate of ⁹⁹mTc-sestamibi in patients with idiopathic dilated cardiomyopathy.

ObjectiveAlthough a higher washout of 99mTc-sestamibi (MIBI) from the ischemic myocardium was reported, little is known about it in idiopathic, nonischemic dilated cardiomyopathy (DCM). Using a quantitative electrocardiographic-gated single-photon emission computed tomography strategy, regional myocardial function may be obtained in conjunction with regional tracer perfusion. The aim of this study was to investigate the significance of regional washout of MIBI compared with regional systolic function in patients with DCM. MethodsRest quantitative electrocardiographic-gated single-photon emission computed tomography was performed in 20 patients with DCM who had no significant coronary stenosis on coronary angiogram and in five normal volunteers. single-photon emission computed tomography imaging was observed at 30 min and 4 h after 740 MBq of MIBI injection, and the regional washout rate (WR) was calculated using a 20-segment model. ResultsThe mean global ejection fraction was 28.2±12.4% and the mean end-diastolic volume was 177±78 ml. The myocardial segments were divided into three groups on the basis of the mean WR of normal volunteers: group A (n=164): WR≥25.4% (=mean+SD); group B (n=138): 19.6%⩽WR<25.4%; group C (n=98): WR<19.6% (=mean−SD). The regional wall thickening of group A segments was significantly less than that of the other groups (11.6±0.7 vs. 14.0±0.9 and 14.9±0.7%, respectively, P<0.05). The global left ventricular ejection fraction showed significant negative correlation to the extent of group A segments per patient (R=−0.65, P<0.005), indicating that higher washout was the result of decreased systolic function in DCM hearts. ConclusionRegional higher WR of MIBI may indicate a significant marker for myocardial damage in asymptomatic to mildly symptomatic patients with DCM.

Anomalous Right Coronary Artery Arising from the Left Sinus of Valsalva in a Young Athlete

Cardiac events associated with congenital coronary abnormalities are rare but potentially life-threatening in a young population. Most of these patients are not diagnosed before their initial cardiac event. Amongst such coronary artery anomalies, sudden death is frequently seen in an anomalous origination of a coronary artery from the opposite sinus. We herein present the case of a patient who presented with sudden cardiac arrest associated with an anomalous right coronary artery originating from the left sinus of Valsalva. Surgical treatment was selected because there was evidence of reversible ischemia based on the findings of a stress test.

Scintigraphic prediction of left ventricular functional recovery early after primary coronary angioplasty using single-injection quantitative electrocardiographic gated SPECT.

ObjectiveThe clinical usefulness of characterizing reperfused myocardium by perfusion/thickening assessment using electrocardiographic gated single photon emission computed tomography (SPECT) has not been investigated. We evaluated whether single-injection gated SPECT with 99mTc tetrofosmin early after primary percutaneous coronary intervention (PCI) can predict left ventricular (LV) functional recovery. MethodsGated SPECT was performed 3 days after primary PCI in 45 patients with acute myocardial infarction and revascularized segments were classified into perfusion/thickening mismatched segments, matched normal and matched abnormal segments. Gated SPECT was repeated 3 months later to evaluate the changes in LV ejection fraction (ΔLVEF). ResultsAmong 332 revascularized segments, there were 83 mismatched segments, 163 matched abnormal segments and 86 matched normal segments. In all the patients, LVEF increased significantly from 3 days to 3 months after primary PCI (52±13 to 57±14%, P<0.0001). Patients were divided into two groups according to ΔLVEF: 24 patients with LV functional recovery (ΔLVEF ≥5%) and 21 patients without LV functional recovery. The number of mismatched segments in patients with LV functional recovery was significantly greater than that in patients without (2.7±1.7 vs. 0.8±1.4, P<0.0003) despite no differences in the number of matched abnormal and matched normal segments. There was a significant correlation between ΔLVEF and the number of mismatched segments (r=0.56, P<0.0001) and LVEF at 3 months after primary PCI was related to the number of matched abnormal segments (r=−0.78, P<0.0001). ConclusionSingle-injection gated SPECT early after primary PCI can predict LV functional recovery.

Atypical morphology and myocardial perfusion of mid-ventricular ballooning: A case report

Although some atypical types of transient left ventricular apical ballooning syndrome have been reported, only a few atypical types of transient mid-ventricular ballooning have been reported. A 70-year-old female underwent surgery for urothelial carcinoma. At day 5 after the surgery, she was admitted to our department without cardiac symptoms because of ST elevation in leads I, II, III, aVF and V1-V6 indicating acute coronary syndrome. She was diagnosed with stress induced cardiomyopathy based on an angiographically normal coronary artery, newly developed extensive wall motion abnormality (hyperbasal contraction and akinesis from the mid-left ventricle to the apex without hypercontraction of the small area adjacent to the apex) based on left ventriculography, and a small elevation of myocardial enzymes incongruous with the area of contraction abnormality. Myocardial scintigraphy with 99mTc-tetrofosmin showed a severely reduced myocardial perfusion in an extensive mid-ventricular area without a left ventricular base and top of apex, in accord with a wall motion abnormality different from typical apical ballooning or typical mid-ventricular ballooning previously diagnosed in our hospital. This is the first report presenting an atypical mid-ventricular ballooning based on the myocardial atypical perfusion findings.