Toshihiko Yamasa

The Left Ventriculographic Pattern and Serial Electrocardiographic Changes in Hypertrophic Cardiomyopathy Patients with Giant Negative T Waves

The configuration of the left ventriculogram (LVG) was classified in 64 patients with hypertrophic cardiomyopathy (HCM) observed in ECG, and characteristics of the configuration and serial changes in SV1+RV5 and giant negative T (GNT) waves were studied. The LVG configuration was classified into the spade (15 patients), papillary-muscle hypertrophy (PMH; n = 23), oval (n = 24) and banana types (n = 2). The spade, PMH and oval types were observed for mean periods of 66, 90 and 91 months, respectively. Serial changes in ECG were as follows: GNT decreased from 16.7 +/- 3.3 to 13.3 +/- 5.1 mm in the spade type and decreased significantly from 16.9 +/- 5.9 to 9.8 +/- 6.9 mm in PMH but showed no changes in the oval type. SV1+RV5 decreased significantly from 69.0 +/- 14.9 to 58.2 +/- 14.7 mm in PMH but showed no significant changes in the spade or oval types. Thus GNT decreased progressively in many patients with the exception of a few with the oval type. From these findings, we consider that apical hypertrophy had been established at the time of the initial LVG and changed over time thereafter in the spade and PMH types but that hypertrophy was still in progress in some patients with the oval type.

Landiolol dramatically improved Takotsubo cardiomyopathy in an older patient: Letters to the Editor

An 85-year-old woman, with no past history of heart disease, underwent nephrostomy for right hydronephrosis. The next day after the operation, she was successfully removed from mechanical ventilation. However, she consulted at our department the next day because of acute dyspnea from acute heart failure. Her blood pressure was 170/100 mmHg, heart rate was 110 b.p.m., body temperature was 37.0 C, respiratory rate was 20 breaths/min and oxygen saturation was 96% at 3 L/min oxygen by nasal cannula. Laboratory data included the following findings: white blood cell count, 17 100/mm; hemoglobin, 9.4 g/dL; blood urea nitrogen, 12.9 mg/dL; creatinine, 0.43 mg/dL; aspartate aminotransferase, 31 IU/L; alanine aminotransferase, 9 IU/L; lactate dehydrogenase, 236 IU/L; creatine kinase, 70 IU/L; creatine kinase MB, 8 ng/mL; troponin I, 3.447 ng/mL; C-reactive protein, 22.5 mg/dL; and natriuretic peptide, 1818.1 pg/mL. Initial electrocardiogram showed sinus rhythm mild ST segment elevation in V2–4, and inverted T waves in V2–3. Chest X-ray showed cardiomegaly and pulmonary congestion. Transthoracic echocardiography showed akinesis of the middle segment of the left ventricle (LV), with and an LV ejection fraction of 25% without outflow obstruction of LV and mitral regurgitation. Emergent coronary angiography showed no significant coronary stenosis, but left ventriculography showed akinesis of the middle segment of LV (Fig. 1a,b). Therefore, the patient was diagnosed as midventricular Takotsubo (or stress-induced) cardiomyopathy (TC). Continuous intravenous infusion of landiolol, an ultrashort-acting cardioselective β1-blocker, was started at a dose of 10 mg/min/kg because the patient had tachycardia and hypertension. After starting landiolol, her blood pressure and heart rate were controlled (Fig. 1c), and LV dysfunction gradually improved and

We need more useful surrogate markers for the efficacy of beta‐blockers for the treatment of Takotsubo cardiomyopathy

increased outpouring of catecholamines are currently the prevailing hypotheses. Also, it is not known whether TTS is complete by the time of clinical presentation, or if the hyperactive ASNS and circulating catecholamines continue to perpetuate their damaging effect on the cardiomyocytes. The aforementioned need to be explored, if we wish to make progress in unraveling the pathophysiology of TTS. To this effect, repeated sampling of blood-borne catecholamines and direct (not indirect, like when e.g. heart rate variability is assessed) monitoring of ASNS need to be implemented, immediately when TTS is suspected. There is currently available technology aimed at recording skin nerve activity in the thorax, which is a reliable surrogate of the stellate ganglia nerve input to the heart, and which has been already used in the evaluation of patients with seizure disorders, atrial fibrillation and ventricular arrhythmias. Such technology could provide monitoring of ASNS, along with electrocardiogram monitoring, using the same routine electrocardiogram electrodes and a recorder/analysis system of the filtered bandwidth of 500–1000 Hz signals for the former. Monitoring of the ASNS in the early phase of the TTS phenotype might provide the appropriate platform to evaluate the pathophysiology of TTS, and explore whether β-blockers, particularly ultra-short-acting (e.g. landiolol or esmolol), have a role in the management of patients with TTS.

Comparison of Neointimal Tissue Characteristics Between Bare-metal and Second-generation Drug-eluting Stents Nine Months after Implantation in Patients with ST-segment Elevation Myocardial Infarction

Background: Neointimal tissue characteristics after implantation of stents are related to late/ very late stent thrombosis and/ or restenosis of target lesion. However, the difference of them has not been fully elucidated among bare-metal stents (BMS) and second-generation drug-eluting stents (DES). Methods: The present study uses optical coherence tomography (OCT) to compare neointimal tissue characteristics among BMS (n = 22), Endeavor zotarolimus - (E-ZES; n = 21), everolimus - (EES; n = 22) and biolimus A9 - (BES; n = 23) eluting stents in the patients with STEMI who underwent follow-up coronary angiography at nine months after stent implantation. Results: Quantitative coronary angiography revealed significantly higher restenosis rates for BMS and E-ZES than EES and BES. OCT showed significantly lower and higher rates for covered and uncovered EES, respectively, than for BMS and E-ZES. The malapposition rate for E-ZES was significantly lower than those of other two types of DES. The neointima of EES and BES was significantly thinner than that of BMS and E-ZES. Evagination was more prevalent in BES among the four stents, and the rate of evagination/strut significantly correlated with positive remodeling (r = 0.312, p = 0.006). Conclusion: Neointimal tissue characteristics were different among BMS and second-generation DES at nine months after implantation into patients with STEMI. This might be related to the differences of future cardiac events.

Calcification around the Struts of a Sirolimus-eluting Stent Approximately 16 Months after Implantation in an Autopsy Case

Drug-eluting stents (DES) are widely used for the treatment of coronary artery disease, and a sirolimus-eluting stent (SES; Cypher) was the first DES introduced into clinical practice. Although pathological reactions of coronary arteries to SES have been described in autopsy cases, there are few reports regarding calcification of the coronary arteries after SES implantation. The present report describes the findings of an autopsy conducted 16 months after SES implantation that showed remarkable persistent calcification. In addition, previously reported pertinent pathological findings are also described.

Comparison of the Brachial-ankle Pulse Wave Velocity between Patients with Acute Coronary Syndrome and Effort Angina Pectoris

Objective Coronary artery disease (CAD) is one of the clinical categories of atherosclerotic diseases. There have been reports indicating that the pathological findings of coronary artery plaque differ between acute coronary syndrome (ACS) and effort angina pectoris (EAP). The brachial-ankle pulse wave velocity (baPWV) has been reported to be a good indicator of atherosclerotic disease. However, the baPWV may not be equally effective for evaluating ACS and EAP. In this study, we compared the baPWV in patients with ACS and those with EAP. Methods Two hundred and seventy patients were enrolled in this study. All patients underwent coronary angiography, and were separated into normal (CONT), ACS and EAP groups according to the clinical and coronary angiographic findings. The baPWV was evaluated and the results were compared among the groups. Results The baPWV was significantly higher in the EAP group than in the other groups. The baPWV in the ACS group was almost the same as that of the CONT group and was significantly higher in the EAP group than in the ACS group across almost all age groups. Conclusion The present study showed that the baPWV is high in patients with EAP. In contrast, the baPWV in the ACS group was almost normal and was similar to that of the CONT group. ACS occurs due to plaque rupture induced by atherosis, which may occur independent of sclerosis in the coronary artery. EAP may occur in proportion to systemic arterial sclerosis. The baPWV is suitable for screening for EAP, but not for ACS.

Formation of Two Aneurysms from a Coronary Artery-Pulmonary Artery Fistula

Accessible online at: www.karger.com/crd Aneurysm formation from a coronary artery-pulmonary artery fistula is very rare. A few reported cases were detected after acute cardiac tamponade and were complicated by rupture of the aneurysm [1]. Other cases were detected coincidentally at coronary angiography [2–4]. Here, we present a rare case of two aneurysms from a coronary arterypulmonary artery fistula detected coincidentally by chest computed tomography (CT). A 58-year-old woman with a history of left mastectomy for breast cancer was referred to our hospital for the examination of abnormal shadows on chest CT scans. She had been periodically checked for recurrence and metastasis of breast cancer by chest CT until July 6, 2000, when shadows of a mass in the vicinity of the base of the aorta were first identified (fig. 1a). Coronary aneurysms were suspected. The size of the aneurysms was not so large so that the patient was followed up conservatively. On February 6, 2002, a repeat chest CT showed an enlargement of the shadows of the mass (fig. 1b). The patient had no history of Kawasaki disease, Takayasu’s arteritis, chest trauma or radiation therapy. No symptoms, such as chest pain, suggestive of coronary heart disease, were reported. Physical examination showed no audible heart murmurs. Selective