Toshihiro Muramatsu

Waon Therapy for Managing Chronic Heart Failure – Results From a Multicenter Prospective Randomized WAON-CHF Study –

BACKGROUND Waon therapy improves heart failure (HF) symptoms, but further evidence in patients with advanced HF remains uncertain. METHODSANDRESULTS In 19 institutes, we prospectively enrolled hospitalized patients with advanced HF, who had plasma levels of B-type natriuretic peptide (BNP) >500 pg/ml on admission and BNP >300 pg/ml regardless of more than 1 week of medical therapy. Enrolled patients were randomized into Waon therapy or control groups. Waon therapy was performed once daily for 10 days with a far infrared-ray dry sauna maintained at 60℃ for 15 min, followed by bed rest for 30 min covered with a blanket. The primary endpoint was the ratio of BNP before and after treatment. In total, 76 Waon therapy and 73 control patients (mean age 66 years, men 61%, mean plasma BNP 777 pg/ml) were studied. The groups differed only in body mass index and the frequency of diabetes. The plasma BNP, NYHA classification, 6-min walk distance (6MWD), and cardiothoracic ratio significantly improved only in the Waon therapy group. Improvements in NYHA classification, 6MWD, and cardiothoracic ratio were significant in the Waon therapy group, although the change in plasma BNP did not reach statistical significance. No serious adverse events were observed in either group. CONCLUSIONS Waon therapy, a holistic soothing warmth therapy, showed clinical advantages in safety and efficacy among patients with advanced HF.

Pseudoaneurysm after heart transplantation with history of LVAD driveline infection

An infective complication of the aorta is a potential cause of early and late mortality after heart transplantation. We report the case of a 21-year-old male cardiac transplant patient in whom a pseudoaneurysm of the recipient site of ascending aorta coincided with the site of the outflow prosthesis of a preexisting left ventricular assist device; this condition developed 9 months after transplantation.

Collateral pathways observed by radionuclide superior cavography in 70 patients with superior vena caval obstruction.

Schematic representations of collateral pathways that have developed in association with superior vena caval obstruction have been established in studies using radionuclide superior cavography (RNSC). However, these were hampered by the poor resolution of earlier scintillation cameras. Using a modern scintillation camera, we performed RNSC in 70 patients with obstruction of the superior vena caval system, and examined the differences in collateral pathways in the presence or absence of obstruction of the azygos vein. RNSC visualized the site of obstruction and collateral pathways far more readily than in prior studies. When the orifice of the azygos vein was not obstructed, collateral flow drained into the azygos system. When it was obstructed, however, the collaterals drained into the inferior vena caval system. An important collateral pathway comprising the contralateral brachiocephalic vein and the jugular venous arch was also found, which has not previously been reported. Our diagrams of collateral circulation may provide a means of determining the site of obstruction in the superior vena caval system by RNSC.

Hot Spots on Liver Scans Associated With Superior or Inferior Vena Caval Obstruction

Although hot spots on hepatic scintigrams have been reported in association with superior and inferior vena caval obstruction, these studies were not clinically correlated, and are hampered by the poor resolution of earlier scintillation cameras. In this report, a modern scintillation camera was used to study the formation of hot spots associated with superior and inferior vena caval obstruction. Moreover, radionuclide cavography was performed in 70 patients with superior vena caval (SVC) obstruction and in 95 patients with inferior vena caval (IVC) obstruction. As a result, 13 cases of hot spots in the liver were observed. In cases of SVC obstruction, hot spots were seen in the quadrate lobe, the medial segment, and the bare area of the liver. In IVC obstruction, a hot spot was seen in the quadrate lobe in all cases. In rare instances, in cases of both SVC and IVC obstruction, a hot spot was seen in the wide area. For these hot spots to develop, it appears necessary to have systemic-portal venous blood flow through the internal thoracic vein and the paraumbilical vein.

The effect of adaptive servo-ventilation on dyspnoea, haemodynamic parameters and plasma catecholamine concentrations in acute cardiogenic pulmonary oedema

Background: Adaptive servo-ventilation has a potential sympathoinhibitory effect in acute cardiogenic pulmonary oedema (ACPO). Aims: To evaluate the acute effects of adaptive servo-ventilation in patients with ACPO. Methods: Fifty-eight consecutive patients with ACPO were divided into those who underwent adaptive servo-ventilation and those who received oxygen therapy alone as part of their immediate care. Visual analogue scale, vital signs, blood gas data and plasma catecholamine concentrations at baseline and 1 h during emergency care, and subsequent clinical events (death within 30 days, intubation within seven days or between seven and 30 days, and length of hospital stay) were assessed. Pre-matched and post-propensity score (PS)-matched datasets were analysed. Results: During the first hour of adaptive servo-ventilation, plasma catecholamine concentrations fell significantly (baseline versus 1 h: epinephrine p = 0.003, norepinephrine p <0.001, dopamine p <0.001), with falls in blood pressure, heart rate, respiratory rate and pCO2, and rise in HCO3 and pH. In the PS-matched model, visual analogue scale (p = 0.036), systolic blood pressure (from 153.8 ± 30.7 to 133.1 ± 16.3 mmHg; p = 0.025) and plasma dopamine concentration (p = 0.034) fell significantly in the adaptive servo-ventilation group compared with the oxygen therapy alone group. The clinical outcomes between the groups were comparable. Conclusion: In patients with ACPO, emergency care using adaptive servo-ventilation attenuated plasma catecholamine concentrations and led to the improvement of dyspnoea, vital signs and acid-base balance, without adversely influencing clinical outcomes. Using adaptive servo-ventilation, rather than standard oxygen alone, may relieve dyspnoea and improve haemodynamic status, possibly by modulating sympathetic nerve activity.

Cardiac Magnetic Resonance Imaging in Giant Cell Myocarditis Intriguing Associations With Clinical and Pathological Features

Giant cell myocarditis (GCM) is rare and often fatal. Proper diagnosis is crucial, because immunosuppressive therapy has been reported to increase the median transplant-free survival time from 3.0 to 12.3 months.1 Although endomyocardial biopsy plays an essential role in early diagnosis, it may yield false-negative results. Imaging examinations including cardiac magnetic resonance (CMR) may facilitate the diagnosis, but the associations between specific CMR findings and the clinical features and pathological findings remain unclear. We present a patient with characteristic CMR findings, with intriguing associations with the clinical features and pathological findings of the biopsy and autopsy. A 73-year-old woman presented with acute chest pain and dyspnea that had continued for 7 hours. Her medical history was unremarkable, with the exception of uveitis and dyslipidemia. Initial examination showed resting blood pressure 132/83 mm Hg, heart rate 103 bpm, and respiratory rate 17 breaths/min. She required 5 L/min of oxygen via facemask to maintain Spo2>98%. Coarse crackles were heard over both lung fields. X-ray demonstrated mild cardiomegaly with bilateral pulmonary congestion (Figure 1). Electrocardiography, which had been within normal limits 2 years previously, showed changes resembling acute myocardial infarction (Figure I in the online-only Data Supplement). Echocardiography showed global hypokinesis in the left ventricular (LV) wall, and regional akinesis in the septum and inferoseptal wall. Coronary artery angiography revealed no significant stenosis or intracoronary plaque rupture. Her serum creatinine kinase level was high at 2558 IU/L. CMR was performed on day 7. Cine-CMR showed global hypokinesis in …

Relation between prognosis and myocardial perfusion imaging from the difference of end-point criterion for exercise stress testing: A sub-analysis of the J-ACCESS study

BACKGROUND The presence and severity of coronary artery disease may be underestimated in patients who do not reach significant end-points of stress testing during myocardial perfusion imaging. We examined how the effect of the level of exercise may affect the ability of the quantitative gated single-photon emission computed tomography (SPECT) imaging to predict the future cardiac events (cardiac death, non-fatal myocardial infarction and severe heart failure). METHOD Of the 4629 consecutively registered patients for J-ACCESS (Japanese-assessment of cardiac event and survival study by quantitative gated SPECT), 2821 patients who underwent the exercise test were selected, and divided into two groups, which reached a target heart rate (group; n=925) or not (n=1896). Leg fatigue was the most common reason for stopping the exercise test in non-reaching groups, we conducted a study comparing group with leg fatigue group (group II). RESULTS During a 3-year follow-up period, total of 25 cardiac events (2.7%) occurred in group I and total of 73 events (3.9%) occurred in group II. The incidence of cardiac death was slightly but significantly higher in group II (P.04). A summed stress score (SSS) was able to separate the high-risk from low-risk patients in group II. The maximal heart rate was not an independent predictor for cardiac events. In Cox multivariate regression analysis, higher age (70 years), history of DM, EDV at rest and LVEF at rest were predictor of cardiac major events (cardiac death, myocardial infarction, heart failure), and higher age (70 years), ESV at rest were independent predictor of cardiac hard events (cardiac death, myocardial infarction) in group II. CONCLUSION Exercise SPECT imaging provides the useful prognostic information in patients who do not reach a significant end-point due to the leg fatigue. In such patients, those with normal SSS score and normal resting ESV have also a most favorable prognosis.

Intravenous Adenosine Triphosphate Disodium: Its Efficacy and Electrophysiologic Effects on Patients with Paroxysmal Supraventricular Tachycardias

We studied the electrophysiologic effects of intravenous adenosine triphosphate disodium (ATP‐2Na) on 17 patients with paroxysmal supraventricular tachycardias (PSVTs). One patient had sinus node (SN) reentry, two had intraatrial (IA) reentry, 7 patients had AV nodal reentry and seven had atrioventricular reentrant tachycardias (AVRTs) with accessory pathways (APs). ATP‐2Na was injected during ventricular pacing in patients with AV nodal reentry and AVRTs with APs. A bolus injection of ATP‐2Na terminated all the PSVTs within 50 s except for one case of IA reentry (case 2). The sites of block at termination were the atrium in SN reentry and IA reentry, between A and H (AH) or between H and A (HA) in AV nodal reentry, and AH block in all the PSVTs with APs. The sites of action on the patients with AV nodal reentry were both the antegrade and retrograde pathways, while the modes of block were Mobitz type I and type II, respectively. ATP‐2Na during ventricular pacing in patients with AV nodal reentry produced Mobitz type II ventriculoatrial block (VAB) in four of seven cases. ATP‐2Na during ventricular pacing in patients with AVRTs with APs produced changes of atrial activation sequences in two patients, induction of PSVT in two patients, and Mobitz type II VA block in three patients. The former two phenomena suggested a retrograde AV nodal block and raised the possibility of a simple test for retrograde atrial fusion during ventricular pacing in patients with WPW syndrome. Chest discomfort of short duration was most commonly noted after ATP‐2Na administration.

Differing Behavior of Plasma Pentraxin3 and High-Sensitive CRP at theVery Onset of Myocardial Infarction with ST-segment Elevation

Although pentraxin3 (PTX3) has been reported as marker of more directly reflect the vascular inflammatory status than short pentraxin including high-sensitive CRP (hs-CRP), detailed difference in blood levels between PTX3 and hs-CRP at the onset of ST-segment elevation myocardial infarction (STEMI) are not fully investigated. Blood levels of pentraxins (PTX3 and hs-CRP) in 20 patients with early arrival of STEMI (2.9 ± 2.2 hours after onset) were measured at baseline, 24, 48, 72 and 120 hours after primary percutaneous coronary intervention (PCI). Also, the blood levels in infarct-related artery (IRA) were measured by thrombus aspiration during PCI. Samples of control (not myocardial infarction) with normal coronary artery (n=10) were drawn from both coronary and peripheral arteries during diagnostic coronary angiography. At baseline, the levels of PTX3 in both femoral and coronary artery in STEMI were significantly higher than those in control, but the hs-CRP did not different between STEMI and control. The level of both PTX3 and hs-CRP did not different between femoral artery and IRA in STEMI patients at baseline. Systemic level of PTX3 peaked 24 hours (p=0.01) followed by the hs-CRP that peaked 48 hours (p<0.01) after the PCI. PTX3 had appeared earlier than hs-CRP in the systemic circulation in the STEMI patients, but they may not be locally released from the IRA.

Cardiomyocyte and Heart Failure

In recent years, outcome of therapy in patients with heart failure is going up. Many clinical trials have demonstrated that renin angiotensin aldosterone system inhibitors and βblockers have functional roles in stabilizing and /or reversing cardiac remodeling via suppression of the excessive activation of renin angiotensin aldosterone and the adrenergic nervous system. Additively, the cardiac resynchronization therapy and ventricular assist device therapy also achieve remarkable success in heart failure therapy. Conversely, in many counties that come up against an elderly society, heart failure is a looming public health problem. Therefore, much further advancement of heart failure therapy and decrement of patients with heart failure are one of most important assignments in the medical services. In this chapter, we describe the recent topics of heart failure including 1,molecular basis of cardiomyocyte, 2,mechanisms of progression in heart failure, 3,renin angiotensin aldosterone system and heart failure, 4,β-adrenergic receptor and heart failure, 5, non-drug treatment and heart failure, 6,heart transplantation and heart failure, 7,Cardiac regeneration and heart failure.