Yasumasa Fujiwara

Transbrachial intra-aortic balloon pumping for a patient with fulminant myocarditis

A 57-year-old man with acute myocarditis was transferred to our hospital from a local clinic. The patient experienced unexpected sudden cardiac arrest 16 h after admission. Mechanical cardiopulmonary support was started using percutaneous cardiopulmonary support, intra-aortic balloon pumping (IABP), continuous hemodialysis filtration, and temporary cardiac pacing with percutaneous cannulation of the femoral vessels. Hematoma developed at the IABP insertion site on the 5th day after admission. The IABP was removed, and another IABP system was inserted via the left brachial artery. The patient’s condition improved, and the IABP was removed on the 9th day after admission. The remainder of the patient’s in-hospital treatment was uneventful, and he showed near-normal left ventricular systolic function 1 year after discharge.

An adult case of polysplenia syndrome associated with sinus node dysfunction, dextrocardia, and systemic venous anomalies.

A 54-year-old woman was referred to our hospital for symptomatic sinus bradyarrhythmia with a sinus pause of 8 seconds. She was diagnosed with dextrocardia during childhood and discovered to have heterotaxy syndrome when she had an appendectomy during her teenager years. Chest and abdominal examinations by computed tomography showed multiple spleens located on the right side and abnormal drainages of the superior and inferior vena cava. Left isomerism was diagnosed by bilaterally bilobed lungs. Because of a patent bilateral superior vena cava, pacemaker leads were implanted using the right cephalic vein approach. Her fainting symptoms disappeared after pacemaker implantation.

Utility of the 0-hour/1-hour high-sensitivity cardiac troponin T algorithm in Asian patients with suspected non-ST elevation myocardial infarction

BACKGROUND A rapid rule-out or rule-in protocol based on the 0-hour/1-hour algorithm using high-sensitivity cardiac troponin T is recommended by the European Society of Cardiology. However, Asian data are not available. METHODS This prospective cohort study included 413 patients with suspected non-ST elevation myocardial infarction in 3 hospitals in Japan and Taiwan from November 2014 to April 2017. Patients were divided into 3groups-rule-out, observe, and rule-in-according to the algorithm. Major adverse cardiovascular events were evaluated at the 30-dayfollow-up. RESULTS The algorithm ruled out acute myocardial infarction (AMI) in 171 patients with a negative predictive value and sensitivity of 100% (95% confidential interval [CI], 96.8%-100%) and 100% (95% CI, 88.0%-100%), respectively, in the rule-out group. None of the patients were diagnosed with AMI. Among the 127 patients classified into the rule-in group, 47 were diagnosed as having AMI. The positive predictive value and specificity were 33.1% (95% CI, 25.1%-41.9%) and 66.3% (95% CI, 60.2%-72.0%), respectively. Elective catheter intervention was required in 13 patients (5 in the rule-out group, 8 in the observe group) by the 30-dayfollow-up. The Framingham Risk Score (FRS) identified moderate risk in 5 patients and high risk in 8, while the Global Registry of Acute Coronary Events (GRACE) 2.0 risk score identified low risk in 6 patients and moderate risk in 7. CONCLUSION The ESC0-hour/1-hour algorithm could be sufficient in Asian patients. The combination with FRS may be more precise than that with the GRACE 2.0 risk score.

Simultaneous subacute coronary artery stent thrombosis in a carrier of two CYP2C19 loss–of function polymorphisms (*2/*3)

Clopidogrel, a second generation thienopyridine and a selective inhibitor of the platelet adenosine diphosphate (ADP) P2Y12 receptor, is the historical standard anti-platelet treatment added to aspirin following percutaneous coronary intervention (PCI) in order to reduce the risk of stent thrombotic complications. Clopidogrel is an inactive pro-drug that requires hepatic metabolism by cytochrome P450 2C19 (CYP2C19) into its active form in order to inhibit platelet aggregation. Recently, substantial subpopulations have been recognized that exhibit an inadequate response to clopidogrel leading to insufficient antiplatelet effects [1]. Individuals carrying at least one loss-of function allele (either *2 or *3) of the CYP2C19 gene demonstrate reduced active clopidogrel metabolites and suppressed antiplatelet activity [2]. Such patients have been identified to carry a significantly higher risk of stent thrombosis, a major adverse event that is associated with >60% risk of death or myocardial [3]. Of note, the stent thrombosis risk in patients carrying a CYP2C19 loss-of function allele appears to be similarly elevated across stable and unstable patient populations, regardless of elective or urgent PCI, or treatment with bare metal or drug-eluting stents [4,5]. A 61-year-old dyslipidemic, non-diabetic male with stable angina presented for elective cardiac catheterization. Coronary angiography showed complex multivessel disease consisting of a proximal RCA chronic total occlusion (CTO) with collateral flow from conus branch of RCA and a diagonal branch (Fig. 1a, white arrow), and severe proximal LAD stenosis (Fig. 1d, white arrow). Based on the angiographic results, we first treated the RCA-CTO lesion by deploying three overlapping drug eluting stents (DES) (Promus Premier, Boston Scientific)with proximal to distal sizes of 3.5 × 24 mm, 3.0 × 24 mm and 2.5 × 28 mm. The mid stent and proximal stent were then post-dilated with 3.0 mm and 3.75 mm diameter non-compliant balloons, respectively. Post-PCI intravascular ultrasound (IVUS) imaging confirmed good stent apposition with a sufficient stent/lumen diameter ratio in comparison to the proximal and distal reference vessel segments (Fig. 2, upper left panel). Four days later, staged PCI of the proximal LAD lesion was performed with implantation of a 3.0 × 23 mm DES (Xience Alpine, Abott Vascular) with post-dilatation using a 3.0 mm diameter noncompliant balloon. Similar to the RCA results, good stent apposition was shown by IVUS (Fig. 2, upper right panel). Both procedures were successful with no complications (Fig. 1b and e, white arrows). The patient was continued uninterrupted on treatment with dual-antiplatelet therapy consisting of aspirin 100 mg and clopidogrel 75 mg daily, which had been started 30 days prior to the index PCI without adverse effects. He was discharged to home without angina and in stable condition. Fig. 1 Coronary angiography at initial presentation for elective coronary stent placement, and following representation with ST elevation myocardial infarction due to subacute stent thrombosis. Before (a and d) and after (b and e) initial percutaneous coronary ... Fig. 2 Intravascular ultrasound (IVUS) after initial PCI and intracoronary optical coherence tomography (OCT) imaging of multivessel stent thrombosis. Upper panels: IVUS demonstrated good stent expansion and apposition to the vessel wall. Lower panels: Massive ... The day following discharge, the patient developed sudden-onset severe chest pain and diaphoresis at rest. He presented within 2 hours of symptom onset in hemodynamically stable condition (blood pressure 157/92 mmHg, heart rate 83 beats per minute). The electrocardiogram revealed new ST elevations (>2 mm) with inverted T waves in V1 through V3, and stat echocardiography showed severe hypokinesis of the mid-distal-apical anterior wall. Blood tests returned with leukocytosis (12,500 cells/µl). Emergent coronary angiography for acute anterior ST elevation myocardial infarction (STEMI) was performed after administration of unfractionated heparin 5000 units, supported by an intra-aortic balloon pump (IABP), that showed thrombotic occlusion of both the RCA (Fig. 1c, black arrowhead) and LAD stents (Fig. 1f, black arrowhead). Given the clopidogrel failure, a loading dose of prasugrel (20 mg) was orally administered. GPIIb/IIIa inhibitor was not used. We then proceeded to restore flow in the LAD by passing a coronary guidewire through the stent and performing manual aspiration thrombectomy followed by subsequent percutaneous transluminal angioplasty (PTCA) with a 3.0 mm diameter balloon within the stent. Intracoronary optical coherence tomography demonstrated massive thrombus within the LAD stent despite excellent stent strut apposition throughout (Fig. 2, lower right panel). After achieving TIMI3 flow in the LAD (Fig. 1f, right bottom corner), we moved to treat the RCA with aspiration and PTCA in similar fashion resulting in return of TIMI3 flow in RCA (Fig. 1c, right bottom corner). Intracoronary OCT imaging in the RCA also showed massive thrombus in the distal stent (Fig. 2, lower left panel). The patient was discharged day 16 post-PCI on a medical regimen of an αβ-blocker (carvedilol, 5 mg once daily), an angiotensin converting enzyme inhibitor (Perindopril erbumine, 2 mg once daily) and dual anti-platelet therapy with prasugrel 3.75 mg and aspirin 100 mg once daily. At four months follow-up, the patient has been doing well without any evidence of recurrent myocardial ischemia. Genotyping of CYP2C19 gene polymorphyrisms revealed that the patient carries two reduced-function alleles (*2/*3) of the CYP2C19 gene, and he was thus defined as a poor clopidogrel metabolizer. In this case, the patient carried two non-functioning polymorphisms (*2/*3) of the CYP2C19 gene, a deficit known to result in critically reduced clopidogrel antiplatelet activity, that precipitated simultaneous subacute stent thrombosis of two major epicardial coronary arteries. The frequency for the most common loss-of-function variant CYP2C19*2 is <15% in Caucasians and Africans, but affects up to 35% of those of Asian descent; in comparison, CYP2C19*3 is the second-most common genetic mutation, occurring in fewer than 10% of Asians [1]. Therefore, especially in Asian population, the number of patients defined as a “poor clopdigrel metabolizer” carrying the CYP2C19*2/*2 or *2/*3 polymorphisms may be higher than previously postulated. To date, cardiovascular society guidelines recommend against routine gene testing for CYP2C19 polymorphisms for patients treated with clopidogrel after PCI [6,7], primarily because a priori knowledge of CYP2C19 genetic mutations or the results of platelet function testing have not demonstrated an improvement in outcomes [8]. However, while clinical trials may be equivocal, in certain high-risk individual patients, as presented in this case of an Asian patient undergoing elective complex PCI and suffering simultaneous subacute stent thromobisis, it might be reasonable to perform risk estimation using genetic screening or platelet reactivity testing before coronary stenting. In carriers of *2 and/or *3 alleles of CYP2C19 that have less or no CYP2C19 enzymatic activity (intermediate and poor metabolizers) on standard doses of clopidogrel (75 mg daily), two alternative strategies have been considered: 1) increasing the clopidogrel dose by two- to four-fold [9], which more potently decreases platelet activity but has not been proven to reduce cardiovascular events [10], or 2) the preferred approach of switching to alternative P2Y12 inhibitors, such as the third generation thienopyridines prasugrel and ticagrelor that are less influenced by polymorphisms of the CYP2C19 gene. For prasugrel, carriers of the CYP2C19*2 allele are known to produce equivalent concentrations of active prasugrel metabolite and achieve a similar antiplatelet effect to those that do not carry this allele [5]. In this patient, clopidogrel was replaced by prasugrel with no clinical or adverse events observed in early follow up. Based on the clinical course of this case and related evidence, we suggest that when elective PCI is planned in certain patients at high risk for CYP2C19 polymorphisms, such as those of Asian decent, that are also at high risk for critical stent thrombosis due to complex multivessel or left main coronary artery disease, that physicians consider performing genetic testing for CYP2C19 polymorphisms or platelet function testing to evaluate the potential risk of using clopidogrel, or to simply use a third generation thienopyridine primarily.

Reevaluation of cardiac risk scores and multiple biomarkers for the prediction of first major cardiovascular events and death in the drug-eluting stent era

BACKGROUND Risk scores and cardiac biomarker tests allow clinicians to accurately diagnose acute coronary syndrome (ACS) and perform early risk stratification. However, few investigations have evaluated the use of these risk scores and biomarkers for predicting risk of cardiovascular events in drug-eluting stent (DES) era. METHODS This prospective cohort study included 861 patients with ACS. Three risk scores-Global Registry of Acute Coronary Events (GRACEs), Platelet glycoprotein IIb/IIIa in Unstable angina: Receptor Suppression Using Integrilin, and Thrombolysis In Myocardial Infarction-and levels of four biomarkers-N-terminal pro-B-type natriuretic peptide (NT pro-BNP), high-sensitivity troponin T, heart-fatty acid binding protein, and high-sensitivity C-reactive protein-were recorded on admission. Major adverse cardiac events (MACE) (death, cardiovascular events) were evaluated at 30-day and 1-year follow-up. RESULTS At 30-day follow-up, there were 23 (3.1%) deaths from cardiovascular events and 4 (0.5%) cerebral accidents. NT pro-BNP levels and GRACE score were strong MACE predictors, with adjusted odds ratios (ORs) (95% CI) of 2.90 (1.63-5.20) and 1.01 (1.00-1.02), respectively, in logistic model. The C-statistic of NT pro-BNP (0.77; 95% CI, 0.67-0.86) was similar to that of GRACE score (0.76; 95% CI, 0.66-0.87); however, the combined C-statistic was higher (0.81), yielding a net reclassification improvement of 13% (p<0.01). At 1-year follow-up, there were 51 (6.8%) deaths and 10 (1.3%) cerebral accidents. CONCLUSION In the DES era, GRACE score and biomarkers can still predict major cardiac events in patients with ACS for both acute and long-term prognoses.

The use of serum bepridil concentration as a safe rhythm control strategy in patients with atrial tachyarrhythmias

The aim of this study was to evaluate the clinical significance of serum bepridil (Bep) concentration (SBC) for safely managing patients with atrial tachyarrhythmias (AT).

Infective endocarditis associated with acute myocardial infarction caused by septic emboli

A 53-year-old Japanese man presented with severe chest pain. He had suffered from persistent fever, muscle pain, arthralgia, and dyspnea on exertion (New York Heart Association class I) for two and half months prior to admission. He had been treated with several antibiotics for two months and prednisolone for almost one month prior to admission. On the day of admission, he had suffered from chest pain at rest, and had come to our hospital. Electrocardiography showed a normal sinus rhythm with significant ST segment elevation in leads V3-6 and abnormal Q waves in leads V4-6. Transthoracic echocardiography demonstrated left ventricular ejection fraction of 52% with severe mitral regurgitation and an 18-mm vegetation on the anterior mitral valve leaflet. Multiple blood cultures identified Streptococcus sanguis. The diagnosis was acute myocardial infarction and mitral regurgitation associated with infective endocarditis (IE). The incidence of acute coronary syndrome caused by IE is quite low in patients with native valves. After a 6-week course of antibiotics, mitral valve replacement and partial cardiomyotomy were performed. Two years after the surgery, follow-up echocardiography showed almost normal left ventricle function and no mitral regurgitation, and the patient has been living an active life without any complications.

Stability of intrinsic rhythm in pacemaker-dependent patients during pacemaker replacement: Can we predict the need for temporary pacing?

In pacemaker‐dependent patients, the risk of asystole must be managed during device replacement. This study aimed to examine whether we could predict the indication for temporary pacing (TP) during the generator replacement.

Watching National Team Matches in World Cup Soccer 2014 on Television was Associated with Increasing Frequency of Premature Ventricular Contractions

Objective: Psychological triggers, such as emotional stress, increase the incidence of acute cardiovascular events. The association between soccer championships and risk of cardiovascular events remains controversial. A World Cup Soccer (WCS) match involving a national team might be a strong enough trigger to induce cardiovascular events. However, there are no reports of a multicenter study that has investigated the relationship between watching WCS and cardiac arrhythmia. Methods: We assessed 25 patients who were evaluated for ischemic changes and/or arrhythmia using 24-h Holter electrocardiography in four cardiology divisions during WCS 2014. The patients were divided into two groups: the watching (W) group consisted of 7 patients who watched WCS on live television and the Non-Watching (NW) group consisted of 18 patients who did not watch WCS. Heart rates, arrhythmia, and ischemic changes were evaluated. Results: There were no differences in the clinical characteristics, heart rates, premature atrial contraction frequencies, and ischemic changes between the two groups. Although there were no differences in total Premature Ventricular Contractions (PVCs), the frequency of PVCs during matches (61 ± 101 vs. 7 ± 8, P = 0.03) and 1 hour before matches (15 ± 17 vs. 3 ± 5, P = 0.01) were significantly higher in the W group than in the NW group. No sustained ventricular tachycardia or fibrillation was observed. Conclusions: A significant association between watching WCS and frequency of PVCs was observed in patients with/or suspected of having cardiovascular disease. Received Date: February 13, 2016 Accepted Date: March 28, 2016 Published Date: April 01, 2016 Citation: Shimada, K., et al. Watching National Team Matches in World Cup Soccer 2014 on Television was Associated with Increasing Frequency of Premature Ventricular Contractions. (2016) J Heart Cardiol 2(1): 17-21. DOI: 10.15436/2378-6914.16.022 Journal of Heart and Cardiology Open Access Review Article Copyrights:

Clinical Evaluation of Celiprolol in the Treatment of Atrial Tachyarrhythmias

SummaryThe results of the Cardiac Arrhythmia Suppression Trial warn against the use of class Ia and Ic antiarrhythmic agents as first-line therapy for arrhythmia. The objective of the present study was to evaluate the efficacy of celiprolol, a β-blocker, in patients with supraventricular arrhythmia. Celiprolol (200 mg/day) was administered for a mean duration of 90 days (range: 32 to 128 days) to 30 patients with supraventricular arrhythmia, including 7 with chronic atrial fibrillation associated with bradycardia, 18 with paroxysmal atrial fibrillation, and 5 with premature atrial contraction (PAC). The antiarrhythmic effect of celiprolol was assessed based on changes in symptoms and heart rate determined by Holter ECG. After celiprolol therapy, arrhythmic symptoms improved in 60% of the patients. The post-treatment Holter ECG showed a decrease in the daily maximum, but not minimum, heart rate, a good control of heart rate in patients with atrial fibrillation, and a decrease of PACs. Importantly, bradycardia improved even in patients with chronic atrial fibrillation who concomitantly received digitalis. Celiprolol exerted an adequate antihypertensive effect in hypertensive patients but did not affect normal blood pressure. In conclusion, celiprolol may be used as first-line therapy for the treatment of patients with supraventricular arrhythmia.