Yasuro Nakata

Effectiveness of an antioxidant in preventing Restenosis after percutaneous transluminal coronary angioplasty : The Probucol Angioplasty Restenosis Trial

OBJECTIVES The Probucol Angioplasty Restenosis Trial was a prospective, randomized, controlled study that investigated the effectiveness of probucol therapy in reducing the rate of restenosis after percutaneous transluminal coronary angioplasty (PTCA). BACKGROUND Antioxidants have an inhibitory effect on smooth muscle cell growth in experiments in vitro and in vivo, which suggests a possible pharmacologic effect on restenosis after PTCA. METHODS One hundred one patients were randomly assigned to receive 1,000 mg/day of probucol or control (no lipid-lowering) therapy 4 weeks before PTCA. After 4 weeks of premedication, both groups underwent PTCA. Probucol was continued until follow-up angiography 24 weeks after PTCA. Angiographic results were analyzed at a core laboratory by quantitative coronary angiography. RESULTS Dilation was successful in 46 of 50 patients in the probucol group and 45 of 51 in the control group. At follow-up angiography 24 weeks after angioplasty, angiographic restenosis occurred in 9 (23%) of 40 patients in the probucol group and 22 (58%) of 38 in the control group (p = 0.001). Minimal lumen diameter was 1.49 +/- 0.75 mm (mean +/- SD) in the probucol group and 1.13 +/- 0.65 mm in the control group (p = 0.02). Percent diameter stenosis at follow-up angiography in the probucol group was significantly lower than that in the control group (43.9% vs. 56.4%, p = 0.009). The late loss was 0.37 +/- 0.69 mm in the probucol group and 0.60 +/- 0.62 mm in the control group (p = 0.13). The loss/gain ratio was 0.32 +/- 0.74 in the probucol group and 0.56 +/- 0.81 in the control group (p = 0.059). Net gain was greater in the probucol group than in the control group (0.77 +/- 0.70 vs. 0.48 +/- 0.59 mm, p = 0.053). CONCLUSIONS Probucol administered beginning 4 weeks before PTCA appears to reduce restenosis rates.

Cardiac hemangioma: a report of two cases and review of the literature

Cardiac hemangioma is extremely rare. We encountered two patients with cardiac hemangioma detected by thoracic echocardiography during a medical checkup. In the first case, transthoracic echocardiography revealed a pedunculated tumor in the left ventricle. Selective left coronary angiography demonstrated that the main feeding artery of the tumor arose from the third diagonal branch of the left anterior descending coronary artery. In the second case, thoracic and transesophageal echocardiography showed an oval tumor arising from the right atrium. Both tumors were successfully resected. Histopathological examination revealed that one of the tumors was a capillary hemangioma and the other was a mixed capillary and cavernous hemangioma. After operation, both patients had an uneventful recovery without any complications.

Effect of probucol on repeat revascularization rate after percutaneous transluminal coronary angioplasty (from the Probucol Angioplasty Restenosis Trial [PART])

To address the issue of whether probucol reduces clinical events after percutaneous transluminal coronary angioplasty (PTCA), we surveyed clinical status at 1 year after PTCA of 101 patients who had entered the Probucol Restenosis Angioplasty Trial. Repeat angioplasty at index lesions were required in 5 patients in the probucol group and in 12 in the control group, suggesting that probucol administered beginning 4 weeks before PTCA reduces repeat revascularization rates for 1 year.

Clinical and Electrophysiological Characteristics of Atrial Standstill

NAKAZATO, Y., et al.: Clinical and Electrophysiological Characteristics of Atrial Standstill. To clarify the clinical and electrophysiological characteristics of atrial standstill (AS) we studied 11 patients (7 males and 4 females), whose average age was 62 years and who were followed over a period of 4–179 months. Underlying heart disease was present in nine patients and two cases were idiopathic. Major clinical symptoms in the 11 cases included Adams‐Stokes attacks, and dyspnea on exertion. In the standard 12‐lead ECGs obtained on admission, the P wave was absent in six cases. Atrial flutter (AF) was noted in 3, atrial fibrillation (Af) in 1, and multifocal atrial tachycardia in 1. In some cases, the ECG initially showed AF or Af, and was transformed after several years into ectopic atrial tachycardia or an ectopic atrial rhythm with a markedly decreased amplitude of the P wave. Finally, the P wave disappeared over a prolonged period. When intracardiac mapping was performed, the atrial electrograms tended to diminish at the site of high, mid‐lateral right atrium (RA). Electrograms were remained present in the vicinity of the tricuspid valve (TV) annulus. A repeated mapping and pacing study conducted in two patients revealed that the “silent” area spread toward the lower site of RA. During the average follow‐up period of 64 months, four patients died. The interval until death in one patient with myocarditis was 6 months, and in another with dilated cardiomyopathy (DCM) it was 8 months. It appears that the atrial muscular lesion starts in the high lateral RA and progresses toward the lower RA, then to the vicinity of the TV annulus. A diffuse and progressive disturbance may occur not only in the atrial muscle, but also in the atrioventricular conduction system in patients with AS who had progressive myocarditis or DCM.

Response to head-up tilt testing in patients with situational syncope.

The results of head-up tilt testing were compared between 24 patients with situational syncope and 44 age-matched patients with typical vasovagal syncope. Patients with situational syncope showed poor positive responses, especially in the passive tilt results (8.3% vs. 39%, p = 0.0078).

Clinical Significance of QRS Duration During Ventricular Pacing

To clarify the clinical significance of an abnormally prolonged paced QRS duration, we studied 114 patients who had undergone pacing for atrioventricular block (AVB). Patients were divided into two groups: group I consisted of 29 patients with at least one paced QRS duration ≥ 180 msec during the follow‐up period; group II consisted of 85 patients with paced QRS durations < 180 msec. The clinical background, QRS complexes before pacing, and the echocardiographic findings were assessed. Males (P < 0.05), those with H‐V block (P< 0.05) and a wider QRS complex of conducted and escape beats (both P < 0.01) were dominant in group I. The incidence of underlying heart disease was greater in group I than in group II (83% vs 32%, P < 0.01). Reduced left ventricular ejection fraction (LVEF) and increased left ventricular end‐diastolic dimension (LVDd) were more prominent in group I than in group II (LVEF 0.49 ± 0.17 vs 0.68 ± 0.10, P < 0.01, LVDd 57.1 ± 7.9 mm vs 48.5 ± 5.6 mm, P < 0.01). The paced QRS duration correlated with LVEF (r = ‐0.61) and LVDd (r = 0.81). A paced QRS duration ≥ 180 msec was sensitive and specific for a LVEF < 0.5 (83.3% and 85.2%) and LVDd ≥ 60 mm (100% and 81.4%). We conclude that patients with a prolonged paced QRS duration have more serious heart disease, and the paced QRS duration can be a useful indicator of impaired LV function.

Does an Early Increase in Heart Rate During Tilting Predict the Results of Passive Tilt Testing

Head‐up tilt testing is a useful but time‐consuming procedure. If we could accurately predict the tilt testing results; we would be able to substantially shorten the duration of tilt protocol. To clarify the hypothesis that an early increase in heart rate (HR) during tilting can predict the passive tilt results in our protocol (80‐degree angle for 30 minutes), we studied 115 consecutive patients (72 men, 43 women, mean age 46 ± 19 years) who were clinically diagnosed with neurally mediated syncope. Twentynine (25%) patients had a positive tilt test (P group), whereas 86 (75%) patients had a negative test (N group). The early HR increase was defined as the maximum HR during the first 5 minutes of tilting minus the resting HR before tilting. The early HR increase was significantly higher in the P group (23.8 ± 9.5 beats/min) than in the N group (17.5 ± 8.2 beats/min, P = 0.0008), but it was negatively correlated with the tilt duration to positive response (r =−0.52, P = 0.0032) and the patient age in the entire study population (r = 0.62, P < 0.0001). Results of multiple regression analysis indicated that age, tilt result, and tilt duration were independently associated with the early HR increase. As a result, an early HR increase ± 18 beats/min, the best apparent cut‐off point obtained in our study, was a sensitive (100%) marker for prediction of a positive response at ± 15 minutes of tilting, but it showed a low specificity (61 %). In conclusion, an early HR increase during 80‐degree tilting may be only predictive for a positive result ± 15 minutes because it depends on the tilt duration to a positive response and patient age.

ST segment elevation in the right precordial leads following administration of class Ic antiarrhythmic drugs.

Electrocardiographic changes were evaluated retrospectively in five patients without previous episodes of syncope or ventricular fibrillation who developed abnormal ST segment elevation mimicking the Brugada syndrome in leads V1–V3 after the administration of class Ic antiarrhythmic drugs. Pilsicainide (four patients) or flecainide (one patient) were administered orally for the treatment of symptomatic paroxysmal atrial fibrillation or premature atrial contractions. The QRS duration, QTc, and JT intervals on 12 lead surface ECG before administration of these drugs were all within normal range. After administration of the drugs, coved-type ST segment elevation in the right precordial leads was observed with mild QRS prolongation, but there were no apparent changes in JT intervals. No serious arrhythmias were observed during the follow up periods. Since ST segment elevation with mild QRS prolongation was observed with both pilsicainide and flecainide, strong sodium channel blocking effects in the depolarisation may have been the main factors responsible for the ECG changes. As the relation between ST segment elevation and the incidence of serious arrhythmias has not yet been sufficiently clarified, electrocardiographic changes should be closely monitored whenever class Ic drugs are given.

A case of dislodged atrial screw-in lead with migration to the ventricle 1 year postoperatively.

We report a rare case of a 53‐year‐old woman with a dislodged atrial screw‐in lead that migrated to the ventricle 1 year after pacemaker implantation. While such an event is quite unusual, we should be aware of its possibility.

Paroxysmal Atrioventricular Block Induced During Head‐Up Tilt Testing in an Apparently Healthy Man

Paroxysmal AV Block During HUT Testing. Introduction: Prolonged asystole during head‐up tilt testing has been reported, but the occurrence of paroxysmal AV block appears to he rare.