Yoshihiro Himura

Increased thrombin–antithrombin III complex during an episode of paroxysmal atrial fibrillation

Thrombin-antithrombin III complex (TAT) is a marker of thrombin generation, indicating increased coagulability. To investigate whether paroxysmal atrial fibrillation (PAf) is associated with an increased coagulation system, we measured TAT within 24 h after the documentation of PAf in 50 patients with structurally normal hearts. The mean age of the study population was 62 years old. In 32 patients, PAf was documented during routine physical examinations, electrocardiograms or echocardiograms and in the remaining 18 patients, it was reproducibly documented on more than two Holter electrocardiograms. Group I consisted of 38 TAT data sets from 38 patients who did not receive anticoagulant therapy during PAf episodes. At least one week after starting anticoagulant therapy, TAT was measured again in ten patients in whom there was evidence of PAf on the day of measurement. In the remaining 12 patients, PAf occurred while the patients were receiving anticoagulation. Group II consisted of 22 TAT data sets from 22 patients who received anticoagulation during PAf episodes. The average TAT value was 5.8 ng/ml in group I, while it was 2.8 ng/ml in group II (P<0.0001). TAT was greater than 5 ng/ml in 15 of the 38 patients in group I, and in four of the 22 patients in group II. In 20 symptomatic patients, we measured TAT again when the patients maintained sinus rhythm under the same anticoagulant therapy; four patients were receiving and 16 patients were not receiving anticoagulation therapy. TAT decreased from 6.4 to 2.3 ng/ml on average when PAf disappeared and sinus rhythm was maintained (P=0.0009). Increase in the coagulation system occurred transiently during or shortly after PAf episodes in about 40% of PAf patients. As patients with prior anticoagulation had a relatively low TAT value, anticoagulant therapy might be useful in patients with PAf.

Influence of gravity on pulmonary venous flow velocity patterns: Analysis of left and right pulmonary venous flow velocities in left and right decubitus positions

BACKGROUNDnThe pulmonary venous flow signal measured by transesophageal echocardiography is generally recorded from the left upper pulmonary vein in the left lateral decubitus position, whereas that by transthoracic echocardiography is from the right upper pulmonary vein in the left semi-lateral decubitus position. The purpose of this study was to evaluate the influence of the postural change on the peak flow velocities of the left and right pulmonary veins and whether the parameters of the left and right pulmonary venous flow can be used interchangeably.nnnMETHODS AND RESULTSnThe study group consisted of 37 patients with normal left ventricular filling pressure and in whom the systolic forward flow signals from both pulmonary veins recorded in the left and right lateral decubitus positions were clear enough to differentiate as biphasic. The peak early systolic (peak S1) and diastolic velocities were significantly increased when the pulmonary vein was on the recumbent subjects upper side, whereas the peak late systolic velocity (peak S2) was significantly increased when the pulmonary vein was on the recumbent subjects lower side. The peak S1 was higher than the peak S2 when the pulmonary vein was on the recumbent subjects upper side, whereas the reverse relation was seen when the pulmonary vein was on the recumbent subjects lower side.nnnCONCLUSIONSnWe should take into consideration the body position and the side on which the pulmonary vein is situated in evaluating the peak flow velocities of the pulmonary veins.

Abnormal cardiac sympathetic nerve function in a patient with pheochromocytoma. An analysis using 123I metaiodobenzylguanidine scintigraphy

A 23-year-old woman with pheochromocytoma had a high level of plasma norepinephrine (NE) (6039 pg/ml) and 123I metaiodobenzylguanidine (MIBG) scintigram showed decreased myocardial retention. After surgical resection, plasma norepinephrine was normalized and the myocardial retention of 123I MIBG gradually improved. These findings suggest that the possibility that the excess of circulating norepinephrine caused by pheochromocytoma could damage the cardiac sympathetic nerve function and 123I MIBG scintigraphy is a useful method of evaluating abnormalities.

Mitral valve nonbacterial thrombotic endocarditis: a rare multi-surgery-tolerant survivor of Trousseau’s syndrome

BackgroundFew previous reports have documented cases of nonbacterial thrombotic endocarditis associated with Trousseau’s syndrome for which surgery proved possible for both the primary tumor and the cardiac lesion. The effectiveness of direct oral anticoagulants in patients with Trousseau’s syndrome has also received scant attention.Case presentationA 69-year-old man with repeated episodes of cerebral infarction was diagnosed as having nonbacterial thrombotic endocarditis after mitral valve replacement surgery. Stroke recurred preoperatively under apixaban administration. A stomach biopsy also identified gastric adenocarcinoma, and gastric surgery was performed on the 40th postoperative day. The patient was discharged from the hospital and has been free of thromboembolism under a regime of subcutaneous heparin self-injection thereafter.ConclusionsWe have reported a rare multi-surgery-tolerant survivor of Trousseau’s syndrome in whom subcutaneous heparin injection was useful for preventing thromboembolic events over a long period.

Platypnea-orthodeoxia syndrome associated with aortic insufficiency and aortic elongation

An 81‐year‐old female developed dyspnea only upon assuming a sitting position. Trans‐esophageal echocardiography demonstrated left‐to‐right shunt flow across the atrial septum when the patient was sitting, and right‐to‐left shunt flow when she was supine, along with severe aortic insufficiency. She was diagnosed as having platypnea‐orthodeoxia syndrome and her symptoms were completely resolved following aortic valve replacement, closure of a patent foramen ovale, and shortening of an elongated ascending aorta.

Very long-term follow-up data of non-ischemic idiopathic dilated cardiomyopathy after beta-blocker therapy: recurrence of left ventricular dysfunction and predictive value of 123I-metaiodobenzylguanidine scintigraphy

The management of idiopathic dilated cardiomyopathy (DCM) is well established. However, a subset of patients do not have recovery from or have recurrences of left ventricular (LV) dysfunction despite receiving optimal medical therapy. There are limited long-term follow-up data about LV function and the predictive value of iodine-123-metaiodobenzylguanidine (123I-MIBG) scintigraphy, especially among the Japanese population. We retrospectively investigated 81 consecutive patients with DCM (mean LV ejection fraction (EF) 28u2009±u20097.5%) who had undergone 123I-MIBG scintigraphy before starting β-blockers. According to chronological changes in LVEF, study patients were classified into three subgroups: sustained recovery group, recurrence group, and non-recovery group. The outcome measure was cardiac death. Mean age was 59u2009±u200911xa0years and median follow-up was 11.5 (5.8–15.0)xa0years. Thirty-six patients had recovery, 11 had recurrences, and 34 did not have recovery. The sustained recovery group had the best cardiac death-free survival, followed by the recurrence and non-recovery groups. Prolonged time to initial recovery was associated with recurrence of LV dysfunction. Large LVxa0end-diastolic diameter and reduced heart to mediastinum ratio were associated with poor prognosis. In conclusion, with β-blocker therapy, 14% of patients showed recurrences of LV dysfunction. Thus, careful follow-up is needed, keeping in mind the possibility of recurrence, even if LVEF once improved, especially in patients whose time to initial recovery was long. 123I-MIBG scintigraphy provides clinicians with additional prognostic information.

Calcified Masses in the Inferior Vena Cava

Received October 12, 2017; revised manuscript received March 1, 2018; accepted March 27, 2018; released online June 6, 2018 Time for primary review: 68 days Department of Cardiovascular Surgery (Y.S., H.K., T.S., K.D.), Department of Radiology (M.W.), Nagahama City Hospital, Nagahama; Department of Cardiology, Hikone Municipal Hospital, Hikone (N.M., A.N., Y.H.), Japan Mailing address: Yoshiharu Soga, MD, PhD, Director, Department of Cardiovascular Surgery, Nagahama City Hospital, 313 Oh-inui-cho, Nagahama 526-8580, Japan. E-mail: sogakin@dd.iij4u.or.jp ISSN-1346-9843 All rights are reserved to the Japanese Circulation Society. For permissions, please e-mail: cj@j-circ.or.jp Calcified Masses in the Inferior Vena Cava

143 AUGMENTATION INDEX IN RADIAL ARTERY AS CENTRAL HEMODYNAMIC INDEX IS INDEPENDENT VARIABLE FOR AORTIC CALCIFICATION

Background: The aim of this study was to elucidate whether coronary artery and aortic calcification is associated with central hemodynamic indexes. Methods: The subjects consisted of 105 patients with suspected coronary artery disease who underwent multi-detector row computed tomography. Calcification of thoracic aorta and coronary artery was evaluated by the method of Agatston. Central hemodynamic indexes including central blood pressure (CBP), augmentation index in radial artery (AIx) were measured by radial artery tonometry. Results: The patients with aortic calcification (65%) and patients without it (35%) were analysed by univariate analysis. Patients with aortic calcification were older (p<0.001), had higher pulse pressure (p=0.006), higher AIx (p<0.001), and bigger brachial-ankle pulse wave velocity (PWV) (p=0.002). In a multivariate logistic regression analysis, age (odds ratio(OR):14.8, 95% confidence interval(CI) 0.05–0.17) and AIx (OR:4.2, 95%CI 0.01–0.09) were significant independent variables for aortic calcification. Next, patients with coronary artery calcification (47%) and patients without it (53%) were analysed by univariate analysis. Patients with coronary artery calcification were older (p<0.001), had higher prevalence of hypertension (p=0.01), lower brachial diastolic pressure (p=0.02), and bigger PWV (p=0.03). In a multivariate analysis, prevalence of hypertension (OR:4.2, 95%CI 0.02–0.91) and brachial diastolic pressure (OR:4.8, 95%CI 0.004–0.09) were significant independent variables for coronary artery calcification. Conclusions: AIx as central hemodynamic index was independent variable for aortic calcification. In this study, coronary artery calcification was not associated with central hemodynamic indexes. These data may indicate that patients with high central hemodynamic indexes have aortic stiffness rather than coronary arterial stiffness.