Clinical Significance and Prognosis of Right Heart Thrombi Associated With Acute Pulmonary Thromboembolism　- Results of a Multicenter Registry of Thrombolysis in Japan.

BACKGROUND: Thrombolytic therapy is standard treatment in acute pulmonary thromboembolism (PTE) with hemodynamic instability. Although right heart thrombi (RHT) appear to increase mortality in acute PTE, large-scale studies of acute PTE with RHT are scarce.Methods and Results:Patient data (from August 2005 to May 2014) obtained from post-marketing surveillance of thrombolytic therapy using a tissue-type plasminogen activator were analyzed retrospectively. Of the 2,698 confirmed cases of acute PTE who underwent echocardiographic assessment, 166 (6.2%) were diagnosed with RHT. PTE patients with RHT, compared with those without RHT, had higher rates of mortality (20.2% vs. 10.4%, P<0.001), hemodynamic instability (53.0% vs. 37.7%, P<0.001), and PTE recurrence (6.6% vs. 2.3%, P=0.003). When considering PTE-related hemodynamic severity (cardiopulmonary arrest/collapse, massive, submassive, and non-massive), mortality was significantly higher in patients with RHT in the massive (19.8% vs. 7.7%, P=0.002) and submassive (8.0% vs. 2.8%, P=0.018) groups, whereas no significant differences was found between those with and without RHT in the cardiopulmonary arrest/collapse (51.7% vs. 52.1%, P=0.960) and non-massive (1.6% vs. 0%, P=0.596) groups. CONCLUSIONS: PTE patients with RHT had higher mortality, severity, and PTE recurrence rates. RHT was particularly associated with worse outcomes in patients with massive or submassive PTE.

Late lumen enlargement after drug-coated balloon angioplasty for de novo coronary artery disease.

We aimed to identify predictors of late lumen enlargement (LLE) after drug-coated balloon (DCB) angioplasty for de novo coronary lesions. LLE, which is defined as an increase in the luminal diameter of the vessel from the immediate postprocedural measurement to follow-up measurements, is frequently observed after DCB angioplasty for de novo coronary artery disease. No predictors of LLE are known. This retrospective observational study analyzed 196 de novo coronary lesions in 182 patients who underwent both DCB angioplasty and follow-up angiography. Of the 196 lesions, 109 (56%) developed LLE during a mean follow-up period of 7.2 ± 2.5 months. As defined by American College of Cardiology (ACC)/American Heart Association (AHA) lesion types, lesions with LLE were significantly less severe than lesions without LLE (types A, B1, B2 and C 15%, 35%, 38% and 13% vs. 7%, 24%, 45% and 24%, respectively; p = 0.036), although no significant differences in clinical or other lesion background characteristics were observed between the groups. Among type C lesions, chronic total occlusion (CTO) was more frequently observed in lesions with LLE than in lesions without LLE (79% vs 43%, p = 0.036). Lesion severity predicts LLE after DCB angioplasty for de novo coronary artery disease. Among type C lesions, CTO is expected in lesions showing LLE, and preparations should therefore be made prior to DCB application. Further research is needed.

Drug-coated balloon angioplasty for de novo small vessel disease including chronic total occlusion and bifurcation in real-world clinical practice.

The aim of this study is to validate the efficacy of drug-coated balloons (DCBs) for real-world de novo small vessel diseases including chronic total occlusion and bifurcation. DCB angioplasty has been reported to be effective in the treatment of de novo small vessel disease. However, the number of reports that have focused on complex lesions is limited. This observational study comprised consecutive patients who underwent DCB angioplasty for de novo small vessel disease with a reference diameter of less than 2.5 mm by visual estimation. Outcome parameters included late lumen loss, restenosis rate, and major adverse cardiac events, such as cardiac death, non-fatal myocardial infarction, and target lesion revascularization (TLR). Fifty-two patients underwent DCB angioplasty for 59 lesions with a reference vessel diameter of 1.93 ± 0.63 mm. Thirty-eight of the lesions (69%) were classified as type B2/C, including chronic total occlusions (20%) and bifurcations (33%). At the 8-month follow-up, late lumen loss was - 0.01 ± 0.44 mm with a restenosis rate of 20%. No cardiac deaths or myocardial infarctions were reported and only 5 (9%) angiographically driven TLRs were reported. DCB angioplasty offered an acceptable 8-month lumen patency and a stable clinical outcome for real-world complex de novo coronary diseases.

Perforation of the hypopharynx after transesophageal echocardiography.

A 65-year-old obese woman with an oversized neck and dysphagia underwent transesophageal echocardiography (TEE). The procedure was complicated by difficulty in insertion from the pharynx to esophagus, and her head and neck gradually swelled. Computed tomography (CT) revealed extensive emphysema from the neck to superior mediastinum, which suggested pharyngeal perforation. A nasogastric tube was inserted, and the patient received antibiotics to prevent secondary mediastinitis. CT performed 1 week later showed improvement of emphysema and no evidence of mediastinitis. Perforation along the orogastric pathway during TEE is a rare but life-threatening complication to which physicians performing TEE should pay attention.

Clinical features of Mycoplasma pneumoniae infections in the 2010 epidemic season: report of two cases with unusual presentations.

Mycoplasma pneumoniae (Mp) is one of the main pathogens causing community-acquired pneumonia, particularly in young individuals. Host immune response appears to play an important role in prolonged symptoms, as well as in the recent increasing prevalence of drug-resistant Mp isolated from patients. Case 1 had a prolonged clinical course caused by drug-resistant Mp and received steroid therapy despite Mp susceptibility to some antimicrobial agents. Serum cytokine profiles revealed elevation of interleukin-6/-10 and interferon-γ in acute phase. Case 2 had mycoplasmal myocarditis without any respiratory symptoms, which resolved spontaneously without the administration of any antimicrobial agent. These observations suggest that host immune response probably contributes to the etiology of Mp-associated complications.

Evaluating microvascular obstruction after acute myocardial infarction using cardiac magnetic resonance imaging and 201-thallium and 99m-technetium pyrophosphate scintigraphy.

BACKGROUND: Few studies have compared the ability of cardiac magnetic resonance (CMR) with that of scintigraphy using 201-thallium (201-Tl) and 99m-technetium pyrophosphate (99m-Tc PYP) to evaluate microvascular obstructions (MOs). In the present study the relationship between the scintigraphic and CMR characteristics of MOs after acute myocardial infarction (MI) was examined. METHODS AND RESULTS: The 14 patients (age 69±8 years, 11 males) underwent 201-Tl/99m-Tc PYP SPECT 7±3 days, initial CMR 16±12 days, and follow-up CMR 193±20 days after a reperfused first acute MI. Each image was analyzed using a 17-segment model. Segmental extent of delayed enhancement (DE), wall motion (WM) and degree of 201-Tl uptake were scored in 238 segments. Of 91 MI segments, MO was recognized in 22 (25%) segments on CMR. WM was significantly better in proportion to 201-Tl uptake (P=0.01) in MO segments. All 8 MO segments with WM improvement at follow-up had 99m-Tc PYP uptake, although only 3 (21%) of 14 MO segments that did not show WM improvement at follow-up had 99m-Tc PYP uptake (P=0.001). CONCLUSIONS: 99m-Tc PYP and 201-Tl scintigraphy have the potential to predict WM status and improvement of the MO region after reperfused acute MI.