Continuous drainage for the treatment of gastric cancer with pericardial metastasis and cardiac tamponade: A case report.

Key Clinical Message: Signet-ring cell gastric carcinomas presenting as pericardial effusion early in diagnosis are rare and associated with high mortality and a poor prognosis. There are two interesting aspects of this case: primary gastric carcinoma presenting as cardiac tamponade and the metastatic behavior of gastric signet-ring cell carcinoma. Abstract: This report describes an 83-year-old man diagnosed to have cardiac tamponade due to massive pericardial effusion. A cytological analysis of the pericardial effusion disclosed adenocarcinoma. The patient was treated with continuous pericardial drainage and the amount of pericardial effusion decreased.

Intestinal angina in a patient with hypertrophic obstructive cardiomyopathy: a case report.

BACKGROUND: Intestinal angina is characterized by recurrent postprandial abdominal pain and anorexia. Commonly, these symptoms are caused by severe stenosis of at least two vessels among the celiac and mesenteric arteries. However, intestinal perfusion is affected not only by the degree of arterial stenosis but also by systemic perfusion. We experienced a unique case of intestinal angina caused by relatively mild stenosis of the abdominal arteries complicated with hypertrophic obstructive cardiomyopathy. CASE PRESENTATION: We report an 86-year old Japanese man with hypertrophic obstructive cardiomyopathy and advanced atrioventricular block who was diagnosed with intestinal angina. Computed tomography showed mild stenosis of the celiac artery and severe stenosis of the inferior mesenteric artery, and these lesions were relatively mild compared with other reports. A dual-chamber pacemaker with right ventricular apical pacing was implanted to improve the obstruction of the left ventricular outflow tract. After implantation, the patient's abdominal symptoms diminished markedly, and improvement of the left ventricular outflow tract obstruction was observed. CONCLUSIONS: Although intestinal angina is generally defined by severe stenosis of at least two vessels among the celiac and mesenteric arteries, the present case suggests that hemodynamic changes can greatly affect intestinal perfusion and induce intestinal angina in the presence of mild stenosis of the celiac and mesenteric arteries.

Chronic Ischemia Induced by Woven Coronary Artery Anomaly with Typical Atrial Flutter: Insights from Multiple Imaging Devices.

A 75-year-old man with a 120-bpm tachycardia and typical atrial flutter was admitted. Echocardiography showed a dilated left ventricle with anterior and apical wall akinesia. Tachycardia was terminated with cavotricuspid isthmus ablation. Multiple imaging findings revealed a woven coronary artery anomaly (WCAA) in the left anterior descending artery. Stress myocardial perfusion imaging was performed after ablation in the sinus rhythm and revealed stress-induced ischemia and a fixed low uptake in the WCAA territory. WCAA is generally regarded as a benign condition; however, compromised blood flow within the anomaly, caused by tachycardia-related diastolic shortening, may induce ischemia.

Potential association of bystander-patient relationship with bystander response and patient survival in daytime out-of-hospital cardiac arrest.

AIM: To investigate whether the bystander-patient relationship affects bystander response to out-of-hospital cardiac arrest (OHCA) and patient outcomes depending on the time of day. METHODS: This population-based observational study in Japan involving 139,265 bystander-witnessed OHCAs (90,426 family members, 10,479 friends/colleagues, and 38,360 others) without prehospital physician involvement was conducted from 2005 to 2009. Factors associated with better bystander response [early emergency call and bystander cardiopulmonary resuscitation (BCPR)] and 1-month neurologically favourable survival were assessed. RESULTS: The rates of dispatcher-assisted CPR during daytime (7:00-18:59) and nighttime (19:00-6:59) were highest in family members (45.6% and 46.1%, respectively, for family members; 28.7% and 29.2%, respectively, for friends/colleagues; and 28.1% and 25.3%, respectively, for others). However, the BCPR rates were lowest in family members (35.5% and 37.8%, respectively, for family members; 43.7% and 37.8%, respectively, for friends/colleagues; and 59.3% and 50.0%, respectively, for others). Large delays (≥ 5 min) in placing emergency calls and initiating BCPR were most frequent in family members. The overall survival rate was lowest (2.7%) for family members and highest (9.1%) for friends/colleagues during daytime. Logistic regression analysis revealed that the effect of bystander relationship on survival was significant only during daytime [adjusted odds ratios (95% CI) for survival from daytime OHCAs with family as reference were 1.51 (1.36-1.68) for friends/colleagues and 1.23 (1.13-1.34) for others]. CONCLUSIONS: Family members are least likely to perform BCPR and OHCAs witnessed by family members are least likely to survive during daytime. Different strategies are required for family-witnessed OHCAs.

Antithrombin deficiency in three Japanese families: one novel and two reported point mutations in the antithrombin gene.

INTRODUCTION: Inherited antithrombin (AT) deficiency is associated with a predisposition to familial venous thromboembolic disease. We analyzed the AT gene in three unrelated patients with an AT deficiency who developed thrombosis. MATERIALS AND METHODS: We analyzed the SERPINC1 gene in three patients. Additionally, we expressed the three mutants in the COS-1 cells and compared their secretion rates and levels of AT activity with those of the wild-type (WT). RESULTS: We identified three distinct heterozygous mutations of c.2534C>T: p.56Arginine → Cysteine (R56C), c.13398C>A: p.459Alanine → Aspartic acid (A459D) and c.2703C>G: p.112 Proline → Arginine (P112R). In the in vitro expression experiments, the AT antigen levels in the conditioned media (CM) of the R56C mutant were nearly equal to those of WT. In contrast, the AT antigen levels in the CM of the A459D and P112R mutants were significantly decreased. The AT activity of R56C was decreased in association with a shorter incubation time in a FXa inhibition assay and a thrombin inhibition-based activity test. However, the AT activity of R56C was comparable to that of WT when the incubation time was increased. CONCLUSIONS: We concluded that the R56C mutant is responsible for type II HBS deficiency. We considered that the A459D and P112R mutants can be classified as belonging to the type I AT deficiency.

Multiple anomalous systemic-pulmonary connections and coronary-pulmonary artery fistula associated with large aneurysms in an elderly woman.

We report the repair of a coronary artery fistula arising from the right coronary artery draining into the right pulmonary artery associated with multiple systemic-pulmonary connections.

Acute myocardial infarction following food-dependent exercise-induced anaphylaxis.

A 70-year-old man with a history of food-dependent exercise-induced anaphylaxis (FDEIA) since age 50 was admitted to the emergency department with chest pain and urticaria caused by FDEIA. Coronary angiography revealed total occlusion of the proximal left anterior descending coronary artery. After thrombus aspiration, a bare metal stent was placed into the culprit lesion, resulting in no residual stenosis. Urticaria disappeared on the second hospital day. This is the first reported case, to our knowledge, in which acute myocardial infarction followed FDEIA. Physicians should be aware of acute myocardial infarction as a rare but potential complication of FDEIA.

Impact of severe earthquake on the occurrence of acute coronary syndrome and stroke in a rural area of Japan.

BACKGROUND: Although acute coronary syndrome (ACS) and stroke are known to increase after earthquake, few data exist regarding the effect of earthquake on these cardiovascular events in rural areas. METHODS AND RESULTS: The Noto Peninsula earthquake with a magnitude of 6.9 occurred at 9:45 a.m. on 25 March 2007. The first case of ACS occurred approximately 15 min later, whereas cerebral hemorrhage (CH) occurred 72 h after the onset of earthquake. During the 35 days after earthquake, among 49 patients who were attended by local ambulance, 5 patients with ACS (10.2%) and 8 with CH (16.3%) were documented and 4 died. The total number of both ACS and CH cases was greater than the averages for the same period of the past 3 years in this area (2.0 vs 5 and 2.3 vs 8, P<0.01). Interestingly, the most cases of ACS had occurred within 7 days after earthquake and for CH not until 35 days later. CONCLUSIONS: Even in rural areas a severe earthquake results in increased incidence of ACS and CH, which can occur at different times after the event, although the effects of other environmental factors should be further investigated.

Attitudes toward automated external defibrillator use in Japan.

BACKGROUND: The American Heart Association 2005 Guidelines recommend immediate defibrillation for ventricular fibrillation (VF) of short duration, such as witnessed sudden cardiac arrest. However, it is unclear if public-access automated external defibrillators (AEDs) would actually be used in Japan, because there have been few studies about public attitudes regarding AED use. Therefore, we examined Japanese attitudes toward AED use. METHODS AND RESULTS: Between February and March 2006, 3328 individuals, including high school students, teachers, emergency medical technicians (EMTs), medical nurses, and medical students, were asked about AED knowledge and their willingness to operate an AED. All EMTs, 86% of nurses, and 90% of medical students knew how to use AEDs, while only 15% of high school students and 44% of teachers had such knowledge. All EMTs, 78% of nurses, and 94% of medical students reported they would 'definitely' use the AED, but only 12% of high school students and 35% of teachers gave this reply. The reasons for unwillingness to operate AEDs among both laypeople and health care providers were poor of awareness of what AED is and/or how to use an AED. However, 83% of students and 81% of teachers with AED knowledge reported they would 'definitely' use the AED. CONCLUSIONS: Many non-medical people in Japan would be unwilling to operate an AED, because they do not know what AED is and/or how to use an AED. However, many would be willing to operate AEDs if they had better understanding of AEDs. Thus, it is necessary to improve public knowledge of AEDs and AED use.

The attitudes of Japanese high school students toward cardiopulmonary resuscitation.

BACKGROUND AND OBJECTIVES: It is essential to have a clear understanding of the present condition of cardiopulmonary resuscitation (CPR) training courses and the associated problems. The present study was performed to identify the current conditions of CPR training in Japanese high schools and the attitudes of students toward CPR. METHODS AND RESULTS: We distributed a questionnaire study to the students of 12 cooperating high schools regarding their willingness to perform CPR in 5 hypothetical scenarios of cardiopulmonary arrest: a stranger, a trauma patient, a child, an elderly person, and a relative. Between February and March 2006, a total of 3316 questionnaires were completed. Across all scenarios, only 27% of respondents from general high schools reported willingness to perform chest compression (CC) plus mouth-to-mouth ventilation (MMV), and 31% reported willingness to perform CC alone. Fifty-nine percent of students had previous CPR training, and only 35% were willing to perform CC plus MMV. Most of the respondents who reported that they would decline to perform full CPR, stated that poor knowledge and/or fear of incomplete performance of CPR were deciding factors. CONCLUSIONS: Japanese high school students are reluctant to perform CC plus MMV, despite having received training. The present educational system in Japan has limitations in encouraging high school students to perform CC plus MMV.

Attitudes toward the performance of bystander cardiopulmonary resuscitation in Japan.

BACKGROUND: Early initiation of bystander cardiopulmonary resuscitation (CPR) improves the chances of successful resuscitation and survival. The importance of bystander CPR is attracting more interest, and there has been an increase in attendance at CPR training courses in Japan. However, there have been few reports regarding Japanese attitudes toward the performance of bystander CPR. The present study was performed to identify current Japanese attitudes toward bystander CPR compared to our previous study performed in 1998. METHODS AND RESULTS: Between February and March 2006, participants were asked about their willingness to perform CPR in five varying scenarios, i.e., performing CPR on a stranger, a trauma patient, a child, an elderly person, and a relative, and CPR techniques consisting of chest compression plus mouth-to-mouth ventilation (CC plus MMV) versus chest compression only (CC only). A total of 4223 individuals (male 50%) completed the questionnaire, including high school students, teachers, emergency medical technicians (EMTs), medical nurses, and medical students. About 70% of the subjects had experienced CPR training more than once. Only 10-30% of high school students, teachers, and health care providers reported willingness to perform CC plus MMV, especially on a stranger or trauma victim. In contrast, 70-100% of these subjects reported willingness to perform CC only, which was the same as in our previous study. The reasons for the unwillingness among laypeople to perform CC plus MMV were inadequate knowledge and/or doubt regarding whether they could perform the techniques effectively, while health care providers reported a fear contracting of a disease. CONCLUSIONS: Most laypeople and health care providers are unlikely to perform CC plus MMV, especially on a stranger or trauma victim, but are more likely to perform CC only, as also found in our previous study in 1998. These findings suggest that MMV training should be de-emphasised and the awareness of CC alone should be emphasised because, for whatever reason, people do not want to perform MMV.

Swallow syncope, a case report and review of the literature.

Swallow syncope is a relatively rare syndrome that is treatable when diagnosed. A 66-year-old woman was referred to the department of cardiology because she had been suffering from recurrent syncopal attacks associated with swallowing. An ambulatory electrocardiogram revealed atrial and ventricular asystoles immediately after swallowing soup or tea that were reproducible (max. RR 3.5 s). An electrophysiological study did not detect sinus nodal or atrioventricular nodal dysfunction. The patient had no underlying esophageal disease or cardiac disorder. The patient's symptoms resolved after permanent pacemaker implantation. This report reviews the diagnosis, mechanism and management of swallow syncope.

Doppler tissue analysis of atrial electromechanical coupling in paroxysmal atrial fibrillation.

The aim of this study was to: (1) evaluate atrial electromechanical coupling using M-mode Doppler tissue; and (2) test its clinical impact for detecting atrial abnormalities in paroxysmal atrial fibrillation (AF). Using Doppler tissue, the time intervals from the onset of P wave until the backward motions of the right and left atrioventricular rings in the apical 4-chamber view corresponding to the atrial contractions were measured. In paroxysmal AF group, these intervals were significantly longer than in the control group. Using the criteria that an abnormal time interval from the onset of P wave until the backward motion of the left atrioventricular ring is longer than 112 milliseconds, the sensitivity, the specificity, and the positive predictive values for paroxysmal AF are 73%, 93%, and 93%, respectively. This parameter is affected in patients with paroxysmal AF and should be useful for detecting atrial impairment related to paroxysmal AF.

Ultrasonic analysis of anthracycline-induced myocardial damage using cyclic variation of integrated backscatter.

To test the feasibility of integrated backscatter (IB) for detecting anthracycline cardiotoxicity, we performed conventional echocardiography and IB analysis. For interindividual comparison, 32 patients with non-Hodgkin's lymphoma and 14 control subjects were selected. Of the patients, 10 had been treated with doxorubicin doses of 400 mg/m(2) (high dose). In intraindividual comparison, 8 patients were examined before doxorubicin therapy and at a dose of 100 mg/m(2) and 8 were examined before and at a 300-mg/m(2) dose. Cyclic variation of IB (CV-IB) was obtained at the left ventricular posterior wall, using a modified, commercially available system in M-mode format. In interindividual comparison, CV-IB in high- and moderate-dose groups was smaller. In intraindividual comparison, CV-IB decreased after treatment with 300 mg/m(2) of doxorubicin. CV-IB was affected in some patients treated with a moderate dose of doxorubicin. IB analysis may be helpful for detecting early anthracycline cardiotoxicity.

Ultrasonic tissue characterization in acute myocarditis: a case report.

A 25-year-old woman was admitted because of acute myocarditis. Echocardiogram revealed hypokinesis of the left ventricle with increased wall thickness, but on day 7, the wall motion normalized. Cyclic variation of myocardial integrated backscatter on day I was reduced to 1.8 dB (normal range, 2.9-5.3 dB) and normalized to 3.2 dB on day 3. The normalization of the cyclic variation of integrated backscatter in the myocardium preceded the recovery of the left ventricular wall contractility, suggesting the ability of tissue characterization to predict recovery of cardiac function.