Miction-induced Hypertension Disclosed by Home Blood Pressure Measurement in a Patient with Small Paraganglioma.

A 46-year-old woman complained of a 10-year history of headache, nausea, a precordial oppressive feeling and shortness of breath on miction. She had noted a marked elevation in her blood pressure after miction using home blood pressure measurement. Her catecholamine levels were less than twice the value of the normal upper limit. Several imaging modalities detected a urinary bladder tumor, and 123I-metaiodobenzylguanidine scintigraphy showed positive accumulation. The diagnosis of urinary bladder paraganglioma was confirmed by partial cystectomy. We must keep in mind that paroxysms and hypertension associated with miction are important diagnostic clues of pheochromocytoma/paraganglioma. Home blood pressure measurement was very useful for detecting hypertension in this case.

Cardiac function response to stenting in atherosclerotic renal artery disease with and without heart failure: results from the Carmel study.

AIMS: Consensus-derived guidelines recommend renal stenting for patients with atherosclerotic renal artery disease (ARAD) and heart failure (HF). The aim of this prospective multi-centre observational study was to verify our hypothesis that changes in E/e', an echocardiographic correlate of left ventricular (LV) filling pressure, following renal stenting may differ between ARAD patients with and without HF. METHODS AND RESULTS: This study enrolled de novo ARAD patients undergoing renal stenting at 14 institutions. The primary endpoint was the difference in E/e' change between ARAD patients with and without HF. Clinical and echocardiographic data were prospectively collected at baseline, the day following renal stenting, and 1 month and 6 months afterwards. ARAD patients with HF were defined as patients with New York Heart Association (NYHA) Class 2 and more, or a history of HF hospitalization. A total of 76 patients were included, and 39% were ARAD patients with HF. ARAD patients with HF had significantly lower estimated glomerular filtration rate (P = 0.028) and higher NYHA functional class (P < 0.001) and Minnesota Living with Heart Failure Questionnaire (MLHFQ) score (P = 0.001) than ARAD patients without HF. Also, ARAD patients with HF had significantly lower LV ejection fraction (P = 0.003) and e'-velocity (P = 0.003) and higher E/e' ratio (P = 0.001), left atrial volume index (LAVI) (P = 0.046), LV end-diastolic volume (LVEDV) (P = 0.001), LV end-systolic volume (LVESV) (P = 0.001), and LV mass index (P = 0.009) than ARAD patients without HF. All procedures were successful. In contrast to blood pressure and renal function, there was a significant interaction in E/e' (Pinteraction  < 0.001) between time and HF, and ARAD patients with HF showed a significant (P < 0.001) decrease in E/e' albeit those without HF. By the same token, there was a significant interaction in NYHA class (Pinteraction  < 0.001), MLHFQ score (Pinteraction  = 0.018), E-velocity (Pinteraction  = 0.002), LAVI (Pinteraction  = 0.001), LVEDV (Pinteraction  = 0.003), and LVESV (Pinteraction  = 0.001) between time and HF with a significant improvement in all these variables in ARAD patients with HF (NYHA class, P = 0.001; MLHFQ score, P = 0.002; E-velocity, P = 0.005; LAVI, P = 0.001; LVEDV, P = 0.017; and LVESV, P = 0.011). CONCLUSIONS: Change in LV filling pressure after renal stenting differed between ARAD patients with and without HF, with a significant improvement in LV filling pressure in patients with HF-ARAD. These unique findings might support clinical cardiac benefits of renal stenting in ARAD patients with HF.

Outcomes of everolimus-eluting stent incomplete stent apposition: a serial optical coherence tomography analysis.

AIM: The aim of the present study was to evaluate the natural course of acute incomplete stent apposition (ISA) after second-generation everolimus-eluting stent (EES) when compared with first-generation sirolimus-eluting stent (SES) by using optical coherence tomography (OCT). METHODS AND RESULTS: From the OCT substudy of the RESET trial, we identified 77 patients (EES = 38 and SES = 39) who successfully underwent serial OCT examination at post-stenting and 8-12-month follow-up. The presence of ISA was assessed in the OCT images, and ISA distance was measured from the centre of the strut blooming to the adjacent lumen border. Incomplete stent apposition was observed in all EES and SES at post-stenting, and it was persistent in 26% of EES and 38% of SES at 8-12-month follow-up. Maximum ISA distance was significantly decreased during the follow-up period in both EES (315 ± 94-110 ± 165 µm, P < 0.001) and SES (308 ± 119-143 ± 195 µm, P < 0.001). Receiver-operating curve analysis identified that the best cut-off value of OCT-estimated ISA distance at post-stenting for predicting late-persistent ISA at 8-12-month follow-up in EES and SES was >355 and >285 µm, respectively. CONCLUSIONS: The second-generation EES showed better healing of acute ISA in comparison with the first-generation SES. Optical coherence tomography can predict late-persistent ISA after DES implantation and provide useful information to optimize PCI.

Detection of restenosis after percutaneous coronary intervention in three major coronary arteries by transthoracic Doppler echocardiography.

BACKGROUND: The aim of this study was to evaluate the diagnostic potential of coronary flow velocity reserve (CFR) measurement by transthoracic Doppler echocardiography (TTDE) to detect restenosis in the 3 major coronary arteries: the left anterior descending coronary artery, right coronary artery, and left circumflex coronary artery. METHODS: The lesions of 175 patients who were scheduled for follow-up coronary angiography and TTDE 6 months after undergoing stents implantation were studied. CFR was assessed by TTDE in the targeted arteries into which stents had been implanted. RESULTS: Coronary stents were implanted in a total of 238 angiographic lesions in 175 patients. Doppler recordings of coronary flow in the 3 major arterial lesions were obtained in 211 of the 238 angiographic lesions (89% feasibility). CFR was significantly lower in lesions with restenosis than those without restenosis (1.70 +/- 0.32 vs 2.65 +/- 0.66, P < .01). A CFR value < 2.0 was 89% sensitive and 91% specific for detecting restenosis in the 3 major coronary arteries. Sensitivity and specificity were 86% and 91%, respectively, in the left anterior descending coronary artery (95% feasibility); 92% and 92%, respectively, in the right coronary artery (85% feasibility); and 91% and 92%, respectively, in the left circumflex coronary artery (81% feasibility). CONCLUSION: CFR assessment by TTDE is an accurate method for monitoring restenosis, not only in the left anterior descending but also in the right and left circumflex coronary arteries in patients previously subjected to percutaneous coronary intervention.

A prospective, multicenter, randomized trial to assess efficacy of pioglitazone on in-stent neointimal suppression in type 2 diabetes: POPPS (Prevention of In-Stent Neointimal Proliferation by Pioglitazone Study).

OBJECTIVES: The aim of this study was to clarify whether pioglitazone suppresses in-stent neointimal proliferation and reduces restenosis and target lesion revascularization (TLR) after percutaneous coronary intervention (PCI). BACKGROUND: Previous single-center studies have demonstrated the anti-restenotic effect of a peroxisome proliferator-activated receptor gamma agonist, pioglitazone, after PCI. METHODS: A total of 97 patients with type 2 diabetes mellitus (T2DM) undergoing PCI (bare-metal stents only) were enrolled. After PCI, patients were randomly assigned to either the pioglitazone group (n = 48) or the control group (n = 49). Angiographical and intravascular ultrasound (IVUS) imaging were performed at baseline and repeated at 6-month follow-up. Primary end points included angiographical restenosis and TLR at 6 months follow-up. Secondary end point was in-stent neointimal volume by IVUS. RESULTS: Baseline glucose level and glycosylated hemoglobin (HbA1c) level were similar between the pioglitazone group and the control group. Angiographical restenosis rate was 17% in the pioglitazone group and 35% in control group (p = 0.06). The TLR was significantly lower in pioglitazone group than in control group (12.5% vs. 29.8%, p = 0.04). By IVUS (n = 56), in-stent neointimal volume at 6 months showed a trend toward smaller in the pioglitazone group than in the control group (48.0 +/- 30.2 mm(3) vs. 62.7 +/- 29.0 mm(3), p = 0.07). Neointimal index (neointimal volume/stent volume x 100) was significantly smaller in the pioglitazone group than in the control group (31.1 +/- 14.3% vs. 40.5 +/- 12.9%, p = 0.01). CONCLUSIONS: Pioglitazone treatment might suppress in-stent neointimal proliferation and reduce incidence of TLR after PCI in patients with T2DM.

Usefulness of a combination of systolic function by left ventricular ejection fraction and diastolic function by E/E' to predict prognosis in patients with heart failure.

Left ventricular (LV) ejection fraction (EF) was known as a conventional predictor of heart failure (HF). However, early transmitral flow velocity (E)/early diastolic velocity of mitral annulus (E') correlated well with LV end-diastolic pressure, and E/E' ratio >15 was an excellent predictor of adverse outcomes in patients with HF. This study was designed to determine the prognostic value of a new combined index, E/E' ratio and LVEF, in patients with HF. One hundred twenty-six consecutive patients hospitalized with HF underwent comprehensive echocardiographic-Doppler study when ready for discharge. Patients were divided into the 4 groups of group I (LVEF >40% and E/E' ratio <15), group II (EF >40% and E/E' ratio >or=15), group III (EF or=15). The ability of this index to determine the primary end point (rehospitalization for HF or cardiac death) was assessed. Patients with significant valvular disease were excluded. Of 126 patients, 110 met the inclusion criteria. Follow-up was complete for 108 of 110 patients at 351 +/- 252 days after discharge. There were 27, 30, 21, and 30 patients in groups I, II, III, and IV, respectively. There were 52 patients with the primary end point. On univariate analysis, E/E' ratio, group IV, E', and age were significant predictors. In multivariable analysis, the most powerful independent prognostic indicator of events was group IV (hazard ratio 12.6, 95% confidence interval 2.2 to 74.2, p = 0.005). In conclusion, a new index, a combination of LVEF and E/E' ratio, allowed the identification of patients at higher risk of readmission and cardiac death in patients with HF.

[Primary effusion lymphoma complicating cardiac tamponade: a case report].

A 76-year-old woman was admitted to our hospital because of exertional dyspnea and leg edema during the previous month. Her systolic blood pressure on admission was 80 mmHg with 12 mmHg of pulsus paradoxous, and her pulse rate was 110 beats/min. Chest radiography revealed marked cardiomegaly and echocardiography showed massive pericardial effusion mainly behind the left ventricle and collapse of the right ventricle. The initial diagnosis was pericardial tamponade. Pericardiocentesis and pericardial drainage revealed bloody pericardial effusion. After drainage, her vital signs improved and her symptoms immediately disappeared. The cytological analysis of the pericardial effusion revealed numerous lymphoma cells. Computed tomography of the neck, chest and abdomen showed no evidence of tumor masses, lymph node enlargement, or hepatosplenomegaly. Infectious disease, collagen disease and aortic dissection were excluded. The final diagnosis was primary effusion lymphoma. The prognosis of primary effusion lymphoma is generally unfavorable because it is frequently accompanied by immunodeficiency disease. However, there was no human immunodeficiency virus infection in this patient. Fortunately, the effect of chemotherapy was excellent and the patient is doing well 1 year after the diagnosis.

Augmentation of tissue perfusion by a novel compression device increases neurologically intact survival in a porcine model of prolonged cardiac arrest.

OBJECTIVE: This study was performed to determine the potential efficacy of an automated device with a load-distributing band (AutoPulse, Revivant Corporation), in improving neurologically intact survival after cardiac arrest. DESIGN: Randomized, controlled trial. SETTING: University animal laboratory. SUBJECTS: Forty-four swine (18-23 kg). INTERVENTIONS: Eight minutes after induction of untreated ventricular fibrillation, pigs were randomized to AutoPulse-CPR (A-CPR, n = 22), conventional cardiopulmonary resuscitation (CPR) with 20% anterior-posterior chest displacement (C-CPR20, n = 10) or 30% chest displacement (C-CPR30, n = 12), followed by resuscitation protocol with ventilation, defibrillation and intravenous epinephrine (adrenaline). MEASUREMENTS AND MAIN RESULTS: Aortic and right atrium blood pressure was measured with micromanometers. Regional blood flows were measured with microspheres. Coronary perfusion pressure during A-CPR was significantly higher as compared to C-CPR without epinephrine (A-CPR versus C-CPR20 versus C-CPR30; 16 +/- 1 mmHg versus 7 +/- 2 mmHg versus 11 +/- 2 mmHg, p < 0.05). A-CPR improved both myocardial flow without epinephrine (A-CPR versus C-CPR20 versus C-CPR30; 23% versus 0% versus 4%; percent of baseline, p < 0.05) and cerebral blood flow (40% versus 4% versus 19%, percent of baseline, p < 0.05). Sixteen of 22 animals receiving A-CPR regained spontaneous circulation and survived; 14/22 had normal cerebral performance (CPC 1). Four of 12 animals receiving C-CPR30 regained spontaneous circulation and survived, but only one animal had normal neurological function (14/22 versus 1/12, p < 0.0001). No animal receiving C-CPR20 achieved spontaneous circulation. At necropsy, 67% of C-CPR30 had rib fracture and 33% showed lung injury, while A-CPR and C-CPR20 resulted in no detectable injuries. CONCLUSIONS: Improved hemodynamics with AutoPulse performed CPR results in improved neurologically intact survival without subsequent thoracic or pulmonary injuries in this porcine model of prolonged cardiac arrest.

Effect of fluvastatin therapy on coronary flow reserve in patients with hypercholesterolemia.

Coronary flow reserve was evaluated using transthoracic Doppler echocardiography before and after 3 months of fluvastatin therapy in patients with hypercholesterolemia. Coronary flow reserve increased significantly after lipid-lowering therapy, and coronary microcirculation was improved in patients with hypercholesterolemia.

[Biventricular pacing dramatically improved critical heart failure in idiopathic dilated cardiomyopathy: two case reports].

Two cases of dilated cardiomyopathy with intraventricular conduction delay, or left bundle-branch block and refractory heart failure, were markedly improved by biventricular pacing. The first patient's condition (Case 1) could not be improved despite administration of intravenous inotropic agents. He required mechanical ventilation and continuous hemodialysis as his condition worsened. Biventricular pacing was performed which was soon followed by increased blood pressure and decreased mitral regurgitation. As a result, mechanical ventilation, continuous hemodialysis and intravenous medication could be withdrawn. The second patient's condition (Case 2) deteriorated because of bradycardia due to advanced atrioventricular block. Unexpectedly, temporary right atrium-right ventricle sequential pacing increased mitral regurgitation and then caused heart failure, requiring a higher dose of inotropic and diuretic agents. Therefore, biventricular pacing was performed which rapidly improved both his symptoms and hemodynamic state, allowing reduction of the medication dose. Biventricular pacing dramatically improves critical conditions in patients in life-threatening states.