Modified septal myectomy using a curved knife for left ventricular septal hypertrophy.

An 86-year-old woman presented with chest pain and discomfort. Echocardiography revealed severe aortic valve stenosis and asymmetric septal hypertrophy. Aortic valve replacement and myectomy were performed using a curved knife. The blade was U-shaped in cross-section, and was curved upward along the long axis. Hypertrophic septal myocardium was removed along the long axis of the left ventricle (LV), and a groove for blood flow was constructed. The patient was discharged uneventfully without recurrence of her chest discomfort. Our result suggested that a curved knife is a reasonable option for transaortic septal myectomy in patients with obstructive LV hypertrophy.

Association between aortic valve calcification and myocardial ischemia, especially in asymptomatic patients.

UNLABELLED: Aortic valve calcification (AVC) is recognized as a manifestation of systemic arteriosclerosis. However, it is unclear whether AVC is associated with myocardial ischemia. Stress myocardial perfusion SPECT (MPS) is widely used for the diagnosis of myocardial ischemia. However, routine MPS is not recommended, particularly in asymptomatic patients. Accordingly, we investigated the hypothesis that the presence of AVC is strongly associated with inducible myocardial ischemia, even among asymptomatic patients. METHODS: We investigated 669 consecutive patients who underwent both adenosine stress (201)Tl MPS and echocardiography. We evaluated the extent and severity of myocardial ischemia by the summed difference score (SDS). We defined the presence of myocardial ischemia as SDS ≥ 3 and moderate to severe ischemia as SDS ≥ 8. We classified the severity of AVC according to the number of affected aortic leaflets. We also compared the mean SDS and the prevalence of SDS ≥ 3 and SDS ≥ 8 among patients stratified by the severity of AVC. RESULTS: The presence of AVC was significantly associated with myocardial ischemia (odds ratio [OR], 1.56; 95% confidence interval [CI], 1.10-2.23; P = 0.013) and moderate to severe ischemia (OR, 2.16; 95% CI, 1.26-3.80; P = 0.0061). In 311 asymptomatic patients, AVC was strongly associated with moderate to severe ischemia (OR, 4.31; 95% CI, 1.67-12.8; P = 0.0043). However, the SDS value and the prevalence of SDS ≥ 3 and SDS ≥ 8 did not increase with increasing number of affected aortic leaflets. CONCLUSION: The presence of AVC may be associated with the presence of myocardial ischemia, particularly in asymptomatic patients. However, we found no association between the extent of AVC and inducible myocardial ischemia. The presence of AVC may be a useful anatomic marker to help identify patients at high risk of myocardial ischemia, particularly asymptomatic patients.

Beneficial effects of valsartan on target lesion revascularization after percutaneous coronary interventions with bare-metal stents.

BACKGROUND: Angiotensin II receptor blockers (ARB) have been shown to reduce cardiovascular events in patients at risk. The effect of valsartan on outcomes after percutaneous coronary interventions (PCI) with bare-metal stents (BMS) was investigated. METHODS AND RESULTS: The prospective, randomized study included 191 patients at 5 participating institutions, who were randomly assigned to either a 40-80 mg valsartan add-on or non-ARB treatment. The primary endpoint was a composite of all-cause death, non-fatal myocardial infarction, and target lesion revascularization (TLR) at 18 months. Enrollment was stopped when the use of drug-eluting stents has been expanded in Japan. No significant differences existed between the groups in terms of primary endpoint (18.9% vs. 24.8%; hazard ratio [HR], 0.84; 95% confidence interval [CI], 0.61-1.14; P = 0.26). In the valsartan group, as compared with the non-ARB group, the secondary endpoint of TLR was significantly reduced at a median follow-up 4.4 years; the rate of TLR was from 27.8% to 14.5% (HR, 0.69; 95%CI, 0.49-0.96; P = 0.024). CONCLUSIONS: Valsartan treatment was not superior to non-ARB treatment in reducing the primary endpoint after PCI at 18 months. The pre-specified secondary endpoint of TLR was lower in the valsartan group, but this needs to be proved statistically with an adequate study sampling.

Characterization of noncalcified coronary plaques and identification of culprit lesions in patients with acute coronary syndrome by 64-slice computed tomography.

OBJECTIVES: We sought to characterize noncalcified coronary atherosclerotic plaques in culprit and remote coronary atherosclerotic lesions in patients with acute coronary syndrome (ACS) with 64-slice computed tomography (CT). BACKGROUND: Lower CT density, positive remodeling, and adjacent spotty coronary calcium are characteristic vessel changes in unstable coronary plaques. METHODS: Of 147 consecutive patients who underwent contrast-enhanced 64-slice CT examination for coronary artery visualization, 101 (ACS; n = 21, non-ACS; n = 80) having 228 noncalcified coronary atherosclerotic plaques (NCPs) were studied. Each NCP detected within the vessel wall was evaluated by determining minimum CT density, vascular remodeling index (RI), and morphology of adjacent calcium deposits. RESULTS: The CT visualized more NCPs in ACS patients (65 lesions, 3.1 +/- 1.2/patient) than in non-ACS patients (163 lesions, 2.0 +/- 1.1/patient). Minimum CT density (24 +/- 22 vs. 42 +/- 29 Hounsfield units [HU], p < 0.01), RI (1.14 +/- 0.18 vs. 1.08 +/- 0.19, p = 0.02), and frequency of adjacent spotty calcium of NCPs (60% vs. 38%, p < 0.01) were significantly different between ACS and non-ACS patients. Frequency of NCPs with minimum CT density <40 HU, RI >1.05, and adjacent spotty calcium was approximately 2-fold higher in the ACS group than in the non-ACS group (43% vs. 22%, p < 0.01). In the ACS group, only RI was significantly different between 21 culprit and 44 nonculprit lesions (1.26 +/- 0.16 vs. 1.09 +/- 0.17, p < 0.01), and a larger RI (> or = 1.23) was independently related to the culprit lesions (odds ratio: 12.3; 95% confidential interval: 2.9 to 68.7, p < 0.01), but there was a substantial overlap of the distribution of RI values in these 2 groups of lesions. CONCLUSIONS: Sixty-four-slice CT angiography demonstrates a higher prevalence of NCPs with vulnerable characteristics in patients with ACS as compared with stable clinical presentation.

Incremental prognostic value of cardiac function assessed by ECG-gated myocardial perfusion SPECT for the prediction of future acute coronary syndrome.

BACKGROUND: The prognostic value of ECG-gated rest 201Tl/stress 99mTc-tetrofosmin myocardial perfusion single-photon emission computed tomography for the prediction of acute coronary syndrome (ACS: myocardial infarction (MI) and unstable angina (UA)) and the implications of ejection fraction (EF) has not yet been defined in Japanese. METHODS AND RESULTS: The 1,895 patients were followed up for the occurrence ACS. The mean follow-up interval was 26.9+/-15.5 months. The 142 patients with revascularization within 60 days were censored. Summed stress score (SSS) and summed difference score (SDS) were calculated. The 19 MI and 29 UA occurred (1.1% and 1.6%, respectively). Univariate Cox analysis showed that hypertension (Wald 5.09, p<0.05), poststress EF (Wald 10.9, p<0.01), SSS (Wald 12.4, p<0.001) and SDS (Wald 18.7, p<0.001) were significant predictors of ACS. Multivariate Cox analysis showed that hypertension (Wald 4.27, p<0.05) and SDS (Wald 8.59, p<0.01) were independent predictors. When multiple clinical risk factors (number of coronary risk factors > or =2), significant ischemia (SDS > or =4) and low EF (EF <45%) were applied to multivariate Cox analysis, the combination of significant ischemia and low EF showed the highest predictive value (Wald 11.9; p<0.001) for future ACS. CONCLUSION: Poststress EF added incremental prognostic value for the prediction of ACS.

Plasma levels of oxidized low density lipoprotein are associated with stable angina pectoris and modalities of acute coronary syndrome.

The role of plasma levels of oxidized low density lipoprotein (OxLDL) in the development of coronary heart disease (CHD) has not been fully elucidated. We examined the relationship among plasma levels of OxLDL, measured by an enzyme immunoassay using an antibody against OxLDL (FOH1a/DLH3) and apolipoprotein B, CHD, and modalities at the onset of acute coronary syndrome (ACS). A total of 115 individuals who underwent coronary angiography were studied. Of these, 21 patients complicated with extracoronary cardiovascular diseases were excluded. Consequently, 94 patients (63 men) (ACS: 23, stable angina pectoris (SAP): 46, and normal coronary artery (NCA):25) were eligible for inclusion in the study. Elevated plasma levels of OxLDL were associated with CHD, especially with ACS. In patients with NCA, hypertension was associated with plasma OxLDL. Plasma levels of OxLDL were significantly higher in patients with new-onset type ACS than in those with worsening type ACS (2.98 versus 1.53 mg/dL, P = 0.002). In conclusion, plasma levels of OxLDL are associated with CHD and significantly higher in patients with new-onset ACS. The findings of the present study suggest that plasma OxLDL can be a marker of the development of CHD and modalities of ACS.

Feasibility of a rapid protocol of 1-day single-isotope rest/adenosine stress Tc-99m sestamibi ECG-gated myocardial perfusion imaging.

BACKGROUND: We previously developed a new rapid protocol for single-isotope rest/adenosine stress technetium 99m sestamibi (MIBI) electrocardiography-gated myocardial perfusion imaging examination. The feasibility and limitations of this rapid protocol are unclear. METHODS AND RESULTS: We examined 422 patients who underwent rest acquisition, which eliminates the waiting time, after injection of low-dose MIBI and drinking 400 mL of water. The patients immediately underwent adenosine stress. Stress acquisition was performed 1 hour after injection of high-dose MIBI. The sensitivity and specificity for detecting significant coronary stenoses were 93% and 70%, respectively. The frequency of significant (moderate or severe) inferior wall artifacts on the rest single photon emission computed tomography images among all patients was 16.3%. The frequency of significant artifacts in patients aged 70 years or older was significantly lower than that in patients aged less than 70 years (11.9% vs 26.9%, P = .0001). Multivariate analysis revealed that age less than 70 years and prior myocardial infarction were predictors of significant artifacts on resting images (P < .0001 and P < .05, respectively). CONCLUSIONS: Our rapid protocol for MIBI myocardial perfusion imaging (MPI) provides high-quality images and good patient throughput, and it is effective at reducing the total examination time.

Usefulness of rapid low-dose/high-dose 1-day 99mTc-sestamibi ECG-gated myocardial perfusion single-photon emission computed tomography.

BACKGROUND: The clinical usefulness of a rapid rest low-dose/stress high-dose (dose ratio =1:5) (99m)Tc-sestamibi myocardial perfusion single-photon emission computed tomography (SPECT) protocol for the detection of coronary artery disease was evaluated. METHODS AND RESULTS: In 89 patients, rest images were obtained immediately after the injection of (99m)Tc-sestamibi (256.1+/-28.4 MBq) followed by drinking water (400 ml). Exercise or vasodilator stress test was performed immediately after the completion of rest imaging with the injection of (99m)Tc-sestamibi (1312.3 +/-167.6 MBq). Prior to the post-stress imaging, patients were asked again to drink water (400 ml) in order to eliminate subdiaphragmatic tracer activity. The myocardial count ratio (stress/rest) of (99m)Tc-sestamibi was calculated. Image quality was scored using a 4-point scale system (4= excellent, 3= good, 2= poor, 1= unacceptable). Coronary angiography was performed in 56 patients within 1 month of the SPECT scan. All patients successfully performed the protocol and total examination time was 108+/-7 min. The myocardial count ratio of (99m)Tc-sestamibi was always greater than 6. The image quality was satisfactory both at rest (3.4+/-0.9) and after stress (3.9+/-0.2). The sensitivity and specificity to detect coronary artery stenosis >50% was 84% and 97%, respectively. CONCLUSIONS: This rapid one-day (99m)Tc-sestamibi protocol provides adequate image quality and diagnostic accuracy for detecting coronary artery disease.

Intravascular ultrasound-guided coronary artery stenting for spontaneous coronary artery dissection in a case of acute myocardial infarction associated with vasospasm in a non-culprit coronary artery during the hospitalization.

We report a case of spontaneous coronary artery dissection (SCAD) causing acute myocardial infarction, which was complicated by vasospastic angina (VA). The patient received intravenous administration of t-PA. Emergency coronary angiography demonstrated narrowing of the left anterior descending artery (LAD) due to SCAD. During hospitalization, the patient suffered chest pain, and ECG showed ST elevation in the inferior leads. Sublingual administration of nitroglycerin provided temporary remission. Coronary stent implantation was performed electively using intravascular ultrasound imaging. This is the first reported case of SCAD associated with vasospasm in a non-culprit coronary artery during the hospitalization.

Anomalous origin of the right coronary artery from the pulmonary artery.

A case of anomalous origin of the right coronary artery from the pulmonary artery in a 73-year-old man is presented. The patient had been suffering from chronic heart failure with mitral and tricuspid regurgitation and atrial fibrillation for two years. Surgical repair was performed successfully, including ligation of the right coronary artery and coronary arterial bypass with a radial artery graft.

Exploring a technique for reducing the influence of scattered rays from surrounding organs to the heart during myocardial perfusion scintigraphy with technetium-99m sestamibi and technetium-99m tetrofosmin.

We have devised a new position (Monzen position) which can suppress the influence of scattered rays from surrounding organs (liver, etc.) when conducting myocardial imaging. Unlike the conventional techniques, which require a waiting period of 30-60 minutes before imaging can be started after the infusion of technetium-99m sestamibi or technetium-99m tetrofosmin, this position allows single-photon emission tomography to be started about 5-10 minutes after the infusion of the tracer. Therefore, with this technique the total time required for imaging is reduced and consequently the physical and mental burden of the patient is also reduced. Furthermore, the number of patients who can receive this test at any facility can be increased. This position may also be applicable in myocardial scintigraphy using some other tracers.

Acute effect of atorvastatin on coronary circulation measured by transthoracic Doppler echocardiography in patients without coronary artery disease by angiography.

Thirty-two patients were randomly assigned to treatment with placebo or atorvastatin. The time-averaged peak diastolic velocity (APDV) of the left anterior descending artery without stenosis was measured by transthoracic Doppler echocardiography at rest and under hyperemic conditions before and 1 hour after treatment. APDV increased significantly in the atorvastatin group, at rest and under hyperemic conditions, and coronary flow velocity reserve also increased in the atorvastatin group compared with patients given placebo. Atorvastatin improved the blood flow velocity of the normal coronary artery <1 hour after administration in patients without coronary artery disease by angiography.

Paradoxical peripheral embolism coincident with acute pulmonary thromboembolism.

Paradoxical embolism may occur in patients with acute pulmonary thromboembolism, when patent foramen ovale (PFO) coexists with pulmonary hypertension (right-left shunt). There have been few case reports of paradoxical embolism in peripheral arteries coincident with acute pulmonary thromboembolism. Here, we describe a case of paradoxical peripheral embolism associated with PFO complicated by acute pulmonary thromboembolism. The patient had severe peripheral ischemia due to a massive thrombus and was treated successfully by peripheral thrombectomy, thrombolysis, implantation of a permanent inferior vena cava filter and anticoagulation.

Multiple coronary artery fistulas with a huge right coronary artery showing exacerbation during 16 years of follow-up.

A 38-year-old Japanese woman underwent cardiac evaluation to assess an arrhythmia detected after the delivery of her fourth baby. At the age of 22 years, she had undergone cardiac evaluation, including catheter examination, because of a heart murmur. Coronary angiography showed a huge right coronary artery (RCA) draining to the right atrium and a normal left coronary artery. Because the left to right shunt ratio was trivial and the patient was asymptomatic, conservative observation was undertaken. On the current admission to hospital, there was a grade III continuous murmur at the second left sternal border. The patient underwent right and left cardiac catheter examination in March 2000. Selective coronary angiography demonstrated an enlarged lumen of the RCA, an enlarged aneurysmal cavity in the terminal portion of the RCA, and the postero-descending artery being filled by collateral circulation from the left coronary artery. Moreover, 2 new fistulas had appeared from the left coronary system. An oxygen saturation study showed that the pulmonary to somatic flow ratio (Qp/Qs) was 2.2. The patient underwent surgical treatment in July 2000 and on coronary angiography 1 month later, there was no abnormal shunt flow from either coronary artery into the aneurysmal cavity, although the RCA was still enlarged.

Influence of type 2 diabetes mellitus on cardiovascular disease mortality: findings from the Hawaii-Los Angeles-Hiroshima study.

The present study addressed whether diabetes mellitus was a strong risk factor for cardiovascular disease (CVD) death. Between 1976 and 1984, 927 (404 men) Japanese-Americans in Hawaii aged 40-79 years participated at baseline examination including a 75 g oral glucose tolerance test. Diabetes was defined as fasting serum glucose >or=140 mg/dl, 2 h postload glucose >or=180 mg/dl, or the use of drugs for diabetes. Causes of death were classified by ICD-9 codes on the reports from the Hawaii State Public Health Bureau. Until 1994, 178 individuals suffered death; 81 were attributed to CVD and 43 to coronary heart disease (CHD). The age-adjusted and coronary risk factors-adjusted relative risks for CHD and CVD mortality were significant for diabetes both in men and women. The impact of diabetes on CHD mortality was greater for women. However, no gender difference in the contribution of diabetes to fatal CVD was observed. Serum fasting glucose levels tended to be associated with CHD death and were associated with CVD death in diabetic subjects. In conclusion, diabetes is a strong independent risk factor for CVD mortality in Japanese-American men and women. Hyperglycemia is associated with CVD mortality in diabetic subjects.