Acute impact of right ventricular infarction on early hemodynamic course after inferior myocardial infarction.

BACKGROUND: Right ventricular myocardial infarction (RVMI) is the major cause of hypotension and/or shock (HpS) after acute inferior myocardial infarction (inferior AMI). It is, however, unclear how RVMI affects the acute hemodynamic course. METHODS AND RESULTS: In the present study, 153 patients with inferior AMI caused by right coronary artery occlusion were examined. Associations between in-hospital outcome and HpS before admission (preER-HpS) or HpS after admission (postER-HpS) were assessed using multivariate logistic regression analysis. Multivariate analysis was also conducted to determine a predictor for postER-HpS, including clinical findings in the emergency room as independent variables. HpS developed in 48.4% of patients with inferior AMI. Patients with RVMI more frequently had HpS than their counterparts in the first 6 h after infarction onset. RVMI was, however, not associated with preER-HpS, but was independently with postER-HpS (odds ratio (OR): 10.1; 4.0-27.7), whereas left ventricular failure was associated with preER-HpS, but not with postER-HpS. Furthermore, RVMI (OR: 9.4; 3.6-27.1) identified at presentation predicted postER-HpS. CONCLUSIONS: Independent of concomitant left ventricular involvement, RVMI was significantly associated with postER-HpS, but not with preER-HpS. These findings highlight the importance of identifying RVMI immediately after admission in the setting of inferior AMI. (Circ J 2010; 74: 148 - 155).

Disparity in the process and outcome of the treatment for acute myocardial infarction in Japan: CAMPAIGN Study in the National Hospital Network.

BACKGROUND: A nationwide survey of the process and outcome of treatment for acute myocardial infarction (AMI) has not been conducted in Japan. METHODS AND RESULTS: In the present study 2,007 patients with AMI admitted to 22 national hospitals were registered between July 1999 and January 2002 for CAMPAIGN Study 1; an additional 206 and 238 cases were registered between October and December 2002 (CAMPAIGN 2) and between October and December 2003 (CAMPAIGN 3), respectively. In CAMPAIGN 1, the length of stay varied from 15 to 35 days among hospitals (mean: 24.8 days), and was mainly determined by the schedule of follow-up examinations rather than clinical course. Of the prescriptions at discharge, beta-blockers and angiotensin-converting enzyme inhibitors varied widely; the use of beta-blockers was very low (25%). Nitrates were frequently used (68%) although there is no evidence for secondary prevention. In CAMPAIGNs 2 and 3, the use of beta-blockers increased (36%, 47%) and that of nitrates decreased (24%, 21%). CONCLUSION: CAMPAIGN Study 1 revealed considerable variation in the treatment of AMI during the acute phase among the hospitals. The use of beta-blocker and nitrates as discharge medication was inappropriate. CAMPAIGNs 2 and 3 showed some improvement in the problems revealed by CAMPAIGN 1.

Rates of primary percutaneous coronary intervention worldwide.

BACKGROUND: Primary percutaneous coronary intervention (PCI) is at present the most effective procedure for reducing the mortality rate of patients with acute myocardial infarction (AMI). However, there is a great difference between Japan and other countries in the rate of primary PCI. METHODS AND RESULTS: Registration period, number of patients with AMI, rates of primary PCI or thrombolysis and in-hospital or 30-day mortality rates were analyzed in 3 Japanese, 4 European, 4 American and 2 world-wide databases of AMI. The primary PCI rate is higher (75-94%) in Japan than in the other countries (5.5-49.6%), particularly in low-volume hospitals, and the mortality rates at these centers were similar to those in high-volume hospitals (approximately 4-10%). The primary PCI rate has recently been rising (25-50%) worldwide and most PCI procedures are performed in large-volume centers, except in Japan. CONCLUSIONS: Comparison of the AMI databases suggest there is a relationship between the primary PCI rate and annual PCI caseload in each country. It is interesting that in Japan even low-volume PCI hospitals have comparable numbers of primary PCI cases.

Asymmetric synthesis and biological evaluation of the enantiomeric isomers of the immunosuppressive FTY720-phosphate.

A practical asymmetric synthesis of both enantiomers of the immunosuppressive FTY720-phosphate (2) was accomplished, and the enantiomers were pharmacologically evaluated. Several lipases showed considerable activity and enantioselectivity for O-acylation of N-acetyl FTY720 (3) or N-benzyloxycarbonyl FTY720 (7) in combination with vinyl acetate or benzyl vinyl carbonate as the acyl donors. The synthesis using the lipase-catalyzed acylation as the key step produced the enantiomerically pure (>99.5% ee) enantiomers of 2 in multigram quantities. (S)-Isomer of 2 had more potent binding affinities to S1P(1,3,4,5) and inhibitory activity on lymphocyte migration toward S1P than (R)-2, suggesting that (S)-isomer of 2 is responsible for the immunosuppressive activity after administration of 1. Severe bradycardia was observed in anesthetized rats when (S)-2 was administered intravenously, while (R)-2 had no clear effect on heart rate up to 0.3 mg/kg.

A low-cost digital filing system for echocardiography data with MPEG4 compression and its application to remote diagnosis.

The high cost of digital echocardiographs and the large size of data files hinder the adoption of remote diagnosis of digitized echocardiography data. We have developed a low-cost digital filing system for echocardiography data. In this system, data from a conventional analog echocardiograph are captured using a personal computer (PC) equipped with an analog-to-digital converter board. Motion picture data are promptly compressed using a moving pictures expert group (MPEG) 4 codec. The digitized data with preliminary reports obtained in a rural hospital are then sent to cardiologists at distant urban general hospitals via the internet. The cardiologists can evaluate the data using widely available movie-viewing software (Windows Media Player). The diagnostic accuracy of this double-check system was confirmed by comparison with ordinary super-VHS videotapes. We have demonstrated that digitization of echocardiography data from a conventional analog echocardiograph and MPEG 4 compression can be performed using an ordinary PC-based system, and that this system enables highly efficient digital storage and remote diagnosis at low cost.

[What aspects are inefficient concerning percutaneous coronary intervention in Japan?: International cost-effectiveness comparisons].

OBJECTIVES: To investigate the outcome-cost relationship of percutaneous coronary intervention (PCI) during 1 year in Japan and other countries. Foreign databases showing similar coronary events to those observed in Japan during the follow-up period were chosen. METHODS: The Japanese multicenter prospective observational cost database (JSIC) was compared to the Stent Restenosis Study (STRESS), a university hospital (DUKE), Arterial Revascularization Therapies Study (ARTS), and the Primary Angioplasty in Myocardial Infarction trial (PAMI). The presence of acute myocardial infarction (AMI), implantation of stents, and number of involved coronary vessels are known to affect the costs of the initial hospitalization and during the follow-up period. The JSIC database was subdivided according to those factors and the initial hospitalization expenses and follow-up costs was compared. RESULTS: All foreign databases showed similar outcomes for coronary events (deaths or repeat PCI or bypass surgery)compared to the JSIC during the 1 year follow-up period. The cumulative costs for the non-AMI group in the JSIC, STRESS, DUKE, and ARTS were 23.1, 11.3, 22.2, and 10.7 thousand dollars, respectively, and for the AMI group were 27.6 and 20.1 thousand dollars in the JSIC and PAMI, respectively. Balloon catheter costs of initial hospitalization expenses accounted for 50% in JSIC, 23% in STRESS, 31% in DUKE, and 16% in PAMI, but the mean numbers of balloons and stents used per patient were similar. CONCLUSIONS: Costs for PCI were higher in Japan than in most other countries. The difference derived mainly from the higher costs of catheters, not from the longer hospital stay in Japan.

Actual state of radiation exposure during coronary angioplasty: a multicenter study in the nationwide database for cost analysis of percutaneous transluminal coronary angioplasty in Japan.

Percutaneous coronary intervention (PCI) has been associated with excessive radiation exposure, so the present study was designed to investigate the determinants of fluoroscopic time during PCI among characteristics inherent to the patient, procedure and hospital in 388 consecutive patients between November 1996 and March 1999 in 11 hospitals included in the Nationwide Database for Cost Analysis of percutaneous transluminal coronary angioplasty in Japan. Fluoroscopic time, which reflects radiation exposure, was used as the dependent variable in a multiple linear regression analysis. The mean fluoroscopic time was 27+/-15 min. The negative value of partial correlation of the hospital code (r=-0.374) and acute myocardial infarction (-0.163) indicated that these were explanatory variables that decreased fluoroscopic time. The positive value of the number of intraaortic balloon pump catheters (r=0.144), the number of balloons (r=0.304) and hospital stay (r=0.147) indicated these were explanatory variables that increased fluoroscopic time. The absolute value of r, (r=0.374), of the hospital code was the highest. In the final R(2) (=0.304) of the model, which is the partial R-square that determined the dependent variable, the hospital code showed the highest value. In conclusion, there was an inter-hospital difference in fluoroscopic time. Although the hospital code was found to be the most powerful determinant of fluoroscopic time, the R(2) (=0.304) of the model showed so lower value that other hospital characteristics that were not included in the model may influence the fluoroscopic time.

Usefulness of a second temporary vena cava filter for preventing acute pulmonary thromboembolism.

The usefulness of a temporary inferior vena cava filter (t-IVC-f) for the prevention of acute pulmonary thromboembolism (APTE) associated with venous thromboembolism (VTE) has been established, but not the requirement for an additional therapeutic method when the t-IVC-f has captured a thrombus. A woman underwent implantation of a t-IVC-f just caudal to the bifurcation of the renal vein immediately before cesarean section (C/S) for VTE that had occurred during the third trimester of pregnancy. After receiving a combination of anticoagulant and fibrinolytic therapies after the C/S, the t-IVC-f was found to contain a thrombus and in order to prevent its dissemination during the removal of the closed filter, another filter was inserted and expanded proximal to the first. Insertion of an additional t-IVC-f may prevent occurrence of APTE during removal of the primary filter containing a friable thrombus after fibrinolytic therapy, and the technique proved useful in the present case of VTE during pregnancy.

Synthesis and characterization of the first potent inhibitor of yapsin 1. Implications for the study of yapsin-like enzymes.

The potent peptidic inhibitor, Y1, of the basic residue-specific yeast aspartyl protease, yapsin 1, was synthesized and characterized. The inhibitor was based on the peptide sequence of a cholecystokinin(13-33) analog that yapsin 1 cleaved with an efficiency of 5.2 x 10(5) m(-1) s(-1) (Olsen, V., Guruprasad, K., Cawley, N. X., Chen, H. C., Blundell, T. L., and Loh, Y. P. (1998) Biochemistry 37, 2768-2777). The apparent K(i) of Y1 for the inhibition of yapsin 1 was determined to be 64.5 nm, and the mechanism is competitive. Y2 was also developed as an analog of Y1 for coupling to agarose beads. The resulting inhibitor-coupled agarose beads were successfully used to purify yapsin 1 to apparent homogeneity from conditioned medium of a yeast expression system. Utilization of this new reagent greatly facilitates the purification of yapsin 1 and should also enable the identification of new yapsin-like enzymes from mammalian and nonmammalian sources. In this regard, Y1 also efficiently inhibited Sap9p, a secreted aspartyl protease from the human pathogen, Candida albicans, which has specificity for basic residues similar to yapsin 1 and might provide the basis for the prevention or control of its virulence. A single-step purification of Sap9p from conditioned medium was also accomplished with the inhibitor column. N-terminal amino acid sequence analysis yielded two sequences indicating that Sap9p is composed of two subunits, designated here as alpha and beta, similar to yapsin 1.

[Autoantibodies: new upstream targets of paroxysmal atrial fibrillation in patients with congestive heart failure].

OBJECTIVES: The clinical implications of autoantibodies (Abs) were investigated as upstream indicators of paroxysmal atrial fibrillation in patients with congestive heart failure. METHODS: Circulating Abs against myosin (M-Abs) detected by immunofluorescence, Abs against beta 1-adrenergic receptors (Beta 1-Abs) detected by enzyme-linked immunosorbent assay (ELISA), and Abs against NA-K-ATPase (NKA-Abs) detected by ELISA were screened in 95 congestive heart failure patients with < or = 45% left ventricular ejection fraction (coronary artery disease, n = 48; dilated cardiomyopathy, n = 47) and 48 age-matched control patients with hypertension. No patient received antiarrhythmic therapy. All patients were enrolled with angiotensin converting enzyme inhibitors in the chronic stable state. Relationship of the presence of paroxysmal atrial fibrillation to other clinical variables were assessed by 48-hour Holter monitoring. RESULTS: No control patient had Abs. However, M-Abs, Beta 1-Abs, and NKA-Abs were detected in 22%, 26% and 16% of patients with congestive heart failure (coronary artery disease; 8%, 10%, and 4%, dilated cardiomyopathy; 36%, 43%, and 28%, respectively). Paroxysmal atrial fibrillation was more frequent in patients with dilated cardiomyopathy than in those with coronary artery disease (47% vs 15%, p < 0.01). Multivariate analysis suggested that NKA-Abs was an independent risk factor for the occurrence of paroxysmal atrial fibrillation (p < 0.01), although there were no differences in other clinical factors: age, sex, New York Heart Association functional class, concomitant medication, left ventricular ejection fraction, left atrial diameter, severity of mitral regurgitation, serum potassium, plasma norepinephrine, and atrial natriuretic peptide concentration. CONCLUSIONS: Autoantibodies against sarcolemmal Na-K-ATPase were closely related to the occurrence of paroxysmal atrial fibrillation in patients with congestive heart failure, so an autoimmune process may be an upstream factor in atrial fibrillation.

Coronary disease morphology and distribution determined by quantitative angiography and intravascular ultrasound--re-evaluation in a cooperative multicenter intravascular ultrasound study (COMIUS).

Although previous studies have demonstrated that even quantitative coronary angiography (QCA) can not provide accurate disease morphology, there has not been a systematic comparison of disease morphology determined by QCA and intravascular ultrasound (IVUS), particularly in Japanese patients. Therefore, the present study prospectively examined patients in a multicenter cooperative study. A total of 491 coronary sites from 562 patients (446 men, 116 women; mean age, 64+/-11 years) who underwent coronary interventions were enrolled. The target lesions (>50% diameter stenosis) were evaluated pre-operatively by both QCA and IVUS operating at 30-40 MHz and the percent area stenosis, eccentricity index (EI) and lesion length were determined. The minimal (min) and maximal (max) distances from the center of the stenotic lesion to the outline of the vessel wall were measured, and the EI was calculated by the formula: [(max - min)/max]. By QCA, lesion length was determined by measuring the distance between the proximal and distal shoulders of the lesion. When the lesions were observed by IVUS with a motorized pull-back system, the length was calculated by multiplying the time for observation of the disease and 0.5 or 1 mm/s. Although the severity of the stenosis determined by QCA (86+/-10%, mean +/- SD) did not differ from that by IVUS (83+/-13%), there was no correlation between them (r=0.32, y=0.25x+65) and the correlation did not improve when lesions with remodeling, enlargement (n=176) or shrinkage (n=79) were omitted from the calculation. The EIs by QCA and IVUS were 0.51+/-0.26 and 0.52+/-0.22, respectively (NS), and there was no correlation between them (r=0.30, y=0.36x+33). However, when the lesions with remodeling were excluded, the correlation greatly improved (r=0.80, y=0.84x+10.6, p<0.05). Lesion length determined by QCA (12.4+/-6.1 mm) was significantly shorter than that by IVUS (16.3+/-8.9 mm, p<0.01). These results demonstrate that coronary angiography significantly misinterprets disease morphology in terms of severity, eccentricity and length, in part because of vessel remodeling that can be accurately determined only by IVUS.

Primary cardiac sarcoma mimicking benign myxoma: a case report.

A 53-year-old woman presented with a primary cardiac sarcoma mimicking benign myxoma manifesting as progressive heart failure. Transesophageal echocardiography disclosed two separate tumors in the left atrium which appeared just like myxoma, except for the origin and multiple growth profile. Three separate tumors were identified during the operation arising from the posterior wall of the left atrium, mitral valve orifice and left atrial free wall. The histological diagnosis was malignant undifferentiated sarcoma. Six months later, she noticed dyspnea and arm numbness due to local recurrence of cardiac tumor and brain metastasis. She died suddenly 6 months after the surgery during admission. The clinical and echocardiographic findings are crucial to discriminate malignant cardiac tumors from benign myxoma. Rapidly progressive clinical course, multiple tumor growth and non-septal attachment of the tumor all suggest a malignant profile of the primary cardiac tumors. Careful and precise preoperative evaluation, including echocardiographic survey of the tumor origin and multiple growth profile, are essential to identify malignant cardiac tumor.