Balloon pulmonary angioplasty under awake veno-arterial extracorporeal membrane oxygenation in a patient with class III obesity with chronic thromboembolic pulmonary hypertension complicated with multiple serious comorbidities.

Chronic thromboembolic pulmonary hypertension (CTEPH) is a chronic disease that can rapidly deteriorate into circulatory collapse when complicated by comorbidities. We herein describe a case involving a 43-year-old woman with class III obesity (body mass index of 63 kg/m2) and severe CTEPH associated with total occlusion of the left main pulmonary artery who subsequently developed circulatory collapse along with multiple comorbidities, including acute kidney injury, pulmonary tuberculosis, and catastrophic antiphospholipid syndrome. The patient was successfully treated with two sessions of rescue balloon pulmonary angioplasty with veno-arterial extracorporeal membrane oxygenation (V-A ECMO) support under local anesthesia without sedation, at cannulation and during the V-A ECMO run, to avoid invasive mechanical ventilation. This case suggests the potential usefulness of rescue balloon pulmonary angioplasty under awake V-A ECMO support for rapidly deteriorating, inoperable CTEPH in a patient with class III obesity complicated with multiple comorbidities.

Balloon Pulmonary Angioplasty for Takayasu Arteritis and Peripheral Pulmonary Artery Stenosis Mimicking Chronic Thromboembolic Pulmonary Hypertension.

Balloon pulmonary angioplasty (BPA) has been reported to be effective and safe to an acceptable level in patients with distal-type, inoperable chronic thromboembolic pulmonary hypertension (CTEPH), resulting in improved long-term survival. However, evidenced treatment options and strategy including medical therapy of antithrombotic therapy, glucocorticoids, immunosuppressants, and pulmonary hypertension (PH)-specific therapies are scarce in patients with significant PH and right heart failure associated with Takayasu arteritis and peripheral pulmonary artery stenosis, both of which mimic CTEPH. Moreover, there has been still concern on safety and lack of established methodology in performing BPA for these conditions. In this report, we would like to review recent publications including several case reports and discuss the efficacy, safety, and suitable methods of BPA in this population.

Predictors of recurrence of atrial tachyarrhythmias after pulmonary vein isolation by functional and structural mapping of nonparoxysmal atrial fibrillation.

BACKGROUND: This study aimed to evaluate the predictors of recurrence of atrial tachyarrhythmias by structural and functional mapping: voltage, dominant frequency (DF), and rotor mapping after a pulmonary vein isolation (PVI) in nonparoxysmal atrial fibrillation (AF) patients. METHODS: A total of 66 nonparoxysmal AF patients were prospectively investigated. After the PVI, an online real-time phase mapping system was used to detect the location of rotors with critical nonpassively activated ratios (%NPs) of ≧50% in each left atrial (LA) segment, and high-DFs of ≧7 Hz were simultaneously mapped. After restoring sinus rhythm, low-voltage areas (LVAs < 0.5 mV) were mapped using the Advisor HD grid catheter (HDG). RESULTS: Sixty-four of 66 (97%) AF patients had minimum to mild LVAs regardless of an enlarged LAD and LA volume (45 ± 6.0 mm and 141 ± 29 ml). There were no significant differences in the max and mean DF values and %NPs between the patients with and without recurrent atrial tachyarrhythmias. However, there was a significant difference in the LVA/LA surface area between the patients with and without recurrent atrial tachyarrhythmias (p = .004). Atrial tachyarrhythmia freedom was significantly greater in those with LVAs of ≤3.3% than in those >3.3% after one procedure over 11.6 ± 0.8 months of follow-up (77.1% vs. 33.3%, p < .001). In a multivariate analysis, the LVA/LA surface area after the PVI (HR 1.079; CI, 1.025-1.135, p = .003) was an independent predictor of AF recurrence. CONCLUSIONS: The predictor of atrial tachyarrhythmia recurrence after the PVI was LVAs rather than DFs and rotors in nonparoxysmal AF patients.

Persistence of constrictive pattern despite improvement in symptoms after the waffle procedure: A case report of constrictive pericarditis.

Constrictive pericarditis (CP) is an uncommon disease characterized by clinical signs of right-sided heart failure subsequent to loss of pericardial compliance. Although pericardiectomy is the accepted treatment for improving cardiac hemodynamics in CP, some patients fail to improve after pericardiectomy. We herein report a case of CP that showed some physical and hemodynamic features with a constrictive pattern that persisted despite the improvement in heart failure symptoms after pericardiectomy. A 61-year-old man was diagnosed with CP 7 months after the onset of symptoms of shortness of breath and edema in the legs. The waffle procedure was performed using an ultrasonic scalpel. Post-operative cardiac catheterization demonstrated a dip-and-plateau pattern in both right ventricular (RV) and left ventricular (LV) pressures, but the RV and LV end-diastolic pressures improved. Moreover, Doppler echocardiography showed an improvement in the change in mitral and tricuspid early velocities with respiration. Decrease in intraoperative right atrial pressure and respiratory variability in LV and RV inflow on echocardiography are important predictors of improvement in post-operative heart failure symptoms. Learning objective: Decrease in intraoperative right atrial pressure and respiratory variability in left ventricular and right ventricular inflow on post-operative echocardiography are important predictors of improvement in heart failure symptoms even if some hemodynamic features characterizing constrictive pericarditis (dip and plateau pattern, Friedreich's sign) persist.>.

Validation of Echodynamography in Comparison with Particle-image Velocimetry.

Echodynamography (EDG) is a computational method to estimate and visualize two-dimensional flow velocity vectors by applying dynamic flow theories to color Doppler echocardiography. The EDG method must be validated if applied to human cardiac flow function. However, a few studies of flow estimated have compared by EDG to the flow data were acquired by other methods. In this study, EDG was validated by comparing the analysis of estimating and visualizing flow velocity vectors obtained by original particle image velocimetry (PIV) based on a left ventricular (LV) phantom hydrogel (in vitro studies) and by EDG based on the virtual Doppler velocity. Velocity measured by PIV method and velocity estimated by EDG method in the perpendicular direction and the radial direction were compared. Regression analysis for the velocity estimated in the radial direction revealed an excellent correlation (R2=0.99, slope = 0.96) and moderate correlation in the perpendicular direction (R2=0.44, slope = 0.46). As revealed by the Bland-Altman plot, however, overestimations and higher relative error were observed in the perpendicular direction (0.51 ± 2.75 mm/s) and in the radial direction (-2.15 ± 21.13 mm/s). The percentage error of the norm-wise relative error of the velocity discrepancy is less than 10%, and velocity magnitude followed the same trends and are of comparable magnitude. These findings indicate that good estimates of velocity can be obtained by the EDG method. Therefore, the EDG method was appropriate for estimating and visualizing velocity vectors in clinical studies for higher measurement accuracy and reliability. The clinical in vivo application showed that the EDG method has the ability to visualize blood flow velocity vectors and differentiate the clinical information of vortex parameters both in normal and abnormal LV subjects. In conclusion, the EDG method has potentially greater clinical acceptance as a tool assessment of LV during the cardiac cycle.

Left Ventricular Vortices in Myocardial Infarction Observed with Echodynamography.

Echodynamography (EDG) is a computational method to deduce two-dimensional (2D) blood flow vector from conventional color Doppler ultrasound image by considering that the blood flow is divided into vortex and base flow components. Left ventricular (LV) vortices indicate cardiac flow status influenced by LV wall motion. Thus, quantitative assessment of LV vortices may become new and sensitive parameters for cardiac function. In the present study, quantitative parameters of LV vortices such as vortex index, vortex size, and Reynolds number were calculated and relation between each parameter was assessed. Six healthy volunteers and three patients with myocardial infarction (MI) who underwent color Doppler echocardiography (CDE) were involved in the study. Serial CDE images in apical three-chamber view were recorded and 2D blood flow vector was superimposed on the CDE image. Vortex index, vortex size, and Reynolds number were compared between the normal volunteers and the MI patients. The results showed that vortex index (3.09±2.06 vs. 3.34±2.33, p<; 0.05), vortex size (1.76 0.69 vs. 2.01 ±0.68, p<; 0.05), Reynolds number (1020±603 vs.±1312 1046, p<; ±0.05) were significantly greater in the MI patients than in the healthy volunteers. Vortex equivalent diameter in LV showed significant positive correlation with Reynolds number (R2 = 0.799, y = 0.001x + 0.7098, p <; 0.05) in healthy volunteers and (R2 = 0.6404, y = 0.0005x+1.3185, p<; 0.05) in MI patients. Vortex index showed positive correlation with Reynolds number (R2 = 0.9351, y = 0.002x+0.1397, p<; 0.05) in healthy volunteers and (R2 = 0.758, y = 0.0019x+0.7957, p<; 0.05) in MI patients. In conclusion, EDG provides information on LV hemodynamics by quantitative LV vortices parameters both in healthy volunteers and MI patients.

Left Ventricular Blood Flow Dynamics In Aortic Stenosis Before And After Aortic Valve Replacement.

Surgical intervention for aortic valve stenosis (AS) has been established; however its diagnosis based on echocardiographic assessment is still limited by aortic valvular velocity, aortic valvular pressure gradients, and color Doppler imaging. Echo-dynamography (EDG) is a method to determine intracardiac flow dynamics, such as two-dimensional blood flow velocity, vortex, and dynamic pressure. These flow dynamics may be influenced by left ventricular (LV) wall motion and the resistance in LV outflow caused by AS. The objective of the present study was to assess the changes and differences in LV vortices and vorticity before and after AS surgery. Five patients who underwent aortic valve replacement surgery for AS and five control patients were included. Besides routine echocardiographic measurement, EDG was applied to determine the two-dimensional blood flow vector and vorticity. The LV vortex flow in the isovolumetric contraction phase had multiple formations in preoperative cases. The clockwise vortex was found in all cases postoperatively; the vortex formation showed no significant difference between postoperative and normal control groups. EDG may serve important information on LV flow dynamics, non-invasively.

Deformability of the pulsating left ventricular wall: A new aspect elucidated by high resolution ultrasonic methods.

BACKGROUND: Although the deformability of the left ventricular (LV) wall appears to be important in maintaining effective cardiac performance, this has not been debated by anyone, probably owing to the difficulties of the investigation. OBJECTIVES: This study applies a new technology to demonstrate how the LV wall deforms so as to adjust for optimum cardiac performance. SUBJECTS AND METHODS: Ten healthy volunteers were the subjects. Using echo-dynamography, an analysis at the "microscopic" (muscle fiber) level was done by measuring the myocardial axial strain rate (aSR), while the "macroscopic" (muscle layer) level contraction-relaxation/extension (C-R/E) properties of the LV wall were analyzed using high frame rate 2D echocardiography. RESULTS: Deformability of the LV was classified into three types depending on the non-uniformity of both the C-R/E properties and the aSR distribution. "Basic" deformation (macroscopic): The apical posterior wall (PW) thickness change was concentric and monophasic, whereas it was eccentric and biphasic in the basal part. This deformation was large in the PW, but small in the interventricular septum (IVS). The elongation of the mitral ring diameter and the downward movement of its posterior part were shown to be concomitant with the anterior extrusion of the PW. "Combined" deformation (macroscopic and microscopic): This was observed when the basic deformation was coupled with the spatial aSR distribution. Three patterns were observed: (a) peristaltic; (b) bellows-like; and (c) pouch-like. "Integrated" deformation: This was the time serial aSR distribution coupled with the combined deformation, illustrating the rotary pump-like function. The deformability of the LV assigned to the apical part the control of pressure and to the basal part, flow volume. The IVS and the PW exhibited independent behavior. CONCLUSIONS: The non-uniformity of both the aSR distribution and the macroscopic C-R/E property were the basic determinants of LV deformation. The apical and basal deformability was shared in LV mechanical function.

Visual acuity prognosis after anterior chamber air replacement to prevent pseudo-anterior chamber formation after deep lamellar keratoplasty.

PURPOSE: To investigate the prognosis of patients who received anterior chamber air replacement after deep lamellar keratoplasty (DLKP) during the study period, January 1995 to April 2000. METHODS: The records were studied of 47 patients (54 eyes) (60.6 +/- 21.3 years of age) who underwent DLKP at Dokkyo University Hospital. Visual acuity and endothelial cell loss were assessed in patients (1) with and without Descemet's membrane perforation; (2) with and without the use of anterior chamber air replacement, and for different durations of air replacement; and (3) in the presence or absence of a pseudo-anterior chamber, and in relation to its duration if present. RESULTS: No significant differences in relation to the above three items were found in endothelial cell loss in study years 1 to 5. Average best visual acuity was 0.61 in perforated eyes, 0.54 in unperforated eyes, 0.54 in eyes that received air replacement, and 0.57 in eyes that did not. The average best visual acuity was 0.38 in eyes with a pseudo-anterior chamber and 0.68 in eyes without one. There was a significant correlation between the duration of the pseudo-anterior chamber and loss of visual acuity. CONCLUSIONS: The prolongation of a pseudo-anterior chamber eventually impairs visual acuity, whereas anterior chamber air replacement, used to prevent the development of a pseudo-anterior chamber, causes minimal endothelial cell damage. Anterior chamber air replacement, therefore, is an effective technique by which to prevent the development of a pseudo-anterior chamber.

BAFF/BLyS can potentiate B-cell selection with the B-cell coreceptor complex.

The tumor necrosis factor (TNF)-like ligand BAFF/BLyS (B-cell activating factor of the TNF family/B-lymphocyte stimulator) is a potent B-cell survival factor, yet its functional relationship with other B-cell surface molecules such as CD19 and CD40 is poorly understood. We found that follicular dendritic cells (FDCs) in human lymph nodes expressed BAFF abundantly. BAFF up-regulated a B cell-specific transcription factor Pax5/BSAP (Pax5/B cell-specific activator protein) activity and its target CD19, a major component of the B-cell coreceptor complex, and synergistically enhanced CD19 phosphorylation by B-cell antigen receptor (BCR). BAFF further enhanced B-cell proliferation, immunoglobulin G (IgG) production, and reactivity to CD154 by BCR/CD19 coligation and interleukin-15 (IL-15). Our results suggest that BAFF may play an important role in FDC-B-cell interactions through the B-cell coreceptor complex and a possibly sequential link between the T cell-independent and -dependent B-cell responses in the germinal centers.