Takotsubo cardiomyopathy in two patients with microvascular angina.

We present two cases in which takotsubo cardiomyopathy (TC) developed immediately after a diagnosis of microvascular angina had been established. One patient who had been diagnosed as having endothelium-dependent microvascular angina (microvascular spasm) developed TC three weeks after the initial admission. The other patient was diagnosed as having endothelium-independent microvascular angina (decreased coronary flow reserve) and subsequently developed TC after the discontinuation of nicorandil treatment. These cases may provide insight into the possible mechanisms underlying the pathophysiological findings of TC. .

Changes of cerebral oxygen metabolism and hemodynamics during ECPR with hypothermia measured by near-infrared spectroscopy: a pilot study.

BACKGROUND: The 2010 CPR Guidelines recommend that extracorporeal cardiopulmonary resuscitation (ECPR) using an emergency cardiopulmonary bypass (CPB) should be considered for patients with cardiac arrest. However, it is not yet clear whether this therapy can improve cerebral circulation and oxygenation in these patients. To clarify this issue, we evaluated changes of cerebral blood oxygenation (CBO) during ECPR using near-infrared spectroscopy (NIRS). METHODS: We employed NIRS to measure CBO in the bilateral frontal lobe in patients transported to the emergency room (ER) after out-of-hospital cardiac arrest between November 2009 and June 2011. RESULTS: Fifteen patients met the above criteria. The tissue oxygenation index (TOI) on arrival at the ER was 36.5 %. This increased to 67.8 % during ECPR (P < 0.001). The one patient whose TOI subsequently decreased had a favorable neurological outcome. CONCLUSION: Increase of TOI during ECPR might reflect an improvement in cerebral blood flow, while decrease of TOI after ECPR might reflect oxygen utilization by the brain tissue as a result of neuronal cell survival. NIRS may be useful for monitoring cerebral hemodynamics and oxygen metabolism during CPR.

Prognostic value of venous blood ammonia in patients with out-of-hospital cardiac arrest.

BACKGROUND: Although studies have shown there is a correlation between increased blood ammonia level and hepatic encephalopathy, little information is available for patients with out-of-hospital cardiac arrest. METHODS AND RESULTS: We did a prospective study of 357 adult patients with out-of-hospital cardiac arrest whose venous blood ammonia levels were measured on arrival at the emergency room. The primary endpoint was favorable of neurological outcome to hospital discharge. Of the 357 patients, 25 (7%) had a favorable neurological outcome. The venous ammonia levels were lower in the favorable neurological outcome group than in the unfavorable neurological outcome group (median, 50 µg/dl vs. 210 µg/dl, P<0.0001). The adjusted odds ratio of ammonia levels for favorable neurological outcome was 0.98 (95% confidence interval, 0.96-0.99; P<0.0001). The ammonia cutoff value of 93.0 µg/dl for the identification of favorable neurological outcome had the highest combined sensitivity and specificity, and higher ammonia levels were associated with more accurate negative predictive values (for ammonia levels of 192.5 µg/dl, the negative predictive value was 100%). Hyperammonemia was significantly related to patient variables that had a poor outcome (R=0.439, P<0.001). In addition, there was a significant correlation between venous ammonia level and arterial pH on emergency room arrival (R=0.633, P<0.0001). CONCLUSIONS: The measurement of ammonia was found to provide valuable information regarding neurological outcome to hospital discharge in adult patients with out-of-hospital cardiac arrest.

Double left anterior descending artery arising from right and left sinus of Valsalva in patient with acute coronary syndrome.

An aberrant origin of left anterior descending artery (LAD) from right and left sinus of Valsalva is a rare anomaly but clinically important. Coronary angiography (CAG) was performed in patient with acute coronary syndrome, and revealed severe stenosis at the mid of LAD. The distal of LAD was likely to be a total occlusion. It was proved to be a double left anterior descending artery arising from right and left sinus of Valsalva by multidetector-row computed tomography (MDCT) and following CAG. We describe here congenital coronary anomaly case which would be misleading as a total occlusion.

Early induction of hypothermia during cardiac arrest improves neurological outcomes in patients with out-of-hospital cardiac arrest who undergo emergency cardiopulmonary bypass and percutaneous coronary intervention.

BACKGROUND: Therapeutic hypothermia for comatose survivors of out-of-hospital cardiac arrest has demonstrated neurological benefits. Although early cooling during cardiac arrest enhances efficacy in animal studies, few clinical studies are available. METHODS AND RESULTS: The 171 patients who failed to respond to conventional cardiopulmonary resuscitation were studied prospectively. Patients underwent emergency cardiopulmonary bypass (CPB) plus intra-aortic balloon pumping, with subsequent percutaneous coronary intervention (PCI) if needed. Mild hypothermia (34 degrees C for 3 days) was induced during cardiac arrest or after return of spontaneous circulation. Of the 171 patients, 21 (12.3%) had a favorable neurological outcome at hospital discharge. An unadjusted rate of favorable outcome decreased in a stepwise fashion for increasing quartiles of collapse-to-34 degrees C interval (P=0.016). An adjusted odds ratio for favorable outcome after collapse-to-CPB interval was 0.89 (95% confidence interval (CI) 0.82-0.97) and after CPB-to-34 degrees C interval, 0.99 (95%CI 0.98-0.99) when collapse-to-34 degrees C interval was divided into 2 components. Favorable neurological accuracy of a collapse-to-CPB interval at a cutoff of 55.5 min and CPB-to-34 degrees C interval at a cutoff of 21.5 min was 85.4% and 89.5%, respectively. CONCLUSIONS: Early attainment of a core temperature had neurological benefits for patients with out-of-hospital cardiac arrest who underwent CPB and PCI. (Circ J 2010; 74: 77 - 85).

Acute myocardial infarction in a patient with anomalous origin of the right coronary artery: depiction at whole-heart coronary magnetic resonance angiography and delayed-enhanced imaging.

A 71-year-old man was admitted to our hospital because of anterior chest pain. His electrocardiogram showed ST-segment depression and cardiac enzymes were normal. Non-ST-elevation acute myocardial infarction was suspected and whole-heart magnetic resonance imaging was performed. Whole-heart coronary magnetic resonance angiography (MRA) showed an anomalous origin of the right coronary artery from the left sinus of Valsalva and delayed-enhanced imaging showed transmural hyperenhancement of the inferior wall. Coronary angiography revealed the anomalous origin of the right coronary artery (RCA) from the left sinus of Valsalva and occlusion in the proximal portion of the RCA. Coronary revascularization was achieved by intracoronary thrombolysis followed by stent implantation. Whole-heart coronary MRA and delayed-enhanced imaging allows simultaneous assessment of coronary artery anomaly and extent of myocardial infarction.

Right atrial free-floating thrombus in a patient with massive pulmonary embolism: a case of 'emboli in transit'.

A 78-year-old man was admitted with sudden onset of dyspnea followed by syncope. Contrast-enhanced computed tomography showed embolism in the right main pulmonary artery and left upper pulmonary artery. Echocardiography revealed a large, free-floating thrombus and cine magnetic resonance imaging showed highly mobile, low-signal intensity mass in the right atrium, which protruded into the right ventricle during diastole. During surgery the thrombus migrated into the pulmonary artery trunk, but it was successfully removed.

Diffuse pulmonary hemorrhage as a fatal complication of Schönlein-Henoch purpura.

We report a case of a 69-year-old man with Schönlein-Henoch purpura who developed diffuse pulmonary hemorrhage. He complained of dyspnea and hemoptysis while he was treated with steroids for gastroenteropathy associated with Schönlein-Henoch purpura. The drop in his hemoglobin levels and diffuse ground-glass opacity at all levels of the lung fields on chest computed tomography were a significant clue to diagnosis. Despite pulse therapy, no clinical improvement of the lung was achieved, and he died on the 36th day after the admission. Although the combination of the corticosteroid and immunosuppressive agents is normally recommended, diffuse pulmonary hemorrhage could become a fatal complication in elderly Schönlein-Henoch patients.

Resuscitative value of B-type natriuretic peptide in comatose survivors treated with hypothermia after out-of-hospital cardiac arrest due to cardiac causes.

BACKGROUND: Two randomized studies have shown a neurological benefit of therapeutic hypothermia in comatose survivors after out-of-hospital cardiac arrest, but there are no studies of the cardiac neurohormone of B-type natriuretic peptide (BNP) in patients treated with hypothermia. METHODS AND RESULTS: A prospective study was conducted of 109 comatose patients who were treated with mild hypothermia after out-of-hospital sudden cardiac arrest due to cardiac causes and whose BNP level was measured on arrival at the emergency room. The primary endpoint was a favorable neurological outcome at the time of hospital discharge. A total of 45 of the 109 patients had a favorable neurological outcome. The unadjusted rate of a favorable neurological outcome decreased in a stepwise fashion among patients in increasing quartiles of BNP level (p<0.001) and this association remained significant in subgroups of patients. The BNP cutoff value of 80 pg/ml for a favorable neurological outcome had an accuracy of 87.2%. In the multiple logistic-regression analysis, a BNP level of 80 pg/ml or less was an independent predictor of favorable neurological outcome. CONCLUSIONS: The measurement of BNP was found to provide valuable information regarding the neurological outcome of comatose survivors treated with mild hypothermia after out-of-hospital cardiac arrest due to cardiac causes.

Increasingly well-preserved left ventricular function in hospital survivors with acute myocardial infarction: effect of early and complete reperfusion strategy on left ventricular remodeling.

BACKGROUND: Progress in reperfusion therapy for acute myocardial infarction (AMI) has greatly reduced acute phase mortality, but few data exist regarding the time trends in left ventricular (LV) remodeling in hospital survivors of AMI. METHODS AND RESULTS: The study enrolled 813 patients with AMI who had received reperfusion therapy and survived to hospital discharge. The patients were divided into chronological groups: first treatment received between 1989 and 1992, n=196; 1993 and 1995, n=193; 1996 and 1998, n=211; and 1999 and 2002, n=213. A comparison was made of LV ejection fraction (LVEF) and LV end-diastolic volume index (LVEDVI) at 6 months after symptom onset. Along with the temporal improvements reperfusion therapy, LVEF and LVEDVI improved over time (55+/-14, 58+/-13, 59+/-13, 61+/-13%, p<0.001; 98+/-30, 94+/-27, 90+/-31, 76+/-27 ml/m2, p<0.0001). Multiregression analysis revealed that shortening of the door-to-Thrombolysis In Myocardial Infarction (TIMI)-3 time (time interval from arrival at the emergency room until patients achieved TIMI-3 flow) and achieving substantial TIMI-3 flow were independent predictors for LV remodeling. CONCLUSION: Although this was a retrospective analysis, the results demonstrated that the change in reperfusion therapy aiming at complete reperfusion at an earlier stage after AMI onset has contributed to improving post-MI remodeling.

Efficacy of calcium channel blocker in the secondary prevention of myocardial infarction--retrospective analysis of the 10-year prognosis or coronary thrombolysis-treated patients.

BACKGROUND: Calcium channel blockers (CCBs) may have a positive influence on the long-term prognosis of Japanese patients with ischemic heart disease. METHODS AND RESULTS: The effect of nifedipine-retard (NR) (n=202) compared with that of non-CCB treatment (n=92) on the secondary prevention of myocardial infarction (MI) was retrospectively investigated in patients who had survived acute MI between 1987 and 1996. The primary endpoint was the occurrence of cardiac death or non-fatal MI. The median follow-up was 6.3+/-2.4 years. The incidence of cardiac events was 8.9% in the NR group and 14.1% in the non-CCBs group (p=0.14, odds ratio (OR): 0.584, 95% confidence interval (CI): 0.286-1,193). However, subanalysis revealed that NR significantly reduced the incidence of cardiac events in patients aged less than 55 years (4.2 vs 18.2%, p=0.016, OR: 0.180, 95%CI: 0.045-0.721) and those who did not smoke (8.6 vs 16.4%, p=0.048, OR: 0.462, 95%CI: 0.203-0.999). CONCLUSION: Although this was a retrospective analysis, it showed that NR did not cause an increase in the incidence of cardiac events in post-MI patients; it even prevented cardiac events, especially in those who were less than 55 years of age and in non-smokers, suggesting the potential usefulness of CCBs in the secondary prevention of MI in Japan.

B-type natriuretic peptide as a marker of resuscitation in patients with cardiac arrest outside the hospital.

BACKGROUND: Although the circulating concentration of B-type natriuretic peptide (BNP) has both a prognostic and diagnostic value in heart disease, no data are available regarding its resuscitative value for out-of-hospital cardiac arrest. METHODS AND RESULTS: The present study was a prospective study of 401 patients whose BNP was measured on arrival at the emergency room after an out-of-hospital cardiac arrest with a cardiac cause. The primary endpoint was survival to hospital discharge. The unadjusted rate of survival to hospital discharge decreased in a stepwise fashion among patients in increasing quartiles of BNP concentration (p<0.001). After adjusting for independent predictors of resuscitation, the odds ratios for survival to hospital discharge in the second, third and fourth quartiles of BNP were 0.13 (95% confidence interval (CI), 0.04-0.46), 0.10 (95% CI, 0.03-0.41), and 0.004 (95% CI, 0.00-0.16), respectively. The BNP cutoff value of 100 pg/ml for survival had a sensitivity of 83% and a negative predictive value of 96%. CONCLUSIONS: The measurement of BNP was found to provide valuable predictive information for survival to hospital discharge in patients with out-of-hospital cardiac arrest of cardiac etiology.