A case of coronary artery compression syndrome resulting from peri-valvular regurgitation and long-standing atrial fibrillation.

A man in his 70s with a history of mitral valve replacement (MVR) and long-standing persistent atrial fibrillation (AF) presented with effort angina. Coronary angiography revealed severe stenosis of the left main coronary artery (LMCA). As it was an emergent case, PCI (percutaneous coronary intervention) was selected for treatment. Intravascular ultrasonography revealed no atherosclerotic lesions in the LMCA. The LMCA was effectively dilated by the drug-eluting stent. No elevation in intracardiac pressure was observed in cardiac catheterization after PCI. Computed tomography scan indicated potential compression of the LMCA by the surrounding structures. In cases of long-standing persistent AF and an enlarged atrium after MVR, the possibility of LMCA stenosis due to anatomical changes should be considered. Learning Objectives: ◾Peri-valvular regurgitation and long-standing persistent atrial fibrillation can potentially cause atrial enlargement.◾Coronary artery stenosis without atherosclerosis can occur due to compression from surrounding structures or shifting of the coronary artery.◾Stent therapy provides a temporary solution and coronary artery bypass grafting or switching should be considered if re-stenosis occurs.

Idiopathic ventricular arrhythmias arising from the posterior septum of tricuspid and mitral annuli: comparison of electrocardiographic characteristics and outcomes of catheter ablation.

PURPOSE: Ventricular arrhythmia (VA) arising from the tricuspid annulus in the posterior septum (PS) (TAPS-VA) has similar electrocardiographic characteristics as VA arising from the mitral annulus in the PS (MAPS-VA) because the two locations are adjacent. We examined the electrocardiographic characteristics that differentiate MAPS-VA from TAPS-VA and the efficacy of catheter ablation. METHODS: We studied 13 patients whose VAs were successfully ablated in the TAPS (n = 7) and MAPS (n = 6). RESULTS: QRS morphologies of both groups were characterized by left and right bundle block morphologies in lead V1, superior axis deviation, and precordial transition at ≤ lead V3 in nine patients. Compared with TAPS-VA, MAPS-VA had (1) R < S wave in lead II, (2) precordial transition in lead V2, (3) s-wave in lead V6, and (4) slurred initial part of the QRS complex in the precordial leads, e.g., [4a] pseudo delta wave ≥ 34 ms, [4b] intrinsicoid deflection time ≥ 85 ms, and [4c] maximum deflection index ≥ 0.55. Patients who met ≥ 2 of (1)-(3) and any of [4a]-[4c] could be classified as having MAPS-VA, with a sensitivity and specificity of 100%. VA recurred in one patient in the TAPS group during the median follow-up of 7 (interquartile range 6 to 15.5) months. CONCLUSIONS: VA arising from the PS has superior axis deviation, and left and right bundle block morphologies with relatively early precordial transition. MAPS-VA can be differentiated from TAPS-VA based on electrocardiographic characteristics. This study provides useful information for treatment involving catheter ablation for VA arising from the PS.

Differences between cardiac memory T wave changes after idiopathic left ventricular tachycardia and ischemic T wave inversion induced by acute coronary syndrome.

BACKGROUND: Cardiac memory (CM) after idiopathic left ventricular tachycardia (ILVT) mimics ischemic T wave inversion (TWI) induced by acute coronary syndrome (ACS). We aimed to establish electrocardiography criteria for differentiating the CM from ischemic TWI. METHODS AND RESULTS: We evaluated 16 ILVT and 48 ACS patients. We identified TWI after ILVT in 9/16 patients (CM group), typically in leads II, III, aVF, aVR, and V4-6. The characteristics of CM were similar to TWI induced by ACS involving right coronary artery, but the CM group had more TWI in V4 and shorter QTc. The criteria of (1) positive T in aVL, (2) negative or isoelectric T in II, and (3) negative T in V4-6 or (4) QTc <430ms were 100% sensitive and 96% specific for the CM group. CONCLUSION: CM after ILVT can be differentiated in most cases from ischemic TWI by the distribution of TWI and the QTc.

Two-year clinical outcome in patients with small coronary artery disease treated with everolimus- versus paclitaxel-eluting stenting.

BACKGROUND: Percutaneous coronary interventions involving small coronary vessels represent a true challenge because of the increased risk of restenosis and adverse outcomes. We evaluated the 2-year clinical outcomes between single everolimus-eluting stents (EES) and paclitaxel-eluting stents (PES) in small coronary artery disease. METHODS: From the data of SACRA (SmAll CoronaRy Artery treated by TAXUS Liberté) and PLUM (PROMUS/Xience V Everolimus-ELUting Coronary Stent for sMall coronary artery disease) registries, 245 patients with 258 lesions and 264 patients with 279 lesions, respectively, were enrolled in this study. RESULTS: The 2-year clinical driven target lesion revascularization (4.5% vs. 10.6%, p=0.01) and target vessel revascularization (8.0% vs. 13.9%, p=0.03) rates were significantly lower in the EES group compared with the PES group. Major adverse cardiac events in the EES group tended to be lower than those in the PES group (8.7% vs. 14.3%, p=0.05). On the other hand, all new lesions for remote target vessel revascularization were observed at the proximal site of target lesions in both groups and those rates were not different between the two groups (3.4% vs. 3.3%, p>0.99). CONCLUSION: EES showed better clinical results at 2-year follow-up compared with PES in small coronary artery diseases, however, new lesions at the proximal remote site of the target lesion remain problematic.

Differentiating between comatose patients resuscitated from acute coronary syndrome-associated and subarachnoid hemorrhage-associated out-of-hospital cardiac arrest.

BACKGROUND: Upon initial evaluation in the emergency department (ED), it is often difficult to differentiate between comatose patients resuscitated following acute coronary syndrome (ACS)-associated and subarachnoid hemorrhage (SAH)-associated out-of-hospital cardiac arrest (OHCA). We assessed the clinical differences between resuscitated comatose ACS-OHCA and SAH-OHCA patients during initial evaluation in the ED. METHODS: Data of 1259 consecutive OHCA patients were analyzed retrospectively. Of these, 23 resuscitated comatose ACS-OHCA patients and 20 resuscitated comatose SAH-OHCA patients were included in the final analysis. Clinical data obtained during initial evaluation in the ED were compared between groups. RESULTS: Pulseless electrical activity (PEA) or asystole as the initial cardiac rhythm, female gender, and preserved left ventricular ejection fraction (≥50%) on the echocardiogram were significantly more common in the SAH-OHCA group (p<0.05 each). Although ST-T abnormalities suggesting myocardial damage (ST elevation and/or ST depression) were noted in most patients in both groups via 12-lead electrocardiogram (95%, ACS-OHCA group; 85%, SAH-OHCA group, p=0.50), reciprocal ST depression was significantly more often absent in the SAH-OHCA group (p=0.025). Initial PEA/asystole and presence of 1 other factor was sufficient to differentiate SAH-OHCA patients from ACS-OHCA patients (100% sensitivity, 91% specificity, 95% accuracy). CONCLUSIONS: Initial ED evaluation is sufficient to differentiate between comatose ACS-OHCA and SAH-OHCA patients prior to further diagnostic work-up (e.g. emergent coronary angiography and head computed tomography).

Favorable outcomes of patients with vasospastic angina associated with cardiac arrest.

BACKGROUND: The long-term survival of vasospastic angina (VSA) patients is generally good, so long as they remain on calcium channel blockers (CCBs) and avoid smoking. However, the pathogenesis, appropriate treatments, and prognosis of VSA associated with cardiac arrest remain unclear. This study aimed to elucidate the clinical features and long-term outcomes of patients with VSA associated with cardiac arrest. METHODS AND RESULTS: Eighteen consecutive patients with VSA associated with cardiac arrest [13 patients resuscitated after out-of-hospital cardiac arrest (OHCA) and 5 resuscitated after in-hospital-cardiac arrest] were retrospectively analyzed. Sixteen of the eighteen patients were smokers. None had other cardiac diseases possibly causing cardiac arrest. Although 1 patient resuscitated after OHCA later died of cerebral hypoxia, the remaining 17 were discharged without complications. One patient died of cancer 50 months after resuscitation. The other 16 patients are still alive and none have shown ventricular arrhythmias, syncope, or cardiac arrest during a mean follow-up of 67 months. All are treated with long-acting CCBs/nitrates and successfully quit smoking. Six patients received implantable cardioverter defibrillators (ICD). However, none demonstrated any ventricular arrhythmias and appropriate ICD actuation was achieved. CONCLUSION: Appropriate medical treatment can achieve favorable long-term outcomes even for patients with VSA associated with cardiac arrest.

Percutaneous coronary intervention by retrograde approach for chronic total occlusion of the proximal left anterior descending artery via a gastroepiploic artery graft.

Coronary arteries connecting to septal branch are often occluded in post-coronary artery bypass graft cases. A 70-year-old male had undergone CABG; radial artery graft to the LCX, and gastroepiploic artery (GEA) graft to the RCA. Coronary angiography revealed total occlusion in proximal LAD, while both graft vessels had good flow. Retrograde percutaneous coronary intervention (PCI) procedure from the septal channel via GEA graft to the RCA was performed for total occlusion of LAD. Despite the tortuous GEA, deep engagement with a 4-french guiding catheter ensured powerful back-up force. After retrograde wire crossing, two drug-eluting stents were implanted, successfully.

Artificial myocardium with an artificial baroreflex system using nano technology.

Where is the place which should be helped in a patient with congestive heart failure? The answer may be contraction of the heart. At Tohoku University, development research of "the artificial myocardium" has been conducted, using a ball screw type electromagnetic motor. Furthermore, super-miniaturization is being attempted at present. Thus, a system with shape memory alloy is being developed. The cooling speed problem was solved by the application of the Peltier element. A drive at a speed equal to that of a heartbeat was realized by the application of this system. At present, a ventricular assist device is used for patients waiting for a heart transplant in Japan. An air driven type system disturbs a patient's QOL remarkably because it is connected to the drive device. With our concept, energy is provided by using the electromagnetic force from outside of the body by the use of transcutaneous energy transmission system. Magnetic shielding by amorphous fibers was used at Tohoku University to improve the total efficiency. A natural heart can alter the cardiac output corresponding to the demand. Artificial internal organs must participate in the system of the living body, too. Tohoku University has developed a resistance based artificial heart control algorithm, which simulated a baroreflex system to cope with every demand. Nano level sensing equipment is now under development at Tohoku University. At present, development is being conducted aiming at an "intelligent artificial myocardium".