[Cholesterol embolism after percutaneous transluminal coronary angioplasty procedure: a case report].

A 68-year-old man with chest pain was treated under a diagnosis of angina pectoris based on coronary angiography by percutaneous transluminal coronary angioplasty including stent implantation performed by the femoral approach. About 1 month after intervention, his renal function deteriorated and purpura appeared on both feet, especially at the toe tips. He was treated under a tentative diagnosis of cholesterol embolism conservatively at the out-patient clinic. However, he was admitted by ambulance due to worsening renal failure 2 months later and died from multiple organ failure 2 weeks after admission. Autopsy examination identified cholesterol embolism due to crystal emboli in several organs. Cholesterol embolism rarely occurs after angiographic or interventional procedures, but is difficult to diagnose clinically and there is no established therapy. The number of intervention and angiography procedures is increasing, so the occurrence of embolism as a complication of these procedures might also increase.

Fractional myocardial flow reserve (FFRmyo) after coronary intervention as a predictor of chronic restenosis.

The angiographic assessment of coronary stenosis has many limitations, especially after coronary intervention. To determine the physiologic significance of such lesions, we measured the mean translesional pressure gradients at rest (P1), those during hyperemia induced by intracoronary administration of papaverine (12 mg in the left and 8 mg in the right coronary artery) (P2), and fractional myocardial flow reserve (FFRmyo) which is derived from the ratio of the mean distal coronary pressure and aortic pressure during hyperemia. Our objective was to determine the relations among P1, P2, and FFRmyo and restenosis as potential predictors of chronic restenosis. The grouped study consisted of 32 patients with ischemic heart disease scheduled to undergo intervention. The distal coronary pressure was measured using a 0.014 inch pressure monitoring wire (Pressure Guide, Radi Medical Systems, Uppsala, Sweden). The guidewire was advanced through the lesional segment. The mean percent diameter stenosis (%DS) was 67.9 +/- 13.3% before intervention and 22.9 +/- 15.3% after intervention. The mean P2 (9.9 +/- 5.3 mmHg) was significantly higher than the mean P1 (4.5 +/- 3.6 mmHg; p < 0.0001). There was no correlation of P1, P2 or FFRmyo with the %DS after intervention. Follow-up angiography (after 6 months) performed on all patients revealed restenosis (%DS > or =50%) in four patients (12.5%). There was no correlation between P1 and the %DS at the follow-up angiography, but the relation between P2, FFRmyo and the %DS at the follow-up angiography was significant (r = 0.599, p < 0.01; r = 0.703, p < 0.0001, respectively). As a measurement of P2, FFRmyo is useful for the determination of the endpoint of intervention in consideration of prevention of restenosis. A new endpoint may be established after further evaluation in a greater number of patients.

[CABG after patch angioplasty of the left main coronary: artery report of a case].

A 57-year-old man was admitted to our hospital because of restenosis of the left main coronary trunk (LMT) after patch angioplasty for the LMT lesion. PTCA was repeated four times during three years after patch angioplasty, but recent coronary angiogram still demonstrated 75% restenosis of the LMT lesion. Double-CABG was performed to LAD and LCX using the left internal thoracic artery and saphenous vein graft. Postoperative coronary angiogram revealed an excellent result. A careful consideration must be given to the indication of the patch angioplasty of the LMT lesion.

Efficacy and safety of the 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitor fluvastatin in hyperlipidemic patients treated with probucol.

The objective of this open trial was to investigate the efficacy and safety of the 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitor fluvastatin in hypercholesterolemic patients already receiving probucol. All of the participants had hypercholesterolemia. i.e. serum total cholesterol > or = 220 mg/dl, despite administration of probucol, 500 mg/day, for more than 4 weeks. After this, fluvastatin, 30 mg/day, was added to probucol treatment for 12 weeks. Twenty-seven patients were recruited into this study; all were evaluated for safety, and 22 were evaluated for efficacy. The addition of fluvastatin to the probucol regimen produced a significant further reduction in serum total and low-density lipoprotein cholesterol concentrations (of 18 and 20%, respectively; p < 0.001); these effects were fully established within 4 weeks of treatment and were maintained throughout the treatment. Fluvastatin did not affect the serum high-density lipoprotein cholesterol concentration. Fluvastatin treatment decreased serum triglyceride concentrations slightly in all patients (not significant); in patients with hypertriglyceridemia, triglyceride levels were decreased significantly by 34% (p < 0.01; serum triglycerides > or = 150 mg/dl). In addition, fluvastatin significantly decreased serum apolipoprotein B, C-II, C-III and E levels, whereas serum apolipoprotein A-I and A-II levels were unaffected. One patient complained of slight abdominal discomfort during fluvastatin administration, but relationship to fluvastatin remains unclear. One patient had slight elevation of the serum alanine aminotransferase level, and another patient had an elevated gamma-glutamyl transferase level. The addition of fluvastatin to probucol treatment can be considered to be an effective and well tolerated treatment in hypercholesterolemic patients.

[Comparison of exercise-stress single photon emission computed tomography with thallium-201 reinjection and postextrasystolic potentiation to assess myocardial viability in patients with myocardial infarction].

Myocardial viability was examined in 20 patients with myocardial infarction 24 +/- 3 (mean +/- standard deviation) days after onset. Postextrasystolic potentiation (PESP) was measured by left ventriculography and thallium-201 (Tl) single photon emission computed tomography (SPECT) redistribution was assessed after stress loading and reinjection of Tl. The results were compared with the improvement of left ventricular segmental wall motion after coronary revascularization which was performed successfully in all patients. The uptake of Tl was impaired initially in 41 segments, classified into three groups: normal group, 13 segments with smooth reversion to normal; new fill-in group, 15 segments with a new fill-in after reinjection of Tl; no fill-in group, 13 segments with no fill-in after reinjection. When evaluated by the PESP before coronary revascularization, segmental wall motion was significantly augmented in all segments in the normal group and new fill-in group (p < 0.001), but not in the no fill-in group. After coronary revascularization, left ventriculography revealed that segmental wall motion was significantly improved in normal group and new fill-in group, but not in the no fill-in group except for mild improvement in five segments. The sensitivity and specificity of PESP (90% and 93%) and Tl SPECT (80% and 100%) for improvement of segmental wall motion after the coronary revascularization were very high, with the accuracy of either method attaining 87%. This result indicates that both Tl SPECT and PESP are useful for detecting viable myocardium in patients with recent myocardial infarction.

[Clinical evaluation of 123I-metaiodobenzylguanidine myocardial scintigram in patients with valvular heart disease].

Myocardial sympathetic nerve function can be evaluated by 123I-metaiodobenzylguanidine (MIBG) scintigraphy. Congestive heart failure is closely related to myocardial sympathetic nerve function. This study evaluated the severity of congestive heart failure in 30 patients with valvular heart disease [aortic regurgitation (AR): n = 20, mean age = 70 +/- 13 years; mitral regurgitation (MR): n = 10, mean age = 61 +/- 18 years], who had chronic heart failure by MIBG myocardial scintigraphy. Single photon emission computed tomography (SPECT) and anterior planar myocardial images were obtained 15 minutes (initial images) and 4 hours (delayed images) after injection of MIBG (111MBq). Defect score was determined by the delayed SPECT images visually as a semi-quantitative index. Myocardial MIBG uptake was quantified by the heart to upper mediastinum uptake ratio on the delayed anterior planar images (H/M) and mean cardiac MIBG washout rate during 4 hours was calculated from the bull's eye display data (clearance). These indices were compared with the NYHA class and echocardiographic findings of the patients. MIBG regional defect in the delayed image was most frequently seen in the inferoposterior wall, and defect score and clearance were significantly higher and the H/M ratio was significantly lower in NYHA class III patients than in class II patients. In patients with AR, clearance significantly correlated with left ventricular end-systolic dimension. In patients with MR, both the H/M ratio and clearance significantly correlated with left atrial dimension. Defect score, H/M, and clearance were closely related to the severity of AR and MR. These results indicate that MIBG scan can be used to assess the severity of valvular heart disease.

[Clinical significance of diffuse vasoconstriction of coronary arteries--a study using hyperventilation thallium-201 myocardial imaging].

Hyperventilation Thallium-201 imaging was evaluated for the examination of the existence of ischemia in the cases of diffuse vasoconstriction under the ergonovine maleate provocative test for coronary artery. Transient myocardial perfusion defect (PD) was demonstrated in 14 patients with ergonovine induced vasospasm (group S), and 13 of these patients also demonstrated redistribution (RD) (92.4%). In 14 patients with diffuse vasoconstriction (group D), nine demonstrated PD, and all of them revealed RD. On the other hand, only one of ten (10%) patients demonstrated PD and RD in a group of patients without spasm or diffuse vasoconstriction (group N). In addition, the left ventricular myocardium was divided into nine segments on a SPECT image, and the mean minimum washout rate (WOR) of each segment was evaluated. These values were compared with the percent change of the lung/heart ratio between early and delayed images (delta L/H%). Both the mean minimum WOR mean and delta L/H% of group D were significantly smaller than that of group N (p < 0.001), and only approximated to group S. Thus, the possibility of myocardial ischemia of diffuse vasoconstrictive coronary artery is implicated and such patients are supposed to be treated medically as vasospastic angina.

[Quantitative analysis of right ventricular overloading by 201Tl myocardial SPECT].

Clinical usefulness of quantitative analysis of right ventricular overloading was evaluated by 201Tl myocardial SPECT in comparison with cardiac catheterization and MRI. Seventy-four MBq of 201TlCl was intravenous injected and 201Tl myocardial SPECT was performed on 40 patients (mean age: 61.0 +/- 11.8) with right ventricular overloading. Regions of interest (ROI) were selected on right and left ventricular walls in a midventricular short axis image of SPECT and uptake of each ROI were counted. The right ventricle (RV)/left ventricle (LV) 201Tl uptake ratio (R/L-Tl) was calculated. Wall thickness of RV and LV were measured on MRI and the RV/LV wall thickness ratio (R/L-WT) was calculated. RV and LV pressure were recorded in cardiac catheterization, and the RV/LV systolic pressure ratio (R/L-P) was calculated. There was significant positive correlation (Y = 0.73X + 0.19, r = 0.71, p < 0.001) between R/L-Tl and R/L-WT. R/L-Tl was positively correlated with R/L-P in patients with pressure overload (Y = 1.14X - 0.049, r = 0.85, p < 0.001) and in patients with volume overload (Y = 0.51X + 0.023, r = 0.88, p < 0.001) and the slope of the regression line in patients with pressure overload was significantly steeper than that in patients with volume overload (p < 0.001). In conclusion, quantitative analysis of right ventricular overload by 201Tl myocardial SPECT is useful to estimate RV/LV wall thickness ratio and pressure ratio.

[Apical sequestration in hypertrophic cardiomyopathy: its clinical features and pathophysiology].

The clinical and pathophysiological significance of apical sequestration, in which an apical cavity was sequestered from the remainder of the left ventricle by cavity obliteration was investigated in patients with hypertrophic cardiomyopathy (HCM). Among 196 consecutive patients, 24 with apical sequestration and 70 control subjects proven to have no sequestration with left ventriculography were selected for this study using echocardiography combined with Doppler color flow imaging. Various cardiac disorders occurred significantly more frequently in patients with apical sequestration than in the 70 controls: NYHA > or = II, 83% vs 51%; thromboembolism, 17% vs 3%; ventricular tachycardia, 47% vs 11%; and apical asynergy, 75% vs 4%. Continuous Doppler ultrasound revealed that all 24 patients with sequestration had a high systolic blood flow velocity across the obliterated cavity (2.7 +/- 0.9 m/s). During isovolumic relaxation or early diastolic filling or both, 21 of them had paradoxical jet flow directed toward the basal cavity away from the apex, with the peak flow velocity ranging from 1.0 m/s to 3.5 m/s (mean 1.9 +/- 0.7). The maximal diastolic pressure gradient across the obliterated cavity ranged between 4 mmHg and 49 mmHg using the simple Bernoulli's equation, which suggested a significantly higher pressure in the sequestered apical chamber during early diastole. Patients with sequestration were classified into 2 groups; 17 with (group A) and 7 without (group B) apical hypertrophy. The time interval from the closing of the aortic valve to the onset of filling into the sequestered cavity was longer in group A than in group B (401 +/- 191 vs 131 +/- 145 ms, p < 0.01) as assessed by the pulsed Doppler technique. Angiographic asynergy of the apex was more frequent in group A than in group B (100 vs 29%, p < 0.01). In group B, the midventricular cavity was incompletely obliterated throughout the cardiac cycle; whereas, in group A, it was obliterated completely in systole and partially in diastole. Apical sequestration is not uncommon in HCM; it is accompanied by abnormal segmental wall motion, which may be related to ventricular arrhythmias and thromboembolism. Prolonged cavity obliteration with a higher systolic apical pressure and a persistent diastolic intraventricular gradient may play a pathogenic role in apical aneurysmal formation in the absence of fixed coronary artery disease, particularly in patients with apical hypertrophy.

Giant right atrial thrombus in Noonan syndrome combined with Eisenmenger's complex.

A 54-year-old woman with the Noonan syndrome was admitted with congestive heart failure and a giant right atrial thrombus with atrial septal defect detected by two-dimensional echocardiography. The thrombus vanished on oral anticoagulant therapy with warfarin. The thrombus is considered to result from hemostasis in the right atrium due to congestive heart failure and to her specific skeletal characteristics. This report describes the first case of Noonan syndrome with right atrial thrombus.

Assessment of biological age by principal component analysis.

A method of assessing biological age by the application of principal component analysis is reported. Healthy individuals (462) randomly selected from about 6000 men who had taken a 2-day health examination were studied. Out of the 30 physiological variables examined in routine check-ups, 11 variables were selected as suitable for the assessment of biological age based on the results of factor analysis and the physiological meaning of each test. This variable set was then submitted to principal component analysis, and the 1st principal component obtained from this analysis was used as an equation for assessing one's biological age. However, the biological age calculated from this equation is expressed as a score, so the estimated score was transformed to years (biological age) using the T-score idea. The biological age estimated by this method is practically useful and theoretically valid in contrast with the multiple regression model, because this approach eliminates and overcomes the following 2 big problems of the multiple regression model: (1) the distortion of the individual biological age at the regression edges; and (2) a theoretical contradiction in that a perfect model will merely be predicting the subject's chronological age, not his biological age.