Pericarditis-complicated takotsubo cardiomyopathy in a patient with rheumatoid arthritis.

A 64-year-old woman with medication-controlled rheumatoid arthritis (RA) was admitted to our hospital complaining of chest pains. An electrocardiogram showed elevated ST-segments in the inferior leads, and inverted T-waves in the left precordial leads. Left ventriculography demonstrated apical ballooning, and cardiac magnetic resonance imaging demonstrated apical ballooning of the left ventricle, and moderate pericardial effusion. The patient was diagnosed with takotsubo cardiomyopathy (TTC), complicated by pericarditis. In the literature, autoimmune disorders have been associated with TTC. We suggest that this patient's pericardial effusion was caused by TTC, and that her coexisting RA might have played a role in the etiology of the significant pericardial fluid accumulation.

Pericardial Involvement in IgG4-related Disease.

We herein report the case of a 65-year-old man with pericardial involvement associated with autoimmune pancreatitis. Chest CT imaging showed pericardial thickening. The patient responded to corticosteroid therapy, and the pericardial thickening resolved. Multiple organs are involved in immunoglobulin G4 (IgG4)-related disease (IgG4-RD); however, only a few cases of IgG4-related chronic constrictive pericarditis have been reported. To our knowledge, this is the first reported case of IgG4-RD with pericardial involvement at an early stage. This case indicates that recognizing pericardial complications in autoimmune pancreatitis is important and that CT imaging may be useful for obtaining the diagnosis and providing follow-up of pericardial lesions in cases of IgG4-RD.

Impact of lesion morphology and associated procedures for left main coronary stenting on angiographic outcome after intervention: sub-analysis of Heart Research Group of Kanazawa, HERZ, Study.

Whether the lesion morphology and associated interventional procedures for the left main coronary artery disease (LMCA) could affect clinical outcome is still controversial. Therefore, we examined the impact of lesion morphology and associated procedures on clinical and angiographic outcomes of stenting for the LMCA. Among 7,660 patients with coronary intervention registered, we analyzed early angiographic results of 228 patients (179 men, mean age 69.4 years) concerned with LMCA lesions. In 121 out of 228 patients having long-term angiographic results, we examined the occurrence of major adverse coronary events (MACE) particularly in terms of the presence of acute coronary syndrome (ACS), the kind of stents, bear metal or drug eluting, the lesion morphology and associated procedures. Early angiographic success rate of LMCA stenting was 100 %, and clinical success rate was 94.3 %. During follow-up period for 3 years, MACE was observed in 17 patients. Under these conditions, multiple stenting (p < 0.01) and complicated procedures such as such as Y-stent, T-stent and crush stent (p < 0.01) were listed as risks for MACE, although there was no statistical difference in kinds of stent. Multivariate analysis demonstrated the significant disadvantage of complicated procedures using the bear metal stent on the occurrence of MACE (p < 0.01). These results demonstrate that the complicated procedures have great impact on clinical and angiographic outcomes after stenting for LMCA lesions, and suggest the simple procedure with a single stent for LMCA lesions in the present cohort. Whether the presence of ACS can affect the prognosis should further be sought.

Polymorphic ventricular tachycardia in a patient with hypertrophic cardiomyopathy and digitalis intoxication.

We report the case of a 74-year-old woman who presented with recurrent episodes of polymorphic ventricular tachycardia (PVT) with a normal QT interval due to digitalis intoxication (serum digoxin concentration, 5.0 ng/mL) and severe hyperkalemia (serum potassium level, 8.3 mEq/L). In addition, laboratory data showed elevated levels of blood urea nitrogen (54 mg/dL) and serum creatinine (1.57 mg/dL), suggesting dehydration. She had been treated with a combination of digoxin and eplerenone for atrial fibrillation and heart failure. The PVT resolved after treatment for hyperkalemia. Cardiac magnetic resonance imaging and left ventriculography showed left ventricular hypertrophy predominantly in the apex, suggesting apical hypertrophic cardiomyopathy (HCM). We presume that the presence of HCM was related to the occurrence of PVT in this patient with digitalis intoxication and hyperkalemia. .

Coronary arteriovenous fistulas complicated by complete atrioventricular block: A case report.

We report the case of a patient with bilateral coronary arteriovenous fistulas (CAVFs) connecting the right coronary artery and left circumflex coronary artery with the right atrium who had progression of first-degree atrioventricular (AV) block to complete AV block during a 4-year period. The His bundle electrogram revealed that the complete AV block was the result of a block at the level of the AV node. Dipyridamole stress thallium-201 myocardial imaging showed decreased perfusion in the inferoapical wall. Coronary angiography and computed tomography showed fistulas that arose from the AV nodal branch of the right coronary artery and from the distal portion of the circumflex coronary artery and drained into the right atrium. Because the fistulas were small, they were not repaired surgically, and a permanent pacemaker was implanted to treat the complete AV block. We presumed that the complication by complete AV block was due to abnormalities of the arteries feeding the AV node and chronic ischemia resulting from a coronary steal associated with the fistulas. To the best of our knowledge, this is the first report of CAVF complicated by complete AV block.

A case of left ventricular diverticulum: Change of characteristics after myocardial infarction and usefulness of cardiac computed tomography.

A 72-year-old man with an old myocardial infarction was admitted to our hospital for cardiac reexamination. He had suffered from an inferior myocardial infarction when he was 60-year-old. The left ventriculogram had then shown a small contractile diverticulum at the apical portion of the left ventricle. Anterior myocardial infarction had recurred when he was 63-year-old. The left ventriculogram performed after the anterior myocardial infarction revealed that the diverticulum had become dilated and non-contractile. On admission, electrocardiography and chest X-ray showed no remarkable changes from the previous studies. Cardiac computed tomography (CT) demonstrated an apical left ventricular diverticulum with narrow communication to the main chamber and myocardial discontinuity of the wall at the site of the diverticulum. Tc-99m tetrofosmin myocardial images showed a perfusion defect in the apex. We presumed that a muscular left ventricular diverticulum had changed to the fibrous type after the anterior myocardial infarction. Cardiac CT imaging provides accurate evaluation of the left ventricular diverticulum and is useful for the differentiation between a left ventricular diverticulum and an aneurysm.

Pilsicainide intoxication presenting as left ventricular dyssynchrony in a patient on hemodialysis.

We report here a case of pilsicainide intoxication presenting as left ventricular dyssynchrony in a patient who had been treated on hemodialysis. This is the first report that assessed cardiac function during pilsicainide intoxication by left ventriculography and right heart catheterization.

Takotsubo cardiomyopathy with marked ST-segment elevation and electrical alternans complicated with hyperglycemic hyperosmolar state.

This is the first report of a case of Takotsubo cardiomyopathy with a hyperglycemic hyperosmolar state (HHS). This case presented with marked ST-segment elevation and electrical alternans, uncommon findings in Takotsubo cardiomyopathy. We believe that hyperosmolarity-induced myocardial dehydration and consequent increase in intracellular calcium concentration may be the mechanism of Takotsubo cardiomyopathy and electrical alternans in HHS.

Syncope due to paroxysmal atrioventricular block in a patient with systemic sclerosis: a case report.

A 79-year-old woman with systemic sclerosis was admitted to our hospital because of syncope. On admission, electrocardiogram showed progression of intraventricular conduction defect. Chest radiograph showed marked cardiomegaly. Echocardiogram revealed deterioration of left ventricular systolic function. We suspected progressive myocardial disease with Stokes-Adams attack. When we were preparing a temporary pacemaker, paroxysmal atrioventricular block with asystole for 15 seconds and convulsion occurred. Electrophysiological study showed His-ventricular block and sinus node dysfunction. A permanent pacemaker was implanted. In systemic sclerosis, progression of ventricular conduction defect may warrant prompt electrophysiological study and prophylactic pacemaker implantation.

Ruptured aneurysm of the sinus of Valsalva with Wildervanck syndrome (cervico-oculo-acoustic syndrome), blepharoptosis and short stature: case report.

A 62-year-old woman was admitted to hospital because of nausea. A grade 5/6 continuous murmur was audible near the left sternal border at the second intercostal space. Chest X-ray showed cardiomegaly and bilateral pleural effusion. She was diagnosed as heart failure and a diuretic was prescribed. After remission of the heart failure, echocardiography showed shunt flow from the right coronary cusp to the right ventricle. Aortography revealed that an aneurysm of the right coronary sinus of Valsalva had ruptured into the right ventricle. Coronary angiography revealed a single coronary artery. Chest computed tomography revealed persistent left superior vena cava. Surgical repair was carried out and the patient made an uneventful recovery. In addition to these cardiovascular abnormalities, she had Wildervanck syndrome (Klippel-Feil syndrome, Duane syndrome and sensorineural hearing disturbance), blepharoptosis and short stature. This rare combination has not been reported previously.

Acute myocardial infarction following hormone replacement in hypothyroidism.

Patients with hypothyroidism have an increased risk of coronary artery disease because of significant changes in lipid metabolism and arterial hypertension. We report a 67-year-old man who developed acute myocardial infarction following hormone replacement in hypothyroidism in spite of no previous cardiac symptoms and no ischemia in intravenous dipyridamole myocardial perfusion imaging. Careful examination for ischemic heart disease should be performed before hormone replacement in hypothyroidism.

Decline of plasma brain natriuretic peptide level after carvedilol therapy to treat dilated cardiomyopathy presenting with mechanical alternans.

Mechanical alternans is observed in patients with severe left ventricular dysfunction. We report a case of dilated cardiomyopathy with mechanical alternans. He presented with a remarkable decrease in plasma brain natriuretic peptide (BNP) levels after beta-blocker therapy despite persistency of the mechanical alternans. Mechanical alternans may persist after improvement of hemodynamics, diastolic function, and plasma BNP levels. Mechanical alternans may reflect persistent organic or functional myocardial damage such as abnormal intracellular Ca(2+) cycling in cardiomyocytes.