Impact of severe coronary disease associated or not associated with diabetes mellitus on outcome of interventional treatment using stents: results from HERZ (Heart Research Group of Kanazawa) analyses.

Percutaneous coronary intervention (PCI) using a drug-eluting stent (DES) leads to less re-stenosis than PCI using a bare metal stent (BMS), however there is still controversy whether use of a DES for severe coronary disease leads to an acceptable outcome in patients with diabetes mellitus (DM). In this study 8159 lesions were treated in 6739 patients (mean age 68.9 years) with coronary artery disease. Use of a DES significantly decreased the re-stenosis rate compared with BMS in both DM (9.6% versus 21.3%) and non-DM (9.5% versus 17.1%) patients. The re-stenosis rate was significantly higher in DM than in non-DM patients in the BMS group but not in the DES group. There was no statistically significant difference in event-free survival after stenting of patients with left main coronary artery (LMCA) disease between the BMS and DES groups. It was concluded that, compared with BMS, DES reduced re-stenosis in patients with DM, however, we advise careful treatment after using DES for severe coronary disease, including LMCA lesions, in patients with DM.

Evaluation of left and right ventricular functional parameters with automatic edge detection program of ECG gated blood SPET.

An analysis program for ECG gated, blood pool, single photon emission tomography (SPET GBP) is available. This program permits the automatic evaluation of left and right ventricular function, but its reliability has not been thoroughly assessed. The objective of this investigation was to examine the reliability of the parameters derived from SPET GBP. Fifty-three patients who had undergone both SPET GBP and planar, ECG gated, blood pool scintigraphy (planar GBP) were enrolled in the study. Planar GBP was performed with a single-headed gamma camera. From a left anterior oblique projection, data were acquired at 24 frames/cardiac cycle with ECG gating during the equilibrium state. SPET GBP was carried out utilizing a triple-headed gamma camera, with 60 projection views over 360 degrees, with 60 s per view, in 16 frames/cardiac cycle. Left ventricular ejection fraction (LVEF) and right ventricular ejection fraction (RVEF) were calculated by using the analysis program. The reproducibility of these values and the correlation between SPET and planar GBP were assessed. To evaluate the effect of cut-off frequencies of a Butterworth filter, six different cut-off frequencies (order=8, 0.3-1.0 Nyquist) were tested with data obtained from 12 patients. The reproducibility of LVEF by SPET GBP was satisfactory (intra-observer, r=0.95; inter-observer, r=0.96), whereas reproducibility of RVEF by SPET GBP was fair (intra-observer, r=0.83; inter-observer, r=0.83). LVEF with SPET GBP was well correlated (y=1.1x+6.62, r=0.85, P<0.01) with LVEF readings of planar GBP. However, LVEF with SPET GBP was overestimated (mean difference of 12) in comparison with that of planar GBP. The RVEF derived from SPET GBP showed poor correlation (y=0.52x+33, r=0.53, P<0.01) with planar GBP. No significant effect of cut-off frequencies of Butterworth filters was evident in the calculation of LVEF and RVEF (P=0.48 and 0.67) with SPET GBP. It is concluded that SPET GBP with QBS is useful for the evaluation of LVEF. However, measurement of the RVEF showed lower reproducibility compared with measurement of the LVEF.

Differentiation of soft tissue haemangioma by 201Tl scintigraphy.

Radiological diagnosis of deep soft tissue is often difficult. In the present study, thallium-201 ( Tl) uptake into haemangiomas and deep malignant soft tissue tumours was investigated in order to assess its clinical utility. Tl scintigraphy was reviewed in four patients presenting with soft tissue haemangiomas. Early and delayed planar images, obtained at 15 min and 3 h following the intravenous injection of Tl (111 MBq), were examined. The Tl uptake ratio was calculated by dividing the count density of the tumour region of interest (ROI) by that of the background ROI. Results were compared with those of five cases of rhabdomyosarcoma and a single instance of angiosarcoma. All haemangioma lesions demonstrated increased Tl uptake in early images. However, Tl uptake in delayed images was markedly decreased. No significant differences were observed in the early uptake ratio between haemangiomas (1.60-2.72) and reference malignant tumours (1.48-2.45); however, the difference was significant in delayed images (range, 1.01-1.26 vs. 1.43-2.03, respectively) ( P<0.02). Deep soft tissue haemangiomas revealed Tl accumulation in early images; however, a rapid washout was observed in delayed images. This distinctive feature may facilitate the use of Tl scintigraphy in the diagnosis of haemangiomas.

Right ventricular metastasis from a primary cervical carcinoma.

A 49-year-old female presented with a 1-month history of cough and low-grade fever. Echocardiography showed a large mass in the right ventricle and percutaneous right ventricular endomyocardial biopsy provided the histologic diagnosis. Despite radiotherapy and chemotherapy, the patient died. At autopsy, the metastatic deposit in the heart was larger than the primary cervical carcinoma.

Hyperthyroidism complicated with sick sinus syndrome.

A 50-year-old woman was transported to a hospital complaining of marked general malaise and epigastralgia with diarrhea and vomiting. Her electrocardiogram showed sinus arrest with a duration of nearly 8 sec. Atrial pacing with an external pacemaker improved her symptoms promptly. Following transfer to our hospital 3 days later, bradyarrhythmia was not detected despite the removal of the external pacemaker. Transient atrial fibrillation was found in our hospital, and she was diagnosed as hyperthyroidism based on findings of finger tremor, exophthalmos, diffuse goiter and an abnormally high level of thyroid hormone. On cardiac catheterization, left ventriculography showed anterior wall hypokinesis and mild mitral regurgitation. Coronary arteriography showed the absence of organic stenosis. Right ventricular endomyocardial biopsy showed myocardial hypertrophy and partial disarray, but no findings of myocarditis. Electrophysiological study showed the normal upper range of AH-time (120 msec) and HV-time (50 msec), and prolongation of corrected sinus recovery time (CSRT, 955 msec). After a euthyroid state was successively induced for about 10 days by methylmercaptoimidazole therapy, AH-time, HV-time and CSRT were shortened to 85, 35 and 290 msec respectively. Her complaints and sick sinus syndrome disappeared after the treatment of hyperthyroidism without a pacemaker.

Spherical liquefaction necrosis of mitral annular calcification in a chronic dialysis patient--liquefaction necrosis of mitral annular calcification.

A 60-year-old woman on chronic dialysis consulted our department for closer examination of transient atrial fibrillation and a mitral regurgitant murmur. Echocardiography revealed a left atrial abnormal dense echogenic spherical mass, the diameter of which was 2 cm. She died of cerebral bleeding 3 months later. At autopsy, the submitral mass-like structure consisted of light-gray pasty material, which was liquefaction necrosis of a mitral annular calcification. These findings were different from those of the so-called mitral annular calcification found in the elderly or in chronic renal failure patients. The existence of such calcification must be kept in mind and not be mistaken for cardiac tumor.

Pulmonary infiltrates with eosinophilia due to naproxen.

An increasing number of drugs have been implicated in the etiology of eosinophilic pneumonia characterized by the development of pulmonary infiltrates, and peripheral blood eosinophilia. Naproxen is a commonly used nonsteroidal anti-inflammatory drug which may be added to the growing list of pharmacologic agents associated with infiltrative pulmonary lesions. A case of eosinophilic pneumonia induced by Naproxen is described. The results of TBLB, a lymphocyte stimulation test, and a challenge test supported this diagnosis.

Left atrial myxoma presenting as acute myocardial infarction.

A 58-year-old man with left atrial myxoma complicated with acute myocardial infarction is presented. On coronary arteriography, 50% stenosis and a saccular aneurysm was found just below the stenosis at segment 1 of the right coronary artery. Ergonovine provocation study was negative. It was proposed that the myocardial infarction probably was caused by coronary embolization from the left atrial myxoma.

Complete atrioventricular block following radiation therapy for malignant thymoma.

Complete atrioventricular block following radiation is very rare. We present a case which developed after radiation therapy for malignant thymoma. The etiology of conduction disturbances due to radiation is unknown. In our case, serial electrocardiograms showed stepwise progression of the conduction disturbance, and His bundle electrocardiograms revealed new prolongation of the H-V interval. Endomyocardial biopsy specimens demonstrated occlusion in small arteries and diffuse degenerative changes in the myocardium. We therefore attributed the complete atrioventricular block in our patient to secondary damage to the conduction system, caused by radiation-induced occlusive changes in the small arteries supplying the conduction system.

[Regression of giant negative T waves in hypertrophic cardiomyopathy: cases simulating either dilated cardiomyopathy or severe coronary artery stenosis].

Two cases of hypertrophic cardiomyopathy (HCM), in whom giant negative T waves resolved during 10 years, are reported. Case 1: A 33-year-old man was admitted in 1975 for careful evaluation because of an ECG abnormality. The ECG revealed a giant negative T wave (GNT) in V5 (-15 mm) and high voltage (SV1 + RV5 = 81 mm). The thickness of the apical wall was 18 mm; the anterior wall, 12 mm; the posterior wall, 16 mm; and the interventricular septum, 17 mm on the left ventriculogram and biventriculogram. The coronary angiogram was normal. From these data, this patient was diagnosed as having HCM. However, follow-up studies disclosed resolution of the GNT with decreased high voltage (SV1 + RV5 = 26 mm). The catheterization performed in 1985 showed a decrease of wall thickness: the apical wall to 10 mm; the anterior wall, 9 mm; the posterior wall, 14 mm; and the interventricular septum, 14 mm. Ejection fraction was markedly decreased from 79.8% to 27.1%, and the wall motion was generally reduced. The coronary angiogram was normal. These findings resemble the clinical pictures of dilated cardiomyopathy (DCM). Case 2: A 58-year-old man was admitted in 1974 because of easy fatiguability. His ECG revealed a GNT in V4 (-10 mm) and high voltage (SV1 + RV5 = 75 mm). The patient was diagnosed as having HCM by cardiac catheterization, right ventricular biopsy and other procedures. In 1985, the depth of the GNT and the voltage of SV1 + RV5 regressed significantly (SV1 + RV5 = 26 mm). The thickness of the apical wall was, 12 mm; the anterior wall, 19 mm; the posterior wall, 13 mm; and the interventricular septum 14 mm during recatheterization. Coronary angiography disclosed stenoses of the left main trunk (75%), the left anterior descending artery (99%) and the left circumflex artery (50%). The right coronary artery was totally occluded. In conclusion, these two cases of HCM had similar changes in their ECG during long-term follow-up studies, but the process was different. One case finally showed clinical pictures of DCM; the other, severe coronary stenoses. These suggested that blood flow to the myocardium is an important determinant for the development of clinical features simulating DCM in cases with HCM.

[Electrocardiographic and angiographic follow-up of patients with hypertrophic cardiomyopathy].

Electrocardiographic follow-up was conducted for 17 patients with hypertrophic cardiomyopathy including six cases who received left ventriculographic follow-up. 1. Serial ECG changes were as follows: 1) In seven patients negativity of the T wave appeared or increased concomitantly with increased voltage of SV1 + RV5 (A-1 group). 2) In four patients, negativity of the T wave decreased or disappeared with the decreased voltage of SV1 + RV5 (A-2 group). 3) In six patients, there were insignificant changes of both T wave and SV1 + RV5 (B group). 2. Results of serial left ventriculography and biventriculography were as follows: 1) Two patients (A-1 group) showed an increased voltage of SV1 + RV5 (25 mm----48 mm, 42 mm----54 mm), and increased thickness of the apical wall (10 mm----12 mm, 8 mm----11 mm) and the anterior wall (13 mm----16 mm, 10 mm----16 mm). However, the thickness of the posterior and interventricular septal walls did not change. The configuration of the end-diastolic left ventriculogram (RAO 30 degrees) changed from a round configuration to the so-called "beak" configuration. 2) Two patients (A-2 group) showed a decreased voltage of SV1 + RV5 (81 mm----26 mm, 73 mm----53 mm), decreased thickness of the apical wall (18 mm----10 mm, 21 mm----15 mm) and the anterior wall (12 mm----9 mm, 17 mm----12 mm). The end-diastolic left ventriculogram changed from a spade-like configuration to a round configuration. In the analysis of diastolic function measured by digitized cineangiograms using a picture-analyzer, diastolic dysfunction was already present at the initial observation. The diastolic and systolic dysfunction progressed during serial observations. These patients showed the clinical pictures of dilated cardiomyopathy at the final observation. 3) Two patients with no remarkable changes of the T wave (B group) showed insignificant changes in configuration of the left ventriculogram and wall thickness. In conclusion, serial changes in configuration of the left ventricle and wall thickness, especially of the anterior and apical walls, are compatible with the serial changes of the ECG in hypertrophic cardiomyopathy. The patients whose negative T waves decreased or disappeared had diastolic dysfunction at the initial observation, and deterioration of both diastolic and systolic dysfunctions during serial observations.

Clinical studies on diabetic myocardial disease using exercise testing with myocardial scintigraphy and endomyocardial biopsy.

Nine diabetics without significant coronary stenosis participated in an exercise testing protocol with thallium-201 myocardial scintigraphy. Endomyocardial biopsy of right ventricle was also obtained. There were 4 patients with abnormal perfusion (positive group) and 5 patients with normal perfusion (negative group). All cases of the positive group were familial diabetics and there was only one case of dietary treatment, whereas in the negative group, there were only 2 cases of familial diabetics and 3 cases receiving dietary treatment. No statistical differences between the positive and negative groups were observed for the data of exercise performance and hemodynamic parameters in cardiac catheterization at rest. However, the mean ejection fraction in the positive group (62 +/- 13%) was significantly lower than in the negative group (77 +/- 4%). In both groups, the mean diameter of myocardial cells and the mean percent fibrosis of biopsy specimens showed significant increases compared with the control group. The mean percent fibrosis in the positive group (24.1 +/- 8.5%) compared with that in the negative group (16.5 +/- 5.9%) showed a tendency to increase. It is suggested that the abnormal perfusion of thallium-201 in the positive group indicates subclinically a pathological change of microcirculation caused by diabetes mellitus.