Idiopathic internal jugular vein thrombosis in a patient with severe dizziness.

Upper torso deep vein thrombosis usually occurs in association with an indwelling venous catheter and/or malignancy as part of a paraneoplastic syndrome. However, idiopathic internal jugular vein thrombosis is a rare but potentially fatal condition. We report a 59-year-old woman who presented with severe dizziness. Ultrasonography and contrast-enhanced multislice computed tomography revealed thrombi in the left internal jugular vein. This patient had no malignancy, coagulation disorder, or infection. A ventilation/perfusion scan of the lungs showed no evidence of pulmonary embolism. This is a rare case of idiopathic thrombosis of the internal jugular vein.

Aortic valve calcification and increased stiffness of the proximal thoracic ascending aorta: association with left ventricular diastolic dysfunction and early chronic kidney disease.

PURPOSE: The aim of this study was to clarify the relationship between the severity of aortic valve calcification (AVC) and stiffness of the proximal thoracic ascending aorta (TAA), and to examine their influence on left ventricular (LV) function and renal function. METHODS: A total of 138 hypertensive patients including 32 with diabetes mellitus and 60 with dyslipidemia were divided into four groups based on the severity of AVC. We analyzed the elastic properties of the proximal TAA from the following strain-rate indices based on tissue Doppler imaging: maximum strain rate [SR(+)], minimum SR [SR(-)], and the time between the QRS peak and the peak SR(-) of the proximal TAA (SRT). RESULTS: SR(+) and SRT were significantly greater in patients with moderate AVC than in patients with mild AVC. SRT and SR(-) were well correlated with age, peak velocity across AV, TAA wall thickness (IMC), LV diastolic function, and renal function. SRT was independently related to IMC, dyslipidemia, and LV diastolic function. CONCLUSION: The severity of AVC was correlated with the elastic properties of the proximal TAA. The SR indices are useful for assessing the relation of TAA stiffness to LV function and renal function in patients with AVC.

A training session in a clinical simulation laboratory for the acquisition of clinical skills by newly recruited medical interns.

In organized orientation programs for newly recruited medical interns of the Nippon Medical School Hospital, the working committee of the clinical simulation laboratory introduced a laboratory training session that was designed to improve the clinical skills of the medical interns. The session consisted of 6 training courses, comprising internal examination, tracheal intubation, auscultation of heart sounds, bandaging and the collection of samples of venous and arterial blood. Medical interns rotated to a new course every 30 minutes and did practical trainings in each of the 6 skills. A total of 36 newly recruited medical interns participated in the training session. The majority of medical interns took part in the practical training actively and positively. The session was efficiently carried out from the standpoints of human resources and the teaching hours involved. A post training questionnaire survey, completed by the medical interns, revealed that many of them valued the sessions for comprehensibility of the instructions, the descriptions in the manual and the content of the training; however, only 21% thought that they had successfully acquired the clinical skills. Medical interns must continually engage in self-training to steadily acquire basic clinical skills. The convenience of a clinical simulation laboratory, together with the reinforcement of the education of clinical skills during internship, is necessary to strengthen the educational benefits of the training session.

Evaluation of the elastic properties of the thoracic descending aorta with strain-rate measurement with transesophageal echocardiography: its correlation with the left ventricular diastolic function assessed with transthoracic echocardiography.

Arterial stiffening may contribute to secondary myocardial dysfunction. The aim of this study was to assess the stiffness of the thoracic descending aorta (TDA) by performing strain-rate measurements with transesophageal echocardiography (TEE) and to examine the relation of the findings to left ventricular (LV) function. Eight patients (group I) without risk factors for arteriosclerosis and 52 patients (group II) with a high risk of arteriosclerosis underwent transthoracic echocardiography (TTE) and TEE simultaneously. The values of distensibility of the TDA (-SR) in groups I and II were -11.7 +/- 2.4 and -4.6 +/- 2.5, respectively (p<0.001), and the values of the recoil of the TDA (+SR) were 20.5 +/- 8.2 and 6.8 +/- 5.0, respectively (p<0.001). The LV ejection fraction showed no relation with -SR or +SR, but LV diastolic function (e' and E/e') was correlated with +SR (p=0.002 and p=0.046, respectively). Strain-rate measurements obtained with TEE were useful for evaluating impairment of the elastic properties of the TDA and the pathophysiologic mechanisms underlying the arterial-ventricular relationship.

Longitudinal Doppler strain measurement for assessment of damaged and/or hibernating myocardium by dobutamine stress echocardiography in patients with old myocardial infarction.

BACKGROUND: The ratio of systolic lengthening to combined late and postsystolic shortening (L/TS ratio) on longitudinal Doppler strain imaging (Doppler SI) may be an index of myocardial viability. We hypothesized that measuring the postsystolic index (PSI) and the L/TS ratio during dobutamine stress echocardiography (DSE) could quantitatively identify viable myocardium with the potential for regional functional recovery. METHODS: Thirty-eight patients with old myocardial infarction (OMI) underwent DSE with Doppler SI and coronary angiography (Group 1). To clarify the value of measuring the PSI and L/TS ratio by DSE with Doppler SI in patients with OMI, these Doppler parameters and visual analysis of wall motion abnormality (WMA) were compared on a segmental basis. To investigate the prediction of regional functional recovery, 10 patients with OMI (Group 2) and stenosis of the infarct-related coronary artery underwent DSE with Doppler SI before and after percutaneous coronary intervention. RESULTS: In Group 1, 143 out of 556 segments showed a biphasic WMA pattern during DSE. There were no segments with evidence of necrosis. The PSI at peak stress was > or =0.25 in 114 out of 143 segments and the L/TS ratio at peak stress was >0 in 82 out of 114 segments. Regarding functional recovery, 42 of the 73 segments with WMA at rest showed improvement after reperfusion. The wall motion score (WMS) showed 86% sensitivity and 71% specificity for predicting regional recovery, while PSI and L/TS ratio showed 61% vs. 84% sensitivity and 60% vs. 79% specificity, respectively. The AUC for the ROC curve of the L/TS ratio as a predictor of regional recovery was significantly larger compared with that of WMS (0.894 vs. 0.783, p<0.05). CONCLUSIONS: The peak stress L/TS ratio could be a specific and quantitative marker for identifying myocardial viability that has the potential for regional functional recovery.

Impact of percutaneous transluminal septal myocardial ablation on refractory paroxysmal atrial fibrillation in patients with hypertrophic obstructive cardiomyopathy.

Atrial fibrillation is commonly observed in patients with hypertrophic obstructive cardiomyopathy. Episodes of paroxysmal atrial fibrillation are often torturous and limit the quality of life by causing congestive heart failure, transient hypotension, or bradycardia. Control of paroxysmal atrial fibrillation in patients with hypertrophic obstructive cardiomyopathy is considered to be important for symptomatic improvement and prevention of the development to chronic atrial fibrillation. The authors report on 3 patients with hypertrophic obstructive cardiomyopathy who suffered from paroxysmal atrial fibrillation despite receiving medical treatment using antiarrhythmic agents. However, after undergoing percutaneous transluminal septal myocardial ablation, the incidence of episodes became significantly less frequent. Percutaneous transluminal septal myocardial ablation is normally performed for attenuating left ventricular obstruction by reducing the systolic anterior motion of the mitral leaflet. However, in these patients, this procedure was also effective in preventing supraventricular arrhythmia, probably by improving left ventricular diastolic dysfunction, smooth blood inflow into the left ventricular, and decreasing the pressure stress against the left atrial wall.

Myocardial scintigraphy in a patient with transient mid-ventricular ballooning cardiomyopathy: case report.

We report a case of a 51-year-old man with transient mid-ventricular ballooning cardiomyopathy. Left ventriculography demonstrated mid-ventricular ballooning and akinesis with hypercontractile apical and basal segments. Iodine-123-beta-methyl-p-iodophenyl-penta-decanoic acid myocardial scintigraphy showed decreased uptake in the mid-ventricle, corresponding to the mid-ventricular akinetic region. This is the first report of a transient mid-ventricular ballooning cardiomyopathy observed by not only left ventriculography but myocardial scintigraphy.

Relationship between brain natriuretic peptide, myocardial wall stress, and ventricular arrhythmia severity.

We previously demonstrated that the severity of arrhythmias is reflected by circulating brain natriuretic peptide (BNP) concentrations in patients without signs of congestive heart failure. In the present study, we evaluated the relationships between the severity of the arrhythmia, BNP concentration, and echocardiographic findings. The subjects consisted of 52 patients with ventricular premature contractions (VPC) but no manifestations of heart failure and no digoxin or beta-blocker therapy. Patients underwent Holter monitoring, plasma sampling for BNP measurement, and transthoracic echocardiography (TTE). We scored the motion of 16 left ventricular segments, deriving a wall-motion score index (WMSI) by totaling the scores and dividing by the number of segments scored. Twenty-three patients with Lown grade I to II arrhythmias constituted group A while group B consisted of 29 Lown III to IV patients. Group B had BNP concentrations triple those in group A (57.2 versus 18.1 pg/mL, P < 0.01). Left ventricular ejection fraction (LVEF) was similar in groups A and B (65.2% versus 62.1%, NS). Although left ventricular end-diastolic dimension (LVEDD) was normal in both groups, group B exhibited a larger LVEDD than group A (50 versus 46 mm, P < 0.005). The correlation (r) between BNP and interventricular septum thickness (IVST) was 0.27 (P = 0.013) in group A and 0.37 (P < 0.0001) in group B. Between BNP and posterior wall thickness (PWT), the correlation was 0.23 (P = 0.014) in group A versus 0.33 (P < 0.0001) in group B. The WMSI in group B was higher than in group A (1.34 versus 1.11, P < 0.05). We believe that besides the changes in echocardiographic parameters, the BNP elevation in group B could be a response to abnormal wall stress from the severe ventricular arrhythmias.

Improvement of the diagnostic accuracy in computer-assisted differential diagnosis for wide QRS premature complexes.

The differential diagnosis of wide QRS premature contractions is often inaccurate in most ECG machines with automatic computer-assisted diagnosis. The purpose of the present study was to improve the accuracy of the automated differential diagnosis between premature ventricular contractions (PVC) and supraventricular contractions with aberrant conduction (A-PSC). The study investigated 180 consecutive electrocardiograms (ECGs) with wide QRS premature contractions picked up from 3,723 in the ECG database. A new algorithm, Detection of Wide QRS Complex --> Second Derivative --> Absolute Value --> Smoothing --> T Wave Subtraction --> P' Detection, was compared with a conventional QRS morphology algorithm and P' algorithm without T wave subtraction. The rate of false positives was reduced step by step (22.3% in the conventional algorithm, 7.8% in the P' without T subtraction algorithm and 3.0% in the P' with T subtraction algorithm), resulting in a marked increase in diagnostic accuracy for A-PSC from 77.2% to 90.6% and 95.0%, respectively. In a general population with external samples, the newest algorithm showed 77.8% sensitivity, 99% specificity, and 98.9% accuracy for diagnosis of A-PSC. The new algorithm for differential diagnosis of wide QRS complexes is simple, reliable, and easy to apply to most 12-lead ECG machines with computer-assisted automatic diagnosis.