Pseudo-hyperacute T Waves in a Giant Hiatal Hernia.

An 89-year-old woman with a giant hiatal hernia complained of persistent chest pain. An electrocardiogram (ECG) showed hyperacute T waves, suggesting the early phase of ST-elevation myocardial infarction. After endoscopic drainage for hiatal hernia, the chest pain disappeared, and the ECG abnormalities resolved. The present case illustrates that compression of the heart by a giant hiatal hernia can induce T wave elevation mimicking acute coronary syndrome.

Clinical impact of cardiac magnetic resonance in patients with suspected coronary artery disease associated with chronic kidney disease (AQUAMARINE-CKD study): study protocol for a randomized controlled trial.

BACKGROUND: Although screening for coronary artery disease (CAD) using computed tomography coronary angiography in patients with stable chest pain has been reported to be beneficial, patients with chronic kidney disease (CKD) might have limited benefit due to complications of contrast agent nephropathy and decreased diagnostic accuracy as a result of coronary artery calcifications. Cardiac magnetic resonance (CMR) has emerged as a novel imaging modality for detecting coronary stenosis and high-risk coronary plaques without contrast media that is not affected by coronary artery calcification. However, the clinical use of this technology has not been robustly evaluated. METHODS: AQUAMARINE-CKD is an open parallel-group prospective multicenter randomized controlled trial of 524 patients with CKD at high risk for CAD estimated based on risk factor categories for a Japanese urban population (Suita score) recruited from 6 institutions. Participants will be randomized 1:1 to receive a CMR examination that includes non-contrast T1-weighted imaging and coronary magnetic angiography (CMR group) or standard examinations that include stress myocardial scintigraphy (control group). Randomization will be conducted using a web-based system. The primary outcome is a composite of cardiovascular events at 1 year after study examinations: all-cause death, death from CAD, nonfatal myocardial infarction, nonfatal ischemic stroke, and ischemia-driven unplanned coronary intervention (percutaneous coronary intervention or coronary bypass surgery). DISCUSSION: If the combination of T1-weighted imaging and coronary magnetic angiography contributes to the risk assessment of CAD in patients with CKD, this study will have major clinical implications for the management of patients with CKD at high risk for CAD. TRIAL REGISTRATION: Japan Registry of Clinical Trials (jRCT) 1,052,210,075. Registered on September 10, 2021.

Pseudoxanthoma elasticum resulting in acute coronary syndrome.

Pseudoxanthoma elasticum (PXE) is a rare hereditary disorder that causes elastic tissue degeneration in the skin, eyes, and cardiovascular system. Gastrointestinal bleeding and fundus hemorrhage are serious complications associated with PXE prognosis as well as cardiovascular involvement. This is a rare case of acute coronary syndrome in a PXE patient with high bleeding risk. Learning objective: Pseudoxanthoma elasticum (PXE) resulting in acute coronary syndrome (ACS) is rare. Given PXE patients are generally at very high bleeding risk, antithrombotic therapy as secondary prevention after ACS onset should be taken into full consideration.

Clinical Utility of Diffusion-weighted Whole-body Magnetic Resonance Imaging with Background Body Signal Suppression for Assessing and Monitoring IgG4-related Disease.

A 77-year-old man with symptoms of chest pain was diagnosed with immunoglobulin G4 (IgG4)-related disease. Fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) revealed an intense uptake in the submandibular gland, lymph nodes and abdominal aortic wall. Diffusion-weighted imaging with background body signal suppression (DWIBS) revealed signal enhancements at the same location as those of the FDG-PET/CT findings. The DWIBS signal intensity decreased after steroid treatment, so we decreased the steroid dosage. Relapse did not occur. DWIBS makes it possible to adjust the medicine dosage while confirming the therapeutic effects and will likely be a useful method for monitoring IgG4-related disease.

Massive pulmonary embolism with cardiac arrest in pregnancy: A case report.

A 39-year-old woman developed a pulmonary embolism at 28 weeks of gestation, after a 4-week period of bedrest, and required emergencycesarean section due to a decrease in fetal heart rate. Pulseless electrical activity (PEA) developed after intravenous anesthesia. The fetus was delivered 5 min after PEA onset, during cardiopulmonary resuscitation of the mother. Intravenous recombinant tissue-plasminogen activator injection, percutaneous cardiopulmonary support, and 24-h hypothermia therapy were administered to the mother, followed by inferior vena cava filter insertion, combined with catheter thrombus fragmentation and percutaneous thrombectomy. Both the patient and her baby survived. .

Clinical utility of non-contrast T1-weighted magnetic resonance imaging in percutaneous coronary intervention: A case report.

Coronary high-intensity plaques (HIPs) visualized by non-contrast T1-weighted imaging (T1WI) in cardiac magnetic resonance (CMR) are associated with slow-flow phenomena during percutaneous coronary intervention (PCI). We report a case of a 52-year-old man who had undergone left anterior descending artery stent implantation for unstable angina 5 years previously. He underwent CMR imaging for screening of vulnerable plaques. A lesion in the proximal right coronary artery showed HIP on non-contrast T1WI. Invasive coronary angiography showed progressive stenosis and PCI was performed. Non-contrast T1WI indicated a high risk for a slow-flow phenomenon. A distal protection device (Parachute™ (Tri-Med, Osaka, Japan)) was deployed at the distal site of the lesion. Following balloon dilation, a filter no-reflow phenomenon developed. Coronary flow was improved with removal of the Parachute™ after debris aspiration. Histological examination revealed aspirated debris composed of white thrombi, foamy macrophages, and cholesterol crystals. .

Characterization of high-intensity plaques on noncontrast T1-weighted magnetic resonance imaging by coronary angioscopy.

BACKGROUND: A recent study showed that coronary high-intensity plaques (HIPs) visualized by noncontrast T1-weighted imaging (T1WI) in cardiac magnetic resonance were associated with coronary events. We used coronary angioscopy to analyze HIP plaque morphology. METHODS AND RESULTS: A total 17 lesions from 17 patients with stable or unstable angina pectoris were evaluated at the culprit lesion by noncontrast T1WI using 1.5-T magnetic resonance; of them, nine (53%) were HIPs and eight (47%) were non-HIPs, and all were analyzed by coronary angioscopy. We assessed the existence of thrombus and plaque yellow color grade (YG). YG was assessed visually according to a four-grade scale: 0, white; 1, light yellow; 2, yellow; 3, intense yellow. The frequency of thrombus was significantly higher in HIPs than in non-HIPs (89% vs. 25%, respectively; p=0.007). YG was significantly more frequent in HIPs than in non-HIPs (2.2±0.4 vs. 0.7±0.7, respectively; p=0.01). CONCLUSIONS: These data indicated that HIPs on noncontrast T1WI were associated with the presence of high-grade yellow plaque with thrombus.

Relationship between yellow plaque grade and tissue protrusion after stent implantation: A coronary angioscopy study.

BACKGROUND: Tissue protrusion detected with optical coherence tomography after percutaneous coronary intervention using stents is one of the risk factors for early stent thrombosis. However, tissue protrusion features have not been described. The aim of this study was to compare tissue morphology at stented sites with or without tissue protrusion by using coronary angioscopy. METHODS: Using optical coherence tomography and coronary angioscopy, we assessed 42 patients [31 men, 11 women; age, 70.7±7.4years; acute coronary syndrome (ACS), n=19; effort angina pectoris (EAP), n=23] after stenting. RESULTS: Twenty patients had tissue protrusion. ACS patients had a higher incidence of tissue protrusion than EAP patients (70.0% vs 29.4%; p=0.002). The plaque at the protrusion site had higher-grade yellow plaque with thrombus than those without protrusion (2.35±0.67 vs 1.40±0.67; p<0.001). The plaque at protrusion sites developed more thrombi (60.0% vs 22.7%; p=0.041). CONCLUSIONS: Tissue protrusion after stent implantation was associated with high-grade yellow plaque with thrombi.

A case of in-stent restenosis with pathologically proven chronic inflammation seven years after sirolimus-eluting stent implantation.

A 67-year-old man was admitted to our hospital due to chest pain at rest. Seven years previously, the patient underwent percutaneous coronary intervention (PCI) of the left ascending artery and implanted sirolimus-eluting stent (SES). Coronary angioscopy (CAS) performed at that time showed a white plaque at the SES site. Two years after the first PCI, repeat CAS demonstrated light yellow plaques at the SES site. At the time of his presentation to our hospital, coronary angiography showed in-stent restenosis at the SES site, and CAS demonstrated the plaque rupture with presence of dense yellow plaque and various thrombi. After distal protection, drug-eluting balloon treatment was performed. Collected specimens from culprit sites included foamy macrophages, cholesterin crystals, neutrophils, and fibrin, suggesting that progressive neoatherosclerosis at the SES site triggered the acute coronary syndrome. This study highlights the importance of ensuring careful patient follow-up after SES implantation. .

Differences of plaque characterization of high-intensity and non high-intensity plaques on non-contrast T1-weighted magnetic resonance imaging using angioscopy and optical coherence tomography.

Coronary high-intensity plaques (HIPs) visualized by non-contrast T1-weighted imaging (T1WI) in cardiac magnetic resonance (CMR) were associated with coronary events. We report a case of a 68-year-old man with an old myocardial infarction. He had undergone CMR to exclude new coronary artery disease, because he sometimes had an atypical chest symptom. The moderate stenosis in the right coronary artery (RCA) showed non HIP on non-contrast T1WI. We observed HIP in the proximal left anterior descending artery (LAD) without significant stenosis. Non HIP lesion in the RCA showed fibrous and calcified plaque without thrombus by optical coherence tomography (OCT) and angioscopy. On the other hand, the HIP lesion in the LAD showed lipid plaque with thrombus by OCT, and yellow plaque with mobile mixed thrombus by angioscopy. .

A patient with acute coronary syndrome and shock due to occlusion of both native coronaries and bypass grafts who was rescued by revascularization.

A 72-year-old male was admitted to our hospital because of chest pain in a pre-shock condition. He underwent coronary artery bypass grafting (CABG) 25 years prior. The most recent coronary angiography revealed total occlusion of both native coronaries and the saphenous vein graft (SVG) that was anastomosed to the right coronary artery. Emergency coronary angiography revealed that his SVG anastomosed to the left circumflex artery (LCX) and the distal left anterior descending artery (LAD) were also occluded. Emergency revascularization of the SVG anastomosed to the LCX and distal LAD restored blood flow and hemodynamic function. Subsequently, he received reoperative CABG to the LCX and LAD, and his angina and chronic heart failure improved. Careful follow-up is needed in patients having an old and deteriorated SVG. .

[Forced medical intervention in psychiatric inpatient treatment].

In anticipation of ratification of the Convention on the Rights of Persons with Disabilities, the Japanese Government made a Cabinet decision to promote institutional reforms concerning disabled persons, in which involuntary hospitalization and medical intervention for persons with mental disabilities would be reviewed. In response to the decision, the Cabinet launched the Council to Promote Reform for "Promotion Council reform Persons with Disabilities" in the Cabinet Office, and the Ministry of Health, Labour and Welfare set up a task force aimed to build systems of community mental health care. Although the activities have been progressing, according to published documents, the effectiveness and efficacy of the countermeasures presented in the documents seem insufficient. Fundamental reforms of systems for the treatment and support of persons with mental disabilities are needed.