Changes in Serum Fibroblast Growth Factor 23 in Patients With Acute Myocardial Infarction.

BACKGROUND: Fibroblast growth factor 23 (FGF23) induces cardiac remodeling. We investigated the changes in serum FGF23 levels in patients diagnosed with acute myocardial infarction (AMI).Methods and Results:A total of 44 patients diagnosed with AMI were included in the current study. All patients underwent emergency percutaneous coronary intervention (PCI). The median of peak creatine kinase (CK) and CKMB values was 1,816 U/L and 159 U/L, respectively. Serum levels of FGF23, calcium, and inorganic phosphate (iP) were measured before PCI, and on days 1, 3, 5, 7 after PCI. Serum FGF23 levels showed a slight, but significant decrease on days 1 and 3 after PCI, and a 1.5- and 2.0-fold increase on days 5 and 7, respectively, after PCI. As compared with propensity score-matched patients without AMI, serum FGF23 was significantly lower among the current cohort of AMI patients. In 22 subjects who underwent a follow-up echocardiographic examination at 6 months after the onset of AMI, the log-transformed relative increase in FGF23 on day 7 significantly and negatively correlated with changes between LVEF on admission and that at 6 months afterward. CONCLUSIONS: After a slight decrease on days 1 and 3 after admission, serum FGF23 increased significantly on days 5 and 7. The underlying mechanism and potential clinical importance of these observations require further investigation.

High serum bilirubin is associated with lower prevalence of peripheral arterial disease among cardiac patients.

Several studies have shown that subjects with higher serum bilirubin may have a lower risk of cardiovascular disorders. We herein investigated whether serum bilirubin concentration is associated with lower extremity ischemia among cardiology patients. In total, 935 patients without a history of angioplasty or bypass surgery of the lower limb arteries and who had bilateral ankle-brachial index measurements were included in the study. Peripheral arterial disease (PAD) was defined to be present when ABI of either or both sides was <0.9. Overall, the serum total bilirubin concentration ranged between 0.1 and 2.7mg/dL (normal range, 0.1-1.0mg/dL). Across the bilirubin tertiles, age did not differ significantly. On the other hand, male patients (median 0.6mg/dL, interquartile range (IQR) 0.4-0.7mg/dL) had significantly higher bilirubin levels than female patients (median 0.5mg/dL, IQR 0.4-0.7mg/dL, P=0.014). Logistic regression analysis showed that, as compared with the lowest bilirubin tertile (0.1-0.4mg/dL), the highest tertile (0.7-2.7mg/dL) was significantly negatively associated with prevalent PAD after adjusting for sex, age, eGFR, white blood cell count, inorganic phosphate, HbA1C, total and HDL cholesterol, triglycerides, current smoking, diabetic medication, and statin use. This association remained significant when only those with serum bilirubin in the normal range were included in the analysis. Among cardiology patients, serum bilirubin concentration was significantly negatively associated with prevalence of PAD. The underlying mechanism and therapeutic indications should be investigated in further investigations.

Is Serum Uric Acid Independently Associated With Left Ventricular Mass Index, Ejection Fraction, and B-Type Natriuretic Peptide Among Female and Male Cardiac Patients?

Mean serum uric acid (SUA) levels are higher in men than women. In addition, recent studies have suggested that the SUA threshold at which the cardiovascular risk might increase may vary between women and men. In the current retrospective study, by analyzing the data from 219 female and 519 male patients who were free from uric acid-lowering medication, we investigated whether SUA is associated with left ventricular mass index (LVMI), left ventricular ejection fraction (LVEF), and plasma levels of B-type natriuretic peptide (BNP) independent of confounding factors, such as serum calcium, inorganic phosphate, and fibroblast growth factor 23 (FGF23), in a gender-specific manner.In multivariate stepwise linear regression analysis in which age, blood pressure, eGFR, corrected calcium, inorganic phosphate, and FGF23 were entered as potential covariates, SUA was selected as a factor significantly associated with LVEF, LVMI, and plasma levels of BNP in both genders. On the other hand, however, after adding diuretic use as a potential covariate, the association between SUA and LVEF lost statistical significance in both genders, and that between SUA and BNP lost significance among female patients. These findings suggest that diuretic use is a non-negligible confounder in understanding the observed association between SUA and cardiac dysfunction and heart failure.In summary, SUA is associated with left ventricular hypertrophy independent of confounding factors including FGF23 and diuretic use in female and male patients. Whether lowering SUA can influence the progression of cardiac remodeling awaits further investigation.

Association between suPAR and cardiac diastolic dysfunction among patients with preserved ejection fraction.

Serum levels of the soluble urokinase-type plasminogen activator receptor (suPAR) reflect immune and inflammatory activation, and are shown to be associated with cardiovascular outcomes. We herein investigated the potential association between suPAR and left ventricular diastolic dysfunction among patients with preserved left ventricular ejection fraction (LVEF) and sinus rhythm. Among 291 patients who had sinus rhythm and an LVEF of ≥50% enrolled in the study, 26 (8.9%) were considered to have diastolic dysfunction. Patients with diastolic dysfunction had lower estimated glomerular filtration rate (eGFR), and higher systolic blood pressure (BPs), BNP, C-reactive protein, and suPAR than those without diastolic dysfunction. As compared with the first suPAR quartile, the fourth suPAR quartile was significantly associated with both diastolic dysfunction with an odds ratio of 8.95 [95% confidence interval (CI), 1.04-77.0, P < 0.05] after adjusting for sex, age, BPs log(eGFR), CRP, and diuretic use. On the other hand, receiver-operating characteristic curve (ROC) analysis showed that addition of log(suPAR) to the combination of age, sex, and log(eGFR), CRP, and diuretic use did not significantly improve the prediction of diastolic dysfunction. Among cardiac patients with preserved LVEF, serum suPAR was associated with diastolic dysfunction independent of confounding factors by logistic regression analysis. However, according to the ROC analysis, the utility of suPAR as a biomarker for diastolic dysfunction may be limited from a clinical point of view.

A case of IgG4-related lymphadenopathy, pericarditis, coronary artery periarteritis and luminal stenosis.

Immunoglobulin G4 (IgG4)-related disease is an emerging new clinicopathological disorder that is characterized by elevation of serum IgG4 levels and histological findings of IgG4-positive plasmacytic infiltration. IgG4-related disease may appear synchronously or metachronously in a wide variety of organs. The current patient was found to have pericardial effusion and retroperitoneal fibrosis. He was subsequently diagnosed with coronary artery stenosis. (18)F-FDG positron emission tomography showed enhanced FDG uptake in lymph nodes as well as pericardial and peri-aortic tissue. Histopathology of the mediastinal lymph node showed the infiltration of numerous IgG4-positive cells, leading to the diagnosis of IgG4-related lymphadenopathy with pericardial and periarterial involvement.

Plasma Pentraxin3 Level Is Associated With Plaque Vulnerability Assessed by Optical Coherence Tomography in Patients With Coronary Artery Disease.

The role of pentraxin 3 (PTX3) has been implicated in the process of plaque vulnerability. However, few studies have addressed the direct relationship between plaque morphology and plasma PTX3. We evaluated the relationship between coronary vulnerable plaque, assessed by optical coherence tomography (OCT), and plasma PTX3 in patients with coronary artery disease (CAD).OCT was used to determine plaque vulnerability in 51 patients with non-ST segment elevation acute coronary syndrome (NSTE-ACS; n = 17) and stable angina (SA; n = 34). Both highly-sensitive C-reactive protein and systemic plasma PTX3 were measured.Based on the OCT findings, patients were divided into 3 groups; a fibrous plaque (n = 18), thick-cap fibroatheroma (ThCFA) (n = 19), and thin-cap fibroatheroma (TCFA) (n = 14) groups. ThCFA was defined as a lipid-rich plaque (lipid content in ≥ 2 quadrant) covered with ≥ 65 µm thick fibrous cap, and TCFA was that with < 65 µm. There were no differences in patient characteristics between the 3 groups except for the presence of ACS and eicosapentaenoic acid levels. TCFA was more frequently observed with plaque rupture and intraluminal thrombus compared with the other 2 groups. Plasma PTX3 levels were higher in the TCFA group compared with the fibrous plaque and ThCFA groups, and showed weak correlation with cap thickness.Plasma PTX3 level was associated with plaque vulnerability assessed by OCT in patients with CAD.

Repetitive fulminant influenza myocarditis requiring the use of circulatory assist devices.

A 52-year-old man was admitted to our hospital due to shortness of breath that developed one week after the diagnosis of influenza infection. He had a past history of myocarditis associated with influenza B infection 16 years before the current admission. The patient's left ventricular function showed diffuse hypokinesis with a left ventricular ejection fraction of 28%. Due to the progression of heart failure, the infusion of catecholamines and insertion of an intra-aortic balloon pump were required. The patient was discharged uneventfully on the 23rd hospital day. A significant increase in the serum antibody titer against influenza A virus subtype H3N2 led to a diagnosis of recurrent fulminant influenza myocarditis.

Association between serum immunoglobulin G4 concentration and cardiac function among elderly cardiology inpatients.

AIM: To study whether there is an association between serum immunoglobulin G4 (IgG4) concentration and cardiac function among cardiology inpatients. METHODS: This retrospective study included 91 patients who had sinus rhythm. Of 91 patients, 70 patients (77%) were aged ≥ 60 years (elderly group) and the remaining 21 patients (23%) were aged <60 years (younger group). RESULTS: Serum IgG4 concentrations were found to be negatively correlated with brain natriuretic peptide (BNP) and with E/e', an indicator for cardiac diastolic function in the elderly group, but not in the younger group. In contrast, IgG4 was significantly correlated with neither left ventricular mass nor ejection fraction in either group. Multivariate regression analysis showed that, in the elderly group, the association between IgG4 and E/e', and that between IgG4 and BNP, were independent of age, sex, systolic blood pressure and renal function; log-transformed IgG4 showed a negative association with log-transformed E/e' and log-transformed BNP, with a standardized correlation coefficient of -0.26 (95% confidence interval -0.49 to -0.03, P = 0.030 and -0.22 (95% confidence interval -0.44 to -0.11, P = 0.043), respectively. CONCLUSION: Serum IgG4 concentration might be associated with cardiac diastolic function among elderly cardiology inpatients.

Serum uric acid is associated with left ventricular hypertrophy independent of serum parathyroid hormone in male cardiac patients.

BACKGROUND: Several studies have shown that serum uric acid (UA) is associated with left ventricular (LV) hypertrophy. Serum levels of parathyroid hormone (PTH), which has bbe shown to be correlated with UA, is also known to be associated with cardiac hypertrophy; however, whether the association between UA and cardiac hypertrophy is independent of PTH remains unknown. PURPOSE: We investigated whether the relationship between serum uric acid (UA) and LV hypertrophy is independent of intact PTH and other calcium-phosphate metabolism-related factors in cardiac patients. METHODS AND RESULTS: In a retrospective study, the association between UA and left ventricular mass index was assessed among 116 male cardiac patients (mean age 65 ± 12 years) who were not taking UA lowering drugs. The median UA value was 5.9 mg/dL. Neither age nor body mass index differed significantly among the UA quartile groups. Patients with higher UA levels were more likely to be taking loop diuretics. UA showed a significant correlation with intact PTH (R = 0.34, P<0.001) but not with other calcium-phosphate metabolism-related factors. Linear regression analysis showed that log-transformed UA showed a significant association with left ventricular mass index, and this relationship was found to be significant exclusively in patients who were not taking loop and/or thiazide diuretics. Multivariate logistic regression analysis showed that log-transformed UA was independently associated with LV hypertrophy with an odds ratio of 2.79 (95% confidence interval 1.48-5.28, P = 0.002 per one standard deviation increase). CONCLUSIONS: Among cardiac patients, serum UA was associated with LV hypertrophy, and this relationship was, at least in part, independent of intact PTH levels, which showed a significant correlation with UA in the same population.

Association between circulating fibroblast growth factor 23, α-Klotho, and the left ventricular ejection fraction and left ventricular mass in cardiology inpatients.

BACKGROUND: Fibroblast growth factor 23 (FGF23), with its co-receptor Klotho, plays a crucial role in phosphate metabolism. Several recent studies suggested that circulating FGF23 and α-Klotho concentrations might be related to cardiovascular abnormalities in patients with advanced renal failure. PURPOSE: Using data from 100 cardiology inpatients who were not undergoing chronic hemodialysis, the association of circulating levels of FGF23, α-Klotho, and other calcium-phosphate metabolism-related parameters with the left ventricular ejection fraction (LVEF) and left ventricular mass (LVM) was analyzed. METHODS AND RESULTS: LVEF was measured using the modified Simpson method for apical 4-chamber LV images and the LVM index (LVMI) was calculated by dividing the LVM by body surface area. Univariate analysis showed that log transformed FGF23, but not that of α-Klotho, was significantly associated with LVEF and LVMI with a standardized beta of -0.35 (P<0.001) and 0.26 (P<0.05), respectively. After adjusting for age, sex, estimated glomerular filtration rate, and serum concentrations of intact parathyroid hormone, and 25-hydroxyvitamin D as covariates into the statistical model, log-transformed FGF23 was found to be a statistically positive predictor for decreased left ventricular function and left ventricular hypertrophy. CONCLUSIONS: In cardiology department inpatients, circulating FGF23 concentrations were found to be associated with the left ventricular mass and LVEF independent of renal function and other calcium-phosphate metabolism-related parameters. Whether modulation of circulating FGF23 levels would improve cardiac outcome in such a high risk population awaits further investigation.

An unmappable ventricular tachycardia in the arrhythmogenic right ventricular cardiomyopathy: elucidation of critical isolated delayed components with high-resolution electroanatomical mapping.

Unmappable ventricular tachycardia (VT) is a challenge in the management of arrhythmogenic right ventricular cardiomyopathy (ARVC). We report a feasible strategy for a curative ablation. In the present case with ARVC, the clinical VT showed a single morphology of left bundle branch block with inferior axis. Neither activation mapping nor entrainment mapping could be done because of instability of the haemodynamics. Furthermore, pace mapping could not be obtained due to electrically unexcitable scars covering with the RV. We found isolated delayed components (IDCs) in the diastolic phase recorded within the scar areas. Electroanatomical mapping (CARTO) with tiered decreasing voltage definition revealed that IDCs were delineated on the narrow conducting channels along or between the complete scars (amplitude < or =0.1 mV). Isolated delayed components on the narrow channels were targeted under the guidance with CARTO. After 11 radiofrequency applications, the clinical VT was eliminated. Moreover, epsilon waves recorded on the 12-lead electrocardiogram disappeared. No ventricular tachyarrhythmia was recognized at 6-month follow-up. Isolated delayed component ablation with high-resolution CARTO map was feasible and provided a curative approach in the treatment of an unmappable VT in ARVC.

The results of a new distal protection method in intervention for chronic total occlusion of the superficial femoral artery.

Aims. To determine the efficacy of a new distal protection method in SFA CTO interventions. Methods and Results. From June 2003 to February 2009, ninety-two consecutive, chronic total occlusions of superficial femoral arteries were treated with catheter-based intervention using a bidirectional approach. Nine of these cases were managed with our original, distal protection method, based on symptoms, angiographic images, wire resistance, and intravascular ultrasound images. The average age was 73 years; eight patients were male. The mean occlusion length was 17.1 cm. A distal protection balloon was inserted from the retrograde sheath in the popliteal artery and placed distal to the occluded lesion after successful wire crossing. Lesion dilatation with a balloon was performed antegradely and debris was removed by 6Fr. guiding catheter. Debris was retrieved from all lesions, consisting mainly of thrombus. Where we decided not to use the distal protection method, there was no distal thromboembolism. Conclusion. In SFA-CTO intervention, the risk of distal embolization is 10%, which can be anticipated and eliminated by the distal protection method.

Bacteroides coprophilus sp. nov., isolated from human faeces.

Three Gram-negative, anaerobic, rod-shaped bacteria (strains CB40, CB41 and CB42(T)) were isolated from human faeces. Based on phylogenetic analysis and specific phenotypic characteristics, these strains were included in the genus Bacteroides, and 16S rRNA gene sequence analysis indicated that these strains represented a novel species. The strains were most closely related to the type strains of Bacteroides barnesiae and Bacteroides salanitronis, with sequence similarities of 93.4 and 89.8 %, respectively. The G+C content of strain CB42(T) is 44.7 mol%. Major fatty acids were anteiso-C(15 : 0), C(16 : 0), iso-C(17 : 0) 3-OH and C(18 : 1)omega9c. On the basis of the data presented, a novel Bacteroides species, Bacteroides coprophilus sp. nov., is proposed, with CB42(T) (=JCM 13818(T)=DSM 18228(T)) as the type strain.

Prevotella copri sp. nov. and Prevotella stercorea sp. nov., isolated from human faeces.

Six strains (CB7(T), CB18, CB23, CB26, CB28 and CB35(T)) were isolated from human faeces. Based on phylogenetic analysis, phenotypic characteristics, cellular fatty acid profiles and menaquinone profiles, these strains could be included within the genus Prevotella and made up two clusters. 16S rRNA gene sequence analysis indicated that five strains were most closely related to Prevotella veroralis, sharing about 92 % sequence similarity; the remaining strain was most closely related to Prevotella shahii, sharing about 90 % sequence similarity. All six strains were obligately anaerobic, non-pigmented, non-spore-forming, non-motile, Gram-negative rods. The cellular fatty acid compositions of the six strains differed significantly from those of other Prevotella species. Five strains (CB7(T), CB18, CB23, CB26 and CB28) contained dimethyl acetals and the major menaquinones of these strains were MK-11, MK-12 and MK-13. The major menaquinones of CB35(T) were MK-12 and MK-13. Based on phenotypic and phylogenetic findings, two novel species, Prevotella copri sp. nov. and Prevotella stercorea sp. nov., are proposed, representing the two different strain clusters. The DNA G+C contents of strains CB7(T) and CB35(T) were 45.3 and 48.2 mol%, respectively. The type strains of P. copri and P. stercorea are CB7(T) (=JCM 13464(T)=DSM 18205(T)) and CB35(T) (=JCM 13469(T)=DSM 18206(T)), respectively.

[Initial and long term outcomes of stent implantation for iliac compression syndrome].

OBJECTIVES: The initial and long term outcome of stenting in the iliac vein were investigated in patients with iliac compression syndrome. METHODS: Iliac compression syndrome was diagnosed with venography and intravascular ultrasonography that demonstrated severe stenosis at the iliac venous compression site. Fourteen patients with symptomatic iliac compression syndrome were treated with stent implantation. The patency of the stents was examined at short and long term follow-up examinations. RESULTS: Thirteen patients presented with left iliac venous compression and only one patient presented with right iliac venous compression. Twelve of the 14 patients had acute deep venous thrombosis, so temporary vena cava filter implantation was performed during the procedure in these 12 patients. Procedural success was defined as less than 50% stenosis after stent implantation with good flow and without major complication (death, surgical repair for vein, or symptomatic pulmonary embolization). Procedural success was achieved in 13 of 14 patients, and these 13 patients showed improvement of symptoms. In the unsuccessful case, the compression site was resolved by stenting, but good flow was not obtained due to remaining femoral vein occlusion. The self-expandable stent was used for 6 patients, and the balloon-expandable stent was used for 8 patients. Angiographic or ultrasonographic follow up was performed in 10 patients at mean follow up of 8 months, but no restenosis was documented. CONCLUSIONS: Stent implantation for symptomatic iliac compression syndrome is a safe and effective procedure to resolve venous disease symptoms. Despite the small number of patients, long term outcome has been excellent in this study.

Case report: Focal ablation for atrial fibrillation originating from the inferior vena cava and the posterior left atrium.

We identified a case of paroxysmal atrial fibrillation (AF) originating from inferior vena cava (IVC) and the low-posterior left atrium (LA). Both foci, the IVC and the low-posterior LA, simultaneously served not only as trigger but also as driver for maintenance of AF. During AF, the IVC and the low-posterior LA continuously demonstrated the rapid and fractionated potentials that exit into both atria with conduction block. Focal ablation for ectopic beats within the IVC and the low-posterior LA completely eliminated the storm of AF.

Two atrial reentrant tachycardias originating from the superior vena cava: electrophysiological characteristics and radiofrequency ablation.

A case with two different types of atrial reentrant tachycardia of superior vena cava (SVC) origin is presented. Recent clinical studies have shown that the origin of focal atrial tachycardia typically lies in the venous structures connecting to both atria--the coronary sinus, the superior and inferior vena cava, and the pulmonary vein. These foci have atrial muscle fiber extensions which have electrophysiological characteristics essential to generation of focal ectopic firing. However, little is known about reentrant mechanism of these venous structures. In this report, we present a case of two atrial tachycardias (SVT1 and SVT2) independently originating from the SVC. SVT1 had 430 ms of tachycardia cycle length, and SVT2 had 390 ms of tachycardia cycle length. Both of them showed the character of reentry, and their earliest activations were recorded in the SVC. They were successfully eliminated by focal radiofrequency ablation in the SVC.

Catheter ablation for an incessant form of antiarrhythmic drug-resistant ventricular fibrillation after acute coronary syndrome.

A 77-year-old man was admitted with an acute coronary syndrome (ACS), severe heart failure (HF), and repeated ventricular fibrillation (VF) episodes. A single premature ventricular complex (PVC) induced ventricular tachycardia (VT), which degenerated to VF reproducibly. This PVC was eliminated by catheter ablation at the left ventricular posteroseptal region where double Purkinje potentials preceding the ventricular wave had been recorded. The electrical storm disappeared, and programmable stimulation failed to induce any tachyarrhythmias after the ablation. A Purkinje fiber network-related PVC served as a trigger and as a substrate for VT and VF in a case of ACS with HF.

Bundle brunch reentrant ventricular tachycardia with two distinct conduction patterns in a patient with complete right bundle branch block.

We report a rare case of bundle branch reentrant ventricular tachycardia [BBRVT]. A 67-year-old female was admitted for management of wide QRS tachycardia (right bundle branch block [RBBB] and a southwest axis). The mapping procedure revealed the tachycardia circuit consisted of the left anterior fascicle (LAF) as an antegrade, and the right bundle as a retrograde pathway. She presented RBBB during sinus rhythm. LAF ablation changed the tachycardia configuration to a northwest axis and prolonged the cycle length. Left posterior fascicle ablation terminated the tachycardia, and complete atrioventricular block occurred, which showed the unidirectional conduction over the right bundle.