The aim of this study was to clarify the effect of preinfarction angina on heart rate variability (HRV) in anterior wall acute myocardial infarction (AMI). A total of 36 patients experiencing their first anterior wall AMI were prospectively examined. The patients were divided into 2 groups according to the presence (group A, n=24) or absence (group B, n=12) of preinfarction angina. HRV was assessed on 24-h Holter electrocardiograms recorded on day 3. Peak creatine kinase activity was significantly lower in group A than in group B (2,747±1,939 vs 4,891±2,639 IU/L, p<0.05). The SD of all RR intervals and ultra-low frequency, very low frequency, and low frequency powers was significantly less reduced in group A than in group B (86±24 vs 64 ±22 ms, p<0.05; 2,098±1,462 vs 867±502 ms², p<0.01; 1,430 ±1,042 vs 546±344 ms², p<0.01; and 354±272 vs 186±136 ms², p<0.05; respectively). High frequency power, low frequency/high frequency, and pNN50 did not differ significantly between the 2 groups. In conclusion, preinfarction angina has a favorable influence on HRV in the early phase of anterior wall AMI. (Circ J 2002; 66: 431 - 434)

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It has been reported that women with acute myocardial infarction (AMI) have a higher short-term mortality rate than men, but the reason is unclear and it is not known if it also applies to unstable angina pectoris (UAP). In addition, most previous studies have not presented angiographic findings. In the present study, the findings from 1,408 patients with AMI (group A: 361 women, 1,047 men) and 332 patients with UAP (group B: 103 women, 229 men) who underwent coronary angiography within 30 days of onset were analyzed. In both groups, the women were older and had a higher rate of hypertension and a lower rate of smoking than the men. There was no significant difference in Killip class or the number of diseased vessels between the women and men in both groups. Interventions (coronary angioplasty and coronary artery bypass grafting) were performed less frequently in the women than in the men (87.2% vs 91.8%, p=0.04) in group A, but not in group B (80.6% vs 81.2%, NS). In both groups, the overall mortality rate during hospitalization was higher in women than in men (group A: 14.4% vs 7.4%, p<0.0001, group B: 7.8% vs 1.7%, p=0.007). Multivariate analysis revealed that female gender was an independent predictor of in-hospital mortality in group B (odds ratio (OR): 6.4, 95% confidence interval (CI) 1.1-37.0, p=0.04), but not in group A (OR: 1.7, 95% CI 0.98-2.9, p=0.06). The independent predictors of in-hospital mortality, other than female gender were age, prior congestive heart failure, prior cerebrovascular disease and a higher Killip class in group A, and in both groups a higher number of diseased vessels. In conclusion, Japanese women with acute coronary syndromes present with similar angiographic findings and hemodynamics, but have a higher in-hospital mortality than male patients. Our results suggest that older age may be a potential explanation for the higher in-hospital mortality in women with AMI, but female gender itself may be an important predictor for it among those with UAP. (Circ J 2002; 66: 435 - 440)

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The tolerability and effectiveness of amiodarone in patients with advanced heart failure (HF) who are intolerant of β-blockers was investigated in 22 patients (13 with and 9 without 180±26 mg/day of amiodarone). Heart rate (HR), blood pressure (BP), left ventricular diastolic dimension and fractional shortening (FS) using echocardiography, plasma atrial natriuretic peptide (ANP), brain natriuretic peptide (BNP) and norepinephrine concentrations were determined at baseline and after 1 and 3 months of therapy. Although 9 patients tolerated amiodarone without any signs of HF, it was exacerbated in 4 patients. In 10 patients taking amiodarone who could be followed medically for 3 months, HR decreased after 1 month and remained unchanged until after 3 months (81±12 vs 65±7 vs 65±7 beats/min), accompanied by decreased concentration of BNP (688±485 vs 392±203 vs 261 ±192 pg/ml). FS increased significantly only after 3 months (0.12±0.05 vs 0.14±0.05 vs 0.16±0.04). Amiodarone may be used in patients with advanced HF who are intolerant of β-blockers. (Circ J 2002; 66: 441 - 444)

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The prognosis for patients with a residual scar from myocardial infarction (MI) after coronary artery bypass grafting surgery (CABG) has not been fully evaluated, so the present study retrospectively evaluated such patients with stress myocardial single photon emission computed tomography (SPECT) at 100 months after CABG. The study group consisted of 24 subjects (23 males, 1 female; mean age, 59±9 years) in whom CABG had been performed more than 100 months (mean follow-up period 135±25 months) previously. The 24 subjects were classified into 3 groups according to their summed stress score (SSS) and summed reversibility score (SRS) in the early period after CABG. Eight subjects with MI (SSS≥2 and SRS<2) were classified into the group MI, 8 subjects with ischemic myocardium (SSS≥2 and SRS≥2) was classified into the group RE, and 8 subjects with normal perfusion (SSS<2 and SRS<2) was classified into group N. None of the subjects in group MI required revascularization. Cardiac events occurred in 4 of the group RE patients and all required revascularization. As to the SPECT scoring system, the long-term SSS of group MI (6.4 ±3.1) was not different from that in the early periods (4.3±4.0; NS). However, the long-term SSS values of group RE (8.8±6.2) were significantly greater than those soon after CABG (3.4±1.8; p=0.03). In group N, there was also no difference in the SSS values between the early period (0.3±0.5) and the long-term period (0.0±0.0; NS). Patients with a residual scar from MI in the early period after CABG did not worsen over a period of 100 months. Moreover, there was no significant difference in the SPECT score in the segment with the residual scar in the short or long term after CABG. However, the extent of reversibility was directly associated with the presence of clinical events. Therefore scintigraphic imaging remains an important and clinically relevant risk stratification tool. Stress myocardial SPECT, early after CABG, can be used to predict the possibility of future cardiac events or the need for revascularization. (Circ J 2002; 66: 445 - 449)

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The safety and myocardial protective effect of perfused ventricular fibrillation (VF) under moderate hypothermia were investigated. Through a midline sternotomy and opening the left atrium from the right side, isolated mitral valve surgery was performed under aortic cross-clamping (ACC) and cardioplegic arrest using Bretschneider HTK solution in 96 patients, and under perfused VF in 20 patients (VF Group). Patient characteristics, clinical outcomes, and perioperative variables were compared. A satisfactory surgical view was obtained in all VF Group patients. Patient characteristics in the 2 groups were similar, and both groups had comparable results for mortality and morbidity, operation time, cardiopulmonary bypass time, peak levels of creatine kinase (CK) and its myocardial fraction, hours of mechanical ventilation, intensive care unit stay, and postoperative left ventricular ejection fraction. Even in VF Group patients with preoperative critical hemodynamic compromise, inotropes could be discontinued within 3 days. Thus, no detrimental effect of perfused VF was observed. On the other hand, in patients who underwent ACC and cardioplegic arrest of 120 min or longer, peak levels of CK and its myocardial fraction were significantly higher than those of the rest of C group patients and VF Group patients. Perfused VF under moderate hypothermia can be a good alternative myocardial protection strategy during mitral valve surgery, particularly in patients in whom ACC is unsuitable or the duration of ACC is expected to be long. (Circ J 2002; 66: 450 - 452)

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The slope of the regression line between carbon dioxide output (VCO₂) and minute ventilation (VE) (SLOPE) is useful for evaluating ventilation - perfusion inequality during exercise. A cardiopulmonary exercise test was carried out in 8 pulmonary hypertension (PH) patients without hypoxemia (group PH), 38 male patients with old myocardial infarction (group OMI), and 20 healthy men (group Ctrl). The average SLOPE for each group was 36.3±3.3, 28.7±0.9 and 25.6±0.5, respectively. There were significant differences among them. Group OMI was divided into 3 groups: OMI class 0: peak oxygen consumption (VO₂) ≥ 21 ml · kg^-1 · min^-1; OMI class I: 14 ml · kg ^-1 · min^-1 ≤ peak VO₂ < 21 ml · kg^-1 · min^-1; OMI class II: peak VO₂ < 14 ml · kg^-1 · min^-1. There were no significant differences in peak VO₂ between the groups PH and OMI class I, but the SLOPE in the group PH was greater than the SLOPE in OMI class I (p=0.0019). Compared with OMI class II, group PH had a greater peak VO₂ (p=0.0215), although their SLOPE was equivalent to that of OMI class II. These results suggest that PH patients have severe ventilation - perfusion inequality despite good exercise capacity. When performing a cardiopulmonary exercise test on PH patients, it is necessary to observe not only VO₂ or VCO₂, but also VCO₂/VE, in order to prevent aggravation of the ventilation - perfusion inequality, which leads to exercise-induced hypoxemia. (Circ J 2002; 66: 453 - 456)

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The clinical significance of T-wave alternans (TWA) in hypertrophic cardiomyopathy (HCM) is unclear, so SV₁+RV ₅ and QT dispersion on 12-lead electrocardiograms (ECG), the parameters of the left ventricle on echocardiography and the family history of HCM and sudden death were investigated in 53 patients with HCM who experienced TWA. The maximal numbers of successive ventricular ectopic beats (max VE) and nonsustained ventricular tachycardia (NSVT) were measured by Holter monitoring. In 13 patients, genetic abnormalities were examined. In 22 patients, the hypertrophy of myocytes, disarray and fibrosis were histopathologically examined using a scoring method. TWA was positive in 27 patients (TWA+ group), negative in 14 (TWA- group) and indeterminate in 12. The ECG and echocardiographic parameters, family history and genetic abnormalities did not significantly differ between the TWA+ and TWA- groups. Max VE, the percentage of patients with NSVT and disarray score in the TWA+ group were significantly higher than those in the TWA- group (3.6±3.6 vs 1.3±0.7, 37% vs 0%, 1.9±1.1 vs 0.7±0.5; p<0.05). TWA in HCM correlates with histopathological changes, especially disarray and ventricular tachyarrhythmia, and measuring it may be a noninvasive means of detecting high-risk patients with HCM. (Circ J 2002; 66: 457 - 462)

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While lowering the blood cholesterol level has been shown to decrease the risk of coronary heart disease (CHD) in Western countries, little is known about the relationship between lipid-lowering drugs and CHD risk in Japan. A case - control study of nonfatal acute myocardial infarction (AMI) was conducted in Japan. A total of 658 cases aged 40-79 years and 1,274 community controls matched to each case by sex, year of birth, and residence were compared for their use of lipid-lowering drugs and level of serum total cholesterol. The study used 2 definitions of hypercholesterolemia: (i) either serum total cholesterol ≥6.21 mmol/L (240 mg/dl) or current use of hypolipidemic drugs; and (ii) either serum total cholesterol of ≥5.69 mmol/L (220 mg/dl) or current use of hypolipidemic drugs. Unconditional logistic regression analysis was used to adjust for hypertension, angina pectoris, diabetes mellitus, smoking, alcohol use, and physical activity as well as for sex and age. As compared with nonhypercholesterolemic subjects, those with untreated hypercholesterolemia had a significantly increased risk of AMI whereas no increase in the risk was observed for treated hypercholesterolemia. In the group with hypercholesterolemia, regardless of the definition, the adjusted odds ratios decreased progressively when the achieved cholesterol levels were lower. (Circ J 2002; 66: 463 - 468)

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Increased QT dispersion predicts the occurrence of lethal ventricular arrhythmias complicating percutaneous transluminal coronary angioplasty (PTCA). Moreover, these arrhythmias occur more frequently at the first balloon inflation. Activation of the K_ATP channel may influence QT dispersion and ventricular arrhythmias during coronary angioplasty, so 40 consecutive patients with stable angina were randomized to receive 3 mg/h of nicorandil infusion or placebo and QT dispersion and the incidence of ventricular ectopy were investigated before and throughout PTCA. There were no significant differences in QT dispersion at baseline between the nicorandil group (42±8 ms) and placebo (42±12 ms). At the first balloon inflation, the QT dispersion in the nicorandil group (51±13 ms) was significantly less than that observed with placebo (76±16 ms, p<0.001). However, the QT dispersion at the second inflation was similar in both groups (nicorandil: 45±12 ms; placebo: 52±14 ms). Ventricular ectopy was observed in 1 patient receiving nicorandil and 5 patients in the placebo group during the first inflation, and none in the nicorandil and 1 patient in the placebo group during the second balloon inflation. Activation of the K_ATP channel may inhibit the development of ventricular arrhythmias during PTCA, particularly at the first balloon inflation. (Circ J 2002; 66: 469 - 472)

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Coronary artery calcification (CAC) was assessed by cinefluoroscopy and its extent was scored (CAC score) in 2,163 consecutive patients undergoing coronary angiography, based on the angiographic and clinical data, the patients were categorized into 8 types of coronary artery disease (CAD). The CAC score was lowest in angiographically normal subjects (0.12±0.60) and highest in patients with silent myocardial ischemia (14.31±8.61). Risk factors for CAC were advanced age, male sex (at age <80 years), hypertension, diabetes mellitus, and a high grade of organic coronary stenosis. The CAC score in patients with acute coronary syndrome (unstable angina + acute myocardial infarction; 5.48±7.42) was significantly lower than that in those with chronic CAD (silent ischemia + stable angina; 9.72±8.73; p<0.0001), but was still higher than that in normal subjects or those with vasospastic angina (0.92±2.88; p<0.0001). The results indicate that CAC is a manifestation of coronary atherosclerosis and its appearance depends on the pathological type of ischemic heart disease. Fixed stenosis with a slow and chronic process tends to be associated with CAC. The clinical implication of extensive CAC in acute coronary syndrome compared with normal subjects should be further investigated. (Circ J 2002; 66: 473 - 478)

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Thirty-five consecutive patients with massive and submassive pulmonary embolism (PE) were reviewed. In 75% of these cases, PE could be suspected on the basis of electrocardiogram alone. Echocardiography was quite useful for diagnosing PE and assessing right ventricle after-load at the bedside. Spiral computer tomography was effective for obtaining a definitive diagnosis even in a relatively hemodynamically unstable patient. Thrombolysis therapy was given to 30 cases and was apparently effective in 17 cases (17/30, 56.7%). Percutaneous cardiopulmonary support (PCPS) was needed for 7 severe cases. Seven patients, including 5 of the PCPS recipients, underwent surgical embolectomy. Overall mortality was 28.6% (10/35), and surgical mortality was 28.6% (2/7). The significant predictors for mortality were systolic blood pressure <100 mmHg, dopamine >5 μg · kg^-1 · min^-1, pH <7.4, PaCO₂ >40 torr, base excesss <-5 mmol/L, urine output <0.8 ml · kg^-1 · h^-1, intubation, cardiopulmonary resuscitation, duration from attack to emergency room >5 h, shock duration >4 h, aspartate aminotransferase >100 U/L, alanine aminotransferase >100 U/L and lactate dehydrogenase >600 U/L. Predictors of surgical intervention were dopamine >5 μg · kg ^-1 · min^-1, shock duration >4 h and PCPS. Early initiation of thombolysis therapy is recommended, except in case where it is absolutely contraindicated. Because it is difficult in the early phase of PE to make a decision to perform surgery, aggressive application of PCPS is recommended for the cardiogenic shock associated with massive PE. (Circ J 2002; 66: 479 - 483)

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Long-term mortality from congenital cardiovascular malformations (CCVM) remains unknown in most countries. Age- and sex-specific mortality rates from CCVM in Japan from 1968 through 1997 were determined from analyses, with official permission, of individual death records held by the Japanese Government. CCVM with chromosomal anomalies were not included. The number of deaths analyzed was 82,919. The mortality rate declined by 64% from 3.36 per 100,000 population in 1968 to 1.22 in 1997, largely because of a decrease in mortality among patients under 20 years of age. Infant mortality remained high until 1978, then sharply declined from 1979 to 1987 with the advent of 2-dimensional echocardiographic diagnosis and prostaglandin E1 therapy. The cumulative mortality rates in the first 20 years of life were expected to decline among cohort members born after 1978. In contrast, the mortality rates for subjects over 20 years of age increased during the 30-year study period. Mortality rates were higher for males than for females. The mortality rate among young patients with CCVM is expected to decline still further, suggesting that many if not most children with CCVM will survive to adulthood. (Circ J 2002; 66: 484 - 488)

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To establish the relationship between the cross-sectional geometry of the post-deployment stent and the degree of in-stent neointimal hyperplasia (INH), intravascular ultrasound (IVUS) was used to examine cross-sections of the coronary arteries from 23 patients with coronary stents 6 months after implantation. Stent cross-sectional area (Sa) and stent perimeter (Sp) from 200 stent cross-sections, and the stent radius (Sr) and thickness of INH (Id) of 2,880 radial axes, were measured, and the mean degree of roundness (Rd) of stent cross-section was calculated for each stent as Rd = 4πSa / Sp². The degree of deformity (Df) of the stent cross-section was also calculated by comparing it with a hypothetical circle (the area of this hypothetical circle was equal to the Sa): Df = Sr / R, where R is the radius of the hypothetical circle. The area of INH was significantly larger in the Rd<0.87 group (n=84) than in the Rd≥0.87 group (n=116) (3.83±1.26 vs 3.16±1.32 mm², p<0.0005). There were significant differences in the thickness of INH among the 3 groups classified by the value of Df (Df<0.95: n=425, 0.21±0.12 mm; 0.95≤Df<1.05: n=2008, 0.29±0.15 mm; Df≥1.05: n=447, 0.34±0.15 mm, overall p<0.0001). These data suggest that in-stent neointimal proliferation is more likely to occur in stented coronary arteries with a more oval than rounded cross-section, and particularly within the more pronounced and curved portion of the oval. (Circ J 2002; 66: 489 - 493)

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Recent developments in tissue harmonic imaging and intravenous contrast agents have enhanced left ventricular endocardial border delineation (EBD). In a total of 48 patients with poor quality images, apical 4- and 2-chamber views were obtained with fundamental, tissue harmonic and contrast harmonic imaging with or without intravenous Levovist, an air-filled contrast agent. The left ventricle (LV) was divided into 12 segments, and the EBD of each segment was scored: (1) not visible, (2) barely visible, (3) well delineated. The EBD index (EBDI), defined as the sum of the endocardial scores divided by 12 was obtained for each patient. Of a total of 576 LV segments, 231 were scored as 1 by fundamental imaging and that number decreased to 125 segments by tissue harmonic imaging and 116 segments by fundamental imaging with Levovist. The number of segments scored as 1 decreased to 38 segments by tissue harmonic imaging with Levovist, and to 29 segments by contrast harmonic imaging with Levovist. The EBDI by fundamental imaging was 1.85±0.29, which improved significantly with the addition of Levovist (2.10±0.36, p<0.001) and was nearly identical to that by tissue harmonic imaging (2.15±0.32, p=NS). Tissue and contrast harmonic imaging with Levovist further enhanced the EBDI (2.43±0.26, 2.51±0.27, respectively). Levovist enhances EBD, even in the fundamental mode, to the level obtained with tissue harmonic imaging. Tissue harmonic and contrast harmonic imaging are the best modalities for enhancing EBD after Levovist injection. (Circ J 2002; 66: 494 - 498)

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Although a recent clinical study reported the beneficial effects of pentoxifylline (PTX), a phosphodiesterase inhibitor, on both symptoms and cardiac function in dilated cardiomyopathy (DCM), the precise mechanism of the drug has not been delineated. This study examined the efficacy of PTX in the treatment of experimental autoimmune myocarditis (EAM), as a model of the autoimmune mechanism involved in DCM. Oral PTX, or saline as control, was administered to Lewis rats at 150 mg/kg body weight per day bid daily from 5 days before immunization with cardiac myosin until death on Day 21. Histological examination of the hearts showed PTX significantly reduced the severity of EAM. mRNA expression of tumor necrosis factor (TNF)-α, interleukin (IL)-4, IL-6, and IL-10 was significantly reduced in peripheral blood mononuclear cells, but expression of IL-4 and IL-6 was upregulated in heart tissue. PTX in vitro could suppress T cell proliferation and inhibit TNF-α and interferon-γ production. In conclusion, the immunomodulatory effects of PTX had a significant therapeutic result in EAM. This is the first report to describe such an effect of PTX in a specific animal model for DCM. (Circ J 2002; 66: 499 - 504)

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Recent experimental results regarding the action potential duration restitution curve have explained the transition from ventricular tachycardia (VT) to fibrillation (VF) in terms of spiral wave (SW) meandering and breakup. However, it remains unclear whether VF always has a steep restitution curve. The present study was designed to test the hypothesis that afterdepolarizations occur at excitable gaps during VF and affect the SW dynamics, even if the restitution curve is gentle. Homogeneous and isotropic 3-dimensional tissue was simulated with a LRd model. Because of the gentle restitution curve, it was not expected that SW instabilities would occur in this condition. In the tissue, a stationary SW reentry was initially observed; however, afterdepolarizations erupted from the excitable gap near the SW tip, and the SW then meandered widely. Following that, afterdepolarizations erupted far from the SW tip, resulting in SW breakup. In this manner, the wave dynamics degenerated into a chaotic state within a few seconds. Furthermore, not only triggered activity but also subthreshold afterdepolarizations were found to cause SW instabilities. These results suggest that afterdepolarizations may play an important role in the transition to VF and that the mechanism is independent of restitution properties. (Circ J 2002; 66: 505 - 510)

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Cardiac microvascular endothelial cells (EC) play an important role in the physiological regulation of coronary blood flow, but their function has not been rigorously examined, because suitable in vitro models have not been available. Cardiac macrovascular and microvascular EC were isolated and cultured from 14-16-week-old Sprague-Dawley rats to examine the pharmacological responses of carbachol-induced nitric oxide (NO) production using a Griess method. Carbachol-induced NO production was only detected in cardiac macrovascular EC, which suggests that endothelial production of NO differs between macrovascular and microvascular EC. Next, cardiac microvascular EC was treated with either vehicle, angiotensin-converting enzyme (ACE) inhibitor (captopril, 10 μmol/L) or angiotensin II type 1 (AT1) receptor antagonist (CV11974, 10 μmol/L) for 4 days. Carbachol-induced NO production was improved by captopril (136±45 nmol, p<0.01 vs vehicle) and CV11974 (146±30 nmol, p<0.01 vs vehicle). Angiotensin II concentration in the culture medium and protein expressions of endothelial nitric oxide synthase and AT1 receptor in the EC were similar among the 3 groups. Interestingly, the level of muscarinic subtype 3 (M₃) receptor was significantly increased in the EC treated with captopril (214%, p<0.01) and CV11974 (296%, p<0.01). When cardiac microvascular EC were treated with neomycin (non-selective phospholipase C inhibitor), carbachol-induced NO production was also improved (146±35 nmol, p<0.01, neomycin 1 mmol/L) together with increased expression of M₃ receptor (p<0.01). These data suggest that the upregulation of the M₃ receptor by captopril or CV11974 occurs via a phospholipase C-dependent pathway. Cardiac microvascular EC also produced NO constitutively, as did the macrovascular EC, but carbachol-induced NO production was decreased. The present data suggest that the upregulation of the M₃ receptor by the ACE inhibitor and AT1 receptor antagonist is a new beneficial effect of these drugs on microvascular endothelial function. (Circ J 2002; 66: 511 - 515)

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Supravalvular aortic stenosis (SVAS) is recognized in cases of Williams syndrome and in sporadic cases not associated with other features of the syndrome. It is also well recognized as associated with peripheral pulmonary stenosis (PPS). A male patient was diagnosed as having PPS at the age of 1 year and 8 months, and was found at the age of 18 years to have SVAS. Cardiac catheterization showed that he had a localized type of SVAS and regression of the PPS. Chest X-ray showed that he did not have the normal thoracic curvature. His 19-year-old sister had also been diagnosed with PPS, and his 43-year-old mother was known to have a harsh systolic cardiac murmur of unknown etiology. Cardiac magnetic resonance imaging showed a localized type of SVAS in his mother also, though not in his sister, both of whom had a somewhat straight thoracic spine, most noticeably in the mother, though not to the degree observed in the patient. This case appears to be familial, though it is not clear whether this skeletal abnormality is an unknown phenotypic feature of this cardiovascular disease. (Circ J 2002; 66: 516 - 518)

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A young adult patient with untreated sarcoidosis spontaneously developed a left ventricular (LV) aneurysm in the anterolateral free wall. Single-photon emission computed tomography (SPECT) using Gallium-67 clearly demonstrated widespread abnormal uptake, including the LV aneurysm. Thallium-201 SPECT revealed a perfusion defect in the anterolateral wall, and abnormal uptake of technetium-99m pyrophosphate was seen, especially in the borders of the defect lesion. (Circ J 2002; 66: 519 - 521)

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A 61-year-old woman had acromegaly associated with mitral regurgitation (MR) resulting from prolapse of the posterior mitral leaflet. At the age of 51 years, the patient was diagnosed with hypertension and a cardiac murmur. She had the characteristic acromegalic appearance, but without visual disturbance. Blood chemistry revealed an elevated plasma concentration of growth hormone and glucose intolerance. Echocardiography showed remarkable dilation of the left ventricle and prolapse of the anterolateral commissure with severe MR. Magnetic resonance imaging of the brain revealed a pituitary microadenoma. MR was successfully corrected by quadrangular resection of the posterior leaflet, including the prolapsed portion, and prosthetic ring annuloplasty. The patient recovered uneventfully. (Circ J 2002; 66: 522 - 524)

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A 62-year-old woman was referred because of an abnormal mediastinal shadow that had first been noted 4 years ago on the left cardiac border on plain chest roentgenogram and which had gradually increased in size since. A huge saccular aneurysm in coronary-pulmonary fistula into which both the left and right coronary arteries drained was revealed by computed tomography and coronary angiography. The patient underwent aneurysmal resection and ligation of the fistulas. Histological study of the aneurysmal wall did not reveal atherosclerotic change but instead cystic medial necrosis, although there was no other clinical manifestation associated with this. (Circ J 2002; 66: 525 - 527)

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