Percutaneous coronary intervention (PCI) devices are much more expensive in Japan than in the United States, but their prices were reduced in April 2002. This study evaluated the impact of that change in the price of PCI devices on medical expenses. In-hospital costs of 22 consecutive patients who underwent elective single-vessel PCI without a debulking procedure before April 2002 were collected and the in-hospital cost of each patient was recalculated by applying the current prices of the PCI devices and those in the USA. For patients treated with PCI before April 2002, the in-hospital cost was ¤1,456,375±358,781, but when the current price is used, the in-hospital cost is estimated to be ¤1,355,812 ±313,237 (7% reduction). If the prices of the devices were reduced to those in USA, there would be a 53% reduction (¤689,417 ±99,139). Although the change in the price of PCI devices in April 2002 has reduced in-hospital costs, the devices are still much more expensive in Japan than in the USA. Further reduction of the price is required to make PCI more cost-effective. (Circ J 2003; 67: 576 - 578)

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This study investigated the contribution of hemodynamic and humoral factors to the variation in the depressor responses to exercise therapy and the significance of the baseline values of these factors in predicting the depressor response of essential hypertensives to mild exercise therapy. Patients with mild to moderate essential hypertension (n=122, F/M: 97/25) performed a bicycle ergometer exercise at a workload equivalent to the lactate threshold for 10 weeks. In all of the patients, systolic and diastolic blood pressures (BP) significantly decreased after 1 week of exercise, continued to decrease until 4 weeks, and were stable from 4 weeks to 10 weeks. Changes in the plasma volume and humoral factors during the study did not differ significantly between responders and non-responders. A multiple logistic regression analysis showed that higher baseline mean BP (MBP) was significantly associated with a poor depressor response (odds ratio 1.84, p=0.002). A variance component analysis indicated that baseline MBP accounted for only 11.2% of the total variance of the depressor response. In conclusion, these summarized results showed that variations in the depressor response to mild exercise therapy were partly determined by baseline MBP, but not by humoral factors, suggesting the possible involvement of other factors, including genetic factors. (Circ J 2003; 67: 579 - 584)

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Guidelines for the prevention and management of infective endocarditis (IE) in children with congenital heart disease (CHD) have not been established, so the aim of this study was to clarify the incidence, practical prevention and management of IE in patients with CHD in Japan through a nationwide survey. A written questionnaire was sent to members of the Japanese Society of Pediatric Cardiology and Cardiac Surgery and information was obtained from 236 cardiologists in 228 institutions. Four hundred and eight patients with IE were hospitalized during 1997 to 2001 (1/173 admissions with CHD including those hospitalized for cardiac catheterization or surgery). Prevention of IE for CHD was undertaken by 92% of cardiologists, usually oral penicillins (73%) and less frequently cephems (18%) were prescribed. The Duke criteria were used as clinical criteria by 38%. Blood culture was performed once only by 40%. Penicillins and aminoglycosides (38%) were frequently administered for management of culture-negative IE. There were variations in the dose and duration of antibiotics for prevention and management of IE. It appears that the prevalence of IE in CHD is rising and the nationwide survey revealed more variations in practical prevention and management of IE in patients with CHD than expected. The results should be helpful in making future guidelines for management of IE in CHD. (Circ J 2003; 67: 585 - 591)

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Surgery for thoracic aortic aneurysm (TAA) in patients 75 years and older is a high risk, but data for their natural history are not available. In the present study the subjects were 62 patients with TAA aged on average 78 years (range, 75-85 years) enrolled between August 1994 and December 2001: 20 operatively treated patients (OPE) and 42 medically managed patients (MED). All of them had been included in the indication for TAA surgery at the time of consultation. Hospital mortality rates and survival rates (Kaplan-Meier method) were compared among emergency OPE, elective OPE, and MED. There were 136 total patient-years of follow-up. Actuarial survival in MED (ie, the natural history) was 83% at 1 year after consultation and 41% at 3 years. Hospital mortality rates in emergency and elective OPE were 27% (3/11) and 0% (0/9), respectively (p=0.22), and the corresponding 3-year survival rates were 44% and 83% (p=0.019). Actuarial survival in elective OPE was higher than that in MED (p=0.022), but that of emergency OPE was similar to that for MED (p=0.17). Patients aged 75 years and older with TAA should undergo an elective operation if the aneurysm diameter is larger than 6 cm and if the patient is asymptomatic and in good anatomicosurgical, physical, and social condition. (Circ J 2003; 67: 592 - 596)

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Aortic arch atherosclerotic lesions can cause ischemic cerebrovascular disease (ICVD). The association between carotid and aortic atherosclerosis was examined, and it was investigated whether noninvasive carotid evaluation aids in the identification of aortic lesions as potential ICVD risk. The subjects comprised 147 patients with ICVD who had undergone carotid ultrasonography and transesophageal echocardiography. Carotid and aortic arch atherosclerosis was evaluated by measuring the maximum intima - media thickness (IMT), with aortic IMT of at least 4 mm, mobile plaques and/or ulcers defined as complex aortic lesions with potential ICVD risk. Carotid IMT was linearly associated with aortic IMT (r=0.53, p<0.001), and the association was independent of traditional cardiovascular risk factors (β =0.36, p<0.001). Also, each 1 SD greater carotid IMT was associated with 4.2-fold (95% confidence interval: 2.5-7.0) higher likelihood of complex aortic lesions, with the likelihood little modified when controlling for cardiovascular risk factors. In particular, complex aortic lesions were found in 78% of patients with the highest carotid IMT tertile, compared with 14% of those with the lowest tertile (p<0.05). Based on these findings, carotid atherosclerosis is associated with aortic atherosclerosis, representing a risk factor for aortic lesions that are a potential ICVD risk. (Circ J 2003; 67: 597 - 600)

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Short-term fluctuations in sinus cycle length after a single ventricular premature complex (VPC) have attracted considerable interest and has been termed heart rate turbulence (HRT). The onset and slope of HRT have each been reported to be independent and powerful predictors of clinical prognosis in patients with myocardial infarction (MI), but there are no data available for patients with hypertrophic cardiomyopathy (HCM). Thus the present study analyzed the 2 HRT variables to determine their prognostic value in HCM patients. Holter monitoring data were obtained from 104 HCM patients, 44 MI patients and 56 normal controls, from which singular VPCs followed by ≥20 normal sinus beats were isolated and the HRT onset and slope were automatically calculated. HRT onset and slope were abnormal in MI patients, but not in HCM patients, as compared with normal control subjects (onset -1.1±2.9, -2.1±3.4, -1.4±5.1%; slope 10.6 ±8.6, 18.0±13.9, 16.6±9.7 ms/beat, respectively). During the follow-up period of 27±10 months, 7 HCM patients and 10 MI patients either died from cardiac death or were hospitalized for congestive heart failure. In MI patients, HRT onset was higher and the HRT slope was lower in patients with cardiac events than in patients without (onset 1.1±2.7 vs -1.7±2.7%, p=0.011; slope 5.7±4.3 vs 12.0±9.0 ms/beat, p=0.028). In HCM patients, however, the HRT onset and slope were similar between patients with and without cardiac events (onset -2.0±2.0 vs -2.1 ±3.5%, p=0.98; slope 18.1±10.9 vs 18.0±14.0 ms/beat, p=0.68). In conclusion, unlike MI patients, the HRT variables in selected HCM patients were not abnormal and failed to predict the clinical prognosis. (Circ J 2003; 67: 601 - 604)

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The predictive values for long-term outcome in 127 consecutive patients with acute myocardial infarction (AMI) after successful primary percutaneous transluminal coronary angioplasty (PTCA) were prospectively investigated in the present study. The primary endpoint was a composite of cardiac death, nonfatal AMI, and recurrent angina. Follow-up angiography was performed in 120 patients to assess restenosis. The primary endpoint occurred in 21 patients during a follow-up period of 35±24 months. These patients had a higher lipoprotein(a) [Lp(a)] concentration (p=0.0105) and more prevalence of multivessel disease (p=0.0028) than the other patients. The subjects were divided into 2 groups at the 75th percentile Lp(a) value: group A had an Lp(a) concentration ≥47 mg/dl and group B <47 mg/dl. Kaplan-Meier analysis showed a lower cardiac event-free survival rate in group A (p=0.0007) and in patients with multivessel disease (p=0.001). In Cox proportional hazards regression analysis, an Lp(a) level ≥47 mg/dl (relative risk[RR] 5.5, 95% confidence interval [CI] 2.0-15.0, p=0.0007) and multivessel disease (RR 5.3, 95% CI 2.0-13.7, p=0.0006) were independent predictors of the primary endpoint. An elevated Lp(a) concentration on admission and multivessel disease are significant predictors for long-term adverse outcome in AMI patients treated by primary PTCA. (Circ J 2003; 67: 605 - 611)

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The utility of thrombolysis in patients with acute pulmonary thromboembolism (APTE) remains controversial, although anticoagulation therapy for APTE is well-established in Western countries. Nonetheless, large clinical trials of antithrombotic treatments for APTE have yet to be performed in Japan. In the present study, the association between antithrombotic treatments (thrombolysis and anticoagulation) and the clinical outcomes was retrospectively investigated in 225 APTE patients. In-hospital mortality was significantly lower in hemodynamically stable patients who received anticoagulation therapy than in those who received no adequate therapy (0% vs 33%). Thrombolysis in patients with or without cardiogenic shock failed to improve the in-hospital outcomes compared with those who received anticoagulation treatment (8% vs 3%). There was no significant difference in the bleeding rate between patients receiving thrombolysis and anticoagulation (3% vs 3%). These results indicate that anticoagulation could reduce the mortality of hemodynamically stable APTE patients and that the outcome after thrombolysis or anticoagulation treatment was similar. However, this study was limited because it was executed retrospectively. Further prospective randomized trials to investigate the efficacy of thrombolysis in Japan should be performed to completely address this issue. (Circ J 2003; 67: 612 - 616)

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The clinical results of percutaneous transluminal coronary rotational atherectomy (PTCRA) in dialysis patients were retrospectively evaluated in comparison with coronary artery bypass grafting (CABG). From 1997 to 2001, 44 consecutive dialysis patients with 61 lesions underwent PTCRA and 55 consecutive dialysis patients underwent CABG. The initial success rate of PTCRA was 98%. The PTCRA group had a shorter hospital stay (13±17 vs 60±35 days, p=0.0001) and a lower rate of complications (11% vs 42%, p=0.001) than the CABG group. Although neither event-free survival without death nor myocardial infarction (MI) was significantly different between the CABG and PTCRA groups during the mean follow-up period of 21±14 months, 20 patients (45%) in the PTCRA group needed repeat revascularization of the target lesion. In conclusion, PTCRA may be a safe alternative modality for revascularization of high-risk CABG candidates, with excellent short-term results although the long-term outcome is inferior to that of CABG because of the higher restenosis rate. (Circ J 2003; 67: 617 - 621)

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The present study investigated whether magnetocardiograms (MCGs) could noninvasively detect the His potential. In 22 patients, the His - ventricular (HV) intervals in MCGs (64-channel system, 2-min signal averaging, filter: 0.1-100 Hz, and band-eliminating filter of 50 Hz) were compared with those recorded in an electrophysiologic study (EPS, filter: 30-400 Hz). In 14 of the patients (64 %), the His potential was recorded in the MCGs. There was a correlation between the HV intervals in the MCGs and those in the EPS (R = 0.81, p<0.01). This study indicates that MCGs can be used to investigate the specialized conduction systems for which EPS is currently used. (Circ J 2003; 67: 622 - 624)

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Brachytherapy is a promising method of preventing and treating coronary stent restenosis. The present study was designed to observe the therapeutic effects of a radioactive balloon loaded with Holmium-166 (¹⁶⁶Ho) in a porcine coronary stent restenosis model. A radioisotope of ¹⁶⁶Ho was coated onto the balloon surface using polyurethane (20 Gy at 0.5 mm depth). Stent overdilation injuries were induced in 2 coronary arteries in each pig (n=8). Four weeks after the injury, control balloon dilation was performed in one coronary artery (Group I) and radiation therapy using the ¹⁶⁶Ho coated balloon in the other coronary artery (Group II) in each pig. Follow-up coronary angiography and histopathologic assessment were performed at 4 weeks after the radiation therapy or the control balloon dilations. With regard to complete blood cell counts, liver function tests, lipid profiles and coagulation tests, there were no differences between the baseline and after radiation. On quantitative coronary angiographic analysis, reference and target artery diameter showed no differences between the 2 groups before, or 4 and 8 weeks after stenting. On histopathologic analysis of groups I and II, the injury score was 1.34±0.09 and 1.32±0.10, the area of internal elastic lamina was 4.99±0.17 mm² and 4.82±0.20 mm², and the luminal area was 3.20±0.10 mm² and 3.45±0.14 mm², respectively (p=NS). The neointimal area was 1.78±0.11 mm² in group I and 1.36±0.12 mm² in group II (p=0.017), and the histopathologic area of stenosis was 35.1±1.6% in group I and 27.6±1.9% in group II (p=0.005). In conclusion, β-radiation of the stented porcine coronary artery using a radioactive ¹⁶⁶Ho coated balloon inhibited stent restenosis without any side effects. (Circ J 2003; 67: 625 - 629)

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Microbubbles have been reported to enhance ultrasound (US)-related side effects in animal systems. The present study investigated the influence of contrast ultrasonography (US) with perflutren lipid microspheres, a recently developed second-generation contrast agent, on microvessels. Rat mesentery was exposed to 1.8-MHz pulsed US with intravenous injection of perflutren (0.1 or 1.0 ml/kg) or Levovist^® (300 mg/kg), and the microvessel bleeding and endothelial cell injury was examined. Impaired endothelial cells were identified by the fluorescence of propidium iodide. Microvessel bleeding was examined also in the rat myocardium. The interaction between 0.1 ml/kg of perflutren and US exposure did not cause microvessel bleeding, and did not increase endothelial cell injury compared with the sham operation, unless frequent, strong US exposure occurred. When the dose was increased to 1.0 ml/kg, the combination of perflutren and US exposure resulted in capillary bleeding and increased endothelial cell injury in capillaries and venules (p<0.01). However, the incidence of microvessel bleeding and endothelial cell injury did not exceed that with Levovist^® microbubbles. In the myocardium, microvessel bleeding was not observed under any conditions. In conclusion, perflutren lipid microspheres enhanced US-related microvessel injury as with other contrast agents at the dose of 1.0 ml/kg, but not with 0.1 ml/kg and the appropriate US setting. (Circ J 2003; 67: 630 - 636)

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An 81-year-old man developed multiple coronary aneurysms, including the left main truncus, that were unexpectedly found by coronary angiography. He had been followed-up for 14 years because of angina pectoris; his initial coronary angiograms in 1985 showed some stenotic segments but no aneurysmal changes. The patient died of gastric cancer in March 2000. On microscopic examination of the coronary arteries, the prominent feature was an inflammatory reaction in the medial layer, comprising chiefly small lymphocytes and plasma cells. The internal and the external elastic membranes were destroyed, presumably causing the aneurysmal dilatation of the vessels. There was a moderate degree of concomitant atherosclerotic fibrointimal thickening. No evidence of vasculitis was seen in sections of the aorta, peripheral arteries, and other major organs. The present case is unique because the cellular infiltrates were confined to the coronary media and although a definite diagnosis was not made, it was probably an atypical form of vasculitic disease; namely, isolated coronary vasculitis. (Circ J 2003; 67: 637 - 639)

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A 48-year-old woman with cyanosis was referred for investigation of atrial septal defect (ASD). Blood gas analysis on admission revealed moderate hypoxemia, and a pressure study during right heart catheterization revealed pulmonary hypertension (PH). Spiral computed tomography (CT) scan disclosed extensive thrombi in dilated large symmetrical pulmonary arteries with clear lung fields, and large strand-like thrombi on the inner surface of the pulmonary arterial wall along the vascular curvature were visualized by virtual CT angioscopic imaging. The thrombi were eventually considered to be not thromboemboli but thrombi in situ, because no segmental or larger defects were detected in the lung perfusion scan, although it showed cardiovascular imprints and an inhomogeneously decreased perfusion pattern. Pulmonary thrombi in situ are an uncommon manifestation in patients with ASD, and have not been described from the evidence of both CT and lung perfusion scans. The findings indicate that pulmonary thrombi in situ are not associated with occlusion of the large pulmonary arteries and the resultant development of PH. The patient was conservatively treated with medication, and the pulmonary thrombi did not show significant change with anticoagulant therapy. She died suddenly at the age of 51 years. (Circ J 2003; 67: 640 - 642)

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In peripheral arterial obstructive disease, more than 50% of all lesions are localized in the femoropopliteal segment and surgical revascularization is the treatment of choice. Percutaneous transluminal angioplasty (PTA) is recommended for short lesions, with subsequent stent implantation if the result is sub-optimal or dissections occur after PTA or for restenosis. There are both acute and late complications with stent implantation. In the present patient, stents were placed in the left popliteal artery where the left knee joint flexes, and obstruction because of stent fracture occurred 6 months later. The patient eventually underwent left femoro-popliteal saphenous vein bypass grafting. (Circ J 2003; 67: 643 - 645)

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A 75-year-old man recovered from an episode of acute influenza. A myocarditis with a normalized level of serum cardiac troponin T, but less than 2 weeks after recovery, he rapidly fell into cardiogenic shock and died of fulminant myocarditis. The autopsied heart showed marked inflammatory cell infiltration that mainly consisted of mononuclear cells positive for CD8, suggesting that the second bout of myocarditis was caused by viral re-infection. (Circ J 2003; 67: 646 - 648)

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Wrong:Fig2 and Fig3
Right:Fig2 and Fig3

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