Advances in endocardial mapping techniques and ablation have greatly increased the indications for catheter-ablation of supraventricular arrhythmias. Rate or rhythm control is a valid treatment option for patients with atrial fibrillation; however, all patients with one or more risk factors should be treated with oral anticoagulants. The early success rate and long-term cure of atrial fibrillation by radiofrequency catheter ablation continues to increase. The number of centers offering this treatment option has increased substantially. Implantable defibrillator-cardioverters are the primary treatment modality for patients with ventricular tachycardia and their role in primary prevention is also being defined. Future advances in arrhythmia management will include improvements in catheter design and energy sources for ablation, and greater monitoring capacity of implantable devices. (Circ J 2003; 67: 651 - 655)

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The present study collected data about 6,112 Japanese male patients from 447 outpatient clinics. Of those who underwent medical examination by a general practitioner on an outpatient basis, up to 81% had some degree of erectile dysfunction (ED), ranging from mild to severe. ED was noted to be predominant among patients affected by cardiovascular disease (CVD) or diabetes mellitus (DM), and the presence of CVD increased the risk of ED. In an aging society, patients undergoing treatment for ED as part of their routine medical care are highly likely to have concomitant CVD. As shown in the present survey, clinicians need to be aware of the high incidence of ED among such patients, because ED represents a symptom originating from damage to the vascular endothelium. A total of 41% of ED patients are either willing to receive pharmacotherapy for ED or will consider treatment. Active treatment of ED with sildenafil is suitable for patients with CVD. (Circ J 2003; 67: 656 - 659)

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Vascular endothelial growth factor (VEGF) strongly promotes angiogenesis, and monocyte-colony stimulating factor (M-CSF) regulates the differentiation, proliferation, and survival of monocytes. Both VEGF and M-CSF are expressed in atherosclerotic lesions. The present study was performed to clarify the role of VEGF and M-CSF in the development of peripheral artery disease (PAD). The serum VEGF and M-CSF concentrations were determined in patients with arteriosclerosis obliterans (ASO) and thromboangitis obliterans (TAO). In both patient groups the serum VEGF concentrations were significantly higher than those in the control subjects. In contrast, the serum M-CSF concentrations in the ASO patients were significantly higher than those in both the TAO patients and control subjects, but there were no differences in the M-CSF concentrations between the TAO patients and control subjects. There was no correlation between the serum concentrations of VEGF and M-CSF. In conclusion, the serum VEGF concentration was increased in ASO and TAO patients, but increased concentration of M-CSF was seen only in ASO patients. These results may reflect a difference between ASO and TAO in disease pathogenesis. (Circ J 2003; 67: 660 - 662)

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To evaluate its efficacy in detecting myocardial ischemia in children, iodine-123-labeled 15-(p-iodophenyl)-3-R, S-methylpentadecanoic acid (BMIPP) myocardial single photon emission computed tomography (SPECT) imaging was performed in 16 pediatric patients with Kawasaki disease (KD, 11 male, 5 female; mean age and range: 13 years 8 months and 8 years 11 months to 17 years 7 months). Five children with chest pain and no cardiac disease were studied as controls (2 male, 3 female; mean age and range: 13 years 4 months and 9 years 4 months to 17 years 11 months). Selective coronary angiography was also performed in the 16 patients to evaluate the location of coronary stenosis and coronary aneurysms. The SPECT images were expressed as polar maps (Bull's eye maps) and the `defect' area was defined as where the uptake of BMIPP was less than the standardized BMIPP images of the 5 control children. In the 16 patients, 33 segments had coronary aneurysms and 10 (10/33: 30.3%) had significant coronary stenosis on selective coronary angiography. Nine of the 10 (90%) segments with significant coronary stenosis showed a defect on the BMIPP image whereas only 6 of the 23 (26.1%) segments without coronary stenosis showed a defect on BMIPP imaging. The sensitivity of BMIPP SPECT imaging for detection of coronary stenosis was 90% (9/10) and its specificity was 73.9% (17/23), whereas the sensitivity of ²⁰¹Tl SPECT imaging was 80% (8/10) and its specificity was 60% (14/23). There was no significant difference between the BMIPP and 201Tl SPECT images in either the sensitivity or specificity for the detection of coronary stenosis. In the present series, only one case had discordant BMIPP uptake (BMIPP uptake < ²⁰¹Tl uptake) in which there was a large coronary aneurysm and re-canalization after complete obstruction at segment 1 of the right coronary artery. This discordant BMIPP uptake reflects the possibility of ischemic but viable myocardium after re-canalization of a large aneurysm in KD. In conclusion, BMIPP SPECT imaging is useful for detecting the areas of ischemic myocardium caused by coronary artery stenosis in children with KD. (Circ J 2003; 67: 663 - 666)

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Plaque characterization by intravascular ultrasound (IVUS) before percutaneous coronary intervention (PCI) was evaluated in 81 consecutive patients with acute myocardial infarction (AMI) to establish if IVUS can predict the occurrence of the `no-reflow' phenomenon. Angiographic no-reflow was defined as TIMI flow grade 1 or 2 without any mechanical obstruction in the epicardial artery. Patients were divided into 2 groups according to the post-PCI angiograms: normal flow (group R, n=60) and no-reflow (group NR, n=21). Although the incidence of either soft or noncalcified plaque was not statistically different between the groups, positive vessel remodeling was more frequent in group NR than in group R (57.1% vs 31.6%, p<0.05). Lipid core was also more frequently found in group NR than in group R (61.9% vs 25.0%, p<0.01). Positively remodeled vessels with lipid-rich plaques as characterized by IVUS before PCI predicted the occurrence of angiographic no reflow with a sensitivity of 43% and a specificity of 60%. (Circ J 2003; 67: 667 - 671)

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To analyze the clinical significance of eccentric aortic regurgitation (AR) complicating the right coronary cusp prolapse associated with a ventricular septal defect (VSD), the Doppler echocardiograms of 129 patients were reviewed. In 102 patients, AR was classified as mild and in 27 patients it was classified as moderate. Eccentric AR was defined as the jet distributing in an eccentric direction. In 15 patients of the moderate group, AR was already moderate at the initial examination and of these, the AR was eccentric in 14 and central in 1. In 12 patients who initially had mild AR, it became moderate during follow-up. In 7 patients with mild, central AR, 6 worsened to central moderate AR and 1 evolved to eccentric moderate AR. Eccentric mild AR patients all developed eccentric moderate AR. Within the mild AR group, 5 of 9 patients with eccentric AR progressed from mild to moderate, whereas only 7 of 105 patients with central AR did so (p<0.01). In conclusion, eccentric AR may be an advanced finding of the AR associated with right coronary cusp prolapse in some patients, but in others eccentric AR is highly likely to progress and is malignant. (Circ J 2003; 67: 672 - 675)

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Percutaneous coronary intervention (PCI) has been associated with excessive radiation exposure, so the present study was designed to investigate the determinants of fluoroscopic time during PCI among characteristics inherent to the patient, procedure and hospital in 388 consecutive patients between November 1996 and March 1999 in 11 hospitals included in the Nationwide Database for Cost Analysis of percutaneous transluminal coronary angioplasty in Japan. Fluoroscopic time, which reflects radiation exposure, was used as the dependent variable in a multiple linear regression analysis. The mean fluoroscopic time was 27±15 min. The negative value of partial correlation of the hospital code (r=-0.374) and acute myocardial infarction (-0.163) indicated that these were explanatory variables that decreased fluoroscopic time. The positive value of the number of intraaortic balloon pump catheters (r=0.144), the number of balloons (r=0.304) and hospital stay (r=0.147) indicated these were explanatory variables that increased fluoroscopic time. The absolute value of r, (r=0.374), of the hospital code was the highest. In the final R² (=0.304) of the model, which is the partial R-square that determined the dependent variable, the hospital code showed the highest value. In conclusion, there was an inter-hospital difference in fluoroscopic time. Although the hospital code was found to be the most powerful determinant of fluoroscopic time, the R² (=0.304) of the model showed so lower value that other hospital characteristics that were not included in the model may influence the fluoroscopic time. (Circ J 2003; 67: 676 - 681)

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Little is known about the influence of hemodynamic changes on ventricular performance during pregnancy in patients with congenital heart disease. A prospective evaluation was made of 17 pregnancies in 11 women with repaired tetralogy of Fallot (ToF). Twenty age-matched non-pregnant women and 41 stable pregnant women without heart disease were studied as controls. Blood pressure (BP), heart rate (HR), left ventricular end-diastolic dimension (LVEDD) and ejection fraction (LVEF), and the Tei index were measured before pregnancy; during the 1st, 2nd, and 3rd trimesters; and after delivery. BP and HR gradually increased during the pregnancy in both groups. The LVEDD in the controls increased throughout the gestation period, then decreased after delivery. In contrast, the LVEDD in the ToF was significantly smaller than that of the controls, and no such increase was observed. The LVEF did not change throughout pregnancy or after the delivery in either group. Although the Tei index of the controls did not change throughout the pregnancy, in the ToF group it was significantly increased in the 2nd and 3rd trimester and then decreased after delivery. These findings suggest that subclinical left ventricular intolerance for volume overload, probably because of the smaller LVEDD, may exist during pregnancy in patients with a repaired ToF. (Circ J 2003; 67: 682 - 686)

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The clinical course of `Takotsubo' cardiomyopathy closely resembles that of acute myocardial infarction (AMI) and coronary angiography (CAG) is usually performed to distinguish the 2 conditions during the acute phase. The present study was designed to determine whether the standard 12-lead electrocardiogram (ECG) findings could help to distinguish `Takotsubo' cardiomyopathy from anterior AMI. The study group comprised 13 patients with `Takotsubo' cardiomyopathy and 13 consecutive patients with anterior AMI. Patients with `Takotsubo' cardiomyopathy had abnormal Q waves less frequently than patients with anterior AMI (15% vs 69%, p=0.008). No reciprocal changes were seen in the inferior leads in patients with `Takotsubo' cardiomyopathy (p=0.0003). The ratio of ST-segment elevation in leads V<sub>4-6</sub> to V<sub>1-3</sub> (ΣSTeV<sub>4-6</sub>/V<sub>1-3</sub>) was significantly higher in patients with `Takotsubo' cardiomyopathy (1.55±0.53 vs 0.57±0.58, p=0.0004). The QTc interval was significantly longer in patients with `Takotsubo' cardiomyopathy. The absence of reciprocal changes, absence of abnormal Q waves, and a ΣSTeV<sub>4-6</sub>/V<sub>1-3</sub> ≥1 all showed a high sensitivity and specificity for diagnosing `Takotsubo' cardiomyopathy. Furthermore, the combination of the absence of reciprocal changes and a ΣSTeV_4-6/V _1-3 ≥1 had a greater specificity (100%) and overall accuracy (91%) than either criteria. Therefore, the standard 12-lead ECG on admission can help to distinguish `Takotsubo' cardiomyopathy from anterior AMI. (Circ J 2003; 67: 687 - 690)

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The echocardiographic measures and plasma concentrations of either atrial natriuretic peptide (ANP) or brain natriuretic peptide (BNP) were compared in elite judo practitioners (static athletes), elite marathon runners (dynamic athletes) and healthy controls to investigate the relationship between the different types of left ventricular (LV) hypertrophy and plasma concentrations of natriuretic peptides in athletes. The LV mass and LV wall thickness of marathon runners and judo practitioners were significantly greater than those of controls. The LV end-diastolic dimension index was significantly larger in the marathon group, but smaller in the judo group. The left atrial dimension (LAD) index was significantly larger only in marathon runners. Plasma BNP concentrations were higher in both the judo and marathon groups than in controls, and positively correlated with LV mass as well as with deceleration time. Plasma ANP concentrations were significantly higher in marathon runners than in the controls and judo groups, and positively correlated with the LAD index, but negatively correlated with ejection fraction. Multivariate analyses showed that the type of athlete and LAD index were independent predictors of plasma BNP and ANP concentrations, respectively. Thus, there is an intimate link between plasma concentrations of natriuretic peptides and cardiac morphology in different types of athletes. (Circ J 2003; 67: 691 - 696)

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Aspirin is used in percutaneus coronary interventions (PCI) for acute myocardial infarction (AMI) to prevent thrombosis. It is reported that the aspirin concentration in blood reaches its peak approximately 20 min after oral administration in healthy volunteers, but the absorption and bioavailability of aspirin in AMI may be quite different. In the present study patients undergoing coronary angiogram for the first time were enrolled as a model of sympathetic excitement and the timing of the antiplatelet effect after oral aspirin administration was investigated. Aspirin (162 mg) was administered to the patients in a catheter laboratory. Platelet count, aspirin concentration, and platelet aggregation were measured at scheduled timepoints before and up to 120 min. Ticlopidine was administered in the same procedure, and platelet count and platelet aggregation were evaluated at 0 and 120 min. There was no significant change in the platelet count. Aspirin concentration in blood had not reached its peak by 120 min. Platelet aggregation induced by collagen or ADP began to be inhibited 45 min after aspirin administration. No significant inhibition of platelet aggregation was observed up to 120 min following ticlopidine administration. During sympathetic excitement, aspirin absorption and its antiplatelet effect were significantly delayed in these patients. Ticlopidine did not show any antiplatelet effect by 120 min. For PCI performed in a patient with a high level of sympathetic excitement, aspirin should be administered at least 45 min before the first balloon dilatation. (Circ J 2003; 67: 697 - 700)

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The aim of this study was to evaluate the effect of β-blockers on insulin resistance in patients with dilated cardiomyopathy (DCM). A secondary aim was to determine the effect of this treatment on plasma concentrations of tumor necrosis factor-α (TNF-α) and to investigate the relationships between this adipocytokine and insulin resistance. Insulin resistance determined using the Homeostatic Model Assessment (HOMA), echocardiographic measurements and analysis of plasma TNF-α concentration were carried out in 47 patients with DCM without diabetes mellitus before and after 6 months of β-blocker therapy. A reduction in left ventricular dimensions and an associated increase in ejection fraction occurred with β-blocker. The treatment resulted in a significant decrease in insulin resistance (HOMA index: Baseline, 2.73±3.36 vs, Month 6, 1.58±1.33, p=0.0347). Beta-blockade was also associated with a decrease in plasma TNF-α concentration although no significant relationship between this change and the improvement in insulin resistance was observed. Beta-blocker therapy in patients with DCM improved not only cardiac function, but also insulin resistance. The mechanism of the change in insulin function remains unclear, but may be related to improvements in left ventricular function or an attenuation of the inhibitory effect of reduction in TNF-α on insulin signaling. (Circ J 2003; 67: 701 - 704)

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Inhibition of angiotensin-converting enzyme (ACE) retards the process of myocardial remodeling and contractile dysfunction that leads to heart failure. However, the intracellular mechanisms by which ACE inhibition preserves myocardial contractility are largely unclear. Using a model of heart failure induced by hypertension in Dahl salt-sensitive (DS) rats, the mechanisms by which ACE inhibitors (ACEI) exert a beneficial effect on myocardial contractility were studied. Dahl salt-resistant (DR) rats, DS rats not given temocapril (DS/T-), and DS rats treated with temocapril (10 mg/kg per day from 10 to 17 weeks of age, DS/T+) were fed an 8% NaCl diet from 8 to 17 weeks of age (n=8, each group). Echocardiography, hemodynamic measurement, histology, contraction of isolated skinned papillary muscle, and Western blot analysis were carried out. At an elevated final blood pressure similar to that of the DS/T- rats, DS/T+ rats exhibited (1) a decrease in left ventricular (LV) mass associated with decreases in both cardiomyocyte size and interstitial fibrosis; (2) improvement of both systolic and diastolic LV function; and (3) an increase in caffeine contraction after constant Ca²⁺-loading with 8-bromo-cAMP into the sarcoplasmic reticulum (SR) associated with an increase in Ser16-phosphorylated phospholamban, as compared with the DS/T- rats. In addition to inhibition of myocardial remodeling, a restoration of the Ca²⁺-handling ability of the SR by normalized phosphorylated phospholamban may contribute to the improved LV contractile function achieved by chronic treatment with an ACEI. (Circ J 2003; 67: 705 - 711)

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A patient with 3-vessel coronary artery disease and left ventricular aneurysm underwent coronary artery bypass grafting combined with the Dor approach. Five days later, ventricular tachycardia following short-coupled ventricular premature contractions suddenly occurred and was not responsive to class IB drugs (lidocaine and mexiletine), requiring frequent electrical cardioversion. After the administration of a novel class III drug, nifekalant hydrochloride, this electrical storm of ventricular tachycardia was completely suppressed together with the disappearance of ventricular premature contractions. Nifekalant hydrochloride (MS-551), a pure K⁺ channel blocker, might be effective for postoperative recurrent ventricular tachyarrhythmias that are refractory to other antiarrhythmic agents. (Circ J 2003; 67: 712 - 714)

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A 32-year-old man with a 20-year history of palpitation showed a short PQ interval and delta wave on 12-lead ECG. An electrophysiological study showed that the atrio-His (AH) and His-ventricular intervals were not influenced by rapid right atrial pacing or by bolus injection of adenosine triphosphate (ATP). The AH interval was shortened by coronary sinus ostium (CSos) pacing. Ventricular stimulus to the atrial activation interval was not affected by ATP but shortened by para-Hisian pacing and orthodromic His bundle activation was followed by atrial activation. The tricuspid - inferior vena cava isthmus was blocked by CSos pacing, but Ith conduction existed during low lateral right atrial pacing. (Circ J 2003; 67: 715 - 717)

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The usefulness of a temporary inferior vena cava filter (t-IVC-f) for the prevention of acute pulmonary thromboembolism (APTE) associated with venous thromboembolism (VTE) has been established, but not the requirement for an additional therapeutic method when the t-IVC-f has captured a thrombus. A woman underwent implantation of a t-IVC-f just caudal to the bifurcation of the renal vein immediately before cesarean section (C/S) for VTE that had occurred during the third trimester of pregnancy. After receiving a combination of anticoagulant and fibrinolytic therapies after the C/S, the t-IVC-f was found to contain a thrombus and in order to prevent its dissemination during the removal of the closed filter, another filter was inserted and expanded proximal to the first. Insertion of an additional t-IVC-f may prevent occurrence of APTE during removal of the primary filter containing a friable thrombus after fibrinolytic therapy, and the technique proved useful in the present case of VTE during pregnancy. (Circ J 2003; 67: 718 - 720)

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A 66-year-old man developed a fever and had a syncopal attack during treatment with imipramine and amantadine for depression and Parkinson's disease. His muscular enzyme levels were very high, so he was diagnosed with incomplete syndrome malin and given hydration therapy. The electrocardiogram recorded an ST segment elevation like acute myocardial infarction in most leads, and the echocardiogram revealed left ventricular dysfunction with severe hypokinesis to dyskinesis of the anterior and apical wall regions, and hyperkinesis of the basal wall. One month from onset, the left ventricular contractility had not changed despite normal coronary arteries. Thallium-201(²⁰¹Tl) myocardial scintigraphy showed a perfusion defect and there was no accumulation of iodine-123(¹²³I) metaiodobenzylguanidine (MIBG) in the entire apex of the heart. Left ventricular function returned to normal and repeat ²⁰¹Tl scintigraphy showed recovery by the 4th month. However, there was still an absence of cardiac MIBG uptake. There are a number of reports from Japan of a syndrome demonstrating such reversible left ventricular dysfunction, called `tako-tsubo cardiomyopathy', but the present case is the first to be associated with syndrome malin. A coronary microvascular abnormality and cardiac sympathetic denervation probably both play an important role in tako-tsubo cardiomyopathy. (Circ J 2003; 67: 721 - 724)

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Because the absence of sarcolemmal dystrophin renders cardiomyocytes vulnerable to mechanical force, the present study investigated whether sarcolemmal membrane fragility upon reperfusion is associated with the loss of membrane dystrophin. Dystrophin was distributed exclusively in the sarcolemmal membrane of buffer-perfused rat cardiomyocytes, but was translocated to the myofibrils during 30 min of ischemia and then lost during reperfusion. Upon reperfusion, the membrane impermeable dye, Evans blue (EB), accumulated in cardiomyocytes depleted of dystrophin. Reperfusion with the contractile blocker 2,3-butanedione monoxime (BDM) resulted in no accumulation of EB in cardiomyocytes despite the loss of dystrophin. Upon withdrawal of BDM, however, EB accumulated in dystrophin-depleted cardiomyocytes. Loss of sarcolemmal dystrophin may be involved in the mechanism of contractile force-induced reperfusion injury. (Circ J 2003; 67: 725 - 727)

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Wrong:24,000 - 6,000units per day
Right:240,000 - 60,000units per day

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