The ultimate goal of heart failure (HF) treatment is to improve the prognosis of patients. Previous basic, clinical, and population studies have advanced the modern treatment of HF, but efficacy is still limited especially in `real world' patients. There are 2 approaches to solve this crucial issue. First is the further development of novel therapeutic strategies based on new insight into the pathophysiology of myocardial remodeling and failure. Second is the improvement of the quality of care in routine clinical practice. The basic approach is to develop the treatment of myocardial remodeling by regulating mitochondrial oxidative stress. In the failing heart, oxygen radicals are the result of defects of mitochondrial electron transport, causing mitochondrial DNA damage and functional decline, and further production of oxygen radicals. Oxidative stress causes myocyte hypertrophy, apoptosis, and interstitial fibrosis by activating matrix metalloproteinases, all of which result in myocardial remodeling and failure. Therefore, mitochondrial oxidative stress and DNA damage are good therapeutic targets. The clinical approach is to develop effective strategies of HF management for the `real world' patients. Readmission because of exacerbation is common in HF patients and further impairs their quality of life. Noncompliance with treatment is the most common precipitating factor for readmission. Regular medical follow-up and social support are important components that should be included in the disease management program of HF patients. These basic and clinical approaches are needed to establish new and effective treatment strategies for Japanese patients with HF. (Circ J 2004; 68: 1095 - 1103)

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Background The purpose of this study was to assess the candidates suitable for cardiac resynchronization therapy (CRT) and to examine the significance of the QRS duration in Japanese patients with idiopathic dilated cardiomyopathy (DCM). Methods and Results The study population consisted of 357 patients. The selection criteria for candidates suitable for CRT were QRS duration =130 ms, left ventricular ejection fraction (LVEF) =35% and New York Heart Association (NYHA) functional class III or IV by ACC/AHA/NASPE 2002 guidelines. We divided the study population into 2 groups: group A with a QRS duration <130 ms, and group B with a QRS duration =130 ms. In 25 of the 375 patients (7.0%), all the criteria were fulfilled. Group B had a significantly larger left ventricular diameter end-diastole and end-systole than group A (P<0.0001). Group B had a lower LVEF (P<0.0001). There was a fair inverse correlation (r=-0.58, P<0.0001) between the length of the QRS duration and LVEF. Conclusion Approximately 7% of the Japanese patients with DCM are CRT candidates. In the present study, we found that prolonged QRS duration was associated with poor systolic function. (Circ J 2004; 68: 1104 - 1109)

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Background Several studies have demonstrated the benefit of the patency of infarct-related artery (IRA) in acute myocardial infarction (AMI). However those studies have not been concerned with myocardial viability in the region-at-risk. In the present study the effect of the patency of IRA was investigated in the setting of anterior AMI with poor viable myocardium in the risk region. Methods and Results From 1993 to 1996 patients with a first time anterior AMI and poor viable myocardium in the region-at-risk at 1 month after onset were identified and enrolled. Patients with a totally occluded IRA were included in the Non-Open group (n=44), and patients with a reperfused IRA were included in the Open group (n=49). At 5 years after onset, left ventricular function was better preserved in the Open group than in the Non-Open group (p<0.05). Kaplan-Meier survival curves for cardiac mortality and event-free survival curves revealed poor prognoses in the Non-Open group over a 5-year period (p<0.05, respectively). The advantages of a patent IRA were further seen in health-related quality-of-life outcomes (p<0.05). Conclusions Even in patients with poor myocardial viability after an anterior AMI, the patency of the IRA is strongly associated with improved long-term survival, independent of residual myocardium viability. (Circ J 2004; 68: 1110 -1116)

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Background The purpose of the present study was to evaluate the efficacy and safety of facilitated percutaneous coronary intervention (PCI) in comparing young and elderly patients with acute myocardial infarction. Methods and Results The present study enrolled 168 initial myocardial infarction patients within 12 h of the symptom onset between 40 and 80 years of age who were indicated on the fibrinolysis and subsequent transluminal (FAST-3) trial. The patients were divided into 4 groups according to their age, peak creatine kinase (CK), peak CK-MB and peak troponin T (Tn-T) levels, and cardiac function were compared between the 4 groups. There were no differences between the 4 groups in terms of the time from arrival at the emergency room (ER) to the achievement of TIMI-3 patency. There were also no significant differences between the 4 groups in terms of the peak CK, peak CK-MB or peak Tn-T levels. Furthermore, there were no significant differences between the 4 groups in terms of the mortality rate or the incidence of hemorrhagic complications at 30 days. Conclusions Facilitated PCI is considered to have an important potential role in the treatment of myocardial infarction in Japan, in which the age of the population is steadily increasing. (Circ J 2004; 68: 1117 - 1122)

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Background Impaired flow mediated dilatation (FMD) and increased wall thickness (WT) of the brachial artery have been associated with atherosclerosis and its risk factors. In this study we sought to determine brachial artery wall thickness in chronic smokers and the instantaneous effect of smoking on brachial artery endothelium dependent vasodilator function in smokers and non-smokers. Method and Results Using a high-resolution ultrasound, WT of posterior brachial artery wall, the diameter of brachial artery at rest and during reactive hyperemia (FMD %), as well as after sublingual administration of nitroglycerine (nitroglycerine mediated dilatation (NMD) %) was measured in 20 smokers and 20 non-smokers. Wall thickness (WT) of the posterior brachial artery wall and the wall index (WI) were greater in smokers than non-smokers. The baseline brachial artery diameter was comparable in smokers and non-smokers. Flow mediated dilation (FMD) was found to be less in smokers than non-smokers. The NMD in smokers also did not differ significantly from that in non-smokers. Flow mediated dilation significantly reduced after smoking compared to baseline in both groups. However, NMD remained unchanged after smoking in both groups. Conclusions Increased WT and impaired endothelium-dependent dilatation of brachial artery suggests that cigarette smoking disrupts vessel wall morphology long before atherosclerosis is manifest. (Circ J 2004; 68: 1123 - 1126)

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Background Cigarette smoking has been shown to temporarily alter cerebral flow velocity and vasomotor reactivity, so the aim of this study was to assess the acute effects of smoking a single cigarette on the common carotid artery (CCA) hemodynamics in healthy nonsmokers. Method and Results Using a 7.0 MHz linear transducer of a computed sonography system, the CCA hemodynamics, including the diameter of the left and right CCA, peak systolic velocity, maximum end-diastolic velocity, time-averaged maximum velocity pulsatility index, resistivity index, flow volume, diameter and area of the CCAs, were measured in 16 healthy nonsmokers before and immediately after smoking a cigarette. Compared with the baseline, heart rate and blood pressure significantly increased, the diameter, flow volume and area of each CCA were unchanged, and the pulsatility index and resistivity index were significantly altered after smoking. In addition, the peak systolic velocity, maximum end-diastolic velocity and time-averaged maximum velocity were significantly altered after smoking. Conclusions Cigarette smoking significantly altered the CCA hemodynamics in nonsmokers, probably as a consequence of enhanced adrenergic activity. (Circ J 2004; 68: 1127 - 1131)

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Background Although analysis of the transmitral inflow (TMF) pattern is widely used for evaluating left ventricular diastolic function and provides valuable information for the management of heart failure (HF) in sinus rhythm, its utility in patients with atrial fibrillation (AF) has not been established. The aim of this study was to investigate the relationship between the ratio of transmitral peak E-wave velocity to flow propagation velocity (E/Vp) obtained by a newly developed dual Doppler system and the plasma B-type natriuretic peptide (BNP) concentration or pulmonary capillary wedge pressure (PCWP) for evaluating the severity of heart failure with AF. Methods and Results In 68 patients with AF, the E/Vp was compared with plasma BNP concentration and PCWP. A cutoff value of ≥1.7 for E/Vp predicted a plasma BNP concentrationl of ≥200 pg/ml, with 80% sensitivity and 84% specificity. Only E/Vp was found to be independently significant by stepwise multilinear regression analysis (r=0.40, p=0.01). PCWP values had good correlation with E/Vp (r=0.63, p<0.01) and were significantly higher in the group with E/Vp ≥1.7 (16±6 mmHg vs 11±4 mmHg, p<0.05). Conclusion The Doppler-derived index of E/Vp correlated well with the neurohormonal and hemodynamic parameters, and was useful for evaluating the severity of heart failure with AF. (Circ J 2004; 68: 1132 - 1138)

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Background The aim of this study was to investigate whether drug-induced changes in fibrillation wave characteristics can predict pharmacological conversion of long lasting persistent atrial fibrillation (AF). Methods and Results The study group comprised 23 consecutive patients with AF lasting ≥1 month. Patients first received bepridil (200 mg/day) for 2-4 weeks. When sinus rhythm was not restored with bepridil, oral aprindine (40 or 60 mg/day) was added to bepridil. Fast Fourier transform analysis of fibrillation waves using lead V1 was performed to calculate the fibrillation cycle length (FCL). The spectral areas were measured and the maximum area divided by the total area was termed the fibrillation organization index (FOI). Sinus rhythm was restored in 16 of 23 patients (70%); 8 of these 16 patients received only bepridil (Group I) and the other 8 responders received bepridil and aprindine (Group II). In Group I bepridil increased both FCL (p<0.001) and FOI (p<0.01) and terminated AF after 20±12 days. In Group II bepridil increased FCL (p<0.001), but did not change FOI. The addition of aprindine terminated AF in association with an increase in both FCL (p<0.005) and FOI (p<0.005) within 19±8 days. In the remaining 7 patients who did not have restoration of sinus rhythm, bepridil increased both FCL and FOI significantly, but less than in Group I, and the addition of aprindine did not further increase either of them. Chemical cardioversion of AF occurred in all patients with FCL ≥190 ms and FOI ≥45% after drug administration. Conclusion Bepridil alone or in combination with aprindine converted long lasting persistent AF in association with an increase in both FCL and FOI. The combination of FCL and FOI after drug administration is helpful in predicting chemical cardioversion of persistent AF. (Circ J 2004; 68: 1139 - 1145)

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Background The aim of the present study was to determine whether repeated 60C sauna treatment improves cardiac arrhythmias in chronic heart failure (CHF) patients, because ventricular arrhythmias are an important therapeutic target in CHF. Methods and Results Thirty patients (59±3 years) with New York Heart Association functional class II or III CHF and at least 200 premature ventricular contractions (PVCs)/24 h assessed by 24-h Holter recordings were studied. They were randomized into sauna-treated (n=20) or non-treated (n=10) groups. The sauna-treated group underwent a 2-week program of a daily 60°C far infrared-ray dry sauna for 15 min, followed by 30 min bed rest with blankets, for 5 days per week. Patients in the non-treated group had bed rest in a temperature-controlled room (24°C) for 45 min. The total numbers of PVCs/24 h in the sauna-treated group decreased compared with the non-treated group [848±415 vs 3,097±1,033/24 h, p<0.01]. Heart rate variability (SDNN, standard deviation of normal-to-normal beat interval) increased [142±10 (n=16) vs 112±11 ms (n=8), p<0.05] and plasma brain natriuretic peptide concentrations decreased [229±54 vs 419±110 pg/ml, p<0.05] in the sauna-treated group compared with the non-treated group. Conclusion Repeated sauna treatment improves ventricular arrhythmias in patients with CHF. (Circ J 2004; 68: 1146 - 1151)

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Background Atrioventricular accessory pathways (AP) with unusually long ventriculo-atrial (VA) conduction times are present in a significant subset of patients with the Wolff-Parkinson-White (WPW) syndrome, not including patients with the permanent form of atrioventricular junctional reciprocating tachycardia. Methods and Results We compared the electrophysiological characteristics and outcomes after radiofrequency (RF) ablation in 34 patients with the WPW syndrome, a VA interval >80 ms, and paroxysmal tachycardia with an RP/PR ratio <1 (the slow group), vs 80 patients with WPW syndrome and a VA interval <80 ms (the fast group). AP were found in the posteroseptal region significantly more often in the slow than in the fast group. In addition, the decremental conductive properties of the AP were more common in the slow than in the fast group. Catheter ablation of AP was highly successful in both groups, although ablation required a greater number of RF applications and longer procedure times in the slow group, especially for AP with decremental conductive properties. Conclusions A posteroseptal AP location was more common in AP associated with long conduction times than in AP with typical conductive properties. Both types of AP were successfully ablated, although the slow group required longer procedures and more RF energy deliveries. (Circ J 2004; 68: 1152-1159)

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Background To examine the prognostic contribution of combined cardiac troponin T (cTnT) and N-terminal pro-brain natriuretic peptide (NT-proBNP) in patients with heart failure (CHF) in the absence of acute coronary syndrome. Methods and Results Between July 2001 and March 2002, 71 consecutive patients (mean age = 68.4±1.4 years, 37 men), hospitalised for heart failure, were studied during hospitalisation and follow up until December 2002. Serum cTnT and NT-proBNP were measured on admission. Actuarial rates of adverse cardiac events, including sudden or CHF death, or rehospitalisation for CHF during follow up were compared with patients grouped according to initial serum cTnT and/or NT-proBNP concentrations. The adverse cardiac event-free rate among the 20 patients with cTnT ≥0.01 ng/ml was significantly lower than the 51 patients with cTnT <0.01 ng/ml (P<0.05). Similarly, the adverse cardiac event-free rate among the 36 patients with NT-proBNP ≥1,357 pg/ml (median) was significantly lower than the 35 patients with NT-proBNP <1,357 pg/ml (P<0.01). The 16 patients with high concentrations of both cTnT and NT-proBNP had a lower adverse cardiac event-free rate than the 31 patients with low cTnT and low NT-proBNP upon commencement of the study (P<0.005). Conclusion Measurements of serum cTnT and NT-proBNP were reliable prognostic markers of adverse cardiac event in patients with CHF. (Circ J 2004; 68: 1160 - 1164)

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Background Although the small dense low-density lipoprotein (sd-LDL) is associated with hypertriglyceridemia, more than 60% of myocardial infarction (MI) patients are normotriglyceridemic in the fasting state. This study was aimed to investigate the relationship between the low-density lipoprotein (LDL) phenotype and postprandial hyperlipemia (PPL) in MI patients. Methods and Results Oral fat tolerance tests were performed in 71 patients with acute MI and fasting triglyceride concentrations below 200 mg/dl. Postprandial changes in the LDL particle diameter (LDL-PD) and lipids over a 6-h period after a meal were compared among 4 groups of patients classified according to fasting triglyceride levels (A, B as <150, and C, D as ≥150) and postprandial triglyceride levels (A, C as <230 and B, D as ≥230). Although fasting concentrations of triglyceride and remnant-like particle (RLP)-triglyceride were significantly higher in group C than in group B, the areas under the curves of the RLPs were significantly higher in group B. The triglyceride-to-cholesterol ratio in the RLPs was significantly higher in the PPL group than in the nonPPL group postprandially. The prevalence of sd-LDL (LDL-PD ≤25.5 nm) was significantly higher in group D but similar between groups B and C (23%, 42%, 50% and 83% in groups A, B, C and D, respectively). Conclusion These results suggest that postprandial accumulation of triglyceride-rich lipoproteins is strongly associated with sd-LDL in MI patients without hypertriglyceridemia. (Circ J 2004; 68: 1165 - 1172)

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Background Visceral fat is related to coronary atherosclerosis, but little is known about the relation between coronary atherosclerosis and percent body fat accumulated in different parts of the body. Methods and Results The subjects were 100 consecutive patients with demonstrated electrocardiographic ischemic changes. Coronary atherosclerosis was assessed using Gensini's coronary score (CS), and for body fat distribution dual energy X-ray absorptiometry was used. The parameters measured were serum lipid concentrations, body weight, body mass index, percent total fat, trunk fat percent, arm fat percent and leg fat percent. Trunk fat percent correlated significantly with CS (p<0.01), and concentrations of low-density lipoprotein cholesterol (LDL-C) (p<0.01) and very low-density lipoprotein cholesterol (VLDL-C) (p<0.05) in men and women. Leg fat percent correlated negatively with CS in both men and women (p<0.01 for each). Concentrations of both LDL-C and VLDL-C correlated positively with CS in both men and women (p<0.01). Conclusion There is a difference between the effect of body fat in the legs and the trunk that suggests leg fat has an anti-atherosclerotic effect and a negative correlation with CS, and conversely, that trunk fat has a pro-atherosclerotic effect and correlates positively with CS. (Circ J 2004; 68: 1173 - 1178)

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Background Successful transfer of the coronary arteries is the most critical step during arterial switch operations for patients with transposition of the great arteries with a single coronary artery ostium and/or intramural coronary arteries. Various techniques have been reported and the present study was an evaluation of them in 10 neonatal patients. Methods and Results Coronary artery transfers are achieved by implantation of coronary buttons to the previously anastomosed neo-aorta using pericardial or pulmonary artery hood techniques. One patient died perioperatively because of myocardial malperfusion. Following prolonged mechanical ventilation, another died from sepsis on the 28th postoperative day. Coronary artery perfusion abnormality was not observed in the remaining patients. Conclusions Transfer of the coronary button by the pericardial or pulmonary artery hood augmentation technique to the previously anastomosed neo-aorta is a practical, easy and convenient combination of methods for the treatment of these patients. (Circ J 2004; 68: 1179 - 1183)

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Background Clinical outcomes and problems following off-pump coronary artery bypass grafting (OPCAB) in elderly patients have not been clarified. Methods and Results The surgical results of elderly patients aged 75 years or older (n=50; 38 males, mean age, 78.8 years) were reviewed and compared with those of younger patients (n=95; 79 males, mean age, 63.0 years). The EuroSCORE score was 6.9±3.5 in the elderly group and 3.0±2.4 in the younger group (p<0.0001). There were no hospital deaths in either group. There was no significant difference in the postoperative complication rate except for atrial fibrillation (40.0% elderly vs 24.2% younger, p=0.0479). Postoperative intensive care unit and hospital stays did not differ. The frequency of blood transfusion was significantly higher in the elderly group (78.0% elderly vs 37.2% younger, p<0.0001). During the mean follow-up of 18.6±8.8 months, there was 1 sudden death in the elderly group, but no cardiac deaths in either group. The 32-month cardiac event-free and survival rates were similar for the 2 groups. Conclusion OPCAB provides satisfactory clinical outcomes for elderly as well as younger patients. (Circ J 2004; 68: 1184 - 1188)

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Background There have been a number of recent reports on the use of autologous bone marrow implantation (BMI) in the treatment of peripheral arterial disease, with a clinical response rate of approximately 70%. However, the factors that influence efficacy have not yet been clarified. We have analyzed the relationship between the number of implanted bone marrow cells and the clinical efficacy of BMI. Methods and Results Eight patients with arteriosclerosis obliterans were treated with BMI. Bone marrow was aspirated from the ilium (500-1,000 ml), the mononuclear cells were separated and then were implanted. The clinical effectiveness of BMI was evaluated by assessing changes in the ankle-brachial pressure index (ABI) and the transcutaneous oxygen pressure (TcO₂) between the pre-treatment baseline, with follow-up testing at 4 weeks. These changes were defined as ΔABI and ΔTcO ₂. The mean number of CD34-positive cells was 1.04±0.60 ×10⁶ /kg body weight. There was a strong correlation between the number of CD34-positive cells and ΔABI (r=0.754, p=0.028). Conclusions It is likely that the number of implanted CD34-positive cells is one of the primary factors that influence the clinical efficacy of BMI. (Circ J 2004; 68: 1189 - 1193)

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Background High pulse wave velocity (PWV) is related to cardiovascular risk in essential hypertension (EHT). It is reported that short-term treatment with an angiotensin II receptor blocker (ARB) decreases PWV, as well as blood pressure (BP), and increases the serum adiponectin, known as an adipocytokine, which has an anti-atherosclerotic effect. However, it is not known whether long-term treatment with ARB prevents the increase in PWV independently of the reduction of BP, and whether adiponectin is related to the chronic effect of ARB on PWV. Methods and Results In order to examine the short-term effect of ARB on PWV, 9 subjects with EHT had PWV measured before and after treatment with an ARB for 1 month. The treatment significantly reduced PWV and BP. For evaluation of the long-term effect of ARB therapy, 56 consecutive subjects with EHT who were already taking anti-hypertensive drugs other than an angiotensin-converting enzyme inhibitor had their PWV measured. We divided the EHT subjects into 2 groups: (1) the ARB group (EHT treated with an ARB for at least 6 months) and (2) the control group (EHT treated with anti-hypertensive drugs other than an ARB). Although there was no significant difference between the 2 groups in BP, age or body mass index, the PWV value in the ARB group was significantly lower than that in the control group. Moreover, the serum adiponectin concentration in the ARB group was significantly higher than that in the control group. Conclusions Long-term treatment with ARB inhibits the progression of arterial stiffness independent of BP reduction. One of the mechanisms may be related to the increased serum adiponectin concentration after treatment with an ARB. (Circ J 2004; 68: 1194 - 1198)

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Background The annual health check followed by lifestyle recommendations has long been the standard national strategy to improve cardiovascular disease (CVD) risk factors in Japan. Exercise at fitness clubs, now widely accessible in major cities, has a novel appeal as a strategy with the additive effect of CVD risk reduction. The Sapporo Fitness Club Trial (SFCT) is a randomized controlled trial to compare the efficacy of the national standard alone (control) with the standard plus exercise at a fitness club (intervention) for the reduction of CVD risk factors. Methods The SFCT has recruited and randomized 561 relatively inactive overweight men and women, aged 40-85 years, with elevated levels of 2 or more of the following: systolic blood pressure, fasting blood glucose, and low-density lipoprotein cholesterol. The intervention group was required to exercise at a fitness club 2-4 times per week. At the end of 6 months, risk factors, aerobic capacity, health-related quality of life measures, and adverse effects are to be compared. Conclusion The SFCT is expected to have a major impact in Japan on public health recommendations on exercise for the reduction of lifestyle-related disease. (Circ J 2004; 68: 1199 - 1204)

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Background The relationship between monophasic action potential duration (MAPD) and effective refractory period (ERP) is poorly understood after myocardial infarction (MI) in vivo. Methods and Results Forty rabbits were randomized into either a sham operation (SO) group (n=10) or MI group (n=30), both of which underwent thoracotomy, but the left anterior descending coronary artery was occluded in the MI group only. The MAPD and ERP of the endocardial, midmyocardial and epicardial cells of the infarction zone were observed at baseline, 2 days after thoracotomy and then 5 min, 15 min, 30 min, 2 days, 14 days and 60 days after coronary occlusion (CO). At baseline, ERP correlated strongly with MAPD₉₀. During the 5-30 min after CO, both MAPD₉₀ and ERP of the 3 layers of the myocardium shortened markedly (eg, MAPD_{90 Mid} was approximately 50% of the baseline value at 5 min after CO). MAPD₉₀ and ERP recovered gradually over the 2-60 days after MI. ERP_Mid exceeded MAPD_{90 Mid} and the post repolarization refractoriness phenomenon appeared during the 5-30 min after CO. Conclusions The different changing trends of the MAPD and ERP of the mid-myocardial cells may underlie the arrhythmias that occur after MI. (Circ J 2004; 68: 1205 - 1209)

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Background Previous experimental and clinical studies have reported that nicorandil, an adenosine triphosphate (ATP)-sensitive K⁺ channel opener, exerts a beneficial effect on microvascular function and clinical outcome after myocardial ischemia. The present study assessed whether intravenous administration of nicorandil affects the 3-dimensional (3-D) architectural characteristics of capillaries and their volume after early myocardial reperfusion. Methods and Results Using the hearts of open-chest anesthetized rats, the left anterior descending artery was occluded for 7 min followed by reperfusion. Nicorandil or saline was infused intravenously during occlusion and reperfusion. The entire coronary microvasculature was filled with contrast medium after the hearts were arrested. Capillaries were observed 3-dimensionally by confocal laser scanning microscopy in both the control area and reperfused area of all samples. The capillary volume fraction was computed from the 3-D images. The reperfused area in both the nicorandil and saline groups showed characteristic architectural changes of the capillaries. Capillary volume fraction in the reperfused area was significantly reduced in saline group, compared with nicorandil group [12.7±7.2% vs 18.1 ±5.3% (p<0.01)]. Conclusions Intravenous nicorandil administration has a beneficial effect on capillary damage after reperfusion. (Circ J 2004; 68: 1210 - 1214)

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An 84-year-old man was referred to the emergency department with severe dyspnea. Based on his physical findings, electrocardiogram, X-ray and echocardiographic findings, congestive heart failure was suspected and drip infusion of prophylactic heparin against intracardiac thrombosis was commenced together with dopamine, nitroglycerin and furosemide. Diuresis occurred and the pulmonary congestion ameliorated remarkably. Starting on the 20th hospital day, the platelet count was gradually reduced (from 256,000 to 55,000 /μl) and the fibrin degradation product concentration rose (27.6 μg/ml). However, prothrombin time was not prolonged (89%), the concentration of antithrombin III was low -normal (69%) and the fibrinogen concentration was high (650 mg/dl). Thus, heparin-induced thrombocytopenia (HIT), rather than disseminated intravascular coagulation (DIC), was suspected. Heparin was withdrawn on the 24th hospital day and replaced by nafamostat mesilate after which the platelet count was restored to 100,000 /μl. Enzyme-linked immunosorbent assay for HIT antibodies was positive. Unfortunately, the patient died from uncontrolled sepsis on the 29th hospital day. At autopsy, platelet-rich thrombi were found in the small pulmonary arteries and intestinal arteries. No evidence of DIC, such as fibrin-rich thrombosis, was observed. This is the first autopsy report of HIT in Japan. (Circ J 2004; 68: 1215 - 1218)

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A 56-year-old man who complained of quadrantic hemianopsia was admitted to determine its etiology. Cerebral angiography revealed no organic stenosis. Echocardiography showed clear direct continuity between a hypertrophied anterolateral papillary muscle and the anterior mitral leaflet, and the left ventricular (LV) outflow tract (LVOT) was narrowed by the presence of an accessory papillary muscle. The LVOT obstruction caused an intra-LV pressure overload that resulted in LV concentric hypertrophy. Arrhythmia, such as paroxysmal atrial fibrillation (PAF), was thought to have caused a cerebral embolism. Mitral valve replacement (MVR), septal myectomy, and myectomy of the abnormal papillary muscle were performed, and complete release of the LVOT obstruction was accomplished. Anomalous insertion of papillary muscle is a rare cause of LVOT obstruction. Echocardiography was useful in identifying the papillary muscle malformation, and surgery was completely curative. (Circ J 2004; 68: 1219 -1222)

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A 53-year-old Japanese man with fulminant myocarditis was referred. Percutaneous cardiopulmonary support (PCPS) was introduced immediately and intravenous immunoglobulin (IVIG) therapy followed for 2 days. Cardiac function showed signs of recovery on the 4th hospital day and the patient was weaned from PCPS on the 7th hospital day. Creatine kinase-MB peaked at 12 h after admission and was 176 ng/ml. Endomyocardial biopsy showed active myocarditis. A marked increase of the neutralizing antibody titer suggested coxsackievirus B3 infection. Plasma concentrations of cytokines and neurohumoral factors were analyzed. Proinflammtory cytokines, such as interleukin (IL)-1β, IL-6 and tumor necrosis factor (TNF-α), and anti-inflammatory cytokines, such as IL-1 receptor antagonist, soluble TNF receptor-1 and IL-10, were elevated on admission and all had decreased on the 7th hospital day. Brain natriuretic peptide and noradrenaline were already elevated upon admission (1,940 pg/ml and 4.6 ng/ml, respectively) and decreased thereafter. Although IVIG therapy under PCPS is a common treatment for fulminant myocarditis, the immunological response in vivo remains unclear. This case demonstrated suppression of serum cytokines after IVIG and PCPS treatment. Immunological parameters in those who have been treated with IVIG and PCPS and survived without complications are of great value for evaluation of the therapy. Further analysis with more cases in a multicenter study is necessary. (Circ J 2004; 68: 1223 - 1226)

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Transcatheter coil embolization for coronary artery to left ventricular fistula was successfully performed in a neonate. At 30 weeks' gestation, fetal echocardiography showed a hypoplastic right ventricle with intact ventricular septum, absent pulmonary valve, tricuspid atresia, and marked distension of the right coronary artery. After birth, the neonate had congestive heart failure and the electrocardiogram showed myocardial ischemic changes in the left ventricular area. Aortography showed a dilated right coronary artery arising from the ascending aorta and draining into the left ventricle. Transcatheter coil embolization was carried out on the 9th day after birth. Since the procedure, no myocardial ischemic changes have been detected. Transcatheter coil embolization is a useful therapy for coronary artery fistula associated with myocardial ischemia. (Circ J 2004; 68: 1227 - 1229)

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Background Although the origin of cardiac myxomas is still controversial, the 2 main hypotheses are that the tumor cells originate either from multipotential mesenchymal cells or from endocardial neural tissue. Methods and Results The production of various cytokines in 2 human cardiac myxoma cell lines was examined by enzyme-linked immunosorbent assay. After 7 days of culture, extremely high concentrations of interleukin-6 were detected in the culture media from both myxoma cell lines. Increased production of CXC chemokines, interleukin-8 and growth-related oncogene-α, were observed in both myxoma cell lines. Endothelin (ET)-1 and its precursor, big ET-1, were detected in the culture media from both myxoma cell lines. The production of both ET-1 and big ET-1 by myxoma cells was higher than by human umbilical vein endothelial cells. Similar to endothelial cells, myxoma cells did not produce stem cell factor, granulocyte colony-stimulating factor, hepatocyte growth factor, or ET-3. Conclusions The similarity of the cytokine production pattern between cardiac myxoma cells and endothelial cells supports the hypothesis that the tumor cells originate from mesenchymal cells capable of endothelial differentiation. Overproduction of CXC chemokines may explain, in part, the malignant potential of histologically benign myxomas. (Circ J 2004; 68: 1230 - 1232)

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