Background The aim of the present study was to identify the relationship between sub-acute stent thrombosis (SAT) and acute-phase inflammatory reactants, such as high-sensitivity C-reactive protein (hs-CRP) and serum amyloid-A protein (SAA), in patients with acute myocardial infarction (AMI) successfully treated with primary coronary stenting. Methods and Results The 381 consecutive AMI subjects were reperfused by primary coronary stenting within 24 h of onset. SAT was confirmed angiographically in 10 patients (2.6%). There were no significant differences between the patients with or without SAT in terms of patient characteristics, Killip classification on admission, or stent diameter, nor were there significant differences between the 2 groups in terms of left ventricular function soon after stenting (left ventricular ejection fraction) or end-diastolic volume index. The plasma levels of both hs-CRP and SAA were significantly higher in the SAT patients than in the others (hs-CRP: 6.7±6.7 mg/dl vs 3.3±3.8 mg/dl, p=0.007; SAA: 699±812 μg/dl vs 208±273 μg/dl, p<0.0001). Multivariate analysis identified SAA as an independent predictor of SAT (risk ratio: 4.9, 95% confidence interval: 1.7-14.9, p<0.05). Conclusion In patients with AMI who are treated with primary coronary stenting, inflammation may be closely related to SAT, for which SAA is a useful predictor. (Circ J 2006; 70: 151 - 155)

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Background High serum lipoprotein(a) (Lp(a)) levels are associated with coronary artery disease. Methods and Results The serum Lp(a) levels of 130 patients with acute myocardial infarction (AMI) who underwent direct percutaneous coronary intervention were investigated. On the basis of Lp(a) level at 1 month after the onset of AMI, the patients were classified into 2 groups (high-Lp(a) (≥30 mg/dl) and low-Lp(a) (<30 mg/dl)) for evaluation of the clinical coronary stenosis progression (CCSP) rate. CCSP is defined as either target lesion revascularization (TLR) or new lesion revascularization (NLR). The CCSP rate was significantly higher in the high-Lp(a) group than in the low-Lp(a) group (65.8% vs 29.3%, p<0.01). In patients who had coronary stents in the acute phase (n=79), the CCSP and NLR rates were significantly higher in the high-Lp(a) group than in the low-Lp(a) group (45.0% vs 20.3%, p<0.05; 35.0% vs 6.8%, p<0.01), but there was no significant difference in TLR rate between the 2 groups (10.0% vs 13.6%, p=0.858). Conclusions High serum Lp(a) level is a significant risk factor for CCSP, but does not influence restenosis after stenting. (Circ J 2006; 70: 156 - 162)

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Background Increased levels of N-terminal pro-brain natiuretic peptide (NT-proBNP) are now recognized as a new and useful biochemical marker that is predictive of clinical outcomes in patients with congestive heart failure (CHF). However, an association between an increased circulating level of this biomarker and clinical outcomes in patients following acute myocardial infarction (AMI) has not been fully delineated. Thus, the purpose of this study was to test whether NT-proBNP can predict prognosis in patients following ST-segment elevated AMI. Methods and Results A prospective cohort study of 242 consecutive patients with ST-segment elevated AMI of onset <12 h who underwent primary percutaneous coronary intervention (PCI) was conducted. Blood samples for plasma concentration of NT-proBNP were collected following vascular puncture. Univariate analysis demonstrated that the 30-day composite major adverse clinical outcomes (MACO) [advanced Killip score ≥3, functional class ≥3 of CHF and 30-day mortality] were strongly associated with elevated NT-proBNP (>243 pg/ml) (p<0.0001), unsuccessful reperfusion (final thrombolysis in myocardial infarction flow ≤2) (p<0.0001), left ventricular ejection fraction (LVEF) <45% (p<0.0001), diabetes mellitus (DM) (p=0.0004) and multivessel disease (p=0.0005). Multiple stepwise logistic regression analysis demonstrated that elevation of NT-proBNP (p=0.0002), LVEF <45% (p=0.0003), DM (p=0.0007), unsuccessful reperfusion (p=0.006), and age (≥70 years) (p=0.031) are independent predictors of 30-day MACO. Additionally, elevation of NT-proBNP, together with advanced Killip score and unsuccessful reperfusion, are significant independent predictors of increased 30-day mortality (all p values <0.005). Conclusion Increased NT-proBNP level was the most independent predictor of 30-day MACO in patients with ST-segment elevated AMI undergoing primary PCI. (Circ J 2006; 70: 163 - 168)

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Background Little is known about the shortening of atrial refractoriness as a result of electrical remodeling in atrial fibrillation (AF) in clinical cases, especially in terms of long-term follow-up, because of a lack of noninvasive testing methods. Methods and Results The present study population comprised 38 consecutive patients with persistent AF (PAF, >1 month). Before and after the follow-up period of 1-14 months, surface ECGs were recorded for analysis. In each case, the fibrillation wave was purified by subtracting the QRS-T complex template and then power spectral analysis was performed. The mean fibrillation cycle length (FCL) and FCL coefficient of variation (FCL-CV) were determined from peak power frequency in 20 epochs in each recording. The change in FCL (FCL) was calculated by subtracting the baseline FCL from the FCL after the follow-up period. To correct for the difference in the follow-up period, ΔFCL was divided by the follow-up period in each case. In 38 cases, mean FCL decreased from 160±20 ms to 151±19 ms (p<0.05), and the FCL-CV also decreased from 15±9% to 12±5% (p<0.05). The corrected ΔFCL was -2.4±7.6 (ms/month) and there was a significant negative correlation between corrected ΔFCL and baseline FCL (p<0.01). Conclusion Shortening of the FCL during a relatively long-term follow-up period was observed in patients with PAF. (Circ J 2006; 70: 169 - 173)

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Background Pulmonary arterial hypertension (PAH) is a poor prognostic disease with limited treatment options. Rho-kinase is involved in the pathophysiology of several diseases underlying smooth muscle hypercontraction, so the purpose of this study was to investigate the efficacy of fasudil, a Rho-kinase inhibitor, in patients with PAH. Methods and Results Fasudil 30 mg was intravenously injected over 30 min in 8 patients (all female, mean ± SD, 41±11 years) with PAH. The lowest total pulmonary resistance (TPR) time was within 30-60 min after administration. Administration of fasudil decreased TPR from 1,069±573 dyne · s · cm ^-5 to 809±416 dyne · s · cm^-5 (p<0.005) and mean pulmonary arterial pressure from 41.3±12.8 mmHg to 37.9±14.6 mmHg (p<0.05). The cardiac index was increased from 2.42±0.73 L · min^-1 · m^-2 to 2.84±0.79 L · min^-1 · m^-2 (p<0.02). Systemic vascular resistance and systolic systemic arterial pressure (SAP) were decreased (p<0.005, p=0.09, respectively), but the decrease in SAP was small (-6.4±9.1 mmHg). Conclusion These results suggest that Rho-kinase is involved in the pathogenesis of human PAH and that fasudil is a novel therapeutic agent. (Circ J 2006; 70: 174 - 178)

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Background The goal of the present study was to investigate the feasibility of mitral valvle repair in patients with infective endocarditis (IE). Methods and Results Twenty-one patients who had undergone mitral valve surgery for IE were reviewed. Valve repair was performed in 8 patients with active and in 6 patients with healed endocarditis: 6 of these 14 patients were New York Heart Association (NYHA) functional class III or IV preoperatively. Valve replacement was performed in 5 patients with active endocarditis and in 2 with healed endocarditis: 6 of these 7 patients were NYHA functional class III or IV preoperatively. Repair techniques included annuloplasty (n=13), resection - suture (n=13), chordal transfer (n=2), and closure of the perforation (n=3). In the valve replacement group, 6 patients required concomitant aortic valve replacement. In the valve repair group, 1 patient died and 1 patient required reoperation for recurrent mitral regurgitation. Postoperative echocardiography demonstrated no (n=8) or mild (n=4) mitral regurgitation at the last follow-up examination. In the valve replacement group, 1 patient died and 1 patient required reoperation because of a paravalvular leak. No cases of recurrent infection occurred in either group. Conclusions Mitral valve repair in patients with IE is feasible and has low morbidity. (Circ J 2006; 70: 179 - 183)

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Background There is frequently discordance in the interpretation of myocardial single-photon emission computed tomography images using both rest iodine-123 15-(p-iodophenyl)-3-(R,S) methylpentadecanoic acid (BMIPP) and stress thallium-201 (²⁰¹Tl); that is, negative BMIPP vs positive ²⁰¹Tl studies. However, little attention has been paid to reverse discordance (ie, positive BMIPP despite negative stress ²⁰¹Tl). Methods and Results In the present study 105 consecutive patients with suspected coronary artery disease (CAD) who underwent both rest BMIPP and stress ²⁰¹Tl imaging were evaluated. No patient with previous myocardial infarction was included. Scintigraphic studies revealed that BMIPP was in concordance with ²⁰¹Tl in 71 patients: both were positive in 38 and negative in 33, whereas both were discordant in 20 and reverse discordant in 14. In patients with reverse discordance, the pattern of BMIPP abnormality was segmental in 8 and spotty in 6; the former was related to coronary territory. Based on the BMIPP findings and clinical symptoms, 7 patients with positive BMIPP despite negative ²⁰¹Tl underwent coronary angiography: 3-vessel CAD was found in 3 patients, 2-vessel CAD in 1, coronary spasm in 2, and insignificant lesions in 1. In the remaining 7 patients, no cardiac event was observed during 2-year follow-up. Conclusions In patients showing positive BMIPP despite negative ²⁰¹Tl, a segmental BMIPP perfusion abnormality indicates a high likelihood for CAD, despite normal stress ²⁰¹Tl imaging. Thus, adding BMIPP to ²⁰¹Tl imaging may help to better identify patients with significant CAD, including multivessel disease. (Circ J 2006; 70: 184 - 189)

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Background Computed tomography (CT) is widely used in clinical practice, but there has not been a detailed report of its effect on the functioning of pacemakers. Methods and Results During CT, ECGs were recorded in 11 patients with pacemakers and the electromagnetic field in the CT room was also measured. The effect of CT on a pacemaker was also investigated in a human body model with and without shielding by rubber or lead. Transient malfunctions of pacemakers during CT occurred in 6 of 11 patients. The model showed that malfunctioning of the pacemaker was induced by CT scanning and this was prevented by lead but not by rubber. The alternating electrical field was 150 V/m on the CT scanning line, which was lower than the level influencing pacemaker functions. The alternating magnetic field was 15 μT on the CT scanning line, which was also lower than the level influencing pacemaker functions. Conclusions Malfunctions of the pacemaker during CT may be caused by diagnostic radiant rays and although they are transient, the possibility of lethal arrhythmia cannot be ignored. (Circ J 2006; 70: 190 - 197)

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Background Although endovascular stent-grafting (SG) has become acceptable for blunt aortic injury (BAI), open surgical repair (OR) does provide reliable, good long-term results. A current surgical strategy for BAI, taking account of associated brain injury, is presented and preferable initial management for BAI is proposed. Methods and Results The surgical strategy for BAI was established in 2001: SG is performed for patients with obvious brain injuries, but OR is performed for patients without brain injury, and conservative treatment should be used initially for patients with critical non-aortic injuries. Between 2001 and 2004 20 patients with BAI were admitted to hospital: 16 blunt aortic ruptures and 4 blunt aortic dissections. Of them 15 patients underwent surgery (SG, 9; OR, 6) and 5 patients were treated conservatively. One patient died from associated lung injury after SG, all patients treated conservatively died because of associated brain injuries or another rupture of BAI, and 2 elderly patients treated by OR died within 1 year from postoperative respiratory failure. Conclusion This brain-injury conscious surgical strategy for BAI provided acceptable early results. OR should be chosen for young patients without brain injury, but endovascular SG seems to be a better initial treatment for elderly patients or patients with other comorbidities. (Circ J 2006; 70: 198 -201)

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Background Myocarditis frequently occurs in the acute phase of Kawasaki syndrome (KS), and a few severe cases have been reported. Four cases of myocarditis in KS required additional catecholamine treatment because of severe left ventricular dysfunction (LVD). Case reports Three cases were relatively older children and 2 cases were complicated with encephalopathy. All 4 developed coronary artery abnormalities during convalescence. There was 1 case of LVD because of prolonged severe inflammation prior to administration of intravenous immunoglobulin (IVIG). The remaining 3 patients had normal values for ejection fraction before the administration of IVIG but decreased values (42-51%) and increased C-reactive protein levels after IVIG administration. These cases demonstrate an association between myocarditis in KS and severe or worsened inflammation. Conclusions Even with prior normal echocardiography, careful observation of cardiac function may be necessary for patients with KS, especially older children, when inflammation deteriorates after administration of IVIG. (Circ J 2006; 70: 202 - 205)

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Background The effect of bepridil, a multichannel blocker, on atrial electrical remodeling was evaluated in a canine rapid atrial stimulation model. Methods and Results In 10 beagle dogs, the right atrial appendage (RAA) was paced at 400 beats/min for 2 weeks. The atrial electrophysiological parameters, including effective refractory period (AERP), were evaluated at three atrial sites: RAA, the right atrium close to the inferior vena cava (IVC) and the left atrium (LA), during the time course of rapid pacing. Five of the dogs were given bepridil (10 mg · kg ^-1 · day^-1 po). In the control group, AERP was significantly shortened at all atrial sites and the AERP shortening (ΔAERP) was larger for the RAA and LA than at the IVC site (p<0.05). In the bepridil group, ΔAERP was smaller than that of the controls at all atrial sites, and the AERP started to return slowly to the pre-pacing level in the second week, regardless of the continuation of rapid pacing. Conclusions In a canine rapid atrial stimulation model, bepridil suppressed AERP shortening. Bepridil might have a reverse electrical remodeling effect, at least for AERP shortening, because it showed slow recovery of AERP in the subacute phase of rapid atrial pacing. (Circ J 2006; 70: 206 - 213)

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A 62-year-old woman experienced an acute type A aortic dissection complicated with profound shock caused by acute myocardial ischemia. Intraoperative transesophageal echocardiography (TEE) identified a circumferentially dissected intimal flap at 5.5 cm above the aortic valve, prolapsing into the left ventricle through the aortic valve during diastole and obstructing both coronary ostia. Acute aortic dissection must be kept in mind when presented with myocardial ischemia and TEE is the most useful method for detecting a prolapsing cylindrical intimal flap. (Circ J 2006; 70: 214 - 215)

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