Circulation Journal
Online ISSN : 1347-4820
Print ISSN : 1346-9843
ISSN-L : 1346-9843
Volume 71 , Issue 9
Showing 1-32 articles out of 32 articles from the selected issue
Clinical Investigation
  • Epidemiology and Current Management in Japan (Japan Multicenter Investigation for Cardiovascular Disease-D (JMIC-D) Committee)
    Yoshiki Yui, Atsushi Hirayama, Hiroshi Nonogi, Kazuo Kimura, Kazuhisa ...
    2007 Volume 71 Issue 9 Pages 1335-1347
    Published: 2007
    Released: August 25, 2007
    JOURNALS FREE ACCESS
    Background A multicenter study was conducted to assess the current medical management of unstable angina (UA) and non-ST-elevation acute coronary syndrome in Japan. Methods and Results This study presents the results of a nationwide questionnaire survey of 770 sites and a case report investigation performed at 20 sites. The questionnaire survey revealed that the number of acute myocardial infarction (AMI) patients treated annually was 1.56-fold greater than the number of UA patients. Non-ST-elevation AMI accounted for 17% of all patients with AMI. Analysis of case reports for 885 UA patients showed extensive use of invasive treatment. In the UA patients, the cumulative incidence of a composite endpoint (all-cause mortality, AMI, and urgent coronary revascularization) was 2% at 1 month and 9% at 6 months. Stratified analysis with respect to the composite endpoint through 6 months showed a significantly lower incidence in patients treated with a calcium-channel blocker than in patients not treated with a calcium-channel blocker. Conclusions In Japan, fewer patients are hospitalized annually for treatment of UA than for AMI. The largest percentage of UA patients had Braunwald class III disease. Non-ST-elevation AMI is managed in Japan according to the principle of early invasive treatment, resembling the treatment for ST-elevation AMI. The outcome of treatment is better for Japanese UA patients than for Japanese AMI patients. (Circ J 2007; 71: 1335 - 1347)
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  • Subanalysis of MUSASHI-AMI
    Tomohiro Sakamoto, Sunao Kojima, Hisao Ogawa, Hideki Shimomura, Kazuo ...
    2007 Volume 71 Issue 9 Pages 1348-1353
    Published: 2007
    Released: August 25, 2007
    JOURNALS FREE ACCESS
    Background Statins are widely used to reduce blood levels of low-density lipoprotein-cholesterol (LDL-C). Each statin has unique pharmacokinetic properties; lipophilicity is one such property and relates to tissue selectivity. Methods and Results The Multicenter Study for Aggressive Lipid-lowering Strategy by HMG-CoA Reductase Inhibitors in Patients with Acute Myocardial Infarction (MUSASHI-AMI) trial evaluated the effect of discretional statin treatment initiated within 96 h after onset of acute myocardial infarction (AMI) in Japanese patients. To clarify whether statin lipophilicity affects prognosis, a post hoc analysis of the MUSASHI-AMI database was performed. Patients who were assigned to receive statin were separated into 2 groups according to the lipophilicity of the statins they were administered: lipophilic statins (atorvastatin, fluvastatin, pitavastatin and simvastatin; LS group; n=131) or hydrophilic statins (pravastatin; HS group; n=110). There was no difference in baseline LDL-C concentrations between the 2 groups. Although LDL-C was decreased more potently in the LS than HS groups (-34% vs -19%; p=0.0069), acute coronary syndrome events tended to occur less frequently (3.6% vs 9.9%; p=0.0530) and the incidence of new Q-wave appearance in electrocardiogram was significantly lower (75% vs 89%; p=0.0056) in the HS than LS groups. Conclusions In normocholesterolemic Japanese patients after AMI, hydrophilic pravastatin could be superior to lipophilic statins at preventing new Q-wave appearance and reducing cardiovascular events. (Circ J 2007; 71: 1348 - 1353)
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  • Data From the Heart Institute of Japan Acute Myocardial Infarction (HIJAMI) Registry
    Junichi Yamaguchi, Hiroshi Kasanuki, Yasuhiro Ishii, Masahiro Yagi, Mi ...
    2007 Volume 71 Issue 9 Pages 1354-1359
    Published: 2007
    Released: August 25, 2007
    JOURNALS FREE ACCESS
    Background Data about the long-term mortality of acute myocardial infarction (AMI) patients with renal insufficiency who received sufficient early revascularization are scant, so the present study evaluated the impact of serum creatinine levels on the long-term mortality in patients with AMI undergoing successful primary percutaneous coronary intervention (PCI). Methods and Results The Heart Institute of Japan Acute Myocardial Infarction (HIJAMI) registry has 3,021 consecutive AMI patients. Primary PCI was attempted in 1,451 patients and successful revascularization was obtained in 1,359 patients (93.6%). An elevated serum creatinine level, defined as creatinine ≥1.2 mg/dl, was observed in 216 patients (15.8%). Univariate analyses showed statistical differences between normal and elevated serum creatinine groups in age, gender, hypertension, previous myocardial infarction, number of diseased vessels and Killip class. During a median follow-up period of 39 [32-49] months, the event-free survival rate was lower in elevated creatinine group than normal creatinine group. Multivariate Cox proportional hazards model showed that serum creatinine level was an independent predictor of long-term mortality (adjusted hazard ratio 1.43 [95% confidence interval 1.03-1.99]). Conclusion The serum creatinine level on admission in patients with AMI predicts long-term mortality, even in those with successful primary PCI. (Circ J 2007; 71: 1354 - 1359)
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  • Observational Study Over a Decade
    Noriyuki Fujii, Ryuta Asano, Masatoshi Nagayama, Tetsuya Tobaru, Kazuh ...
    2007 Volume 71 Issue 9 Pages 1360-1365
    Published: 2007
    Released: August 25, 2007
    JOURNALS FREE ACCESS
    Background In the era of drug-eluting stents, percutaneous coronary intervention (PCI) has been considered an established therapeutic modality for patients with coronary artery disease (CAD). However, little is known about the long-term prognosis. Methods and Results Using data obtained from a single-center registry for cases of first-generation bare metallic stent (BMS) implantation, a 10-year follow-up study in patients with CAD was performed. Data for 125 serial patients (aged 62±9 years, 104 males) in whom a BMS was successfully implanted was analyzed. Cardiac death (n=16 [12.8%]), including sudden cardiac death (n=9 [7.2%]), non-cardiac death (n=17 [13.6%]) and non-fatal acute myocardial infarction (n=16 [12.8%]) were documented. At 10 years, cumulative probabilities of target and non-target lesion revascularization were 20.5% and 41.5%, respectively, and only 39.2% of the patients were free from cardiac events (cardiac death/myocardial infarction/unplanned revascularization). Age and left ventricular ejection fraction (LVEF) were significant predictors of total death, and LVEF and the use of diuretics were predictors of cardiac events. Conclusions Stabilization of the initial stented site was relatively good and the majority of cardiac events might have originated in non-target lesions. Prevention of systemic arteriosclerosis progression is important for patients with CAD, even after successful PCI. (Circ J 2007; 71: 1360 - 1365)
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  • Kimiaki Komukai, Takayuki Ogawa, Hidenori Yagi, Taro Date, Kiyofumi Su ...
    2007 Volume 71 Issue 9 Pages 1366-1369
    Published: 2007
    Released: August 25, 2007
    JOURNALS FREE ACCESS
    Background Acute myocardial infarction (MI) sometimes occurs without painful symptoms and in such cases, prognosis is worsened by delays in diagnosis and revascularization. Renal insufficiency induces many types of neuropathy, but the relation between renal insufficiency and painless MI remains unclear. Methods and Results Patients with MI and elevated creatine kinase levels were retrospectively analyzed. Renal insufficiency (serum creatinine concentration ≥1.5 mg/dl) and other characteristics (age, sex, body mass index, hypertension, smoking, diabetes mellitus, dyslipidemia, history of stroke, previous MI, hemodialysis, and atrial fibrillation) were compared between patients who had MI with painful symptoms (painful MI, n=131) and patients who had MI without painful symptoms (painless MI, n=18). Other variables compared were the time from symptom onset to admission, peak creatine kinase concentration, Killip class, site of MI, emergency coronary angiography, postprocedural Thrombolysis In Myocardial Infarction grade III flow, and in-hospital death. Univariate analysis identified older age, renal insufficiency, and previous MI as predictors of painless MI. Patients with painless MI showed higher rates of Killip class ≥II and in-hospital death and a longer time from symptom onset to admission. However, multivariate analysis identified only renal insufficiency as an independent predictor of painless MI. Conclusions MI without painful symptoms frequently develops in patients who have renal insufficiency, so the possibility of painless MI should be evaluated in such patients to ensure early diagnosis and treatment. (Circ J 2007; 71: 1366 - 1369)
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  • Akio Kawamura, Daniel A. Lombardi, Matthew E. Tilem, David E. Gossman, ...
    2007 Volume 71 Issue 9 Pages 1370-1375
    Published: 2007
    Released: August 25, 2007
    JOURNALS FREE ACCESS
    Background Stroke associated with percutaneous coronary intervention (PCI) is a tragic complication. Despite advances in the practice of PCI, the incidence of stroke complicating PCI has not changed over the decades. The objective of the present study was to evaluate incidence and correlates of stroke occurring in patients with myocardial infarction (MI) undergoing PCI. Methods and Results Stroke was defined as the presence of any new focal neurological deficit lasting ≥24 h that occurred anytime during or after PCI until discharge. In 2,281 consecutive patients with PCIs for non-ST-elevation MI, or ST-elevation MI (STEMI), 20 strokes were identified (0.88%). Strokes were ischemic in 95%. On multivariate analyses, ejection fraction ≤30% (odds ratio =4.3, p=0.003) was the only independent predictor for stroke. In patients who developed stroke within 24 h of PCI, PCI of vein grafts was more frequent, and use of glycoprotein IIb/IIIa inhibitor was less frequent. Those patients tended to present late in the course of MI. Stroke found more than 24 h after PCI was related to diabetes, higher serum creatinine, lower ejection fraction, anterior wall STEMI and emergency use of intra-aortic balloon pumps. Conclusions Low ejection fraction was the only independent predictor for stroke, but risk factors for periprocedural stroke are different from those of stroke occurring more than 24 h after PCI. Upstream use of glycoprotein IIb/IIIa inhibitor might decrease the risk of periprocedural stroke. (Circ J 2007; 71: 1370 - 1375)
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  • Yoshiki Matsuo, Toshio Imanishi, Akio Kuroi, Hironori Kitabata, Takash ...
    2007 Volume 71 Issue 9 Pages 1376-1382
    Published: 2007
    Released: August 25, 2007
    JOURNALS FREE ACCESS
    Background It is not known whether plasma adiponectin levels are associated with the number and function of endothelial progenitor cells (EPCs) in patients with coronary artery disease (CAD). Methods and Results Plasma levels of adiponectin were measured in 70 patients undergoing coronary angiography. The numbers of colony-forming units (CFUs) of EPCs and senescent EPCs, determined by acidic β-galactosidase staining, were counted. The angiogenic growth factors in the culture medium were also measured. There was a significant positive correlation between adiponectin level and CFUs (r=0.257, p<0.05) but not with the occurrence of senescent EPCs. Next, patients were divided into a high adiponectin group (high ADP: ≥6.17 μg/ml, n=36) and low adiponectin group (low ADP: <6.17 μg/ml, n=34). The number of diseased coronary arteries was less in the high ADP group than that in the low ADP patients (1.7±0.8 vs 2.1±0.7, p<0.05). No significant differences between the 2 groups were demonstrated in angiogenic growth factors secreted from EPCs. Conclusions The results suggest that plasma adiponectin levels are associated with the number of EPCs in patients with CAD. (Circ J 2007; 71: 1376 - 1382)
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  • Pum Joon Kim, Ki-Bae Seung, Dong-Bin Kim, Sung-Ho Her, Dong-Il Shin, S ...
    2007 Volume 71 Issue 9 Pages 1383-1386
    Published: 2007
    Released: August 25, 2007
    JOURNALS FREE ACCESS
    Background Vasospastic angina (VA) can occasionally cause acute myocardial infarction (AMI). Methods and Results From January 2003 to June 2005, coronary spastic angina was diagnosed in 292 patients by performing spasm provocation tests. Among the 292 patients, 21 (7.2% of all the VA patients) had an AMI. There were 20 patients who initially visited the emergency room for AMI without suffering prior VA. One patient with a history of VA had an AMI when he discontinued his medication. Among the 21 VA patients with AMI, 14 had experienced severe emotional stress before they visited the emergency room. The spasm provocation test showed that the VA patients with AMI had more multivessel and diffuse spasm than the VA patients without AMI (p<0.001). Conclusion Clinically, the VA patients with AMI usually had their first symptom of VA as the severe chest pain of AMI. Two-thirds of the VA patients with AMI had experienced emotional stress before their AMI. Angiographically, the spasm provocation test for VA patients with AMI showed more multivessel and diffuse spasm than in VA patients without AMI. (Circ J 2007; 71: 1383 - 1386)
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  • A Propensity Score Analysis
    Young-Nam Youn, Byung-Chul Chang, You-Sun Hong, Young-Lan Kwak, Kyung- ...
    2007 Volume 71 Issue 9 Pages 1387-1394
    Published: 2007
    Released: August 25, 2007
    JOURNALS FREE ACCESS
    Background Cardiopulmonary bypass may exacerbate myocardial damage in compromised left ventricles. Early and mid-term outcomes of off-pump coronary artery bypass grafting (OPCAB) vs on-pump coronary artery bypass grafting (On-pump CABG) were compared in patients with poor left ventricular dysfunction, using an analysis of a propensity score matching. Methods and Results Between December 2000 and November 2005, 1,473 patients underwent isolated coronary artery bypass grafting in our institute and 153 patients who had a left ventricular ejection fraction (LVEF) lower than 35% were enrolled. The OPCAB group contained 100 patients and the On-pump CABG group contained 53 patients. Preoperative risk factors were compared and 50 patients in each group were matched. The mean follow-up time was 35.5±17.3 months. Three deaths (3.0%) occurred in the matched cohort, with no significant difference between 2 groups. The operation time, ventilation time, intensive care unit admission time and occurrence of respiratory failure were significantly lower in the OPCAB group. The mean LVEF of the 2 groups improved significantly. The overall 6-year actuarial survival rates of the OPCAB and On-pump CABG group were 88.2% and 72.4% (p=0.2), respectively, and there were no significant differences in 6-year rates of freedom from major adverse cardiac and cerebrovascular events (p=0.97). Conclusions Coronary artery bypass grafting in patients with poor left ventricular dysfunction improved myocardial function. Postoperative respiratory failure was significantly related to the cardiopulmonary bypass for surgical myocardial revascularization. Off-pump and On-pump surgical revascularization resulted in equivalent mid-term outcomes. (Circ J 2007; 71: 1387 - 1394)
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  • Jun Hashimoto, Tadaki Nakahara, Jingming Bai, Naoto Kitamura, Tomotaka ...
    2007 Volume 71 Issue 9 Pages 1395-1400
    Published: 2007
    Released: August 25, 2007
    JOURNALS FREE ACCESS
    Background Perioperative cardiac risk in high risk surgery is often stratified with myocardial perfusion single-photon emission computed tomography (SPECT). However, little and no data are available about intermediate and low-risk surgery, respectively. Methods and Results A total of 1,220 consecutive patients underwent electrocardiography-gated dipyridamole stress SPECT to evaluate myocardial perfusion and cardiac function before intermediate or low risk non-cardiac surgery. Variables predictive of perioperative cardiac events were determined and the usefulness of combining pretest information and the incremental prognostic value of SPECT was estimated. The frequency of all cardiac events depended on clinical risk factors and type of surgical procedures. After sorting the patients with clinical risk factors and surgical risk, assessment of myocardial perfusion or cardiac function yielded significant risk stratification in intermediate, but not in low-risk surgery. Adding functional data to perfusion variables offered an incremental prognostic value for patients with an intermediate clinical risk and scheduled intermediate risk surgery. Conclusions Integrating information about clinical risk factors, type of surgery, myocardial perfusion and cardiac function allows detailed preoperative risk stratification. Preoperative SPECT provides an incremental prognostic value in intermediate, but not in low-risk surgery. (Circ J 2007; 71: 1395 - 1400)
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  • Akira Sezai, Mitsumasa Hata, Shinji Wakui, Tetsuya Niino, Tadateru Tak ...
    2007 Volume 71 Issue 9 Pages 1401-1407
    Published: 2007
    Released: August 25, 2007
    JOURNALS FREE ACCESS
    Background Low-dose continuous human atrial natriuretic peptide (hANP) administration during cardiac surgery has been reported on previously. In the present study, the efficacy of the therapy during emergent coronary artery bypass grafting (CABG) for acute coronary syndrome (ACS) is investigated. Methods and Results One hundred and twenty-four patients patients undergoing emergent CABG for ACS were divided into 2 groups; a group receiving administration of hANP (hANP group) and a group not receiving hANP infusion (non-hANP group). The postoperative peak levels of creatine kinase-MB were significantly lower in the hANP group as compared with those in the non-hANP group. The incidence of postoperative arrhythmias was also significantly lower in the hANP group as compared with that in the non-hANP group. The postoperative brain natriuretic peptide was significantly lower in the hANP group as compared with that in the non-hANP group until 1 year after the operation. The free-rate of cardiac events after the operation was also significantly higher in the hANP group as compared with that in the non-hANP group. Conclusions It is therefore considered that hANP might not only be effective for overcoming some major shortcomings of cardiopulmonary bypass, but also might be effective to attenuate ischemia-reperfusion injury, protect the myocardium, have an anti-arrhythmic effect, and suppress left ventricular remodeling. (Circ J 2007; 71: 1401 - 1407)
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  • A Marker of the Hemodynamic Response to a Fluid Challenge
    Yoshiyuki Tokuda, Min-Ho Song, Norifumi Mabuchi, Akihiko Usui, Yuichi ...
    2007 Volume 71 Issue 9 Pages 1408-1411
    Published: 2007
    Released: August 25, 2007
    JOURNALS FREE ACCESS
    Background This study evaluated the right ventricular end-diastolic volume index (RVEDVI) as a marker of the hemodynamic response to a fluid challenge in the postoperative care of cardiac surgery patients. Methods and Results Continuous RVEDVI and other hemodynamic parameters were analyzed during and after 17 fluid challenges with 480-500 ml colloids (5% albumin, fresh frozen plasma or 6% hydroxyethyl starch) given over 30-60 min following cardiac surgery. Changes in stroke volume index (SVI) were assessed to indicate fluid responsiveness. Responders were defined as those who experienced a 10% or greater increase in SVI. Fluid challenges with simultaneous changing of vasoactive agents were excluded. Linear regression analysis between the percentage change in SVI and baseline RVEDVI revealed a statistically significant but weak correlation (r2=0.249; p=0.041). Although the baseline RVEDVI was higher in non-responders than in responders (112.4±6.1 vs 104.4±5.8 ml/m2; p=0.05), there was a marked overlap of baseline RVEDVI values, which did not allow identification of the threshold value of RVEDVI discriminating responders. Conclusions After cardiac surgery, RVEDVI reflected fluid responsiveness only to a limited degree. Patients should not be resuscitated to an absolute RVEDVI alone and empirical fluid challenge should still be required. (Circ J 2007; 71: 1408 - 1411)
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  • Shinji Nakao, Akiko Goda, Masao Yuba, Misato Otsuka, Mika Matsumoto, C ...
    2007 Volume 71 Issue 9 Pages 1412-1417
    Published: 2007
    Released: August 25, 2007
    JOURNALS FREE ACCESS
    Background Although Doppler left ventricular (LV) filling abnormalities have been extensively analyzed in patients with systolic heart failure (SHF), they have not yet been well characterized in patients with acute to chronic diastolic heart failure (DHF) in the light of plasma brain natriuretic peptide (BNP) levels. Methods and Results In 25 patients presenting with acute DHF and 25 with acute SHF, echo Doppler parameters and plasma BNP levels were obtained on admission and in the chronic stage. The mitral E/A ratio was lower in DHF patients than in SHF patients in the acute stage (1.3 ±0.4 vs 1.8±0.9, p<0.05), and in the chronic stage of DHF the ratio decreased with plasma BNP level, but plasma BNP level was still greater than 100 pg/ml in 15 patients (60%). Among patients with DHF the plasma BNP level did not correlate with the mitral E/A ratio or deceleration time (r=0,25, p=NS; r=0,23, p=NS), but did with estimated pulmonary artery systolic pressure (r=0.64, p<0.01). Conclusions A restrictive mitral flow velocity pattern is observed in only 25% of patients with DHF, so it is particularly important to recognize pseudonormalization in those with possible DHF. Persistently elevated plasma BNP level is not primarily caused by LV diastolic dysfunction, but by secondary alteration for hemodynamic adjustment (elevated LV end-diastolic pressure) in patients with DHF. (Circ J 2007; 71: 1412 - 1417)
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  • Akira Koike, Osamu Nagayama, Ayumi Goda, Masayo Hoshimoto, Kaori Yamag ...
    2007 Volume 71 Issue 9 Pages 1418-1423
    Published: 2007
    Released: August 25, 2007
    JOURNALS FREE ACCESS
    Background It has been recently reported that cerebral oxyhemoglobin (O2Hb) decreases during exercise in nearly 50% of patients with dilated cardiomyopathy. The present study evaluated whether the inhalation of supplemental O2 diminishes the decrease in cerebral O2Hb during exercise. Methods and Results Ten patients with a left ventricular ejection fraction <50% and a clearly observable decrease in cerebral O2Hb during preliminary exercise testing underwent 2 additional symptom-limited incremental exercise tests: 1 while breathing room air (control) and the other while breathing 50% O2. In the latter test, the switch from room air to 50% O2 was performed, on average, at 43.0±14.2 W. Cerebral O2Hb was continuously monitored during exercise using near-infrared spectroscopy. In the control exercise test, cerebral O2Hb gradually decreased as the work rate increased in all the subjects. When the subjects breathed 50% O2, this decrease in cerebral O2Hb was diminished. The change in cerebral O2Hb from rest to peak exercise during the test under 50% O2 was significantly higher than that during the control test (-0.23 ±1.89 vs -2.47±1.57 μmol/L, p=0.002). Similarly, the change in the cerebral tissue oxygenation index was significantly higher in the test under 50% O2 (0.45 ±4.46 vs -3.33±3.06%, p=0.023). Conclusions Impaired cerebral oxygenation during moderate to heavy intensity exercise in patients with left ventricular dysfunction can be offset by breathing supplemental O2. (Circ J 2007; 71: 1418 - 1423)
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  • Shigenori Ito, Sumiko Murai, Masato Sugiura, Takayuki Yoshida, Tatsuya ...
    2007 Volume 71 Issue 9 Pages 1424-1429
    Published: 2007
    Released: August 25, 2007
    JOURNALS FREE ACCESS
    Background Cardiovascular disease is a major cause of death in patients on maintenance hemodialysis (HD). Predictors of congestive heart failure (CHF) events in patients on HD were investigated, focusing on left ventricular (LV) function. Methods and Results One hundred consecutive patients on HD were followed for at least 5 years after index examination performed 1 day after the last HD session. Tests included M-mode and Doppler echocardiography and plasma brain natriuretic peptide (BNP) and hemoglobin (Hb) concentration measurements. Patients with atrial fibrillation or poor echocardiographic images were excluded. Confounding factors included diabetes mellitus (DM), hypertension, age, HD duration, LV fractional shortening, E/A of transmitral flow velocity pattern, Tei index, LV mass index (LVMI), BNP level, Hb, and use of antihypertensive or antiarrhythmic drugs. Six CHF events occurred during 1,703±565 days. DM and Hb <10 g/dl were identified as independent predictors of CHF events in a stepwise Cox regression model after DM, LVMI, BNP, and Hb <10 g/dl were selected in the univariate analysis. The hazard ratio (confidence interval) was 10.96 (1.49-80.44) for DM, and 23.00 (2.41-219.76) for Hb <10 g/dl. The estimated hazard across time was constant (T_COV*DM; p=0.726, T_COV*Hb <10 g/dl; p=0.681) by time-dependent covariates analysis. Conclusion In patients on maintenance HD, DM and anemia (Hb <10 g/dl), but not echo-derived cardiac function, predicted CHF events. (Circ J 2007; 71: 1424 - 1429)
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  • A Dimensional Pitfall to the Circumferential Isolation Technique
    Takumi Yamada, Yoshimasa Murakami, Taro Okada, Naoki Yoshida, Junji To ...
    2007 Volume 71 Issue 9 Pages 1430-1436
    Published: 2007
    Released: August 25, 2007
    JOURNALS FREE ACCESS
    Background The dimensions and electrophysiological characteristics of the antral region of human pulmonary veins (PVs) were investigated. Methods and Results Fifty-five consecutive patients with symptomatic paroxysmal atrial fibrillation underwent PV isolation targeting the PV antrum potentials with a 31 mm multielectrode basket catheter (MBC). The most distal and proximal electrode pairs along the MBC spline where radiofrequency ablation was carried out were identified and the longitudinal distance between those ablation sites (Ld) was measured. When the Ld was ≥6 mm, the PV antrum was defined as noncoaxial. In 56% of the left superior PVs, 42% of the right superior PVs, 63% of the left inferior PVs and 56% of the right inferior PVs, a noncoaxial PV antrum was identified. In each PV, the radiofrequency ablation delivery duration and energy to complete the PV antrum isolation were significantly larger in the PVs with a noncoaxial PV antrum than in those with a coaxial PV antrum. Conclusion The PV antrum is noncoaxial to the PV in >50% of the PVs, a feature that may increase the complexity of the circumferential isolation technique. (Circ J 2007; 71: 1430 - 1436)
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  • Single Center Experience
    Kimie Ohkubo, Ichiro Watanabe, Yasuhiro Takagi, Yasuo Okumura, Sonoko ...
    2007 Volume 71 Issue 9 Pages 1437-1441
    Published: 2007
    Released: August 25, 2007
    JOURNALS FREE ACCESS
    Background The study examined the electrocardiographic and electrophysiologic characteristics in relation to programmed ventricular stimulation (PVS)-induced ventricular fibrillation (VF) in patients with Brugada syndrome. Methods and Results Thirty-four patients with a Brugada-type electrocardiogram (ECG) were enrolled. Twelve patients had a type 1 ECG, 12 had a type 2 ECG, and 10 had a type 3 ECG. PVS was performed with up to 2 ventricular premature beats from the right ventricular apex and outflow tract at 2 basic cycle lengths (600 and 400 ms). VF was induced in 17 of 23 (74%) asymptomatic patients and 10 of 11 (91%) symptomatic patients (p<0.05). The 27 patients in whom VF was induced by PVS and 7 patients without inducible VF were followed up for 47.1±33.7 months. One sudden death occurred during the follow-up period among asymptomatic patients with inducible VF, and no sudden death occurred among patients without inducible VF. Conclusions In conclusion, inducibility of ventricular arrhythmia is high in patients with Brugada syndrome, but it does not correlate with clinical presentation. Few arrhythmic events occur during follow up. However, the present study data suggest that electrophysiologic study-induced VF does not predict arrhythmic events during follow up. (Circ J 2007; 71: 1437 -1441)
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  • Yoshimitsu Soga, Kenji Ando, Takashi Yamada, Masahiko Goya, Shinichi S ...
    2007 Volume 71 Issue 9 Pages 1442-1445
    Published: 2007
    Released: August 25, 2007
    JOURNALS FREE ACCESS
    Background Optimal target vein selection for the pacing lead results in a better outcome, but left ventricular (LV) variability limits this selection. The aim of the present study was to investigate the efficacy of coronary venoplasty for insertion of a LV lead. Methods and Results Transvenous LV lead placement was attempted in 208 consecutive patients from November 2002 to January 2007, with success in 206 patients (99%). Retrospective analysis of the cardiac resynchronization therapy system implantation showed that 4 of the 206 patients (1.9%) required coronary venoplasty for insertion of the pacing lead implant. Using coronary balloon angioplasty catheters of 2.5 mm (2 patients), 3.0 mm (1 patient) and 4.0 mm (1 patient), each target vein was dilated. Of 4 patients, stenoses in 3 were dilated by balloon angioplasty only. However, focal stenosis of 1 patient was not able to be dilated due to severe stenosis. Therefore, part of the lesion was sharpened by rotational atherectomy and the stenosis was successfully dilated. The LV pacing lead could then be inserted and no complications occurred. Conclusion Venoplasty for stenosis was effective in allowing deployment of a LV lead into a target vein in some patients. The safety and complications of the procedure remain unclear. (Circ J 2007; 71: 1442 - 1445)
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  • Daisuke Watanabe, Kazuhiko Shizuka, Shunichi Koyama, Toshihiko Iwamoto
    2007 Volume 71 Issue 9 Pages 1446-1451
    Published: 2007
    Released: August 25, 2007
    JOURNALS FREE ACCESS
    Background Assessment of left atrial (LA) function by transesophageal echocardiography is useful for detecting patients with a high risk thromboembolism secondary to atrial fibrillation (AF). A recent study showed that the atrium is the main source of brain natriuretic peptide (BNP) in AF patients without overt heart failure. The purpose of this study was to assess the possible relationship between LA function and plasma BNP levels in very elderly patients with non-valvular AF. Methods and Results Seventy-four consecutive patients with chronic non-valvular AF (aged, 82±6 years) underwent transthoracic and transesophageal echocardiography and measurement of plasma BNP. Thirteen AF patients who had a history of cerebral embolism or echocardiographic evidence of thrombus (TE+ group) were compared with 61 AF patients who had no such complications (TE- group). The TE+ group demonstrated a lower LA appendage (LAA) velocity and higher plasma BNP level than the TE- group. Assessment of variables by multiple logistic regression analysis revealed that BNP was a significant predictor of thromboembolism. There was a significant negative correlation between the plasma BNP level and the LAA peak flow velocity. Conclusions The present findings would suggest the usefulness of measuring plasma BNP to detect very elderly non-valvular AF patients at high risk for thromboembolism. (Circ J 2007; 71: 1446 - 1451)
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  • Effects of Age, Gender and Physiologic Characteristics
    Takeshi Niizeki, Yasuchika Takeishi, Noriaki Takabatake, Yoko Shibata, ...
    2007 Volume 71 Issue 9 Pages 1452-1457
    Published: 2007
    Released: August 25, 2007
    JOURNALS FREE ACCESS
    Background Serum heart-type fatty acid-binding protein (H-FABP) has been widely used as a marker of cardiac myocyte injury. This study was carried out to examine the relationships of H-FABP levels with age, gender, and other physiologic characteristics in a large population of community-dwelling residents. Methods and Results Serum H-FABP levels were measured in 2,099 subjects who received an annual health check-up (age 40-87 years). The relationships between H-FABP and blood pressure, laboratory data, electrocardiogram (ECG) findings, and lifestyle factors were cross-sectionally analyzed. Mean H-FABP values were significantly higher in men than in women. Serum H-FABP levels were increased with aging significantly. Both the multivariate regression and multiple logistic regression analyses indicated that serum H-FABP levels were independently affected by age, body mass index, creatinine clearance, and ECG abnormality score. Conclusion Serum H-FABP levels were affected by age, gender, obesity, renal function, and ECG abnormality in a large group of volunteers. These effects should be taken into account in determining appropriate reference values for H-FABP. In addition, high serum H-FABP levels may represent latent cardiac injury and have important clinical implications. (Circ J 2007; 71: 1452 - 1457)
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  • Atsushi Saiki, Mitsunori Iwase, Yasushi Takeichi, Hisashi Umeda, Ryouj ...
    2007 Volume 71 Issue 9 Pages 1458-1462
    Published: 2007
    Released: August 25, 2007
    JOURNALS FREE ACCESS
    Background Although measurement of serum creatine kinase levels, as well as myoglobin levels, has been used for screening patients with acute coronary syndrome (ACS), the specificity of both is low. Measurement of cardiac troponin levels is now extensively used for the diagnosis of ACS because of their superior cardiac specificity. However, troponin levels are reportedly elevated not only in patients with ACS but also in those with other diseases. Methods and Results The clinical characteristics of 1,023 patients (mean age: 63.5±16.3 years; males: 665, females: 358) whose serum cardiac troponin I (cTnI) levels had been measured at the initial visit to the emergency room of Toyota Memorial Hospital between April 2004 and March 2005 were retrospectively analyzed. A positive elevation of cTnI was defined as cTnI ≥0.03 ng/ml. There were 432 patients (42.2%) with positive cTnI levels. The cTnI levels (8.48±2.64 ng/ml) in patients with acute myocardial infarction (AMI) were greater than those (0.25±0.07 ng/ml) in patients with unstable angina pectoris (AP), as well as those (0.04±0.01 ng/ml) in patients with stable AP. In terms of the diagnosis of AMI, the sensitivity was high enough (94.6%), but its specificity was relatively low (61.9%). Furthermore, the differentiation between AMI and unstable AP by the cTnI value alone was impossible. The cTnI levels were elevated in patients with a variety of diseases other than ACS, including heart failure, cardiomyopathies, myocarditis, renal failure, tachyarrhythmias, and pulmonary embolism. Conclusions Elevation of the cTnI level is frequently observed in patients in the emergency room with common diseases other than ACS. (Circ J 2007; 71: 1458 - 1462)
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  • Relative Roles of Insulin Resistance and Central Obesity
    Altan Onat, Gülay Hergenc, Ibrahim Sari, Ahmet Karabulut, Gü ...
    2007 Volume 71 Issue 9 Pages 1463-1467
    Published: 2007
    Released: August 25, 2007
    JOURNALS FREE ACCESS
    Background The aim was to investigate the sex-specific effect of hypercholesterolemia interacting with abdominal obesity (AO) in predicting Type 2 diabetes mellitus (DM). The 3,048 participants (aged ≥28 years) were free of DM at baseline, a representative sample of Turkish adults and were evaluated prospectively. Methods and Results As cut-off points for AO were used ≥95 cm in men and ≥91 cm in women, and for hypercholesterolemia ≥5.2 mmol/L. Diabetes was diagnosed using criteria of the American Diabetes Association. Four groups were formed at baseline: Group I subjects had neither AO nor hypercholesterolemia (33.3%), Group II subjects had AO only (27.6%), Group III subjects had hypercholesterolemia only (17.8%), and Group IV subjects had AO combined with hypercholesterolemia (21.3%). Over a mean of 5.9 years, DM developed in 103 women and 116 men. An age-adjusted relative risk (RR) by logistic regression for DM in the 4 groups, using AO as a reference group, disclosed an RR of 1.88 (95% confidence interval 1.14; 3.09) in women and an insignificant RR 1.29 in men (women were predicted to be 1.46 times more likely to develop DM). Hypercholesterolemia alone did not differ significantly from Group I in its ability to predict diabetes. An elevated level of low-density lipoprotein (LDL)-cholesterol (C) (≥3.4 mmol/L) was delineated as the element associated with diabetes in hypercholesterolemia by multiple logistic regression. The identification of 48 participants with familial-combined hyperlipidemia phenotypes alone could not account for most of the centrally obese and hypercholesterolemic women developing DM. Conclusion It was suggested that a diminished effectiveness of insulin resistance in centrally obese Turkish women (but not men) might predispose them to an elevation in LDL concentrations, while other features of visceral adiposity still predispose them to DM. In summary, an elevated LDL-C level interacts with AO in Turkish women to enhance the development of diabetes. (Circ J 2007; 71: 1463 - 1467)
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  • Josef Veselka, Daniela Cerná, Petra Zimolová, Peter Blas ...
    2007 Volume 71 Issue 9 Pages 1468-1472
    Published: 2007
    Released: August 25, 2007
    JOURNALS FREE ACCESS
    Background Implantation of a carotid artery stent after predilation is a standard approach in the endovascular treatment of carotid artery stenoses. Stenting without predilation may be an alternative approach in a certain subset of patients. The present prospective, single-center registry was designed to evaluate the feasibility and safety of direct carotid artery stenting (DCAS) in high-risk patients. Methods and Results Symptomatic patients with stenosis >50% and asymptomatic patients with stenosis >70% were eligible for enrolment. Criteria for high-risk patients included: need or history of open heart surgery, history of myocardial infarction, multivessel coronary artery disease, left ventricular dysfunction (ejection fraction ≤40%), severe pulmonary or renal disease, significant contralateral carotid disease, previous endarterectomy, and age ≥80 years. All procedures were performed using a filter protection device. Patients underwent complete clinical examination before and after DCAS and at 30-day follow-up. A total of 83 consecutive patients (45 males, 68±9 years, 33% symptomatic) underwent 100 procedures and 103 stents were deployed successfully. The technical success rate of stenting was 100%. Predilation of carotid stenosis was necessary in 1 (1%) procedure. Carotid-artery stenoses before and after DCAS were 80±9% and 7±9%, respectively. The median fluoroscopic time for DCAS was 7 min. The overall rate of in-hospital major adverse cerebrovascular events (death, stroke, myocardial infarction) was 5% (2 minor strokes, 3 transient attacks). There was 1 (1%) minor stroke within the 30-day follow-up. Conclusion DCAS is feasible and can be performed with an acceptable risk in high-risk patients. (Circ J 2007; 71: 1468 - 1472)
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Experimental Investigation
  • Toshio Imanishi, Akio Kuroi, Hideyuki Ikejima, Seiichi Mochizuki, Masa ...
    2007 Volume 71 Issue 9 Pages 1473-1479
    Published: 2007
    Released: August 25, 2007
    JOURNALS FREE ACCESS
    Background The present study aimed to elucidate the effect of long-term treatment with nitroglycerin (NTG) on the bioavailability of nitric oxide (NO) examined by a catheter-type NO sensor. The study also examined whether these effects could be modified by an antioxidant, an angiotensin converting enzyme inhibitor, or an angiotensin II type 1 receptor antagonist (ARB). Methods and Results Male New Zealand rabbits were treated for 7 days with NTG patches, either alone or in combination with tempol, enalapril, or valsartan (ARB). The plasma NO concentration was measured with the catheter-type NO sensor. The plasma peroxynitrite concentration was measured by enzyme-linked immunosorbent assay. An increase in plasma NO concentration in response to acetylcholine (ACh) were significantly attenuated in the NTG-treated group as compared with the control. Plasma peroxynitrite concentration in NTG-treated group was significantly higher as compared with the control. The negative effects of NTG were significantly suppressed by the co-treatment with tempol, enalapril or valsartan. Conclusions Chronic treatment of rabbits with NTG elicits the impairment of the ACh-stimulated NO production. In addition, the negative effects of NTG might be prevented by the co-treatment with drugs attenuating nitrosative stress. (Circ J 2007; 71: 1473 - 1479)
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  • Petru Liuba, Päivi Karnani, Erkki Pesonen, Ilari Paakkari, Kennet ...
    2007 Volume 71 Issue 9 Pages 1480-1484
    Published: 2007
    Released: August 25, 2007
    JOURNALS FREE ACCESS
    Background Impaired muscarinic receptor-mediated vasodilation is an important feature of early atherosclerosis. Earlier studies on apolipoprotein E-knockout mice (apoE-KO) mice suggested adverse effects of Chlamydia pneumoniae infection on the endothelial vasomotor responses of aortas to the muscarinic agonist methacholine. Using additional aorta samples the present study investigated the responses to bradykinin. Methods and Results ApoE-KO mice were repeatedly inoculated with either Chlamydia pneumoniae (C. pneumoniae) or saline. At 2, 6, and 10 weeks after the first inoculation, precontracted aorta rings from both groups were exposed to bradykinin in the absence and presence of L-NAME and diclofenac. In noninfected animals, the vasomotor responses to bradykinin were similar at all timepoints (p>0.5). Compared with noninfected animals, the responses in infected animals tended to increase through the study period (p<0.05 at 10 weeks). Although diclofenac and L-NAME had no effect in noninfected mice, they inhibited the responses to bradykinin in infected mice at 6 and, more markedly, 10 weeks (p<0.05 for both). Conclusion Bradykinin stimulation of aorta endothelium from C. pneumoniae-infected apoE-KO animals appears to activate compensatory kinin receptor-related mechanisms that could involve nitric oxide and vasorelaxing prostanoids. Although the precise molecular mechanisms require further investigation, one could speculate that strategies increasing bradykinin availability might reverse the arterial dysfunction during chronic infectious disease. (Circ J 2007; 71: 1480 - 1484)
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Case Report
  • Case Report
    Kotaro Oe, Kiyoo Mori, Tetsuo Konno, Takashi Yoneda, Katsushi Ueyama, ...
    2007 Volume 71 Issue 9 Pages 1485-1487
    Published: 2007
    Released: August 25, 2007
    JOURNALS FREE ACCESS
    A 62-year-old woman was admitted to hospital because of nausea. A grade 5/6 continuous murmur was audible near the left sternal border at the second intercostal space. Chest X-ray showed cardiomegaly and bilateral pleural effusion. She was diagnosed as heart failure and a diuretic was prescribed. After remission of the heart failure, echocardiography showed shunt flow from the right coronary cusp to the right ventricle. Aortography revealed that an aneurysm of the right coronary sinus of Valsalva had ruptured into the right ventricle. Coronary angiography revealed a single coronary artery. Chest computed tomography revealed persistent left superior vena cava. Surgical repair was carried out and the patient made an uneventful recovery. In addition to these cardiovascular abnormalities, she had Wildervanck syndrome (Klippel-Feil syndrome, Duane syndrome and sensorineural hearing disturbance), blepharoptosis and short stature. This rare combination has not been reported previously. (Circ J 2007; 71: 1485 - 1487)
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  • One Case With Huge Vegetation
    Eri Miyata, Shinji Satoh, Kosuke Inokuchi, Akemi Aso, Yoshikuni Kimura ...
    2007 Volume 71 Issue 9 Pages 1488-1491
    Published: 2007
    Released: August 25, 2007
    JOURNALS FREE ACCESS
    Staphylococcus aureus (S. aureus) infective endocarditis (IE) is a severe disease with a high mortality despite intensive therapy. Three cases of S. aureus IE had a rapidly progressive fatal clinical course despite intensive antimicrobial therapy. One case was methicillin-sensitive S. aureus IE, which formed rapidly growing a huge vegetation on a prosthetic mitral valve, complicated with multiple systemic emboli. The other 2 cases were methicillin-resistant S. aureus IE without any predisposing heart disease. (Circ J 2007; 71: 1488 - 1491)
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  • Toshiyuki Itoi, Hisashi Satou, Kenji Hamaoka
    2007 Volume 71 Issue 9 Pages 1492-1495
    Published: 2007
    Released: August 25, 2007
    JOURNALS FREE ACCESS
    Coronary artery multiple fistulae of the left ventricular chamber are extremely rare congenital malformations. We report on 13-year-old monozygotic twin brothers who have identical abnormalities of coronary flow reserve as well as the same morphological findings of multiple coronary fistulae of the 3 major coronary arteries to the left ventricular chamber. The left circumflex coronary artery (LCX) had abundant fine communications with the left ventricular chamber and had a higher flow rate than the left anterior-descending coronary artery. The coronary flow reserve obtained from the LCX was lower than the normal value matched for the same age group. The increased shunt flow resulted in enlargement of the left ventricular chamber. This is the first report of coronary flow characteristics in children with multiple coronary fistulae. (Circ J 2007; 71: 1492 - 1495)
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  • Satoru Nishida, Tamotsu Yasuda, Go Watanabe, Yujiro Kikuchi, Yoshiko S ...
    2007 Volume 71 Issue 9 Pages 1496-1498
    Published: 2007
    Released: August 25, 2007
    JOURNALS FREE ACCESS
    This case report presents the robotically assisted multivessel minimally invasive direct coronary artery bypass grafting (MIDCAB) technique using the bilateral internal thoracic arteries. A 54-year-old man with multivessel coronary artery disease was considered eligible for a robotically assisted myocardial revascularization. The bilateral internal thoracic arteries were harvested completely in a totally skeletonized fashion through three 1-2-cm-long incisions on the left thoracic wall. A small left anterior thoracotomy was then performed. The left internal thoracic artery was anastomosed to the left anterior descending coronary artery, and the composite radial artery graft from the right internal thoracic artery was sequentially anastomosed to the first diagonal branch, the obtuse marginal branch, and the distal right coronary artery on the beating heart without cardiopulmonary bypass. The harvesting time of the grafts was 66 min, and the total operative time was 5 h 58 min. Postoperative angiography revealed that all grafts were widely patent. The postoperative course was uneventful, and the patient was discharged 10 days after the operation. Robotically assisted MIDCAB using the bilateral thoracic arteries is a safe and effective means of myocardial revascularization for patients with multivesssel disease. (Circ J 2007; 71: 1496 - 1498)
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