Objective:
In this study, we attempted to analyze the incidence and outcomes of systemic and coronary stent embolizations during percutaneous coronary interventions and have described the treatment and retrieval methods used.
Methods:
We retrospectively studied 24,038 consecutive coronary angiography procedures carried out at The Baskent University Adana Hospital from 1998 to present to determine the total number of stent embolization events.
Results:
Among them, 4,797 were consecutive coronary stent operations and embolization was encountered in 14 cases (0.29%; 95% CI = 0.14-0.44%, P < 0.0001). The mean age of the patients was 61 ± 8 years and 78% were men. Stent embolization occurred more frequently in cases with significant proximal angulation. Calcified lesions were not noted in any of the cases. In 7 out of 14 cases, stent embolization occurred at an unknown location and the clinical course was uneventful thereafter. Treatment and retrieval methods of the other 7 cases included the following:
1. Emergency cardiac bypass surgery (3 cases, 43%)
2. Advancement of a low profile delivery balloon through the stent, inflating the balloon, and replacing the stent at the lesion site (3 cases, 43%)
3. Crushing the stent against the coronary wall using another stent (1 case, 14%)
4. 4-loop snare (1 case, failed)
None of the cases had bleeding that required transfusion. The stent was not crushed or deployed in the coronary artery causing major cardiac complication in any case.
Conclusion:
Systemic and coronary embolizations of stent procedures are rare. Consequences of coronary stent embolization can lead to prompt cardiac bypass surgery if the retrieval or deployment methods fail. Stent deployment or crushing techniques may be attempted before retrieval in patients who do not suffer from coronary thrombosis and myocardial infarction due to stent embolization.

View full abstract

The aim of this study was to compare the initial and long-term outcomes of sirolimus-eluting stents (SES) and bare-metal stents (BMS) in patients with calcified lesions without performing rotational atherectomy.
The subjects were 79 consecutive lesions (38 in the SES group and 41 in the BMS group) which were confirmed to have superficially calcified lesions by intravascular ultrasound. In all lesions, the stent was implanted after predilatation with a balloon.
The patient characteristics were not different between the 2 groups.
All procedures were successfully performed in both groups. Vessel area was significantly smaller in the SES group than in the BMS group (11.01 ± 3.88 mm² versus 13.08 ± 3.49 mm², P < 0.005), as was the lumen area (5.41 ± 2.31mm² versus 6.48 ± 2.04 mm², P < 0.005). Minimum stent area was significantly smaller in the SES group than in the BMS group (5.61 ± 1.54 mm² versus 6.69 ± 1.74 mm², P < 0.01). In cases in whom angiographic follow-ups were performed, the late loss was significantly smaller in the SES group than in the BMS group (0.19 ± 0.49 mm versus 0.76 ± 0.48 mm, P < 0.001). The restenosis rate was significantly lower in the SES group than in the BMS group (8.8% versus 33.3%, P < 0.05) and the TLR rate tended to be lower in the SES group (7.9% versus 19.5%). Stent thrombosis was not observed in either group.
The results suggest that SES are more effective than BMS and can be used safely when treating calcified lesions if predilatation with a balloon is possible.

View full abstract

Adipocyte-derived adiponectin has an antiatherosclerotic effect that acts independently of its antidiabetic effect. Plasma adiponectin levels are generally low in subjects with coronary artery disease. In this study, the relationship between the plasma adiponectin level and the severity of coronary artery disease, as assessed using the Gensini score, an index for the severity of coronary artery stenosis, was investigated. The subjects of the study were 104 patients (72 men and 32 women; BMI, 23.5 ± 3.3 kg/m²; age, 63.6 ± 10.1 years) admitted to Tokyo University Hospital for coronary angiography. Plasma adiponectin levels were inversely correlated with the insulin resistance index HOMA-IR (P = 0.0127). The plasma adiponectin level was significantly associated with the Gensini score (P = 0.0332). After adjustment for conventional risk factors for cardiovascular diseases, the plasma adiponectin level tended to be inversely correlated with the Gensini score (P = 0.087). The measurement of plasma adiponectin levels may be useful for predicting the severity of coronary artery stenosis.

View full abstract

Background:
Ventricular tachyarrhythmia is one of the most important factors determining the prognosis of patients with heart failure and sudden death can be observed even during stable therapy controlling clinical heart failure. In this study, the usefulness of electrophysiologic study (EPS) for the prediction of a future arrhythmic event was evaluated in patients with heart failure.
Methods and Results:
The patient population consisted of 474 patients with a history of clinical heart failure but without an episode of spontaneous sustained ventricular tachycardia or fibrillation (VT/VF). A Holter ECG was performed in all patients, and 177 of the 474 patients underwent EPS because of a recording of nonsustained VT (NSVT, > 5 beats). When sustained VT/VF was inducible in EPS, the patient was assigned to implantation of a defibrillation device. The patients were divided into 3 groups, ie, 1) no NSVT (n = 297), 2) NSVT + no inducible VT/VF (n = 134), and 3) NSVT + inducible VT/VF (n = 43), and were followed-up for > 12 months. All patients were followed-up under standard therapy for heart failure. There were no significant differences in basic clinical characteristics and therapies among the 3 groups. During the follow-up period of 32 ± 18 months, 56/474 patients suffered a VT/VF episode, ie, 21/297 in no NSVT, 14/134 in NSVT + no inducible VT/VF, and 21/43 in NSVT + inducible VT/VF patients (P = 0.032). All patients were rescued from sudden death among patients with an implanted defibrillator, but 11 patients without a defibrillator died.
Conclusion:
In patients with heart failure, future arrhythmic events could be predicted by EPS and Holter ECG. EPS-guided risk stratification seems to be useful in managing patients with heart failure.

View full abstract

The aim of this study was to compare the conventional Doppler echocardiographic parameters before and after accessory pathway ablation in patients with Wolff-Parkinson-White (WPW) syndrome. Thirty patients (19 males, 11 females) aged 35.5 ± 14.4 years were enrolled in the study. All patients underwent successful radiofrequency catheter ablation (RFCA). Echocardiograhic examination was performed before and after RFCA. Aortic and pulmonary flows, diastolic early (E) and late (A) transmitral filling velocities, their velocity time integrals (VTI), mitral diastolic filling time (DFT), deceleration time (DT), isovolumic relaxation time (IVRT), aortic ejection time, and aortic VTI were assessed before and after RFCA. We found that the pulmonary valve opened earlier than the aortic valve when the accessory pathway was located on the right ventricular side (P = 0.02). Otherwise, if the accessory pathway was located on the left ventricular side, the aortic valve opened earlier (P < 0.01). Intervals between the onsets of aortic and pulmonary flows were shortened after RFCA (P = 0.01). We also observed prolongation of DFT (P < 0.001), increases in A velocity (P < 0.05) and its VTI (P < 0.01), as well as a decrease in the E/A ratio (P < 0.01) and shortening of aortic ejection time (P = 0.01) with restoration of AV conduction. We conclude that Doppler echocardiographic examination can provide clues about accessory pathway location and RFCA causes some significant changes in Doppler echocardiographic time intervals. These changes confirm that cardiac synchrony is restored after RFCA.

View full abstract

We evaluated the long-term efficacy of losartan and low-dose hydrochlorothiazide combination therapy in the treatment of hypertension.
We enrolled 15 Japanese hypertensive outpatients whose 24-hour ambulatory blood pressure was ≥ 135/80 mmHg after candesartan 8 mg (CND group; n = 10) monotherapy or amlodipine 5 mg (AML group; n = 5) monotherapy for 2 months or more. The monotherapy was then switched to losartan 50 mg and hydrochlorothiazide 12.5 mg combination therapy. Ambulatory blood pressure and indices of glucose and lipid metabolism were measured at the end of the monotherapy and after 3 and 12 months of the combination therapy.
In the CND group, 24-hour blood pressure decreased significantly from 137 ± 9/89 ± 4 to 126 ± 8/81 ± 7 mmHg after 3 months (P < 0.05/ P < 0.001) and to 123 ± 7/81 ± 4 mmHg after 12 months (P < 0.01/P < 0.001). In the AML group, 24-hour blood pressure decreased significantly from 137 ± 11/81 ± 7 to 125 ± 12/75 ± 6 mmHg after 3 months (P < 0.05/P < 0.05) and to 124 ± 9/77 ± 7 mmHg after 12 months (P < 0.05/NS). There were significant decreases in systolic blood pressure during the daytime (6:00-21:30), nighttime (22:00-5:30) and early morning (6:00-8:00) after 12 months in both groups. No adverse changes in the indices of glucose or lipid metabolism were observed in either group.
In conclusion, long-term combination therapy with losartan and low-dose hydrochlorothiazide was effective in the treatment of hypertensive patients whose blood pressure was not controlled by candesartan or amlodipine monotherapy alone.

View full abstract

Hypertension (HT) increases the risks of major cardiovascular events and affects a majority of elderly populations. Thus, blood pressure control is the mainstay for prevention of cardiovascular diseases. However, there is only a limited number of parameters for management of HT. This study was performed on consecutive patients between the ages of 35 and 70 years with normotension (NT) and HT in order to determine the possible consequences of HT on retinal vasculature and to avoid debility-induced weight loss.
We studied 120 patients (64 females, 54.3 ± 9.3 years) with NT and 147 (81 females, 57.3 ± 11.0 years) with HT. No case of grade III or IV hypertensive retinopathy (HR) was detected in the groups. Although the prevalences of grades I and II HR were higher and grade 0 HR was lower in the hypertensive group, respectively (P < 0.001 for all), differences according to obesity, diabetes mellitus, hypertriglyceridemia (P < 0.001 for all), and dyslipidemia (P < 0.01) were also significant between the 2 groups. Therefore, only 18.3% (27 cases) of the hypertensives, even in whom the effect of aging could not be excluded, had HT only in the absence of any other risk factor of atherosclerosis. Despite the relatively higher specificities of grades III and IV HR for HT, particularly for hypertensive crisis, funduscopic examination has limited benefit in the management of HT due to the very low prevalences of grades III and IV HR, the multifactorial backgrounds of grades I and II HR, and the association of the multiple risk factors of atherosclerosis in a majority of the hypertensive cases.

View full abstract

We have reported that chronic heart failure (HF) patients with increased serum bilirubin coincident with acute decompensation have a poor prognosis, indicating severe congestion and low tissue perfusion. The aim of this study was to analyze the possibility of increased bilirubin coincident with acute decompensation as a parameter which indicates the need for intravenous inotropic agents. We stratified 131 decompensated chronic HF patients with a LVEF ≤ 40% and systolic blood pressure between 90 and 120 mmHg, based on total bilirubin levels on admission. In patients with high bilirubin (T-Bil ≥ 1.2 mg/dL), intravenous inotropics contributed to significantly more abundant diuresis, body weight reduction, and decreases in bilirubin and serum creatinine in the first 5 in-hospital days compared to those without (group A: inotropics +; n = 24 versus group B: -; n = 38: 1726 ± 418 versus 1458 ± 424 mL/day: P < 0.05, -3.1 ± 1.6 versus -2.1 ± 2.2 kg: P < 0.05, -0.74 ± 0.51 versus -0.04 ± 0.60 mg/dL: P < 0.01, -0.29 ± 0.89 versus -0.01 ± 0.24 mg/dL: P < 0.01), in spite of no significant difference in the doses of diuretics between the 2 groups. On the contrary, patients with low bilirubin (T-Bil < 1.2 mg/dL) recovered from decompensation equally irrespective of inotropic administration (group C: inotropics +; n = 15 versus group D: -; n = 54: 1557 ± 329 versus 1507 ± 406 mL/day, -2.9 ± 1.7 versus -2.8 ± 1.5 kg, -0.01 ± 0.25 versus -0.08 ± 0.23 mg/dL, 0.02 ± 0.24 versus 0.47 ± 0.19 mg/dL; NS, respectively). Inotropics were administered after all because of unimproved hemodynamics in 26% of group B patients, compared to 4% of group D patients (P < 0.01). Increased bilirubin coincident with HF decompensation can be a useful marker indicating the need for intravenous inotropic agent administration.

View full abstract

Objective:
Recently, it has been reported that ischemic postconditioning, a brief episode of ischemia-reperfusion performed after prolonged ischemia, can reduce ischemic myocardial injury. However, the effects of ischemic postconditioning on ischemia/reperfusion injury remain unclear. We investigated the effects of brief ischemia-reperfusion before (ischemic preconditioning) and after (ischemic postconditioning) prolonged ischemia on myocardial ischemia/reperfusion injury, especially reperfusion arrhythmias.
Methods:
Adult male Sprague-Dawley rats weighing about 400-500 g were used. The isolated heart was perfused using a working heart method (Krebs-Henseleit bicarbonate buffer). In the control group, after stabilization, diastolic global ischemia for 15 minutes was produced by a one-way ball valve with electrical pacing (330 bpm, 2.0 V). After ischemia, the heart was reperfused for 20 minutes. In the preconditioning and postconditioning groups, 5-minute global ischemia was produced before and after ischemia for 15 minutes with a 1 minute interval. An electrocardiogram was performed and left ventricular pressure (LVP, +dP/dt, -dP/dt) and CK activity in coronary effluent were measured during the protocol.
Results:
Ischemic preconditioning did not affect the incidence or duration of reperfusion ventricular arrhythmias. Ischemic postconditioning could terminate reperfusion ventricular arrhythmias completely and reduced the duration of reperfusion ventricular arrhythmias significantly (P < 0.01). Furthermore, the recovery ratio of +dP/dt at 20 minutes after initial reperfusion was significantly higher in the postconditioning group than in the other groups.
Conclusion:
These results suggest that ischemic postconditioning can terminate reperfusion arrhythmias with no reduction of cardiac function, and may be useful for correcting stunned myocardium.

View full abstract

A decrease in myocardial intracellular calcium concentration ([Ca²⁺]_i) precedes relaxation, and a monoexponential function is typically used for fitting the decay of the Ca²⁺ transient. However, a logistic function has been shown to be a better fit for the relaxation force curve, compared to the conventional monoexponential function. In the present study, we compared the logistic and monoexponential functions for fitting the [Ca²⁺]_i declines, which were measured using the aequorin method, and isometric relaxation force curves at 4 different onsets: the minimum time-derivative of [Ca²⁺]_i (d[Ca²⁺]_i/dt _min) and force (dF/dt_min), and the 10%, 20% and 30% lower [Ca²⁺]_i levels and forces over the data-sampling period in 7 isolated rabbit right ventricular and 15 isolated mouse left ventricular papillary muscles. Logistic functions were significantly superior for fitting the [Ca²⁺] _i declines and relaxation force curves, compared to monoexponential functions. Changes in the normalized logistic [Ca²⁺] _i decline and relaxation force time constants at the delayed onsets relative to their 100% values at d[Ca²⁺] _i/dt_min and dF/dt_min were significantly smaller than the changes in the normalized monoexponential time constants. The ratio of the logistic relaxation force time constant relative to the logistic [Ca²⁺]_i decline time constant was significantly smaller in mouse than in rabbit. We conclude that the logistic function more reliably characterizes the [Ca²⁺]_i decline and relaxation force curve at any onset, irrespective of animal species. Simultaneous analyses using the logistic model for decay of the Ca²⁺ transient and myocardial lusitropism might be a useful strategy for analysis of species-specific myocardial calcium handling.

View full abstract

The integrity of myocardial structures plays a crucial role in signal transductions and cardiac function. The aim of this study was to test the hypothesis that diabetes mellitus (DM) exerts adverse effects on the integrity of gap junctions (GJs) and induces cellular apoptosis in rat cardiomyocytes that can be abolished by simvastatin or losartan therapy. An experimental model of DM (induced by streptozocin 60 mg/kg body weight) in adult male rats (n = 24) was utilized to investigate the integrity of GJs containing connexin43 (Cx43) and the incidence of cellular apoptosis in the left ventricular myocardium. These rats were divided into 3 groups; group I (insulin therapy only), group II (insulin plus simvastatin 20 mg/kg/day), and group III (insulin plus losartan 20 mg/kg/day). Diabetic rats and 8 healthy rats (group IV) were sacrificed at 3 weeks following DM induction for immunofluorescence analysis. The experimental results demonstrated that the number of intact Cx43 GJs and the integrated area (μm²) constituted by clusters of Cx43 spots were significantly higher in groups II and IV than in group III, and in groups II-IV than in group I (all P values < 0.05). Additionally, the number of apoptotic bodies was remarkably higher in group I than in groups II-IV, and notably higher in groups II-III than in group IV (all P values < 0.05).
Simvastatin is more effective than losartan at inhibiting the effects of DM on the integrity of myocardial ultrastructures. Both drugs effectively prevent cellular apoptosis in diabetic rat heart.

View full abstract

Background:
Symptomatic prolonged sinus pauses upon termination of atrial fibrillation (AF) are an indication for pacemaker implantation.
Methods and Results:
We evaluated the clinical outcomes of 4 patients who showed prolonged sinus pauses (> 2 seconds) upon termination of AF and thus underwent ablation. The ablative procedure included pulmonary vein isolation, superior vena cava isolation, and cavo-tricuspid isthmus ablation. Twenty-four-hour ambulatory electro-cardiogram monitoring was performed before and 1 month after ablation. The maximum sinus pause decreased from 4.5 ± 2.1 seconds before ablation to 1.7 ± 0.2 seconds after ablation. Sinus pauses > 2.0 seconds disappeared after ablation in all 4 patients. Minimum heart rate increased from 35.0 ± 8.1 beats/minute before ablation to 52 ± 6.7 beats/minute after ablation. The number of heart beats in 24 hours did not change significantly after ablation.
Conclusion:
Prolonged sinus pauses after paroxysmal AF may result from depressed sinus node function, which can be eliminated by curative ablation of AF.

View full abstract

Supraventricular tachycardia (SVT) was observed in a 13-year-old male patient with complex clinical features that included univentricular heart with single atrium, pulmonary atresia, and polysplenia syndrome. During electrophysiologic study, atrial burst stimuli reproducibly induced and terminated the SVT, while the occurrence of ventriculoatrial block did not interrupt the SVT. His bundle electrograms (HBEs) were recognized both in the anterior and posterior regions on the common atrioventricular (AV) valve annulus. The posterior His bundle activation was progressively delayed along with the shortening of atrial pacing cycle length until it finally lagged behind local ventricular activation. Thus, antegrade AV conduction was solely via the anterior AV node. In contrast, during the SVT, the earliest activation was observed in the posterior HBE. These observations suggested that the posterior AV node serves as an origin of the SVT and that two AV nodes were linked together possibly through a sling at the infra-Hisian level. Radiofrequency catheter ablation applied to the posterior HBE eliminated the SVT.

View full abstract

Univentricular heart is a rare and complex congenital disease. Its prognosis is usually poor without surgical intervention and long-term survival into adulthood is rare. We report a 41-year-old man with a double inlet left ventricle with pulmonary stenosis and a parachute mitral valve verified by echocardiography and magnetic resonance imaging (MRI).

View full abstract

We report a rescued 37-year-old woman in her 30^th week of gestation with massive pulmonary thromboembolism who was admitted to our cardiac care unit with progressive dyspnea and 2 episodes of syncope. Helical chest CT showed massive pulmonary thromboembolism of both pulmonary arteries. Although 26,000 U/day of heparin was administered following insertion of a temporary filter, hemodynamic evaluation documented no improvement. Since pulmonary artery (PA) pressure increased from 62/22 mmHg to 80/24 mmHg just after an emergency cesarean section on day 2, an emergency transcatheter thrombectomy was performed and it showed decreased PA pressure following extensive thrombus aspiration. Mother and baby were discharged with no complications.

View full abstract