Objective: Coronary artery disease (CAD) involves repeated transient ischemia and reperfusion in the myocardium that produces reactive oxygen species causing bilirubin oxidation and biopyrrins production. This study investigates the urinary-biopyrrin (u-biopyrrin) levels of CAD patients, to assess their utility as a parameter for CAD assessment. Materials and Methods: We retrospectively analyzed 32 CAD patients, 11 non-CAD patients, and 5 post-revascularization patients (PRP). The 32 CAD patients were further divided into subgroups based on the number of vessels involved, namely, 3- or 2-vessel disease (VD) (n=25 and 7, respectively) and the type of myocardial ischemia symptom, namely, unstable angina pectoris (UAP), effort angina pectoris (EAP), or silent myocardial ischemia (SMI) (n=9, 14, and 9, respectively). Participant data were compared between each group. To compare the association between the severity of CAD and u-biopyrrin value, the severity of CAD was evaluated using SYNTAX I and SYNTAX II scores. Results: The u-biopyrrin levels were higher in the CAD group than in the non-CAD and PRP groups. There was no significant difference in u-biopyrrin value between the 3-VD and 2-VD patients, or among UAP, EAP, and SMI patients. The anatomical and clinical severity scores indicated by SYNTAX I and II scores were moderately correlated with u-biopyrrin levels and treatment risk in the receiver operating characteristic curve analysis, the u-biopyrrin level showed a cut-off value of 2.1 mmol/g.cre (AUC, 0.739; sensitivity, 43.75%; specificity, 93.75%). Conclusions: The u-biopyrrin levels were greater in CAD patients than in non-CAD and PRP patients. U-biopyrrin levels moderately correlated with the anatomical and clinical severity of CAD.

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Objectives: Paroxysmal atrial fibrillation (PAF) is observed in some certain patients with acetylcholine (ACh) testing. However, it is uncertain for the reproducibility of ACh-induced PAF. We investigated the reproducibility of occurrence of ACh-induced PAF. Methods: We retrospectively investigated the reproducibility of occurrence of PAF in 70 patients who had ACh testing two times apart from at last one month. Incremental intracoronary injection of ACh into the right coronary artery was 20, 50, and 80 µg, while incremental dose of ACh into the left coronary artery was 20, 50, 100, and 200 µg. Positive provoked spasm was defined as > 90% transient narrowing with ischemic ECG changes or chest symptoms. Results: Among 70 patients, concordance was observed in 59 patients including 50 patients with both sinus rhythm and 9 patients with both positive PAF. The remaining 11 patients had discordance between the first and the second ACh tests. There were no clinical and angiographical differences except organic stenosis between the first and second ACh testing. All 70 patients had neither past PAF nor future PAF. The rate of coincidence was 84%, while discordance was 16%. ACh-inducible PAF was reproduced in 45% of patients who had two times of ACh testing, while the remaining 55% of patients revealed the discordance of ACh-inducible PAF. Conclusions: Less than half patients disclosed the reproducibility of ACh-inducible PAF.

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Papillary muscle rupture is a rare but devastating complication following acute myocardial infarction (AMI). It should be treated with early stabilization of the circulation and early surgery. Here, we report two cases of papillary muscle rupture following AMI with different outcomes. In patient 1, a 78-year-old man was diagnosed with AMI. He presented with hypotension and hypoventilation. Transthoracic echocardiography (TTE) showed moderate mitral regurgitation (MR). Emergency coronary angiography (CAG) demonstrated 90% stenosis of the right coronary artery (RCA) and 100% obstruction of the left circumflex artery. Coronary revascularization was performed before the surgical procedure. The patient died 49 days after cardiac surgery. In patient 2, a 65-year-old man was transferred to our hospital with dyspnea and shock. TTE showed severe MR. CAG showed a dominant RCA without stenosis, left ascending artery with 90% stenosis, and left circumflex artery with 100% obstruction. Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) was established, and emergent surgery was performed without coronary revascularization. The patient was discharged 12 weeks after surgery. Thus, early introduction of mechanical circulatory support and early surgery could be significant in achieving a better outcome.

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