The present study attempted to detect the viability of myocardium by quantitative automatic 3-dimensional analysis of the improvement of regional wall motion using an magnetic resonance imaging (MRI) tagging method. Twenty-two subjects with ischemic heart disease who had abnormal wall motion on echocardiography at rest were enrolled. All patients underwent dobutamine stress echocardiography (DSE), coronary arteriography and left ventriculography. The results were compared with those of 7 normal volunteers. MRI sstudies were done with myocardial tagging using the spatial modulation of magnetization technique. Automatic tracing with an original program was performed, and wall motion was compared before and during dobutamine infusion. The evaluation of myocardial viability with MRI and echocardiography had similar results in 19 (86.4%) of the 22 patients; 20 were studied by positron emission tomography or thallium-201 single photon emission computed tomography for myocardial viability, or studied for improvement of wall motion following coronary intervention. The sensitivity of dobutamine stress MRI (DSMRI) with tagging was 75.9% whereas that of DSE was 65.5%. The specificity of DSMRI was 85.7% (6/7) and that of DSE was 100% (7/7). The accuracy of DSMRI was 77.8% (28/36) and that of DSE 72.2% (26/36). DSMRI was shown to be superior to DSE in terms of evaluation of myocardial viability.

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The strong association between severe coronary stenosis and collateral growth continues to be a paradigm in this field of investigation. The present study was based on the hypothesis that angiogenic growth factors are produced by ischemic cardiac tissue, are diffusible and more concentrated in pericardial fluid, and accelerate the growth of vascular smooth muscle cells (VSMC). Pericardial fluid from 17 patients with stable or unstable angina or acute myocardial infarction (group A) and from 10 patients with nonischemic heart disease (group B) were collected at the time of open heart surgery. Cultured human aortic VSMC were plated at the third passage at a density of 5×10³/100μl and allowed to attach for 24h. The 3-day growth assay was preceded by 72h of growth arrest with 0.4% fetal calf serum (FCS). Growth was restarted by the addition of 90μl of medium containing 0.4% FCS, and 10μl of each pericardial fluid. Cell counts on triplicate wells were performed using a dimethylthiazol (MTT) method on days 0 and 3. The effect of pericardial fluid on the growth of VSMC was evaluated as a ratio (R) of cell numbers on day 3 to those on day 0. The concentration of basic fibroblast growth factor (bFGF) in pericardial fluid was measured by an enzyme-linked immunosorbent assay. The concentration of bFGF in pericardial fluid of group A was 633±127 pg/ml, and significantly (p=0.003) higher than that of group B (86±23 pg/ml). R in group A was 2.29±0.18 and significantly (p=0.019) higher than that in group B (1.68±0.11). The level of bFGF positively correlated with R (p=0.009). These findings indicate that pericardial fluid from patients with ischemic heart disease contains some substances that mediate collateral development, and bFGF might be one of them.

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To evaluate the behavior of cardiac arrhythmias in dipper and nondipper hypertensive patients, 48-h ambulatory blood pressure monitoring, 24-h Holter electrocardiogram recording and echocardiographic studies were performed in 56 untreated outpatients with essential hypertension. These patients were divided into 2 groups according to the presence (dipper, n=33) or absence (nondipper, n=23) of reduction of both systolic and diastolic blood pressure during nighttime by an aerage of more than 10% of daytime blood pressure. Mean 48-h systolic and diastolic blood pressures did not differ between the 2 groups. Nondipper patients had a significantly larger left atrial dimension (31.9±3.8 vs 35.6±3.7mm; p<0.01), left ventricular mass index (114±26 vs 136±36g/m²; p<0.05), as well as a larger number of total supraventricular (16±19 vs 89±197 beats; p<0.05) and ventricular ectopic beats (7±14 vs 47±96 beats; p<0.05) during daytime as compared with dippers. In conclusion, nondipper hypertensive patients are likely to experience supraventricular and ventricular arrhythmias more frequently than dippers. A blunted nocturnal blood pressure fall may be involved in the appearance of cardiac arrhythmias in patients with essential hypertension.

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Atrial flutter (AF) is a troublesome arrhythmia for patients with an implanted pacemaker. Although it has recently become possible to eliminate AF by radiofrequency catheter ablation (RF-CA), the incidence of AF before and after pacemaker implantation has not been clarified. The present study was conducted with 123 consecutive patients (69.3±11.6 (SD) years old) implanted with pacemakers, excluding patients who had chronic atrial fibrillation (AFib) when the pacemaker was implanted; 69 patients with atrioventricular (AV) block and 54 patients with sick sinus syndrome (including 29 patients with bradycardia-tachycardia syndrome). All patients were implanted with physiological pacemakers. The follow-up period was 4.7±1.9 years. In 11 of the 123 patients (8.9%), AF was observed before pacemaker implantation and the incidence was significantly higher in patients with sick sinus syndrome than in those with AV block (16.7 vs 2.9%, p<0.01). Nine of the 29 patients with bradycardia-tachycardia syndrome (31%) had AF. After physiological pacemaker implantation, AF recurred in 9 of the 11 patients, and AF was newly observed in 1 patient. Thus, 10 of the 123 patients (8.1%) had AF after physiological pacemaker implantation. Recurrence of AF was not suppressed by physiological pacing. Thirty of the 123 patients had AFib before implantation of a pacemaker and its occurrence was reduced by physiological pacing (from 24.4% to 12.2%, p<0.05). The incidence of AFib in patients with AF was significantly higher than in those without AF (90.0 vs 5.3%, p<0.001). In conclusion, the recurrence of AF is not prevented by physiological pacing and is closely related to the occurrence of AFib. RF-CA should be considered in patients who have AF before pacemaker implantation.

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To evaluate the pump function of the ventricle, a parameter which (i) incorporates systolic and diastolic function and (ii) separates the heart from preload and afterload is needed. This study utilized ejection fraction (EF), calculated from the end-systolic (ES) and end-diastolic (ED) pressure-volume relationship (PVR) using an arbitrary set of loading conditions. Ten isolated canine hearts with a balloon placed inside the left ventricle were used to determine the ESPVR and EDPVR. An end-diastolic volume (EDV) at a pressure of 15mmHg and an end-systolic volume (ESV) at 70 mmHg were obtained from the EDPVR and ESPVR, respectively. EF was calculated as (EDV-ESV)/EDV. With low-dose (8μg/min) and high-dose (40μg/min) dobutamine infusion, the EF increased from 0.25±0.16 to 0.33±0.13 and 0.57±0.08 (p<0.01), respectively, in conjunction with increases in end-systolic elastance from 3.11±0.83 to 3.48±1.08 and 5.38±1.91 mmHg/ml (p<0.01). It was thus concluded that because the estimation of EF separates the heart from preload and afterload, this method may facilitate comparing overall pump function of hearts beating under different loading conditions.

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Thrombosis associated with atrial fibrillation (AF) is usually caused by a left atrial (LA) thrombus, but it is not always detected. The present study was based on the hypothesis that abnormalities in peripheral artery are responsible for the ischemic stroke associated with AF. Peripheral arterial coagulability was investigated in a rabbit experimental model in which AF was induced by high-frequency stimulation of the right atrium, creating stenosis of the carotid artery together with endothelial damage. The rabbits were classified into 4 groups: (i) sinus rhythm only (group 1), (ii) sinus rhythm after 6h of pacing (group 2), (iii) short AF (continuous pacing for 5min; group 3) and (iv) long AF (continuous pacing for 6h: group 4). The carotid blood flow developed a typical pattern, called cyclic flow reductions (CFRs), the frequency of which (CFRF) was 18.59±2.85 in AF (group 3+4) compared with 14.46±2.1 in sinus rhythm (group 1+2) (p<0.0005). Among the groups with AF, correlation analysis showed an association between CFRF and pulse dispersion (p<0.02, r=0.58). This study suggests that the distinctive hemodynamic effects with AF, in particular pulse dispersion, substantively influence thrombus formation on injured vascular endothelium.

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Coil occlusion of a patent ductus arteriosus (PDA) was attempted with a 0.052-inch Gianturco coil. The patients’ages and body weights at occlusion ranged from 5.8 to 19.7 (12.3±5.0, mean±SD) years and 18.9-99.1 (44.8±23.7) kg, respectively. Three types of 0.052-inch Gianturco coils with loop diameters (mm) and coil lengths (cm) of 6×8 (diameter×length), 8×8, or 8×10 were used. The delivery system was prepared as reported by Hays et al with slight modification. The minimal diameter and the Qp/Qs of the PDA ranged from 2.3 to 4.7 (3.4±0.7) mm, and 1.1-1.8 (1.5±0.3), respectively. There were 7 cases with type A PDA and 3 with type B, and coils were successfully deployed in all. Complete occlusion in the catheter laboratory was achieved in 4 cases. A minor leak disappeared within 24h in 3 cases and at 3 months follow-up in 1 case. A tiny leak without a heart murmur persisted in 2 cases at 3 months’ follow-up. No procedure-related complications occurred. This technique has significant advantages over previously reported techniques using a 0.038-inch coil for type B, or A PDA with a minimal diameter of 3-4 mm or more.

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A 50-year-old woman with rest angina underwent cardiac catheterization; coronary angiography in the presence of acetylcholine revealed 99% coronary spasm of the proximal left anterior descending artery. The patient’s 82-year-old mother was also admitted to hospital with rest angina. Her Holter electrocardiogram showed ST-segment elevation during the attack at rest and coronary angiography showed 99% spasm of the right coronary artery and 90% spasm of the left coronary artery. Both women complained of chest pain during the spasm, which was accompanied by ST-segment depression. The 62-year-old brother of the original patient was also found to have coronary spasm of the left coronary artery. Human leukocyte antigen was analyzed in the 2 women: A2, B51, CW1, DR8 and DQ1 were common factors. A Glu298Asp point mutation of the endothelial nitric oxide synthase gene was investigated in both parents, their 2 daughters and 2 sons, but was not detected in the 3 patients, and was detected only in the 90-year-old father who did not suffer from angina. Nor was the T^-786→C mutation found in the 3 cases. Other causes of familial spasm need to be elucidated.

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Two patients had percutaneous cardiopulmonary support (PCPS) used as a bridge to emergency surgery. A 66-year-old man admitted with profound cardiogenic shock underwent direct stenting under PCPS with the diagnosis of acute myocardial infarction of the left main trunk, with the intention of performing revasculization as soon as possible. Subsequently, double coronary artery bypass grafting was successfully accomplished. A 69-year-old woman, admitted with acute heart failure due to critical aortic stenosis, manifested cardiogenic shock while undergoing catheterization. PCPS was immediately instituted until the acute deterioration of her hemodynamic state could be reversed, and was continued uneventfully till aortic valve replacement was performed. These results suggest that the current PCPS system is an effective response to acute circulatory collapse and will contributed to the improved survival of patients.

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A 36-year-old female was admitted for severe chest pain followed by profound shock. Electrocardiography showed severe ST segment depression (0.5-0.7 mV) in all leads except aV_R and aV_L. Echocardiography revealed an intimal flap in the ascending aorta and coexisting grade 3 aortic regurgitation. She was immediately intubated and transferred to the intensive care unit. Transesophageal echocardiography (TEE) demonstrated an intimal tear at 2 cm above the sinotubular junction, and the ostium of the left main trunk was oppressed by the intimal flap during diastole. Emergency graft replacement of the ascending aorta and aortic hemiarch concomitant with aortic valve resuspension was performed successfully. The ECG changes reversed to normal immediately after the operation. The patient was extubated 2 days postoperatively and discharged from the hospital 14 days postoperatively. TEE is useful for the rapid evaluation of coronary malperfusion as a complication of acute aortic dissection, especially in patients with hemodynamic instability.

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Two cases of atrial standstill are presented, one with cardiac amyloidosis, the other with idiopathic dilated cardiomyopathy. The plasma atrial natriuretic peptide (ANP) concentration was normal to slightly elevated in both patients, despite a marked elevation of the plasma brain natriuretic peptide (BNP) concentration. In the patient with amyloidosis (ANP: 170 pg/ml, BNP: 1220 pg/ml), a dual chamber pacemaker was successfully implanted for the treatment of sinus arrest. However, loss of atrial capture occurred 1 month later. In the patient with dilated cardiomyopathy (ANP: 47 pg/ml, BNP: 422 pg/ml), an electrophysiologic study confirmed persistent atrial standstill and failure to pace from either the right atrium or the coronary sinus. The hypothesis is that the attenuated increase in plasma ANP concentration relative to the increase in the BNP concentration may be a sensitive and useful marker to confirm atrial standstill in the setting of congestive heart failure.

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The antiphopholipid-antibody syndrome is associated with an increased incidence of arterial and venous thrombosis. Although renal infarction has been observed in these patients, stenotic lesions of the renal artery associated with the antiphospholipid-antibody syndrome have not been reported. A 47-year-old male with a history of hypertension for 7 years developed blurred vision secondary to thrombotic occlusion of the central retinal artery. Laboratory and radiologic examinations revealed renal dysfunction, a positive anticardiolipin antibody, and narrowing of the right renal artery. Successful percutaneous transluminal renal artery angioplasty resulted in normalization of the blood pressure and recovery of renal function.

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Cervical aortic arch is a very rare malformation and is occasionally accompanied by other cardiovascular anomalies. A 48-year-old male patient had a left cervical aortic arch with aortic coarctation and saccular aneurysm distal to the coarcted segment. The major clinical manifestations were upper body hypertension with a 50-mmHg discrepancy between the upper and lower limbs and a loud continuous murmur in the upper chest and back. Magnetic resonance angiography successfully depicted the anomalous aorta, and the aortic coarctation and aneurysm were surgically resected and the thoracic aorta was reconstructed. The discrepancy in blood pressure diminished after the operation, but antihypertensive medication was continued to satisfactorily control the hypertension.

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