JAPANESE CIRCULATION JOURNAL
Online ISSN : 1347-4839
Print ISSN : 0047-1828
ISSN-L : 0047-1828
Volume 65, Issue 11
Displaying 1-17 of 17 articles from this issue
Clinical Investigation
  • Takashi Washizuka, Masaomi Chinushi, Minoru Tagawa, Hidehiro Kasai, Hi ...
    Article type: None
    Subject area: None
    2001 Volume 65 Issue 11 Pages 927-930
    Published: 2001
    Released on J-STAGE: October 25, 2001
    JOURNAL FREE ACCESS
    The study prospectively investigated the incidence, cause and efficient management of inappropriate discharge by the fourth generation implantable cardioverter-defibrillator (ICD) system in 45 patients (mean age, 57±16 years). During the follow-up period of 27±17 months, 18 patients (40%) experienced one or more inappropriate therapies: sinus and supraventricular tachycardia (15 patients) and T wave oversensing (3 patients). In the 15 patients, re-programming of the tachycardia detection interval and/or additional treatment with β-blocking agents were effective. In the 3 patients with T wave oversensing, the arrythmia was associated with an increase in T wave amplitude, change in T wave morphology and decreased R wave amplitude, and re-programming of the sensitivity of the local electrogram or changing the number of intervals to detect ventricular tachycardia decreased the number of inappropriate discharges in all 3 patients. In conclusion, inappropriate therapies are common problems in patients treated with the fourth generation ICD system, but most of them can be resolved using the dual-chamber ICD system. However, in patients with T-wave oversensing, it is difficult to avoid inappropriate discharge completely, even if the dual-chamber ICD system is implanted. (Jpn Circ J 2001; 65: 927 - 930)
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  • Keiji Hirooka, Yoshio Yasumura, Yoshio Ishida, Akihisa Hanatani, Satos ...
    Article type: None
    Subject area: None
    2001 Volume 65 Issue 11 Pages 931-936
    Published: 2001
    Released on J-STAGE: October 25, 2001
    JOURNAL FREE ACCESS
    The efficacy of treating dilated cardiomyopathy with metoprolol was compared with that of carvedilol. Metoprolol was administered to 29 patients, and carvedilol to 62. Patients who could not be dosed with up to 40 mg daily of metoprolol or 20 mg daily of carvedilol were defined as intolerant. As well as the tolerability of these β-blockers, the effects on left ventricular end-diastolic dimension (LVDd), fractional shortening (FS), plasma atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) concentrations, the delayed heart and mediastinum (H/M) ratio determined from metaiodobenzylguanidine imaging were compared. Drug intolerance occurred in 24% of patients in the metoprolol group and 19% in the carvedilol group. Among the drug-tolerant patients, LVDd, FS and plasma BNP concentration improved in both groups and to the same degree. Only 25% of drug-tolerant patients in the metoprolol group had a delayed H/M ratio below 1.9 compared with 57% in the carvedilol group. Both metoprolol and carvedilol, when tolerated, improve cardiac function and neurohumoral factors to the same degree. However, carvedilol is preferable to metoprolol for patients with a low delayed H/M ratio. (Jpn Circ J 2001; 65: 931 - 936)
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  • Takeshi Itagaki, Yoshio Ohnishi, Tomoo Inoue, Mitsuhiro Yokoyama
    Article type: None
    Subject area: None
    2001 Volume 65 Issue 11 Pages 937-940
    Published: 2001
    Released on J-STAGE: October 25, 2001
    JOURNAL FREE ACCESS
    The linking phenomenon is an electrophysiological phenomenon of conduction between 2 different pathways, such as bundle branches, atrioventricular node (AVN) and accessory pathways. The present study used electrophysiological studies to investigate this phenomenon in 14 patients with dual AVN pathways. Decremental ramp pacing at intervals of 10 ms was carried out in high right atrium until the atrio-His (A-H) interval was abruptly prolonged (onset), then subsequent incremental ramp pacing at intervals of 10 ms proceeded until the A-H interval abruptly shortened (offset). The linking window (LW) was defined as the difference between the paced cycle lengths of the offset and the onset. The linking phenomenon occurred in 9 patients (64%). The onset depended on the functional refractory period of the fast pathway and once the linking was established in the dual pathways, the LW was related to the difference between the A-H interval immediately before and after the restoration of anterograde fast pathway conduction. These findings suggest that the linking phenomenon in dual AVN pathways occurs because of anterograde conduction block in the fast pathway and the subsequent concealed retrograde conduction of impulses propagated from the slow pathway. (Jpn Circ J 2001; 65: 937 -940)
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  • Jun Watanabe, Kaoru Iwabuchi, Yoshito Koseki, Mitsumasa Fukuchi, Tsuyo ...
    Article type: None
    Subject area: None
    2001 Volume 65 Issue 11 Pages 941-946
    Published: 2001
    Released on J-STAGE: October 25, 2001
    JOURNAL FREE ACCESS
    The case-fatality rate from acute myocardial infarction (AMI) appears to have been declining in recent decades, so the present study reviewed the trend in in-hospital case-fatalities from AMI in Miyagi Prefecture, Japan, 1980-1999. The causes of death and the effects of gender and age on the trend were also analyzed. From the AMI registration database of the Miyagi Study Group for AMI, 12,961 cases of AMI were analyzed. The 30-day in-hospital case-fatality was calculated from the data for 1980-1999: data for causes of death were available for 1980-1997, and the data concerning primary percutaneous transluminal coronary angioplasty (PTCA) for AMI were available for 1997-1999. The in-hospital case-fatality rate declined from 17.0% in the early 80s to 7.3% in the late 90s (approximately 57% reduction). The in-hospital case-fatality rate was higher in female patients. Rhythm failure substantially decreased in the late 1980s. Pump failure is decreasing, but is still the biggest problem. The in-hospital case-fatality rate was significantly lower in patients received PTCA. The declining trend in the in-hospital case-fatality rate suggests the benefits of current therapeutic procedures, including primary PTCA, for AMI. Pump failure is an important target for further decreasing the trend. (Jpn Circ J 2001; 65: 941 - 946)
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  • Michinori Imazu, Kotaro Sumii, Hideya Yamamoto, Mamoru Toyofuku, Tomok ...
    Article type: None
    Subject area: None
    2001 Volume 65 Issue 11 Pages 947-952
    Published: 2001
    Released on J-STAGE: October 25, 2001
    JOURNAL FREE ACCESS
    The present study evaluated whether hyperinsulinemia is a predictor of restenosis after coronary balloon angioplasty in 69 patients who underwent elective coronary balloon angioplasty; patients were excluded if they were known diabetics being treated with insulin. Quantitative coronary angiography was performed before and after angioplasty and at follow-up. Restenosis was defined as the presence of ≥50% stenosis at follow-up. Plasma insulin responses before, 30, 60, and 120 min after 75 g glucose load (OGTT) were measured. Plasma insulin levels were higher in patients with restenosis than in patients without restenosis. Minimal lumen diameter at follow-up was smaller, and percent diameter stenosis at follow-up was higher and late loss was greater in the highest sum of insulin levels during OGTT (Σ insulin) quartile (0.95±0.15 vs 1.47±0.09 mm, p=0.005; 66.3±5.8 vs 40.5±3.3%, p=0.0003; 0.90±0.15 vs 0.49±0.08 mm, p=0.02). Even after adjustment for coronary risk factors and administration of angiotensin converting enzyme inhibitors, the association of hyperinsulinemia with restenosis leads to the conclusion that hyperinsulinemia is a strong risk factor for restenosis. (Jpn Circ J 2001; 65: 947 -952)
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  • Fumiaki Nakao, Yuichiro Wasaki, Masayasu Kimura, Takahiro Iwami, Hiros ...
    Article type: None
    Subject area: None
    2001 Volume 65 Issue 11 Pages 953-957
    Published: 2001
    Released on J-STAGE: October 25, 2001
    JOURNAL FREE ACCESS
    The objective of this study was to clarify the left atrial (LA) reservoir and booster pump function in patients with left ventricular (LV) diastolic dysfunction. To determine LA reservoir and booster pump function, a new algorithm to determine LA functional volume change curve (FVC) was developed from Doppler flow spectra of pulmonary venous flow and LV inflow by transthoracic echocardiography in 110 patients. Patients were classified into normal (N), and abnormal (AB) and pseudonormal (PN) groups on the basis of their Doppler flow patterns. From the indices of FVC, atrial reservoir volume (ARV), passive emptying volume (PEV) and active emptying volume (AEV) were obtained. ARV/stroke volume (SV) was increased in the AB group, but decreased in the PN group compared with N (N, 0.61 ±0.09; AB, 0.73±0.10; PN, 0.52 ±0.13, p<0.05). PEV/SV was significantly decreased in AB, but increased in PN compared with N (N, 0.27±0.07; AB, 0.19±0.07; PN, 0.31±0.18, p<0.05). AEV/SV was significantly increased in AB, but decreased in PN compared with N (N, 0.41±0.08; AB, 0.56±0.10; PN, 0.26±0.19, p<0.05). Thus, in patients with an abnormal relaxation pattern, the LA reservoir and booster pump function are augmented, but in patients with a pseudonormal pattern, both LA reservoir and booster pump function are deteriorated, suggesting a vulnerability to pulmonary congestion. (Jpn Circ J 2001; 65: 953 - 957)
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  • Tsuyoshi Shiga, Michi Wakaumi, Naoki Matsuda, Morio Shoda, Nobuhisa Ha ...
    Article type: None
    Subject area: None
    2001 Volume 65 Issue 11 Pages 958-960
    Published: 2001
    Released on J-STAGE: October 25, 2001
    JOURNAL FREE ACCESS
    In 232 Japanese patients receiving long-term amiodarone therapy for life-threatening ventricular tachyarrhythmias, hyperthyroidism and hypothyroidism developed in 29 patients (12.5%) and 25 patients (10.8%), respectively. In patients with hyperthyroidism, the recurrence of sustained ventricular tachycardia was significantly higher with thyrotoxicosis than in the euthyroid period (31% vs 3%, p<0.01). Holter monitoring showed that the average heart rate and ventricular premature complexes significantly increased with hyperthyroidism. On the other hand, there was no increase in the recurrence of ventricular tachyarrhythmia with hypothyroidism. There was no change in the dose or the plasma concentration of amiodarone or desethylamiodarone in the euthyroid period or when hyperthyroidism or hypothyroidism manifested. It is important to monitor for arrhythmia when hyperthyroidism develops during amiodarone therapy. (Jpn Circ J 2001; 65: 958 - 960)
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  • Makoto Kodama, Hirotaka Oda, Masaaki Okabe, Yoshifusa Aizawa, Tohru Iz ...
    Article type: None
    Subject area: None
    2001 Volume 65 Issue 11 Pages 961-964
    Published: 2001
    Released on J-STAGE: October 25, 2001
    JOURNAL FREE ACCESS
    The frequency of myocarditis and the prognosis for patients remains uncertain and, moreover, the clinical classification of myocarditis is controversial. From 1985 to 2000, 71 adult patients with clinically suspected myocarditis were admitted to 11 cardiovascular centers. Of these, 48 cases had histology proven myocarditis: 41 cases of lymphocytic myocarditis, 6 of giant cell myocarditis and 1 of eosinophilic myocarditis. Myocarditis was classified as acute (30 cases) or chronic (18 cases) according to the onset of the disease, and acute myocarditis was further categorized into common or fulminant type depending on whether or not patients required mechanical circulatory support in the management of heart failure (9 and 21 cases, respectively). Chronic myocarditis was divided into 3 subgroups: a persistent type lasting over 3 months after distinct onset (3 cases), a recurrent type (2 cases) and a latent form (13 cases). The early mortality of these 5 subtypes of myocarditis were acute common 22%, acute fluminant 43%, chronic persistent 33%, chronic recurrent 50%, and chronic latent 38%. The overall early mortality of all patients with myocarditis was 38% in spite of aggressive treatment during hospitalization. On the other hand, the long-term prognosis of patients with myocarditis was favorable; only 4 cases, who survived the active phase, died in the late phase: 1 had fulminant myocarditis and the other 3 had the chronic latent form. Thus, the early mortality of patients with myocarditis was very high regardless of the subtype, but if patients can survive the active phase, they have a favorable prognosis except with the chronic latent form. (Jpn Circ J 2001; 65: 961 - 964)
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  • Hiroaki Shimomura, Fumio Terasaki, Tetsuya Hayashi, Yasushi Kitaura, T ...
    Article type: None
    Subject area: None
    2001 Volume 65 Issue 11 Pages 965-968
    Published: 2001
    Released on J-STAGE: October 25, 2001
    JOURNAL FREE ACCESS
    In failing hearts, cardiomyocytes degenerate and interstitial fibrosis, which indicates cardiomyocyte loss, becomes more prominent in the myocardium. However, the precise mechanism of cardiomyocyte degeneration that leads to cell death is still unclear, although it is presumed that lysosomal function and autophagy play an important role because lysosomal activity increases under stress such as hypoxia. Myocardium that had been resected during partial left ventriculectomy performed in patients with dilated cardiomyopathy (DCM) was examined. Under light microscopy, some cardiomyocytes had a marked scarcity of myofibrils and had prominent cytoplasmic vacuolization. Atrophic and degenerated cardiomyocytes were often observed adjacent to replacement fibrotic tissue. Immunohistochemistry showed positivity for lysosome-associated membrane protein and a lysosomal catheptic enzyme in vacuoles of various sizes in the cardiomyocytes and these lysosomal markers were markedly increased in atrophic and degenerated cardiomyocytes. Electron microscopy revealed that degenerated cardiomyocytes had many vacuoles containing intracellular organelles, such as mitochondria, and were considered to be autophagic vacuoles. In DCM hearts, autophagy appeared to be associated not only with degradation of damaged intracellular organelles but also with progressive destruction of cardiomyocytes. It is possible that autophagic degeneration is one of the mechanisms of myocardial cell death. (Jpn Circ J 2001; 65: 965 - 968)
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  • Taku Inoue, Saori Oshiro, Kunitoshi Iseki, Masahiko Tozawa, Takashi To ...
    Article type: None
    Subject area: None
    2001 Volume 65 Issue 11 Pages 969-973
    Published: 2001
    Released on J-STAGE: October 25, 2001
    JOURNAL FREE ACCESS
    Increased heart rate (HR) is a predictor of cardiovascular mortality, so the present study used a screened cohort to investigate whether the clustering of cardiovascular risk factors is associated with increased HR. Individuals who were receiving medication for hypertension or heart disease and those who did not have an ECG record or who had a record of arrhythmia were excluded. In total, 8,508 subjects (5,299 men, 3,209 women; age range, 18-89 years) were studied. Subjects were divided into 2 HR classes using the value of mean HR + 1 SD as the cut-off point: low HR (HR <77 beats/min, n=7,320) and high HR (HR ≥77 beats/min, n=1,188). For logistic regression analysis, the dependent variable was HR class and the independent variables were the number of risk factors (ie, hypertension, diabetes mellitus, and hypertriglyceridemia each of which was associated positively with HR class by multivariate analysis). The odds ratios and 95% confidence intervals for the number of risk factors were 1.412 (1.216-1.640) for 1 risk factor, 2.800 (2.269-3.455) for 2, and 4.582 (2.815-7.459) for 3. Multivariate regression analyses showed that the number of risk factors from 0 to 3 correlated positively with high HR. HR increased significantly with clustering of risk factors even with low HR (regression coefficient was 1.147, p<0.0001). Modifying the risk factors may lower HR and reduce cardiovascular mortality. (Jpn Circ J 2001; 65: 969 - 973)
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  • Nami Kuroda, Yoshio Ohnishi, Kazumasa Adachi, Mitsuhiro Yokoyama
    Article type: None
    Subject area: None
    2001 Volume 65 Issue 11 Pages 974-978
    Published: 2001
    Released on J-STAGE: October 25, 2001
    JOURNAL FREE ACCESS
    The relationship between the QT indices and microvolt-level T wave alternans (TWA) is unknown in cardiomyopathy, so the present study examined 86 patients with cardiomyopathy who experienced TWA during exercise testing (EXT). The QT interval (QT), duration from the Q wave to the peak of the T wave (QTp), duration from the peak to the end of the T wave and the dispersion of these parameters were measured by 12-lead electrocardiogram at rest and during EXT. In dilated cardiomyopathy (DCM), TWA was positive (TWA+) in 19 patients and negative (TWA-) in 17. No significant difference was observed between the TWA+ and TWA- groups in any parameter. In hypertrophic cardiomyopathy (HCM), TWA was positive in 24 patients and negative in 12. Max QTc, max QTpc and mean QTpc during EXT in the TWA+ group were significantly longer than those in the TWA- group. The sensitivity of TWA for ventricular tachycardia (VT) was high in DCM and HCM, and that of max QTc >500 ms during EXT for VT was high in HCM (93%). TWA is a useful predictor for VT in DCM and HCM, and prolonged max QTc during exercise has a prognostic value in HCM. Repolarization abnormality during exercise plays an important role in the genesis of VT in cardiomyopathy. (Jpn Circ J 2001; 65: 974 - 978)
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Experimental Investigation
  • Kotaro Suehiro, Shin Takuma, Juichiro Shimizu, Takeshi Hozumi, Hideaki ...
    Article type: None
    Subject area: None
    2001 Volume 65 Issue 11 Pages 979-983
    Published: 2001
    Released on J-STAGE: October 25, 2001
    JOURNAL FREE ACCESS
    The estimation of global left ventricular function using M-mode echocardiography has technical limitations in the murine model of myocardial infarction (MI), but the recent improvements in 2-dimensional (2-D) echocardiography using a high-frequency transducer provide more accessible images. Furthermore, intravenous injection of contrast agent has the additional benefit of enhancing the endocardial border in the murine heart. The present study was designed to evaluate the value of 2-D echocardiography with intravenous injection of contrast agent in the assessment of global systolic function of the murine heart with MI. Two-dimensional and M-mode echocardiography without and with intravenous injection of contrast agent (Optison, 0.1-0.15 ml) were performed in 76 awake mice 2 days before and 2 days after left coronary artery ligation. Fractional shortening (FS) was calculated from the end-diastolic and end-systolic diameters on M-mode echocardiography, and fractional area change (FAC) from the end-diastolic and end-systolic areas on 2-D echocardiography. Both FS and FAC were compared with the areas of hypoperfusion observed in the pathological samples. The use of contrast agent improved the number of hearts that could be evaluated by both the M-mode and 2-D method (M-mode: non-contrast 87% vs contrast 99%, p<0.01; 2-D: non-contrast 26% vs contrast 89%, p<0.001). FAC from the 2-D method correlated better with the region of hypoperfusion in the pathological samples than did FS from the M-mode method (FAC: r=0.84 vs FS: r=0.51). In conclusion, FAC obtained from 2-D contrast echocardiography is useful for noninvasive assessment of global systolic function in infarcted murine hearts and can be used to serially assess systolic function in various models of the murine heart. (Jpn Circ J 2001; 65: 979 - 983)
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  • Go Hiasa, Mareomi Hamada, Shuntaro Ikeda, Kunio Hiwada
    Article type: None
    Subject area: None
    2001 Volume 65 Issue 11 Pages 984-990
    Published: 2001
    Released on J-STAGE: October 25, 2001
    JOURNAL FREE ACCESS
    Ischemic preconditioning (IP) and pretreatment with lipopolysaccharide (LPS) reduce myocardial infarct size, but the precise mechanisms remain unknown. Rats were divided into 3 groups: the Control (C) group was subjected to 30 min ischemia followed by 3 h reperfusion; the IP and LPS groups had the same ischemia - reperfusion (I-R) insult with either preconditioning stimuli or pretreatment with LPS, respectively. Infarct size was smaller in the IP (23.4 ±2.3% of risk zone size) and LPS groups (28.5±2.0% of risk zone size) than in the C group (52.3±3.4% of risk zone size). Nuclear factor kappa-B (NF-κB) binding activity increased at 30 min reperfusion and declined thereafter, then rose again at 3 h reperfusion in the C group. The values in the IP (362% of control) and LPS (324% of control) groups were higher before I-R, and then decreased from 30 min (46% and 64% of control, respectively) until 3 h reperfusion (22% and 36% of control, respectively). Nuclear staining of NF-κB after reperfusion was less in the IP and LPS groups than in the C group. Expressions of cytokine mRNAs (interleukin-1β, interleukin-6 and tumor necrosis factor-α) were detected 30 min after the onset of reperfusion and their levels remained high after 3 h of reperfusion. These expressions of cytokine mRNAs after I-R were substantially suppressed by IP and LPS, although IP and LPS alone induced modest expressions of these cytokine mRNAs. These data suggest that IP and LPS contribute to infarct size reduction via the downregulation of NF-κB and the attenuation of cytokine gene expression. (Jpn Circ J 2001; 65: 984 - 990)
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Case Report
  • Kazushi Yukiiri, Katsufumi Mizushige, Takashi Ueda, Tsunetatsu Nanba, ...
    Article type: None
    Subject area: None
    2001 Volume 65 Issue 11 Pages 991-993
    Published: 2001
    Released on J-STAGE: October 25, 2001
    JOURNAL FREE ACCESS
    Cardiac involvement in patients with polymyositis is usually asymptomatic and associated with a mild clinical course. A female patient with muscle weakness and cardiogenic shock, who was diagnosed with polymyositis and fulminant myocarditis, is described. A large amount of methylprednisolone, in addition to intra-aortic balloon pumping and percutaneous cardiopulmonary support, led to the recovery of her cardiac function. However, a massive cerebral embolism occurred and she died. Postmortem histopathological examination showed necroses of muscles and diffuse invasion of mononuclear cells in both the myocardium and the biceps muscle of her arm. Although the mechanism of cardiac dysfunction is not clear, immunosuppressive therapy was effective for fulminant myocarditis in the present case. (Jpn Circ J 2001; 65: 991 - 993)
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  • Kiyotaka Matsuo, Takashi Kurita, Masamichi Eguchi, Kojiro Nakao, Norih ...
    Article type: None
    Subject area: None
    2001 Volume 65 Issue 11 Pages 994-996
    Published: 2001
    Released on J-STAGE: October 25, 2001
    JOURNAL FREE ACCESS
    A 41-year-old woman with arrhythmogenic right ventricular dysplasia (ARVD) underwent the implantation of an implantable cardioverter-defibrillator (ICD), in which the defibrillator electrode was unusually located in the right ventricular (RV) outflow tract. Although fractionated electrograms were demonstrated in the RV apex, which is the usual site for ICD electrodes, normal electrograms were recorded in the RV outflow tract during an electrophysiologic study. An electrode with a screw-in tip was used to fix the implant in the RV outflow tract and obtain successful defibrillation. If normal electrograms are recorded in the RV outflow tract, the site may prove to be an alternative location for an ICD electrode even for ARVD patients. (Jpn Circ J 2001; 65: 994 - 996)
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  • Report of a Case and Review of the Literature
    Kazuya Akiyama, Naohito Taniyasu, Jun Hirota, Yutaka Iba, Kazuma Maisa ...
    Article type: None
    Subject area: None
    2001 Volume 65 Issue 11 Pages 997-1000
    Published: 2001
    Released on J-STAGE: October 25, 2001
    JOURNAL FREE ACCESS
    Gemella morbillorum (G. morbillorum) is part of the commensal flora of the oropharynx and intestinal tract, and on rare occasions causes infective endocarditis. A 55-year-old man with massive aortic regurgitation caused by recurrent infective endocarditis with G. morbillorum had a history of prior endocarditis caused by α-hemolytic streptococcus and multiple antibiotic allergies 5 years prior, and was successfully treated by aortic valve replacement. Almost all the reported cases of endocarditis caused by G. morbillorum have been bacteriologically cured with antibiotics and this is the first reported case of recurrent endocarditis caused by G. morbillorum in which the initial infection was bacteriologically cured by antibiotics and the secondary infection treated with valve replacement. This organism can be one of the causes of infective endocarditis and prompt surgical repair is mandatory if the infection is refractory or there is progression of congestive heart failure under antibiotic cover. (Jpn Circ J 2001; 65: 997 - 1000)
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  • Noriko Inoue, Tomoko Ohkusa, Tomoko Nitta, Masahiko Harada, Kazuya Mur ...
    Article type: None
    Subject area: None
    2001 Volume 65 Issue 11 Pages 1001-1003
    Published: 2001
    Released on J-STAGE: October 25, 2001
    JOURNAL FREE ACCESS
    A 26-year-old man had a loss consciousness for a few minutes while smoking in the standing position, and was referred to hospital. No abnormalities were found in a computed tomography examination of his head, in a 24-h electrocardiogram or in an exercise tolerance test. The head-up tilt test (HUT) while tobacco smoking elicited a positive response in the tilted position, but the HUT without tobacco smoking was negative. The most noteworthy effect of tobacco smoking during the HUT was the high level of plasma epinephrine compared to the levels seen during supine smoking or the HUT alone. Syncope induced by tobacco smoking in the standing position is rare and the mechanism may be the same as that underlying neurally mediated syncope. (Jpn Circ J 2001; 65: 1001 - 1003)
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