A case of aortic valve laceration after balloon aortic valvuloplasty with morphological features.

A 71-year-old man suffered from congestive heart failure due to severe aortic stenosis. We performed balloon aortic valvuloplasty (BAV) as a bridge to transcatheter aortic valve replacement using transesophageal echocardiogram (TEE) by the retrograde approach. Balloon dilatation was carefully performed using an 18 mm balloon. After balloon dilation, TEE showed right coronary cusp (RCC) laceration and severe aortic regurgitation. We discontinued the procedure despite the incomplete result. Aortic valve laceration is a rare complication considered to be mainly caused by the use of large balloon or by balloon slipping. In the present case, TEE showed that the commissure of RCC fused strongly with both the other cusps by thick calcification, and the center of RCC had a spotty low echoic area with soft tissue. The force of the balloon dilatation concentrated to soft tissue area and lacerated the center of RCC. We verified the finding in the operative specimen. When performing BAV, we should pay attention to the morphology of the aortic valve using TEE to avoid aortic valve laceration as a fatal complication. .

Effective treatment of congestive heart failure using adaptive servo-ventilation in an end-stage renal disease patient on hemodialysis.

A 61-year-old man who was being treated with hemodialysis (HD) for end-stage renal disease presented with symptoms of severe congestive heart failure (CHF). Removing excess intravascular fluid during HD was difficult due to the patient's chronic hypotension induced by severe left ventricular (LV) dysfunction. The application of adaptive servo-ventilation (ASV) increased the patient's cardiac output and blood pressure during HD, thus resulting in the effective removal of excess intravascular fluid. Therefore, ASV may be effective for treating CHF in HD patients with LV dysfunction and chronic hypotension.

Beneficial effect of switching from a combination of angiotensin II receptor blockers other than losartan and thiazides to a fixed dose of losartan/hydrochlorothiazide on uric acid metabolism in hypertensive patients.

Among the angiotensin II receptor blockers (ARBs), losartan (LOS) has uricosuric action. The clinical benefits of LOS compared with those of other ARBs may be apparent when it is combined with diuretics, which have an unfavorable influence on serum uric acid (SUA). The effects of switching from combinations of ARBs other than LOS and thiazides to a fixed-dose combination comprising 50 mg LOS and 12.5 mg hydrochlorothiazide on blood pressure (BP), SUA, percent fractional excretion of UA (FEUA), and urine pH were assessed in 57 hypertensive outpatients. A significant reduction in BP was observed after 6 months (P < .01). The switching therapy significantly decreased SUA level (6.0 ± 1.3 vs. 5.7 ± 1.3 mg/dL, P < .01), which was accompanied by increases in FEUA (P < .01) and urine pH (P < .01). The change in SUA was negatively correlated with the changes in FEUA (P < .004) and estimated glomerular filtration rate (P < .05). The change in FEUA was positively correlated with the changes in urine pH (P < .05) but not with BP or estimated glomerular filtration rate. In a separate group of patients treated with ARBs other than LOS (n = 82), a significant BP reduction was observed, but no change in SUA or FEUA was observed. In conclusion, switching therapy decreased SUA level, which was accompanied by an increase in FEUA. This result may depend on the balance between LOS-induced inhibitory action of urate transporter 1 and hydrochlorothiazide-induced plasma volume reduction. The increase in urine pH plays a role in UA urinary excretion.

Switching therapy from variable-dose multiple pill to fixed-dose single-pill combinations of angiotensin II receptor blockers and thiazides for hypertension.

The efficacy and tolerability of switching therapy from free combinations of angiotensin II receptor blocker (ARB) and thiazide (A/T) to a fixed-dose of losartan and hydrochlorothiazide (L/H) has not been evaluated in Japan. We examined effects of switching therapy from variable-dose multiple-pill A/T to a fixed-dose L/H on blood pressure (BP) along with medication adherence and the degree of satisfaction in 91 hypertensive outpatients (mean age, 65.2 ± 9.6 years). After 6 months, a significant BP reduction (132 ± 9/76 ± 10 vs. 126 ± 12/72 ± 11 mm Hg), along with an improvement of attaining target BP (44.0 vs. 61.5%) and that of adherence, were observed. The magnitude of BP reduction in the participants increased their degree of satisfaction more significantly than in the participants who worsened their degree of satisfaction. The estimated glomerular filtration rate and the serum uric acid (UA) level decreased slightly but significantly. The hemoglobin A1c of participants with diabetes mellitus increased slightly but significantly. In conclusion, a switch in therapy from variable-dose, multiple-pill A/T combinations to a fixed-dose, single-pill L/H was effective in decreasing BP and serum UA in Japanese clinical practice. Metabolic side effects of L/H in patients with diabetes mellitus remain to be investigated.

Autologous peripheral blood mononuclear cell implantation for patients with peripheral arterial disease improves limb ischemia.

BACKGROUND: Implantation of bone marrow mononuclear cells, including endothelial progenitor cells, into ischemic limbs has been shown to improve collateral vessel formation. In the present study the safety and feasibility of autologous peripheral blood mononuclear cells (PBMNCs) implantation after granulocyte-colony stimulating factor (G-CSF)-induced mobilization was investigated in patients with severe peripheral arterial disease. METHODS AND RESULTS: Six cases were enrolled: 5 of thromboangitis obliterans and 1 of arteriosclerosis obliterans. Following administration of G-CSF (10 microg . kg(-1) . day(-1)), PBMNCs were harvested and injected intramuscularly (5 legs and 1 arm) for 2 days for the patients with ischemia of the legs. No serious adverse events related to G-CSF administration, harvest or implantation were observed during this study period. Improvement in the ankle - brachial pressure index (ABI: >0.1) was seen in 4 patients at 4 weeks and ischemic ulcers improved in 3 of 3 patients. The mean maximum walking distance significantly increased from 203 m to 559 m (p=0.031) at 4 weeks and was sustained for 24 weeks. Significant improvement was seen in physiological functioning subscale of Short Form-36. CONCLUSION: Implantation of PBMNCs collected after G-CSF administration could be an alternative to therapeutic angioplasty in patients with severe peripheral arterial disease.