Saline-induced Pd/Pa ratio predicts functional significance of coronary stenosis assessed using fractional flow reserve.

AIMS: Fractional flow reserve (FFR), assessed using distal coronary pressure/aortic pressure (Pd)/(Pa) ratio, functionally evaluates coronary stenosis. An assessment method without vasodilators would be helpful. A single intracoronary bolus of saline decreases Pd because of the speculated low-viscosity effect. We hypothesised that saline-induced Pd/Pa ratio (SPR) could functionally evaluate coronary stenosis. This study aimed to test the accuracy and utility of SPR for predicting FFR ≤0.80. METHODS AND RESULTS: In 137 coronary lesions with over 50% angiographic diameter stenosis, SPR was assessed using an intracoronary bolus of saline (2 mL/s) for five heartbeats (SPR-5) and three heartbeats (SPR-3). FFR was obtained after intravenous adenosine infusion (140 µg/kg/min). There was a strong correlation between FFR and SPR-5 or SPR-3 (R=0.941 and R=0.933, respectively). Receiver operating characteristic (ROC) curve analysis demonstrated good accuracy (86.3%) for SPR-5, with a cut-off of ≤0.84 for predicting FFR ≤0.80 (area under ROC curve 0.96, specificity 94.3, sensitivity 79.9). Thirty-three lesions (24%) were located in the "grey zone" (SPR 0.83-0.88). No complications were observed in 673 SPR measurements. CONCLUSIONS: SPR may accurately predict FFR and can limit adenosine use to one in four lesions. Further studies are needed to confirm the validity of SPR.

Pulmonary Tumor Thrombotic Microangiopathy Caused by Urothelial Carcinoma Expressing Vascular Endothelial Growth Factor, Platelet-derived Growth Factor, and Osteopontin.

Pulmonary tumor thrombotic microangiopathy (PTTM) is a fatal cancer-related pulmonary complication. It is generally caused by gastric adenocarcinoma, and several molecules produced by tumor cells are reported to play important roles in its pathogenesis. We herein report an autopsy case of PTTM caused by urothelial carcinoma. Vascular endothelial growth factor (VEGF), platelet-derived growth factor (PDGF), and osteopontin were found to be expressed in both the primary tumor cells and metastatic cells in the PTTM lesions. These findings implicate the possible involvement of VEGF, PDGF, and osteopontin in the pathogenesis of PTTM caused by urothelial carcinoma.

Inferior vena cava filter misplacement in the right atrium and migration to the right ventricle followed by successful removal using the endovascular technique: A case report and review of the literature.

Inferior vena cava filters are effective for preventing the passage of thrombi into the pulmonary arteries in patients with pulmonary embolism and deep vein thrombosis. These filters are indicated in patients with contraindications to anticoagulant therapy or in patients with recurrent acute pulmonary embolism despite the administration of anticoagulant therapy. However, the occurrence of filter-related complications, such as filter migration to the heart, has been increasing. Herein, we report a case of OptEase inferior vena cava filter misplacement in the right atrium. Although the filter migrated to the right ventricle, it was successfully removed and repositioned in the inferior vena cava using endovascular techniques. Unfortunately, moderate tricuspid regurgitation developed, due to the damage to the tricuspid valve that was caused by the procedure. We have also reviewed the relevant literature and discussed the possible strategies for managing cases of filter migration to the heart and preventing filter misplacement.

Arterial thromboembolism in senile systemic amyloidosis: report of two cases.

We describe a rare complication, systemic arterial thromboembolism, seen in two patients with senile systemic amyloidosis (SSA). Case 1 was a 73-year-old man who was tentatively diagnosed as having cardiac amyloidosis. Five months later, he was afflicted by severe left flank pain. CT disclosed renal infarction and then he received endomyocardial biopsy and the transthyretin (TTR) gene analysis, leading to the final diagnosis of SSA. Case 2 was an 88-year-old woman who had been definitively diagnosed as having SSA-related heart failure with atrial fibrillation two years before. She was transferred to the emergency room in our hospital and enhanced CT revealed complete occlusions of the left internal carotid and left vertebral arteries, both subclavian arteries, and the left renal and left internal iliac arteries. Paying much attention to intracardiac thrombosis might be necessary in taking care of SSA patients.

Implantable cardioverter defibrillator for progressive hypertrophic cardiomyopathy in a patient with LEOPARD syndrome and a novel PTPN11 mutation Gln510His.

LEOPARD syndrome (LS), generally caused by heterozygous mutations in the PTPN11 gene, is a rare autosomal-dominant multiple congenital anomaly condition, characterized by skin, facial, and cardiac abnormalities. Prognosis appears to be related to the type of structural, myocardial, and arrhythmogenic cardiac disease, especially hypertrophic cardiomyopathy (HCM). We report on a woman with LS and a novel Gln510His mutation in PTPN11, who had progressive HCM with congestive heart failure and nonsustained ventricular tachycardia, successfully treated with implantable cardioverter defibrillator (ICD). Comparing our patient to the literature suggests that specific mutations at codon 510 in PTPN11 (Gln510Glu, Gln510His, but not Gln510Pro) might be a predictor of fatal cardiac events in LS. Molecular risk stratification and careful evaluations for an indication of ICD implantation are likely to be beneficial in managing patients with LS and HCM.

Assessment of left ventricular dyssynchrony in patients with coronary artery disease during adenosine stress using ECG-gated myocardial perfusion single-photon emission computed tomography.

OBJECTIVES: Some investigators have reported that left ventricular (LV) mechanical systolic and diastolic dyssynchrony occurs in coronary artery disease (CAD) patients without earlier myocardial infarction and narrow QRS complex duration. However, earlier studies evaluated LV dyssynchrony only at rest. The purpose of this study was to investigate LV dyssynchrony in CAD patients with preserved ejection fraction during adenosine stress using electrocardiogram-gated myocardial perfusion single-photon emission computed tomography (SPECT). METHODS: The study population included 18 CAD patients and 18 control subjects. CAD patients had significant stenosis in their coronary arteries by coronary angiogram without earlier myocardial infarction. SPECT images were acquired at rest and during stress with adenosine. The regional time to end systole (TES), time to peak ejection, the time from 0 to peak filling during the whole diastolic period (TPF1), and the time from end systole to peak filling during the whole diastolic period (TPF2) were obtained by using the Quantitative Gated SPECT software. The maximal difference (MD), which is the difference between the earliest and latest temporal parameter among 17 segments, was considered to represent LV dyssynchrony. RESULTS: MD-TES and MD-TPF1 during stress were significantly greater than those of rest in CAD patients (MD-TES: stress=242+/-107 ms, rest=164+/-79 ms; P=0.005, MD-TPF1: stress=249+/-121 ms, rest=164+/-88 ms; P=0.015) but there were no significant differences in control patients. CONCLUSION: LV dyssynchrony was shown in CAD with preserved ejection fraction during adenosine stress.

Efficacy of continuous positive airway pressure on arrhythmias in obstructive sleep apnea patients.

The purpose of this study was to determine the relationship between obstructive sleep apnea (OSA) and cardiovascular disorders in a large Japanese population, and to assess the efficacy of continuous positive airway pressure (CPAP) in the treatment of OSA-associated arrhythmias. The study population comprised 1394 Japanese subjects (1086 men and 308 women) who were divided into four groups on the basis of polysomnography (PSG) analysis as follows: the no sleep apnea (N-SA) group (n = 44, apnea-hypopnea index [AHI] < 5), the mild OSA (Mi-OSA) group (n = 197, 5 < AHI < 15), the moderate OSA (Mo) group (n = 368, 15 < AHI < 30), and severe OSA (SOSA) group (n = 785, AHI < 30). The following baseline characteristics were significantly associated with OSA: age (P < 0.001), gender (P < 0.001), body mass index (P < 0.001), hypertension (P < 0.001), diabetes (P = 0.009), and hyperlipidemia (P = 0.013). In the OSA group, PSG revealed the predominance of paroxysmal atrial fibrillation (PAF) (P = 0.051), premature atrial complex short run (P < 0.005), premature ventricular complex (PVC, P = 0.004), sinus bradycardia (P = 0.036), and sinus pause (arrest >2 s, P < 0.001) during the PSG recording. A total of 316 patients from the group underwent CPAP titration and were then re-evaluated. Continuous positive airway pressure therapy significantly reduced the occurrences of PAF (P < 0.001), PVC (P = 0.016), sinus bradycardia (P = 0.001), and sinus pause (P = 0.004). The results of this study demonstrate a significant relationship between OSA and several cardiac disorders, and also demonstrate the efficacy of CPAP in preventing OSA-associated arrhythmias in a large population of Japanese patients.

Valve repair improves central sleep apnea in heart failure patients with valvular heart diseases.

BACKGROUND: Recent studies suggest that treatment of heart failure (HF) could improve cardiac function and sleep apnea syndrome (SAS), but it is unknown how cardiac surgery may affect SAS in HF patients. Relationships between HF with valvular heart diseases and 2 types of SAS (obstructive sleep apnea (OSA) and central sleep apnea (CSA)) were examined. The effects of valve repair surgery on OSA and CSA was also investigated. METHODS AND RESULTS: Polysomnography, echocardiography and right cardiac catheterization were used to study 150 severe HF patients with mitral valvular and/or aortic valvular diseases. Significant associations between SAS and age, gender, body mass index, or hypertension were observed. The value of the CSA-apnea index (AI) was significantly correlated with pulmonary capillary wedge pressure (PCWP) and mean pulmonary artery pressure (PAP). These associations were not identified for OSA-AI. Valve repair surgery was used to treat 74 patients with severe SAS. The treatment led to a significant improvement in PCWP and mean PAP, and CSA-AI, but not in OSA-AI. CONCLUSIONS: These findings suggest close associations between CSA and cardiac function in HF patients with valvular heart diseases. Furthermore, improvement of cardiac function with valvular surgery reduces the severity of CSA in HF patients with valvular heart diseases.