Aberrant mediastinal basal pulmonary artery encountered at anatomical lung resection: A case report and review of the literature.

INTRODUCTION: Abnormal branching of the pulmonary artery is often encountered in anatomical lung resection, which can potentially result in accidental vessel injury with life-threatening bleeding or extra lung resection. The mediastinal basal pulmonary artery (Arteria Praebronchialis, AP) is a very rare but potentially critical variant. PRESENTATION OF CASE: We present the case of a patient with lung cancer accompanied by the left basal segmental pulmonary artery, independent A8a+9, which was liable to be injured during lower lobectomy with poor interlobar fissure development. This variation was preoperatively recognized using three-dimensional contrast-enhanced computed tomography (3D-CECT) angiography, and vessel injury was avoided. DISCUSSION AND LITERATURE REVIEW: 3D-CECT angiography was effective in identifying this rare but potentially critical variation, and it is desirable to perform it routinely before anatomical lung resection. A review of 31 AP cases revealed that the branching pattern of AP was independent (15 patients, 48 %) and common trunk type (16 patients, 52 %), one half for each. Mediastinal branching of the lingular artery was more frequent among the reported AP cases (71 %) than in general reports. CONCLUSION: When mediastinal branches of left pulmonary artery are encountered, the possibility that it is AP should be always taken into account.

Assessing the efficacy of saline flush in frequency-domain optical coherence tomography for intracoronary imaging.

BACKGROUND: The increased amount of contrast media in frequency-domain optical coherence tomography (FD-OCT) imaging during percutaneous coronary intervention (PCI) has raised potential concerns regarding impairment of renal function. OBJECTIVES: This study aimed to evaluate the effectiveness of heparinized saline flush in FD-OCT-guided PCI and identify clinical factors contributing to optimal image quality. METHODS: We retrospectively collected 100 lesions from 90 consecutive patients, and a total of 200 pullbacks were analyzed for the initial and final evaluation in which saline was used as the flushing medium. RESULTS: The study population had a mean age of 73, with 52% having chronic kidney disease (CKD). The median amount of contrast used was 28 ml, and no complications were observed associated with saline flush OCT. Imaging quality was then categorized as excellent, good, or unacceptable. Among the total runs, 87% demonstrated clinically acceptable image quality, with 66.5% classified as excellent images and 20.5% classified as good images. Independent predictors of excellent images included lumen area stenosis ≥ 70% (adjusted odds ratio [OR] 2.37, 95% confidence interval [CI] 1.02-5.47, P = 0.044), and the use of intensive flushing (adjusted OR 2.06, 95% CI 1.11-3.86, P = 0.023) defined as a deep engagement of guiding catheter (GC) or a selective insertion of guide extension catheter (GE). Intensive flushing was performed in 60% of the total pullbacks, and it was particularly effective in improving image quality in the left coronary artery (LCA). CONCLUSION: The use of saline flush during FD-OCT imaging was safe and feasible, which had a benefit in renal protection with adequate imaging quality.

Deteriorative Effect of a Combination of Hypertriglyceridemia and Low High-Density Lipoprotein Cholesterolemia on Target Lesion Revascularization after Everolimus-Eluting Stent Implantation.

AIM: This study aimed to investigate the association between a combination of elevated triglyceride (TG) and reduced high-density lipoprotein cholesterol (HDL-C) levels and target lesion revascularization (TLR) following everolimus-eluting stent (EES) implantation. The adverse impact of clinical, lesion, and procedural characteristics on TLR in patients with elevated TG and reduced HDL-C levels was also assessed. METHODS: We retrospectively collected data on 3,014 lesions from 2,022 consecutive patients, who underwent EES implantation at Koto Memorial Hospital. Atherogenic dyslipidemia (AD) is defined as a combination of non-fasting serum TG ≥ 175 mg/dL and HDL-C ＜40 mg/dL. RESULTS: AD was observed in 212 lesions in 139 (6.9%) patients. The cumulative incidence of clinically driven TLR was significantly higher in patients with AD than in those without AD (hazard ratio [HR] 2.31, 95% confidence interval [CI] 1.43-3.73, P=0.0006). Subgroup analysis showed that AD increased the risk of TLR with the implantation of small stents (≤ 2.75 mm). Multivariable Cox regression analysis showed that AD was an independent predictor of TLR in the small EES stratum (adjusted HR 3.00, 95% CI 1.53-5.93, P=0.004), whereas the incidence of TLR was similar in the non-small-EES stratum, irrespective of the presence or absence of AD. CONCLUSIONS: Patients with AD had a higher risk of TLR after EES implantation, and this risk was greater for lesions treated with small stents.

Postoperative aortic injury caused by a staple line formed during wedge resection of the lung.

We report a case of aortic perforation caused by the staple line formed during a wedge resection for lung cancer. Six hours after an uneventful wedge resection, sudden frank drainage of blood from the chest tube occurred. A reoperation was performed, and we found bleeding from the aorta. After suturing the bleeding spot on the aorta, we found that the stapling line of the lung rode on the aorta with longitudinal contact. We speculated that the stapling line scratched the aorta in synchrony with the patient's breathing and injured the aorta.

Impact of statin therapy on late target lesion revascularization after everolimus-eluting stent implantation according to pre-interventional vessel remodeling and vessel size of treated lesion.

Clinical evidence demonstrating the impact of statins for preventing late target lesion revascularization (TLR) after newer-generation drug-eluting stent implantation and differences in the effect of statins on late TLR according to pre-interventional vessel remodeling and vessel size is limited. We retrospectively evaluated 1193 de novo lesions in 720 patients who underwent everolimus-eluting stent implantation using intravascular ultrasound from January 2010 to December 2012. The primary endpoint was late TLR. Lesions were divided into the statin group (n = 825) and non-statin group (n = 368). The incidence of late TLR was significantly lower in the statin than non-statin group (1.7% vs. 5.2%, respectively; p = 0.001), and within the statin group, it was significantly lower in the follow-up low-density lipoprotein cholesterol (LDL-C) < 100 than ≥ 100 mg/dL level subgroup (1.0% vs. 3.6%, respectively; p = 0.006). Furthermore, in positive remodeling lesions and non-small vessel size lesions, the incidence of late TLR was significantly lower in the statin than non-statin group (1.6% vs. 8.5% and 1.3% vs. 5.3%, respectively; p = 0.001 and p = 0.004). Lowering the LDL-C level using statins was more effective for preventing late TLR after everolimus-eluting stent implantation. Evaluating pre-interventional vessel remodeling patterns and vessel size might be helpful to stratify lesions at high risk of late TLR.

A case of thymoma-associated multiorgan autoimmunity including polymyositis and myocarditis.

BACKGROUND: Polymyositis and myocarditis associated with thymoma are exceptionally rare conditions and usually accompanied by myasthenia gravis (MG) and have been recognized as critical conditions. Thymoma-associated multiorgan autoimmunity was reported recently with skin, liver, and intestinal manifestations similar to those seen in graft-versus-host disease. CASE PRESENTATION: A 77-year-old female presented to our department with exacerbation of ptosis and local recurrence of thymoma. Chest computed tomography revealed local recurrence of thymoma. Following 6 month observation, erythema on the extremities and body trunk suddenly appeared. Afterwards, the patient developed progressive muscle weakness and fatigue. We diagnosed as myocarditis and polymyositis. She was transferred to the intensive-care unit and received artificial ventilation. Steroid pulse therapy was induced immediately. The blood test findings were markedly improved, but the symptoms of MG and weakness of the muscles persisted. Various treatment including eculizumab was induced, and the symptoms of MG and weakness of the muscles were improved. On the 136th day of hospitalization, she was discharged. CONCLUSION: We were able to cure this patient, as we were able to start treatment immediately after the appearance of severe symptoms. An early diagnosis and treatment are important for curing such patients.

Surgical site infection at chest tube drainage site following pulmonary resection for malignant lesions.

BACKGROUND: We sometimes experience postoperative surgical site infection (SSI) at the chest tube drainage site (CDS) after thoracotomy. The incidence of and risk factors for SSI at the CDS have remained unclear. METHODS: We conducted a prospective study to determine the incidence and risk factors for SSI at the CDS. We analyzed 99 patients who underwent lobectomy or segmentectomy for pulmonary malignant lesions. RESULTS: There were 56 males and 43 females with an average age of 71 years. The postoperative drainage period was 2-15 days. Bacterial species were detected in secretions in 18 of 99 cases (18.2%). Older age was a risk factor for the detection of bacteria at the timing of chest tube removal. Eighteen cases (18.2%) were diagnosed with presence of SSI at the CDS at the timing of staple or suture removal. A pathological diagnosis of squamous cell carcinoma was regarded as a candidate risk factor for SSI. Eleven of 18 SSI patients showed delayed wound healing. A higher level of HbA1c was found in patients with delayed wound healing. Enterococcus faecalis infection may influence the development of complex SSI. CONCLUSIONS: We identified the bacterial profiles, incidence of and risk factors for SSI at the CDS. More intense preoperative glycemic control and an understanding of the bacterial profile and may be useful for reducing the incidence of SSI chest tube drainage sites (CDS).

Effect of Glycemic Control During Follow-up on Late Target Lesion Revascularization After Implantation of New-Generation Drug-Eluting Stents in Patients With Diabetes　- A Single-Center Observational Study.

Background: Few studies have investigated the importance of glycemic control in patients with diabetes mellitus (DM) for reducing the incidence of late target lesion revascularization (TLR) after implantation of new-generation drug-eluting stents (DES). Methods and Results: We retrospectively identified 1,568 patients who underwent new-generation DES implantation. Patients were divided into 3 groups based on diabetic status and glycemic control 1 year after the procedure: those without DM (non-DM group; n=1,058) and those with DM at follow-up with either good (HbA1c <7%; n=328) or poor (HbA1c ≥7%; n=182) control. The cumulative 5-year incidence of clinically driven late TLR after the index procedure was significantly higher in DM with poor control at follow-up than in those with good control at follow-up or non-DM (14%, 4.8%, and 2.9%, respectively; P<0.0001). Multivariate analysis revealed that poor control at follow-up was significantly associated with a higher risk of clinically driven late TLR compared with the non-DM group (hazard ratio [HR] 4.58, 95% confidence interval [CI] 2.50-8.16, P<0.0001). However, good control at follow-up group was not associated with a higher risk of clinically driven late TLR compared with the non-DM group (HR 1.35, 95% CI 0.68-2.56, P=0.38). Conclusions: DM patients with poor glycemic control at follow-up had a significantly higher risk of clinically driven late TLR than non-DM patients.

Successful Surgery of Right Common Iliac Artery Injury during Lumbar Discectomy with Endovascular Balloon Occlusion of the Aorta Performed by Cardiologists.

A 19-year-old woman developed hypotension and abdominal distension during lumbar discectomy. Computed tomography revealed a right common artery injury and a large retroperitoneal hematoma. She was transferred to our hospital and brought to an angiography room directly. Endovascular balloon occlusion of the aorta was performed by cardiologists while surgeons were preparing for surgery. With the hemodynamics stabilized, the injured artery was repaired. In such a case, closing the artery as soon as possible, whether by clamping or by balloon occlusion, is vital. The ability to respond with a "Heart Team" is essential for a small-manpower hospital to rescue a patient with a serious condition.

Post-intervention minimal stent area as a predictor of target lesion revascularization after everolimus-eluting stent implantation for in-stent restenosis: a single-center observational study.

BACKGROUND: Everolimus-eluting stent (EES) is effective for treating in-stent restenosis (ISR). However, the long-term incidence of target lesion revascularization (TLR) is unknown. Further, the role of post-intervention minimal stent area (MSA) measured by intravascular ultrasound (IVUS) in TLR is unknown in this setting. PATIENTS AND METHODS: Overall, 223 ISR lesions (192 patients) that were treated with EES between 2010 and 2016 were analyzed retrospectively. Lesions were divided into two groups according to the post-intervention MSA [ ≤ 5.3 mm: 72 lesions (67 patients), and > 5.3 mm: 151 lesions (138 patients)]. The cut-off point was determined on the basis of receiver operating characteristic curve analysis. RESULTS: The cumulative 5-year incidence of TLR was significantly higher in the group with MSA of 5.3 mm or less than in the group with MSA more than 5.3 mm (15.8 and 7.2%, P = 0.01). After adjusting for confounders, the excess risk of the group with MSA of 5.3 mm or less relative to the group with MSA more than 5.3 mm for TLR remained significant [hazard ratio: 3.07, 95% confidence interval (CI): 1.17-8.51, P = 0.02]. Using multivariate logistic regression analysis, we identified female sex (odds ratio: 2.39, 95% CI: 1.06-5.49, P = 0.04) and stent size of 3.0 mm or less (odds ratio: 13.43, 95% CI: 6.23-32.38, P < 0.0001) as independent predictors of MSA of 5.3 mm or less. CONCLUSION: EES implantation for ISR was associated with an acceptable rate of TLR through long-term follow-up. Postintervention MSA of 5.3 mm or less was associated independently with a higher risk for TLR.

Nine cases of catamenial pneumothorax: a report of a single-center experience.

BACKGROUND: Catamenial pneumothorax (CP) is defined as repeated pneumothorax related to menses and thoracic endometriosis. We performed a retrospective analysis of nine patients with CP to determine the clinical features as well as the effects of treatment and recurrence rates. METHODS: A retrospective review was conducted of the clinical and pathologic data in all CP patients undergoing treatment at our institution. Nine patients underwent treatment for CP. Of these, six underwent surgical treatment 8 times. RESULTS: The median age was 36 years. Six patients had experienced delivery. The laterality of the pneumothorax was right in all patients. Pelvic endometriosis was diagnosed in five patients. Six patients underwent surgical treatment. Partial resection of the lung was performed in four patients and partial resection of the diaphragm in five. Of these, both resections were performed in four patients. A pathological diagnosis of endometriosis was achieved in only three patients. The observation period was 16.7 months. In the six patients with surgical resection, five experienced recurrence at various intervals. Onset of pneumothorax occurred pre- or menstrual period in most cases. CONCLUSIONS: The diagnosis and treatment of CP is not easy. A multidisciplinary approach and skillful management are required. Recurrence of CP is common following a temporary cure of pneumothorax by surgical treatment.

Thoracoscopic Thymectomy Using a Subxiphoid Approach for Anterior Mediastinal Tumors.

PURPOSE: Video-assisted thoracic surgery (VATS) techniques have been widely used for resection of mediastinal tumors. This study investigated the usefulness of the subxiphoid approach in thoracoscopic thymectomy. METHODS: In all, 36 patients with anterior mediastinal tumor underwent thymectomy using the subxiphoid approach in two Japanese institutions. These patients were retrospectively reviewed and analyzed. RESULTS: There were 16 females and 20 males with a mean age of 57 years. Five patients underwent partial thymectomy (PT), 27 underwent total or subtotal thymectomy, and 4 underwent thymectomy with combined resection (CR) of the surrounding organs or tissues. The mean maximum tumor diameter, amount of resected tissue, and blood loss were 4.1 cm, 72.5 g, and 20.6 g, respectively. More than half of tumors were diagnosed as thymoma (n = 19). The operation time was prolonged with a greater volume of thymectomy. The duration of chest tube drainage and postoperative stay were 1.7 ± 1.0 days and 5.9 ± 7.6 days, respectively. Four patients suffered intraoperative and postoperative complications, as follows: bleeding of the innominate vein, bleeding of the internal thoracic vein, crisis of myasthenia gravis (MG), pericarditis, and phrenic nerve paralysis. There were no mortalities after surgery. CONCLUSION: Subxiphoid thoracoscopic thymectomy might be a safe and useful approach for mediastinal tumors.

A pitfall of thoracoscopic thymectomy: a case with intraoperative and postoperative complications.

We have reported the usefulness of the subxiphoid approach in thymectomy. However, such a new operation method may have unknown complications that rarely occur. Surgeons cannot completely avoid intraoperative and postoperative complications. We report a case of intraoperative injury of the orifice of the left internal thoracic vein flowing to the left brachiocephalic vein and postoperative pericarditis following video-assisted thoracic surgery (VATS) thymectomy. The innominate vein has been considered to be the vessel that is most frequently injured especially at the orifice of the thymic veins. We also suggest that the orifice of the left internal thoracic vein is the second dangerous location that requires special care. In addition, postoperative pericarditis occurred in this patient. Pericardial drainage was necessary. No additional complications have been found in the 9 months since the operation. Though VATS thymectomy using the subxiphoid approach is a safe and less-invasive operation, intraoperative and postoperative complications were possible to be occurred.

Long-term outcomes of microvascular decompression and Gamma Knife surgery for trigeminal neuralgia: a retrospective comparison study.

BACKGROUND: There is still no clear guideline for surgical treatment for patients with medically refractory trigeminal neuralgia (TN). When it comes to which surgical treatment to choose, microvascular decompression (MVD) or Gamma Knife surgery (GKS), we should know the long-term outcome of each treatment. METHODS: We analyzed 179 patients undergoing MVD and 52 patients undergoing GKS followed for 1 year or longer. We evaluated the patient's neurological status including pain relief, complications and recurrence. Results were assessed with Barrow Neurological Institute (BNI) pain intensity and facial numbness scores. Overall outcomes were compared between the two groups based on pain relief and complications. RESULTS: BNI pain intensity and facial numbness scores at the final visit were significantly lower in the MVD group than in the GKS group (P < 0.001, P = 0.04, respectively). Overall outcomes were superior following MVD than following GKS (P < 0.001). Following whichever treatment, there were initially high rates of pain-free status "without medication": 96.6% in the MVD group and 96.2% in the GKS group. However, 6.1% in the MVD group and 51.9% in the GKS group fell into a "with medication" state within median periods of 1.83 and 3.92 years, respectively (P < 0.001). Kaplan-Meier analysis revealed that pain recurred more often and later in the GKS group than in the MVD group (P < 0.001). CONCLUSIONS: Considering the long-term outcomes, MVD should be chosen as the initial surgical treatment for patients with medically refractory TN.

Novel ATP-competitive Akt inhibitor afuresertib suppresses the proliferation of malignant pleural mesothelioma cells.

Malignant pleural mesothelioma (MPM), an asbestos-related occupational disease, is an aggressive and incurable tumor of the thoracic cavity. Despite recent advances in MPM treatment, overall survival of patients with MPM is very low. Recent studies have implicated that PI3K/Akt signaling is involved in MPM cell survival and development. To investigate the effects of Akt inhibitors on MPM cell survival, we examined the effects of nine selective Akt inhibitors, namely, afuresertib, Akti-1/2, AZD5363, GSK690693, ipatasertib, MK-2206, perifosine, PHT-427, and TIC10, on six MPM cell lines, namely, ACC-MESO-4, Y-MESO-8A, MSTO-211H, NCI-H28, NCI-H290, and NCI-H2052, and a normal mesothelial cell line MeT-5A. Comparison of IC50 values of the Akt inhibitors showed that afuresertib, an ATP-competitive specific Akt inhibitor, exerted tumor-specific effects on MPM cells. Afuresertib significantly increased caspase-3 and caspase-7 activities and apoptotic cell number among ACC-MESO-4 and MSTO-211H cells. Moreover, afuresertib strongly arrested the cell cycle in the G1 phase. Western blotting analysis showed that afuresertib increased the expression of p21WAF1/CIP1 and decreased the phosphorylation of Akt substrates, including GSK-3ß and FOXO family proteins. These results suggest that afuresertib-induced p21 expression promotes G1 phase arrest by inducing FOXO activity. Furthermore, afuresertib significantly enhanced cisplatin-induced cytotoxicity. Interestingly, results of gene set enrichment analysis showed that afuresertib modulated the expression E2F1 and MYC, which are associated with fibroblast core serum response. Together, these results suggest that afuresertib is a useful anticancer drug for treating patients with MPM.

Plasma brain natriuretic peptide level in older outpatients with heart failure is associated with physical frailty, especially with the slowness domain.

OBJECTIVE: To determine the association between plasma brain natriuretic peptide (BNP) level in patients with heart failure (HF) and physical frailty as well as with each domain of physical frailty. METHODS: Two hundred and six outpatients of cardiovascular medicine aged 60 years and older who had been hospitalized for HF or had been given a prescription medication for HF were included. Physical frailty was assessed using the following five domains: slowness, weakness, exhaustion, low activity, and shrinking, according to the Cardiovascular Health Study. Patients were divided into nonfrailty and frailty groups according to frailty scores. Plasma BNP level was measured. The 6-min walk test was performed to measure endurance. RESULTS: Plasma BNP was significantly different between the two groups (frailty group: 158.0 ± 214.7 pg/mL, nonfrailty group: 65.2 ± 88.0 pg/mL, P < 0.01). Multivariate logistic regression analysis revealed log-transformed plasma BNP (Log BNP) was significantly associated with physical frailty (OR: 1.68, 95% CI: 1.11-2.56), and Log BNP was significantly associated with the slowness domain (walking speed < 1.0 m/s) of physical frailty (OR: 1.75, 95% CI: 1.15-2.67). Additionally, Log BNP was negatively correlated to the 6-minute walk distance (6MWD) (ρ = -0.37, P < 0.01), while 6MWD was positively correlated to walking speed (ρ = 0.66, P < 0.01). CONCLUSIONS: Plasma BNP level was related to physical frailty, especially in the slowness domain. Endurance may intervene in the associations between plasma BNP level and walking speed.

Prognostic value of serial measurements of highly sensitive cardiac troponin I in stable outpatients with nonischemic chronic heart failure.

BACKGROUND: Cardiac troponin I (cTnI) is a useful biomarker in patients with chronic heart failure (CHF), and a highly sensitive cTnI (hs-cTnI) commercial assay has become available. However, the prognostic role of serial measurements of hs-cTnI in stable outpatients with CHF remains unknown. METHODS: At entry to the study, we evaluated 95 stable outpatients with nonischemic CHF showing a serum hs-cTnI (Centaur TnI-Ultra [Siemens Medical Solution Diagnostics, New York, NY], lower limit of detection 0.006 ng/mL) value ≥0.006 ng/mL. To evaluate the role of repetitive measurements of hs-cTnI, we performed echocardiography and measured serum levels of cTnI and N-terminal proBNP at baseline and 6 months later and then prospectively followed up these patients for 4.25 years. RESULTS: During long-term follow-up, there were 27 cardiac deaths. On multivariate analyses, high plasma N-terminal pro-brain natriuretic peptide (≥711 pg/mL, P = .0008), high serum hs-cTnI at baseline (≥0.03 ng/mL, P = .0011), and an increase in hs-cTnI (Δhs-cTnI ≥0 ng/mL, P = .022) after 6 months were independent significant prognostic predictors. The hazard ratio for mortality of patients with high hs-cTnI (≥0.03 ng/mL) and an increase in hs-cTnI (Δhs-cTnI ≥0 ng/mL) was 3.59 (95% CI 1.3-9.9, P = .014) compared with that of those with high hs-cTnI (≥0.03 ng/mL) and a decrease in hs-cTnI (Δhs-cTnI <0 ng/mL). CONCLUSIONS: These findings indicated that not only the serum concentration of hs-cTnI at baseline but also an increase in hs-cTnI were independent and useful prognostic predictors in patients with nonischemic CHF.

Effect of atorvastatin vs. rosuvastatin on cardiac sympathetic nerve activity in non-diabetic patients with dilated cardiomyopathy.

BACKGROUND: Effects of statin therapy on cardiac sympathetic nerve activity in patients with chronic heart failure (CHF) have not previously been evaluated. METHODS AND RESULTS: To compare the effects of lipophilic atorvastatin and hydrophilic rosuvastatin on cardiac sympathetic nerve activity in CHF patients with dilated cardiomyopathy (DCM), 63 stable outpatients with DCM, who were already receiving standard therapy for CHF, were randomized to atorvastatin (n = 32) or rosuvastatin (n = 31). We evaluated cardiac sympathetic nerve activity by cardiac ¹²³I-metaiodobenzylguanidine (MIBG) scintigraphy, hemodynamic parameters and neurohumoral factors before and after 6 months of treatment. There were no differences in the baseline characteristics of the 2 groups. In the rosuvastatin group, there were no changes in MIBG parameters, left ventricular ejection fraction or plasma levels of N-terminal pro-B-type natriuretic peptide (NT-proBNP) after 6 months of treatment. In contrast, the atorvastatin group showed a significant increase in the delayed heart/mediastinum count ratio (2.18 ± 0.4 vs. 2.36 ± 0.4, P < 0.0001), and the washout rate was significantly decreased (34.8 ± 5.7 vs. 32.6 ± 6.3%, P = 0.0001) after 6 months of treatment compared with the baseline values. The plasma NT-proBNP level was also significantly decreased (729 ± 858 vs. 558 ± 747 pg/ml, P = 0.0139). CONCLUSIONS: Lipophilic atorvastatin but not hydrophilic rosuvastatin improves cardiac sympathetic nerve activity in CHF patients with DCM.

Relationship between biological variation in B-type natriuretic peptide and plasma renin concentration in stable outpatients with dilated cardiomyopathy.

BACKGROUND: The aim of the present study was to interpret B-type natriuretic peptide (BNP) level in outpatients with stable chronic heart failure (CHF); it is important to clarify whether the change in BNP represents disease progression or a range of biological variation. METHODS AND RESULTS: To compare biological variation in BNP and biological variation in factors of the renin-angiotensin-aldosterone system (RAS) in stable CHF patients with dilated cardiomyopathy (DCM), the BNP plasma levels and RAS factors were measured in 115 stable outpatients with DCM. According to stepwise multivariate analysis, plasma BNP at baseline (P=0.005), presence of atrial fibrillation (P=0.015), and a high biological variation in plasma renin concentration (PRC; P=0.002) were significant independent dominant factors related to a high biological variation in BNP. Although there was no change in body weight or blood pressure during the 2-month study period, the % change in hematocrit was negatively correlated with % change in BNP (r=-0.327, P=0.0008), and positively correlated with % change in PRC (r=0.671, P=0.001). CONCLUSIONS: There was a significant relationship between biological variation in BNP and biological variation in PRC, suggesting that the physiological interaction between the natriuretic peptide system and RAS may contribute to the biological variation in plasma BNP in stable outpatients with DCM.

Prognostic role of high-sensitivity cardiac troponin T in patients with nonischemic dilated cardiomyopathy.

BACKGROUND: Cardiac troponin T (cTnT) is useful biomarker in patients with chronic heart failure (CHF). However, its clinical use is limited by the low sensitivity of the conventional commercial assay system. Recently, a highly sensitive cTnT (hs-cTnT) assay has become commercially available. METHODS AND RESULTS: To compare the prognostic value of conventional cTnT and hs-cTnT in patients with nonischemic dilated cardiomyopathy (DCM), hemodynamic parameters and the serum levels of conventional cTnT, hs-cTnT and brain natriuretic peptide (BNP) were measured in 85 consecutive CHF patients with nonischemic DCM and then these patients were followed for a mean of 4.1 years. During long-term follow up, there were 20 cardiac deaths. In 85 DCM patients, conventional cTnT was elevated (≥0.03ng/ml) in 4 patients (5%) and hs-cTnT was elevated (≥0.01ng/ml) in 46 patients (54%). In non-survivors (n=20), conventional cTnT was elevated (≥0.03ng/ml) in 2 patients (2%) and hs-cTnT was elevated (≥0.01ng/ml) in 17 patients (85%). In the stepwise multivariate analyses, a high plasma level of BNP (P=0.002), low left ventricular ejection fraction (<30%, P=0.012) and high hs-cTnT (≥0.01ng/ml, P=0.006) were independent significant prognostic predictors, but conventional cTnT (≥0.03ng/ml) was not. CONCLUSIONS: The findings of the present study indicated that a high serum concentration of hs-cTnT is a useful prognostic predictor that is independent of LVEF or BNP in CHF patients with non-ischemic DCM, suggesting that an increased hs-cTnT concentration sensitively reflects ongoing myocardial damage.