Long-term vardenafil therapy improves hemodynamics in patients with pulmonary hypertension.

The phosphodiesterase-5 (PDE-5) inhibitor, sildenafil, has been reported to produce sustained pulmonary vasodilatation in patients with pulmonary hypertension (PH). Recently, vardenafil, a more potent and selective PDE-5 inhibitor than sildenafil, has been approved for the treatment of erectile dysfunction. However, the long-term effects of oral vardenafil in patients with PH are unknown. We studied five consecutive patients with PH; one with primary pulmonary hypertension, two with chronic pulmonary thromboembolism, one with Eisenmenger syndrome (ventricular septal defect) and one with secondary pulmonary hypertension after a ventricular septal defect closure operation. In an acute hemodynamic trial, vardenafil (5 mg) significantly decreased both the pulmonary vascular resistance (PVR) and systemic vascular resistance (SVR) with an increase in cardiac output. In a chronic hemodynamic trial, the maintenance dose of vardenafil (10 to 15 mg) for 3 months significantly decreased the PVR, but not the SVR, with a 20.7% reduction of the PVR/ SVR ratio. Plasma brain natriuretic peptide (BNP) levels were also significantly decreased after 3 months. This pilot study demonstrates that long-term oral vardenafil therapy may be a safe and effective treatment for patients with PH.

Radiofrequency catheter ablation of accessory pathway in a patient with Ebstein's anomaly and atrial septal defect--a case report.

The authors report the case of a 57-year-old woman with Ebstein's anomaly and atrial septal defect. She was referred to their hospital for treatment of refractory paroxysmal wide QRS tachycardia. Her 12-leads ECG in sinus rhythm showed ventricular preexcitation of type B Wolff-Parkinson-White syndrome. In a baseline electrophysiological study, a wide QRS tachycardia with right bundle branch block configurations was induced. This tachycardia was orthodromic atrioventricular reciprocating tachycardia with a right inferior accessory pathway. Radiofrequency current was successfully delivered at the inferior site of the atrialized right ventricle. Radiofrequency catheter ablation seems to be useful for supraventricular tachycardia in patients with Ebstein's anomaly and atrial septal defect.

Large saccular aneurysm in a coronary arterial fistula--a case report.

The authors present a case of a large saccular aneurysm in a coronary artery fistula originating from the proximal left anterior descending coronary artery, draining into the main trunk of the pulmonary artery. The diagnosis was made by 3-dimensional computed tomography and coronary arteriography. Congenital coronary artery fistula is not uncommon. With a saccular aneurysm, however, it is very rare. A ruptured aneurysm will induce sudden death if surgical repair is not done.

The influence of spontaneous termination of atrial fibrillation on P wave-triggered signal-averaged electrocardiogram.

BACKGROUND: Prolongation of total filtered P wave duration (Ad) and low root mean square voltages for the last 20 ms of the P wave (LP20) on a P wave-triggered signal-averaged electrocardiogram (PSAECG) are typically observed in paroxysmal atrial fibrillation (PAF) patients. A shortening of atrial refractoriness and intra-atrial conduction delay (atrial remodeling) have been shown to occur in response to PAF. We, therefore, investigated the effects of spontaneous termination of PAF on the parameters of PSAECG. METHODS: We measured the Ad, LP20 and left atrial (LA) diameter by ultrasonic echocardiography before, within 1 h after, and 3 and 12 months after PAF termination in patients with no structural heart disease (n=11). RESULTS: The PAF duration was 16+/-5 h. The Ads before, within 1 h after, and 3 and 12 months after PAF were 137+/-4, 148+/-4, 137+/-6, and 135+/-7 ms, respectively. The Ad within 1 h after PAF was significantly (P<0.01) longer than at the other three acquisition points. Although the LP20 within 1 h after PAF termination was not significantly different from the other three points, the change in LP20 (within 1 h after PAF-before PAF, -1.1+/-0.4 microV) in the long PAF duration group was significantly (P<0.05) greater than that of the short PAF duration group. LA diameter was unchanged at all points. CONCLUSION: These data suggest that PAF results in prolongation of Ad after termination of PAF.

Acute pericarditis in the recovery phase of transient left ventricular apical ballooning syndrome (takotsubo cardiomyopathy).

A 64-year-old woman was admitted because of persistent chest pain and ST-elevation in the precordial and inferior leads on electrocardiogram. Emergent coronary angiography demonstrated that there was no obstruction, and left ventriculography showed apical akinesis and basal hyperkinesis. She was diagnosed with takotsubo cardiomyopathy. Chest pain subsided within the day of admission followed by T-wave inversion on electrocardiogram. Nevertheless, chest pain and ST-elevation reappeared late on the third hospital day, accompanied by fever and small amounts of pericardial and pleural effusions. Under the administration of nonsteroidal anti-inflammatory drug, the inflammation lessened. This is the first report of acute pericarditis in the recovery phase of takotsubo cardiomyopathy.

Temporary inferior vena cava filter for deep vein thrombosis and acute pulmonary thromboembolism: effectiveness and indication.

Although the temporary inferior vena cava filter (IVC-F) is being used increasingly for protection against pulmonary thromboembolism (PTE), indications for its use are not established. Our strategy for the prevention of PTE is: (1) contraindication or failure of anticoagulation: permanent IVC-F; (2) for patients with residual proximal deep vein thrombosis (a) who have permanent risk factor: permanent IVC-F; (b) who have transient risk factor: temporary IVC-F; (3) others: no IVC-F. Temporary IVC-F was also implanted in deep vein thrombosis (DVT) patients without PTE who were preoperation or had floating thrombus. We investigated the outcome of patients given a temporary IVC-F versus those given a permanent IVC-F to clarify the efficacy and our strategy for implantation of a temporary IVC-F. Subjects were 12 men and 38 women with acute PTE and/or floating DVT admitted to our hospital between April 1999 and April 2002. Patient age was 25-91 years (mean 63 years). Eighteen patients were given a permanent IVC-F (group A) and 32 patients were given a temporary IVC-F (group B) as primary treatment, according to our criteria. There were no major complications in either group. Mortality after implantation of the IVC-F was 35% (6/17) in group A and 16% (4/25) in group B, with no significant difference (P = 0.14). Pulmonary thromboembolism recurred in 18% (3/17) of group A patients but in no group B patients (P = 0.10). All recurrences resulted in death. The 14 patients in group B who were not given a permanent IVC-F after removal of the temporary IVC-F survived. The temporary IVC-F can be used safely in patients with venous thromboembolism and is efficacious in preventing recurrence of PTE. Prognosis after removal of the temporary IVC-F is excellent.

Shifting of puncture site in the fossa ovalis during radiofrequency catheter ablation: intracardiac echocardiography-guided transseptal left heart catheterization.

Intracardiac echocardiography (ICE) serves as an adjunct to fluoroscopy for electrophysiological procedures by identifying critical anatomic landmarks and confirming catheter-endocardial contact. In the present study, we investigated the usefulness of ICE for radiofrequency catheter ablation. ICE was utilized to guide transseptal puncture in 19 patients undergoing radiofrequency catheter ablation. The fossa ovalis, which was one critical anatomic landmark, had an average vertical diameter of 18.5 +/- 6.9 mm and an average horizontal diameter of 10.0 +/- 2.4 mm, as measured by ICE and fluoroscopy. Although there was only a small shift of the puncture site in the horizontal direction, the puncture site shifted towards the upper edge of the fossa ovalis for 17 patients (89%). Furthermore, we could verify that the distance between the apex of the tent-shape formed by the pressure of the puncture needle in the fossa ovalis and the left atrial wall opposing it was sufficient to carry out the procedure safely. Confirming the puncture site using ICE is useful in carrying out transseptal left heart catheterization safely.

T-wave alternans in patients with right ventricular tachycardia.

Microvolt T-wave alternans has been proposed as a new risk marker for ventricular arrhythmias. However, the clinical significance of T-wave alternans in patients with ventricular tachycardia (VT) originating from the right ventricle has been unknown. The study population consisted of 20 patients with arrhythmogenic right ventricular cardiomyopathy (ARVC) or idiopathic VT. T-wave alternans was measured during bicycle exercise testing using the CH 2000 system. Of the 7 patients with ARVC, 6 (86%) were positive for T-wave alternans. On the other hand, only 1 (8%) of 13 patients with idiopathic VT originating from the right-ventricular outflow tract was positive for T-wave alternans.

Role of autonomic tone in the initiation and termination of paroxysmal atrial fibrillation in patients without structural heart disease.

INTRODUCTION: Previous studies have suggested that paroxysmal atrial fibrillation (PAF) of vagal origin often occurs at night and PAF of sympathetic origin occurs during the daytime; however, autonomic tone after spontaneous termination of PAF has not been determined. The aim of this study was to evaluate by heart rate variability (HRV) analysis the relationship between the time of PAF onset and autonomic tone before and after PAF. METHODS AND RESULTS: Twenty-three patients (65 +/- 2 years) who underwent 24-hour ambulatory monitoring, had one or more episodes of PAF (>30 min), and had maintained normal sinus rhythm for >60 min before/after PAF were enrolled in this study. Mean duration of PAF was 6.2 +/- 1.2 hours. HRV parameters were analyzed in a 10-minutes section at 60 minutes, 20 minutes, and immediately before the onset of PAF and after its termination. PAF began at night in 14 patients (group N) and during the daytime in 9 patients (group D). In group N, the high-frequency (HF) component and low-frequency (LF) component showed a significant decrease after PAF; PAF was preceded by a gradual increase in HF and LF. Changes in the LF/HF ratio, however, did not occur before or after PAF. Conversely, group D showed a significant increase in the LF/HF ratio before PAF and a decrease in LF and the LF/HF ratio after PAF, but no changes in HF. These changes in HRV parameters were not influenced by the duration or termination time of PAF. CONCLUSION: This study suggests that the autonomic nervous system plays an important role in both the initiation and termination of PAF. Furthermore, the time of PAF onset influences the autonomic tone at the initiation and termination of PAF.