Thrombectomy and Catheter-Directed Thrombolysis Combined With Antithrombin Concentrate for Treatment of Antithrombin Deficiency Complicated by Acute Deep Vein Thrombosis That Is Refractory to Anticoagulation.

A 22-year-old male was admitted to our hospital with deep vein thrombosis that was complicated by antithrombin deficiency. This deficiency was refractory to anticoagulation therapy. Although catheter-directed thrombolysis could not reperfuse the total occlusion in the left deep vein, a combination of thrombectomy, catheter-directed thrombolysis, and antithrombin concentrate treatment was able to dissolve the clots and ameliorate the blood flow into the left deep vein. Antithrombin concentrate administration would be effective in the treatment of antithrombin deficiency with medical refractory deep vein thrombosis.

[A Case of Heparin-Induced Thrombocytopenia with Discrepancy in the Results of Anti-Platelet Factor 4/Heparin Antibodies between Latex-Particle-Enhanced Immunoturbidimetric Assay and Enzyme Immunoassay].

A female patient in her seventies with diabetes mellitus, hyper-lipidemia and mitral regurgitation was admitted because of the acute heart failure. She was treated with diuretics and vasodilators, however these were not effective. Therefore the CHDF using heparin was required for the patients. After the introduction of CHDF, the platelet count subsequently decreased to less than 7.0 x 10(4)/µl. After stopping CHDF, the platelet count recovered. In the second CHDF treatment, the platelet count decreased again. HIT was suspected because of both the usage of heparin and five points of 4T's score in the patient. Heparin was discontinued immediately and then her platelet count improved. The HIT antibody by latex-particle-enhanced immunoturbidimetric assay was performed simultaneously, however it was not detected. After re-using heparin by heparin lock, platelet count had been decreasing. Furthermore the thrombus was observed in the infusion tube. We considered that a clinical course did not accord with the result of HIT antibody. We measured HIT antibody by another method, an enzyme immunoassay (EIA), and the positive antibody was observed. We encountered a rare case with discrepancy in the results of HIT antibody between two methods. When HIT is suspected by the results from the clinical course and 4T's score, even though the negative HIT antibody, heparin should be discontinued and the different assay for HIT antibody such as an EIA in this case should be performed.

Prognostic value of normal stress-only technetium-99m myocardial perfusion imaging protocol. Comparison with standard stress-rest protocol.

BACKGROUND: Patients with a normal stress image on technetium-99m (Tc-99m) single-photon emission computed tomography (SPECT) have a good prognosis for diagnosing coronary artery disease. However, current guidelines recommend stress and rest imaging to confirm that a stress image is normal. METHODS AND RESULTS: We determined all-cause of cardiac events (acute coronary syndrome and sudden death) in 1,939 patients undergoing stress myocardial perfusion SPECT with Tc-99m radiotracers. Patients with an abnormal stress image were excluded, so we focused on 1,125 patients in whom the stress SPECT study was interpreted as normal. A stress-only protocol was used in 726 patients (adenosine=339; exercise=387), whereas 399 had both stress and rest imaging (adenosine=294; exercise=105). Mean follow-up was 1,252 days. At the end of follow-up, there were 39 cardiac events in the stress-only cohort and 19 in the stress-rest cohort. Kaplan-Meier analysis revealed that there were no differences for the entire cohort of cardiac events not only between the stress-only and stress-rest protocols but also for stressor modality, despite the fact that the stress-rest cohort showed higher coronary risk factors. CONCLUSIONS: Patients determined as having a normal SPECT on the basis of stress imaging alone have a similar cardiac event rate as those who have a normal SPECT on the basis of evaluation of both stress and rest images. This imaging strategy will significantly reduce radiation exposure in a substantial number of patients.

[Recent trends in the clinical characteristics of infective endocarditis: a survey of 54 consecutive cases from 2006 to 2010].

BACKGROUND: It has been reported that the clinical characteristics of infective endocarditis are changing during the course of the decades. However, most of the available data are obtained in the early 2000s or earlier. We therefore evaluated the more recent clinical spectrum of infective endocarditis. METHODS: Fifty-four consecutive patients diagnosed as infective endocarditis based on the Duke criteria at our hospital from January 2006 to December 2010 were evaluated. RESULTS: Of 54 cases, 31 (57%) were male and 23 (43%) were female, with mean age of 57 +/- 17 years. Twenty-three (43%) patients were older than 65 years. The number of patients with diabetes mellitus or undergoing chronic hemodialysis, or cancer were 9 (17%), 5 (9%), and 5 (9%), respectively. In 25 patients (46%), endocarditis occurred without any underlying cardiac disease. The frequencies of streptococcal endocarditis and staphylococcal endocarditis were almost identical [18 (33%) vs. 17 (32%)]. Methicillin resistant staphylococcus aureus was found in 6 patients (11%). CONCLUSIONS: A survey of patients with infective endocarditis from 2006 to 2010 revealed a trend towards increased staphylococcal endocarditis in compromised patients without prior cardiac disorders.

Pseudoaneurysm with left-to-right shunt in a patient with myocardial infarction: evaluation by three-dimensional echocardiography.

It is often difficult to noninvasively differentiate a post-infarction left ventricular (LV) pseudoaneurysm from a post-infarction true aneurysm. A 66-year-old woman with a past history of inferior acute myocardial infarction was admitted to our hospital because of acute decompensated heart failure. Two-dimensional transthoracic echocardiography showed an aneurysm with a narrow orifice in the inferoposterior basal area. The pulmonary to systemic flow ratio (Q p/Q s) was 2.2:1, which corresponded to moderate left-right shunting. Three-dimensional transesophageal echocardiography (3D-TEE) showed the orifice in the perforated right ventricular basal area with a color jet through the orifice from the LV to the right ventricle. Collectively, based on the 3D-TEE findings, we diagnosed the case as inferoposterior pseudoaneurysm with a left-to-right shunt caused by myocardial infarction.

Factors associated with myocardial salvage immediately after emergent percutaneous coronary intervention in patients with ST-elevation acute myocardial infarction.

OBJECTIVE: The amount of myocardial salvage after percutaneous coronary intervention (PCI) is reported to be a major determinant of functional recovery in patients with ST-elevation acute myocardial infarction (MI). However, factors related to the amount of myocardial salvage remain unknown. The goal of this study was to investigate the factors related to the amount of myocardial salvage after emergent PCI in patients with ST-elevation acute MI by incorporating pre- and post-treatment indices and adjunctive treatments. METHODS: Technetium-99m myocardial imaging was performed before, immediately after, and one month after emergent PCI in 161 patients with ST-elevation acute MI, and the defect score was serially evaluated. A good myocardial salvage was defined as >/=4 change (before minus immediately after PCI) of the defect score. RESULTS: Good myocardial salvage was observed in 89 patients. Based on nine clinical variables, logistic regression analysis was performed to determine the important variables related to myocardial salvage. Multivariate analysis revealed that earlier time from onset to PCI (chi (2) = 6.55, P = 0.01, odds ratio = 2.78), larger defect score before PCI (chi (2) = 7.29, P = 0.01, odds ratio = 1.13) and administration of nicorandil before PCI (chi (2) = 9.88, P = 0.008, odds ratio = 4.42) were independently associated with good myocardial salvage. Thrombolysis In Myocardial Infarction (TIMI) flow grade <2 before PCI (chi (2) = 4.91, P = 0.03, odds ratio = 0.36) and TIMI flow grade

Hematobium schistosomiasis control for health management of labor force generation at Nkhotakota and Lilongwe in the Republic of Malawi-assumed to be related to occupational risk.

BACKGROUND: In Malawi, hematobium schistosomiasis is highly endemic. According to previous studies, countermeasures have been conducted mainly in school-aged children. In this study, we focused on the age groups, which are assumed to be major labor force generation. Hematobium schistosomiasis is supposed to be related to occupational activities in schistosome-endemic countries because of its infectious route. We chronologically followed the transition of schistosome egg-positive prevalence before and after mass drug administration of praziquantel (MDA) by using a urine filtering examination. We also analyzed the effectiveness of urine reagent strips from the cost perspective. RESULTS: The egg-positive prevalence was 34.3% (95% CI 28.5-40.5) just before MDA in June 2010 and the highest prevalence was in the age of twenties. The egg-positive prevalence reduced to 12.7% (95% CI 9.2-17.3, p < 0.01) 8 weeks after the first MDA and the prevalence reduced to 6.9% (95% CI 4.6-10.0, p < 0.01) after the second MDA in August 2011. The egg-positive prevalence after MDA in 2013 was reduced from 3.8% (95% CI 2.1-6.9) to 0.9% (95% CI 0.3-3.4) and p value was 0.050. Using urine reagent strips after MDA, the positive predictive value decreased, but the negative predictive value remained high. The cost of one urine reagent strip and one tablet of praziquantel were US$0.06 and US$0.125 in 2013 in Malawi. If the egg-positive prevalence is 40%, screening subjects for MDA using urine reagent strips, the cost reduction can be estimated to be about 24%, showing an overall cost reduction. CONCLUSIONS: MDA of praziquantel can assuredly reduce schistosome egg-positive prevalence. The combination of MDA and urine reagent strips could be both a practical and cost-effective countermeasure for hematobium schistosomiasis. It is key to recognize that hematobium schistosomiasis could be considered a disease that is assumed to have some concern with occupational risk at Nkhotakota and Lilongwe in Malawi. From this point of view, it is very important to manage workers' health; the sound labor force generation is vital for economic growth and development in these areas and countries.

Non-invasive detection of ischemic left ventricular dysfunction using rest gated SPECT: expectation of simultaneous evaluation of both myocardial perfusion and wall motion abnormality.

OBJECTIVE: Although the accurate detection of ischemic etiology is important in the management of patients with severe left ventricular (LV) dysfunction, it is difficult to determine using a non-invasive strategy. The present study investigates whether perfusion and regional functional abnormalities identified by quantitative electrocardiographic gated single-photon emission computed tomography (QGS) at rest can detect ischemic LV dysfunction in patients with severe LV dysfunction. METHODS: Rest QGS with (99m)Tc-tetrofosmin was performed on 54 consecutive patients with LV ejection fraction of

IgA Vasculitis with Simultaneous Cardiopulmonary Involvement.

A 60-year-old man with a history of hypertension, type 2 diabetes, and reflux esophagitis was admitted to our hospital with hemoptysis, dyspnea, and leg edema. We diagnosed him with adult IgA vasculitis based on the presence of purpura, elevated serum IgA fibronectin complexes, pathophysiological findings, a skin biopsy showing leukocytoclastic vasculitis, and immunofluorescence studies demonstrating granular IgA and C3 deposits in the blood vessel wall. He showed concurrent cardiopulmonary involvement without involvement of the gastrointestinal system and kidneys, which are commonly affected in IgA vasculitis patients. Following treatment with prednisolone, the patient recovered with improvement in cardiopulmonary manifestations.

Efficacy of Oxycodone for Dyspnea in End-stage Heart Failure with Renal Insufficiency.

A 67-year-old man with dilated cardiomyopathy and renal insufficiency was admitted to our hospital with dyspnea secondary to end-stage heart failure. We introduced oxycodone for medically refractory dyspnea instead of morphine because of the patient's renal insufficiency. After the administration of oxycodone, his dyspnea was alleviated without any adverse opioid effects, such as respiratory depression. After treating his heart failure, he was able to leave the intensive care unit. Oxycodone may therefore be a reliable agent for the treatment of dyspnea in patients with end-stage heart failure and renal insufficiency.

Nicorandil was an Effective Treatment Option for a Patient with Bland-White-Garland Syndrome.

A 75-year-old woman who had previously been diagnosed with Bland-White-Garland syndrome was admitted to our hospital for acute decompensated heart failure (ADHF). Following her recovery from ADHF, pharmacologic stress myocardial scintigraphy revealed myocardial ischemia in the basal anterior area of the left ventricle. Moreover, myocardial scintigraphy showed the improvement of the myocardial ischemia after 6 months of nicorandil administration.

Effect of beta-blockers on the mortality of Japanese patients with myocardial infarction.

BACKGROUND: After a myocardial infarction, a higher prevalence of coronary vasospastic response has been reported in the Japanese population than in the Caucasian population. Beta-blockers may exacerbate coronary vasospasm. However, beta-blockers are given to Japanese patients after an acute myocardial infarction, though the mortality benefit is unknown. Thus, we investigated the mortality benefit of beta-blockers given to Japanese patients after an acute myocardial infarction. METHODS: We prospectively studied consecutive patients with a first myocardial infarction admitted to the coronary care unit of Kansai Medical University Hospital, Osaka, Japan from May 1994 through the end of 2001. Patients who died during hospitalization or who were referred for coronary artery bypass graft surgery were excluded. The association of beta-blocker use with mortality after discharge was assessed by a proportional hazards regression analysis. RESULTS: There were 546 patients and 400 (73.3%) patients were treated with beta-blockers at the time of discharge from hospital. During a mean follow-up of 2 years, 46 (8.4%) patients died. Beta-blocker therapy was associated with a reduced mortality after adjustment for age, gender, Q wave myocardial infarction, reperfusion therapy during acute phase, Killip functional class, serum creatinine level, cardiovascular risk factors, and medications (hazard ratio=0.51, 95% confidence interval=0.27 to 0.95). CONCLUSIONS: Contrary to the concern that beta-blocker therapy might induce coronary vasospasm and reduce survival, beta-blocker therapy improved survival after discharge in Japanese patients with a first myocardial infarction.

'Takotsubo' cardiomyopathy in a maintenance hemodialysis patient.

An 84-year-old woman undergoing maintenance hemodialysis presented with chest discomfort lasting several days and electrocardiographic abnormalities. She had stopped smoking 2 weeks earlier and was experiencing irritability. Upon admission, electrocardiography showed ST-segment elevation in leads I, II, aVF, and V2-6 and an abnormal Q wave in leads II, III, and aVF. Ultrasound cardiography showed left ventricular anteroapical akinesia and basal hyperkinesia. The chest discomfort disappeared without specific therapy. During hospital days 1-5, the ST-segment elevation gradually improved. Giant negative T waves then developed. The left ventricular asynergy resolved by day 8. Radionuclide imaging with iodine-123-beta-methyl-p-iodophenyl pentadecanoic acid, but not with technetium-99 m-sestamibi, showed an apical defect. Elective coronary angiography showed no stenosis. 'Takotsubo' cardiomyopathy was diagnosed. After discharge, the patient continued regular dialysis without cardiac symptoms. We concluded that endogenously activated sympathetic nerve action in hemodialysis patients, especially those under emotional or physical stress, might be a causative factor for Takotsubo cardiomyopathy.

Scintigraphic prediction of left ventricular functional recovery early after primary coronary angioplasty using single-injection quantitative electrocardiographic gated SPECT.

OBJECTIVE: The clinical usefulness of characterizing reperfused myocardium by perfusion/thickening assessment using electrocardiographic gated single photon emission computed tomography (SPECT) has not been investigated. We evaluated whether single-injection gated SPECT with 99mTc tetrofosmin early after primary percutaneous coronary intervention (PCI) can predict left ventricular (LV) functional recovery. METHODS: Gated SPECT was performed 3 days after primary PCI in 45 patients with acute myocardial infarction and revascularized segments were classified into perfusion/thickening mismatched segments, matched normal and matched abnormal segments. Gated SPECT was repeated 3 months later to evaluate the changes in LV ejection fraction (deltaLVEF). RESULTS: Among 332 revascularized segments, there were 83 mismatched segments, 163 matched abnormal segments and 86 matched normal segments. In all the patients, LVEF increased significantly from 3 days to 3 months after primary PCI (52+/-13 to 57+/-14%, P<0.0001). Patients were divided into two groups according to deltaLVEF: 24 patients with LV functional recovery (deltaLVEF > or = 5%) and 21 patients without LV functional recovery. The number of mismatched segments in patients with LV functional recovery was significantly greater than that in patients without (2.7+/-1.7 vs. 0.8+/-1.4, P<0.0003) despite no differences in the number of matched abnormal and matched normal segments. There was a significant correlation between deltaLVEF and the number of mismatched segments (r=0.56, P<0.0001) and LVEF at 3 months after primary PCI was related to the number of matched abnormal segments (r=-0.78, P<0.0001). CONCLUSION: Single-injection gated SPECT early after primary PCI can predict LV functional recovery.

Left ventricular apical ballooning syndrome in a patient with infundibular stenosis of the right ventricle: A case report.

A 73-year-old female patient with a past history of right ventricular infundibular stenosis was admitted to our intensive care unit because of right ventricular dysfunction. On the fifth day of hospitalization, she suddenly experienced dyspnea without chest pain despite the improvement of her condition by initial medical treatment. Although electrocardiography revealed no ST-segment elevation, echocardiography and myocardial perfusion using 99mTc-MIBI revealed new development of severe symmetrical akinesia and reduced perfusion of the left ventricular (LV) apex and mid-ventricle. LV apical ballooning syndrome was diagnosed based on the minimal elevation of cardiac enzymes (peak cardiac troponin I 0.18 ng/ml) despite the presence of large regions of focal myocardial damage in the myocardium and the absence of positive ECG diagnosis and urgent coronary angiography. Previous coronary angiography revealed normal coronary arteries and the left anterior descending artery without full irrigation around the apex making apical ballooning. On the 12th day of hospitalization, despite the use of positive inotropic treatment, it was impossible to maintain hemodynamic stability, and the patient died prior to the functional recovery of the left ventricle.

Obesity as an independent risk for left ventricular diastolic dysfunction in 692 Japanese patients.

BACKGROUND: Both obesity and left ventricular (LV) diastolic dysfunction are associated with an increased risk of cardiovascular morbidity and mortality. There is a paucity of data as to whether obesity is independently associated with LV diastolic dysfunction. METHODS: Adult patients with sinus rhythm referred for a transthoracic echocardiography between July, 2007, and December, 2007, were prospectively included. Exclusion criteria were patient who had a history of congenital or valvular heart disease, treatment with pacemaker implantation or implantable cardioverter defibrillator, myocardial infarction, or impaired LV systolic function. Diastolic function was classified by an algorithm incorporating data from mitral and pulmonary venous flow indices, and Doppler tissue imaging. Body mass index (BMI) was evaluated as a categorical variable (normal weight <25.0 kg/m(2); overweight 25.0 to <30.0 kg/m(2); and obese ≥30 kg/m(2)). Logistic models were used to assess the risk of abnormal LV diastolic function associated with BMI categories. RESULTS: Of a total number of 692 patients who met all study criteria (mean 59 ± 15 year-old; 50% women, 48% hypertension, 16% diabetes, 26% overweight, 8% obese), 538 (78%) had abnormal LV diastolic function. In multivariate analyses adjusting for age, sex, and cardiovascular risk factors, obesity was independently associated with LV diastolic dysfunction (odds ratio [OR]: 2.98, 95% confidence interval [CI]: 1.12-7.88; P = 0.03) compared to normal weight. LV mass did not weaken this association (OR: 2.88, 95% CI: 1.08-7.68; P = 0.04). Overweight was not independently associated with LV diastolic dysfunction. CONCLUSION: Obesity was associated with LV diastolic dysfunction independent of cardiovascular risk factors and LV mass.

Atypical morphology and myocardial perfusion of mid-ventricular ballooning: A case report.

Although some atypical types of transient left ventricular apical ballooning syndrome have been reported, only a few atypical types of transient mid-ventricular ballooning have been reported. A 70-year-old female underwent surgery for urothelial carcinoma. At day 5 after the surgery, she was admitted to our department without cardiac symptoms because of ST elevation in leads I, II, III, aVF and V1-V6 indicating acute coronary syndrome. She was diagnosed with stress induced cardiomyopathy based on an angiographically normal coronary artery, newly developed extensive wall motion abnormality (hyperbasal contraction and akinesis from the mid-left ventricle to the apex without hypercontraction of the small area adjacent to the apex) based on left ventriculography, and a small elevation of myocardial enzymes incongruous with the area of contraction abnormality. Myocardial scintigraphy with 99mTc-tetrofosmin showed a severely reduced myocardial perfusion in an extensive mid-ventricular area without a left ventricular base and top of apex, in accord with a wall motion abnormality different from typical apical ballooning or typical mid-ventricular ballooning previously diagnosed in our hospital. This is the first report presenting an atypical mid-ventricular ballooning based on the myocardial atypical perfusion findings.