Healing process of myocardial edema in acute perimyocarditis: Observation by speckle-tracking echocardiography and cardiac magnetic resonance parametric mapping.

This report describes the case of a 42-year-old male patient with acute viral perimyocarditis. The case study serves as a demonstration of the use of speckle-tracking echocardiography and cardiac magnetic resonance (CMR) imaging in monitoring myocardial changes associated with perimyocarditis. It explores the possibility that regional longitudinal strain (LS) may predict prognosis in the affected areas of the myocardium, and could reflect more advanced areas of myocyte damage within myocardial edema.

Cardiac pseudomass due to enlarged epicardial adipose tissue: Comparison of echocardiography and cardiac magnetic resonance imaging.

A 75-year-old woman underwent preoperative echocardiography, which revealed a mass in the left atrium; however, cardiac magnetic resonance imaging showed no mass. Echocardiography revealed an enlargement of the epicardial adipose tissue in the left atrioventricular groove, therefore a pseudomass. Causes of cardiac pseudomass on echocardiography have been reported. Suspected pseudomasses should be reliably differentiated from a tumor or thrombus, and if new forms are found, the images must be shared for the benefit of clinicians.

Comparison of neointimal coverage between durable-polymer everolimus-eluting stents and bioresorbable-polymer everolimus-eluting stents 1 year after implantation using high-resolution coronary angioscopy.

OBJECTIVES: We aimed to compare the coronary angioscopic appearance of neointimal coverage (NIC) over durable-polymer everolimus-eluting stents (XIENCE-EES) and bioresorbable-polymer everolimus-eluting stents (SYNERGY-EES) 1 year after implantation. BACKGROUND: XIENCE-EES and SYNERGY-EES have been developed to prevent delayed arterial healing associated with first generation drug-eluting stents. However, the process of arterial healing after XIENCE-EES and SYNERGY-EES implantation has not been clarified. METHODS: Patients who underwent implantation of XIENCE-EES (n = 20) or SYNERGY-EES (n = 20) were enrolled in this study. Coronary angiography and coronary angioscopy were performed 12 ± 1 months after stent implantation. The NIC over the stent was classified into four grades: grade 0, stent struts fully exposed; grade 1, stent struts bulging into the lumen and, still visible; grade 2, stent struts embedded in neointima but still visible; and grade 3, stent struts fully embedded and invisible. Stents exhibiting more than one NIC grade was defined as heterogeneous. Moreover, presence of thrombi was investigated. RESULTS: The distribution of dominant NIC grade (XIENCE-EES: grade 0, 0%; grade 1, 25%; grade 2, 50%; grade 3, 25%; SYNERGY-EES: grade 0, 0%; grade 1, 5%; grade 2, 15%; grade 3, 80%; P = 0.002) and NIC heterogeneity was significantly different (P = 0.004). Thrombi were more frequent in XIENCE-EES than in SYNERGY-EES (40 versus 10%, respectively; P = 0.03). CONCLUSION: Compared with XIENCE-EES, SYNERGY-EES were well covered by neointima and accompanied by fewer thrombi. These findings implied arterial healing of SYNERGY-EES was better than that of XIENCE-EES.

AST-120, an Adsorbent of Uremic Toxins, Improves the Pathophysiology of Heart Failure in Conscious Dogs.

PURPOSE: Several lines of evidence suggest that renal dysfunction is associated with cardiovascular toxicity through the action of uremic toxins. The levels of those uremic toxins can be reportedly reduced by the spherical carbon adsorbent AST-120. Because heart failure (HF) causes renal dysfunction by low cardiac output and renal edema, the removal of uremic toxins could be cardioprotective. METHOD: To determine whether blood levels of the uremic toxin indoxyl sulfate (IS) increase in HF and whether AST-120 can reduce those levels and improve HF. We induced HF in 12 beagle dogs by 6 weeks of rapid right ventricular pacing at 230 beats per min. We treated six dogs with a 1-g/kg/day oral dosage of AST-120 for 14 days from week 4 after the start of rapid ventricular pacing. The other six dogs did not receive any treatment (control group). RESULTS: In the untreated dogs, IS levels increased as cardiac function deteriorated. In contrast, plasma IS levels in the treated dogs decreased to baseline levels, with both left ventricular fractional shortening and pulmonary capillary wedge pressure also improving when compared with untreated dogs. Finally, AST-120 treatment was shown to reduce both myocardial apoptosis and fibrosis along with decreases in extracellular signal-regulated kinase phosphorylation, the Bax/Bcl-2 ratio, and TGF-ß1 expression and increases in AKT phosphorylation. CONCLUSIONS: IS levels are increased in HF. AST-120 treatment reduces the levels of IS and improves the pathophysiology of HF in a canine model. AST-120 could be a novel candidate for the treatment of HF.

Rescue Percutaneous Coronary Intervention for a Lethal "Jailed" Septal Perforator Branch to Resolve Delayed Complete Atrioventricular Block.

Delayed complete atrioventricular (AV) block associated with an occluded septal perforator branch (SPB) is an uncommon complication after performing percutaneous coronary intervention (PCI) for the left anterior descending coronary artery (LAD). Here we report the case of a 74-year-old man who underwent elective PCI for proximal LAD complicated with occlusion of the first major SPB and developed a complete AV block 78 hours after PCI was performed. The patient received a temporary transvenous pacemaker via the jugular vein and successfully underwent balloon angioplasty of the lethal "jailed" SPB, resulting in recovery from the complete AV block. Permanent pacemaker implantation was avoided. Our findings indicate the importance of postprocedural monitoring and consideration of rescue PCI for an occluded SPB in cases of complicated AV conduction disturbances.

Novel Synthesized Radical-Containing Nanoparticles Limit Infarct Size Following Ischemia and Reperfusion in Canine Hearts.

PURPOSE: Although nitroxyl radicals such as 2,2,6,6-tetramethylpiperidine-1-oxyl (TEMPO) scavenge free radicals, their short half-life and considerable side effects such as systemic hypotension and bradycardia have limited their clinical application. Since a radical-containing nanoparticle (RNP) delivers nitroxyl radicals with a prolonged half-life specific to ischemic hearts, we investigated whether RNPs reduce infarct size without the occurrence of substantial side effects and whether nitric oxide (NO) contributes to the cardioprotective effects of RNPs. METHODS: The left anterior descending coronary arteries of dogs were occluded for 90 min, followed by reperfusion for 6 h. Either RNPs, micelles (not containing TEMPO) (control), or 4-hydroxy-TEMPO (TEMPOL) was injected into a systemic vein for 5 min before reperfusion. We evaluated the infarct size, myocardial apoptosis, plasma NO levels in coronary venous blood, and the RNP spectra using an electron paramagnetic resonance assay. RESULTS: RNPs reduced infarct size compared with the control group and TEMPOL group (19.5 ± 3.3 vs. 42.2 ± 3.7 vs. 30.2 ± 3.4%). RNPs also reduced myocardial apoptosis compared with the control and TEMPOL group. Coronary venous NO levels increased in the RNP group. CONCLUSIONS: In conclusion, the administration of 2,2,6,6-tetramethylpiperidine-1-oxyl as a RNP exerted cardioprotective effects against ischemia and reperfusion injury in canine hearts without exerting unfavorable hemodynamic effects. RNPs may represent a promising new therapy for patients with acute myocardial infarction.

An interaction between glucagon-like peptide-1 and adenosine contributes to cardioprotection of a dipeptidyl peptidase 4 inhibitor from myocardial ischemia-reperfusion injury.

Dipeptidyl peptidase 4 (DPP4) inhibitors suppress the metabolism of the potent antihyperglycemic hormone glucagon-like peptide-1 (GLP-1). DPP4 was recently shown to provide cardioprotection through a reduction of infarct size, but the mechanism for this remains elusive. Known interactions between DPP4 and adenosine deaminase (ADA) suggest an involvement of adenosine signaling in DPP4 inhibitor-mediated cardioprotection. We tested whether the protective mechanism of the DPP4 inhibitor alogliptin against myocardial ischemia-reperfusion injury involves GLP-1- and/or adenosine-dependent signaling in canine hearts. In anesthetized dogs, the coronary artery was occluded for 90 min followed by reperfusion for 6 h. A 4-day pretreatment with alogliptin reduced the infarct size from 43.1 ± 2.5% to 17.1 ± 5.0% without affecting collateral flow and hemodynamic parameters, indicating a potent antinecrotic effect. Alogliptin also suppressed apoptosis as demonstrated by the following analysis: 1) reduction in the Bax-to-Bcl2 ratio; 2) cytochrome c release, 3) an increase in Bad phosphorylation in the cytosolic fraction; and 4) terminal deoxynucleotidyl transferase dUTP nick end labeling assay. This DPP4 inhibitor did not affect blood ADA activity or adenosine concentrations. In contrast, the nonselective adenosine receptor blocker 8-(p-sulfophenyl)theophylline (8SPT) completely blunted the effect of alogliptin. Alogliptin did not affect Erk1/2 phosphorylation, but it did stimulate phosphorylation of Akt, glycogen synthase kinase-3ß, and cAMP response element-binding protein (CREB). Only 8SPT prevented alogliptin-induced CREB phosphorylation. In conclusion, the DPP4 inhibitor alogliptin suppresses ischemia-reperfusion injury via adenosine receptor- and CREB-dependent signaling pathways.

Impact of Either GLP-1 Agonists or DPP-4 Inhibitors on Pathophysiology of Heart Failure.

Since diabetes mellitus (DM) is the most common cause of heart failure (HF), it is critically important to clarify whether incretin hormones including glucagon-like peptide-1 (GLP-1), which play an important role in blood glucose control, mediate cardioprotection. There are many lines of basic research evidence indicating that GLP-1 improves the pathophysiology of HF: In murine and canine HF models, either GLP-1 analogues or DPP-IV inhibitors improved cardiac functions. The first question that arises is how either GLP-1 analogues or DPP-IV inhibitors mediate cardioprotection. Cardiovascular diseases are tightly linked to impaired glucose tolerance (IGT): IGT is not only one of the causes of cardiovascular events but also the result of HF. Indeed, the treatment of IGT improved HF, showing that one of the mechanisms attributable to DPP-IV inhibitors is related to the improvement of IGT. Intriguingly, either DPP-IV inhibitors or GLP-1 analogues mediate cardioprotection even without IGT, suggesting two possible explanations: One is that GLP-1 analogues directly activate the prosurvival kinases, such as Akt and Erk1/2, and another is that DPP-IV inhibition increases cardioprotective peptides such as BNP and SDF-1α. The next question is whether cardioprotection is translated to clinical medicine. Small scale clinical trials proved their cardioprotective effects; however, several large scale clinical trials have not proved the beneficial effects of DPP-IV inhibitors. Taken together, GLP-1 analogues or DPP-IV inhibitors can mediate cardioprotection, however, what needs to be clarified is who mainly receives their benefits among the patients with cardiovascular diseases and/or DM.

Impact of different coronary angioscopic findings on arterial healing one year after bioresorbable-polymer and second-generation durable-polymer drug-eluting stent implantation.

BACKGROUND: The advantage of using bioresorbable-polymer drug-eluting stent (BP-DES) compared with second-generation durable-polymer drug-eluting stent (2G DP-DES) still remains controversial in clinical situations. The purpose of this study to evaluate the degree of re-endothelialization and the prevalence of high-grade yellow-colored plaque (YCP), which might concern arterial healing after BP-DES and 2G DP-DES implantation using a high-resolution coronary angioscopy (CAS). METHODS: In total, 104 DESs (52: 2G DP-DES and 52: BP-DES) were prospectively observed using CAS 12±1 months after coronary intervention. The grade of neointimal coverage (NIC) over the stent was scored on a 4-point scale from 0 (no coverage) to 3 (complete coverage). YCP grade was also scored on a 4-point scale as 0 (white) to 3 (intensive yellow). High-grade YCP was defined as maximum grade ≥2. Moreover, the prevalence of high-grade YCP and the incidence of thrombus were investigated. RESULTS: BP-DES revealed better dominant NIC grade and less NIC heterogeneity than 2G DP-DES (p=0.0001 and p=0.015, respectively). The prevalence of high-grade YCP was lower for BP-DES than for 2G DP-DES (p=0.05). However, the incidence of thrombus was not significantly different (p=0.41). Multivariate analysis identified that low-density lipoprotein cholesterol levels [odds ratio (OR), 1.03; 95% Confidence Interval (CI): 1.01-1.06, p=0.01] and the usage of BP-DES [OR, 0.36; 95% CI: 0.14-0.91, p=0.03] as independent predictors of high-grade YCP. CONCLUSIONS: Compared with 2G DP-DES, BP-DES was less heterogeneous and well-covered NIC and less prevalence of the high-grade YCP implying optimal arterial healing.

Efficacy and safety of apixaban in a patient with systemic venous thromboembolism associated with hereditary antithrombin deficiency.

A 40-year-old man with progressively worsening dyspnea was admitted to our hospital. On physical examination, pulse oximetry results demonstrated 80% oxygen saturation in room air. The lungs sounded clear, and both extremities appeared normal, without pitting edema. His echocardiography revealed a pressure overload in the right ventricle. Suspecting the presence of pulmonary thromboembolism, we performed an enhanced computed tomography (CT). CT results revealed systemic venous thromboembolism (VTE) involving the superior mesenteric vein, inferior vena cava (IVC), right common iliac vein and pulmonary arteries, as well as splenomegaly and edema of the small intestine with ascites. After insertion of a retrievable IVC filter, we prescribed 10 mg of apixaban twice daily for the first 7 days, followed by 5 mg twice daily as long-term therapy. Confirming no exacerbation of the VTE symptoms, we removed the IVC filter 14 days after admission. Additionally, hereditary antithrombin deficiency was unraveled as the etiology of systemic VTE. Although an enhanced CT at 6 months follow-up showed that almost all previous VTE had dissolved, we decided to prescribe apixaban indefinitely. Fortunately, he has not experienced a recurrence of VTE or any bleeding events to date. .

Clinical efficacy of a stent-in-stent procedure for stent fracture in a narrowing anastomosis of femoral-popliteal bypass represented repetitive acute limb ischemia.

A 72-year-old male with sudden onset pain and coldness in his left lower limb was referred to our hospital. An emergency angiography of the lower limbs demonstrated the cause of acute limb ischemia as a subsequent acute thromboembolism at the site of a narrowing anastomosis of femoral-popliteal bypass (FPB). In particular, the site of the narrowing anastomosis had already been fixed using a nitinol stent 4 years previously. We confirmed that the severe stent fracture resulted from misalignment. After local lysis therapy, we decided to deploy another nitinol stent to in-stent restenosis (ISR) lesion of the stent fracture. Final angiography confirmed full patency in FPB without flow delay. Additionally, to maintain the patency of arterial flow, we prescribed aspirin and warfarin. After 2 years of operation, his follow-up ankle-brachial pressure index on the left side remained 0.86 and no ischemic leg pain was observed to date. Stent-in-stent procedure using another nitinol stent for ISR treatment for the narrowing anastomosis in FPB indicated feasible and effective results. .

Combination of Carbon Dioxide Angiography and Outback® Elite for Revascularization of a Patient with Renal Insufficiency with Bilateral Femoropopliteal Chronic Total Occlusions.

A new reentry device (Outback Elite) system has been available in Japan since June 2016. This new device enables easier treatment of chronic total occlusion (CTO) in the lower extremities. We report a case of a woman in her 70s who underwent revascularization using this new device twice to treat both of her femoropopliteal CTO lesions. She was referred to our hospital complaining of intermittent claudication in both legs. She had a long history of diabetes mellitus complicated with severe chronic kidney disease. Her estimated glomerular filtration rate was <20. She refused surgical revascularization; therefore, we performed our treatment without iodine contrast medium. First, magnetic resonance imaging was performed to confirm that the CTO lesions had caused severe claudication before intervention. Subsequently, the Outback Elite device and carbon dioxide (CO2) angiography made it possible to revascularize both of her legs without iodine contrast medium. At 6 months after the procedures, we did not observe exacerbation of claudication in her legs.

Amyloid Light-Chain Amyloidosis Manifesting as Heart Failure with Preserved Ejection Fraction in a Patient with Hyper-Immunoglobulin E-emia.

BACKGROUND: Considering the increased prevalence of heart failure with preserved ejection fraction (HFpEF) as a result of the aging population, the pathophysiology of HFpEF needs to be examined. Furthermore, many comorbidity profiles in patients with HFpEF have been reported. Hypertrophic cardiomyopathy is a well-known specific etiology of HFpEF. Cardiac amyloidosis, which mimics infiltrative and hypertrophic cardiomyopathy, resulting from intensive amyloid deposition, is easily overlooked. CASE REPORT: A 53-year-old man with a 2-week history of persistent breathlessness was referred to our hospital. Upon admission, transthoracic echocardiography showed concentric mild left ventricular (LV) hypertrophy without a characteristic granular sparkling appearance or pericardial effusion, preserved ejection fraction, and bi-atrial enlargement with normal ventricular chambers. Doppler-derived LV diastolic filling demonstrated a prominent restrictive pattern indicating LV stiffness and elevated LV filling pressure. Blood tests revealed severe elevation of B-type natriuretic peptide and marked elevation of immunoglobulin E without eosinophilia. He was diagnosed with primary amyloid light-chain (AL) amyloidosis via skin and endomyocardial biopsy. CONCLUSIONS: We encountered a rare case of hypertrophic cardiomyopathy with HFpEF and identified a Doppler-derived restrictive filling pattern suggestive of early-stage heart failure in infiltrative cardiomyopathies. We suggest that infiltrative cardiomyopathies, such as cardiac amyloidosis, should be considered if hypertrophic cardiomyopathy is observed in a patient with HFpEF.

Impact of low-dose prednisolone on refractory pitting edema manifesting remitting seronegative symmetrical synovitis with pitting edema syndrome.

We encountered an elderly male patient who after cardiac surgery for mitral stenosis had refractory pitting edema in both legs involving painful leg joints after a 1-month history of waxing and waning arthralgia. His family doctor had prescribed a combination of diuretics, 40 mg furosemide and 25 mg spironolactone; however, pitting edema in his lower legs persisted. He was diagnosed with worsening of congestive heart failure because of a previous cardiac surgery and was transferred to our hospital. On admission, we closely observed the patient's condition and noticed that his body temperature increased to 38.0 °C every evening. Furthermore, his ankle joints felt feverish and were swollen. Therefore, we suspected polyarthritis as an etiology, although we initially suspected rheumatoid arthritis (RA). Antibody testing did not support RA diagnosis; therefore we concluded the association of remitting seronegative symmetrical synovitis with pitting edema (RS3PE) syndrome with his condition. After daily treatment with 15 mg prednisolone, the refractory edema symptom dramatically improved. The concept of RS3PE syndrome could explain such as an impressive clinical course. .