Proximal superficial femoral artery puncture using an ascending approach for stent re-occlusion in the common femoral artery.

We aimed to describe a technique for approaching the common femoral artery (CFA) in cases where doing so is difficult owing to an occluded lesion caused by a previously implanted stent. A 72-year-old woman had severe stenotic lesions in both iliac arteries that required an approach via the bilateral femoral arteries. The right CFA had a previously implanted stent and a completely occluded lesion that extended from the superficial femoral artery (SFA). A 20G needle was inserted through the proximal SFA, and the needle tip was advanced into the CFA stent and passed through the occluded lesion using a microcatheter and guide wire (GW). This allowed us to insert a guide catheter via the GW into the occluded lesion. No complications, such as bleeding, were observed after the procedure. When the CFA is occluded by a stent, an ascending approach through the proximal SFA is a viable treatment option. Learning objective: An occluded lesion due to a previously implanted stent makes approaching the common femoral artery difficult. Hence, alternative approaches are needed. In this regard, an approach via the proximal superficial femoral artery may prove useful.

Comparison of HERG channel blocking effects of various beta-blockers-- implication for clinical strategy.

beta-Blockers are widely used in the treatment of cardiovascular diseases. However, their effects on HERG channels at comparable conditions remain to be defined. We investigated the direct acute effects of beta-blockers on HERG current and the molecular basis of drug binding to HERG channels with mutations of putative common binding site (Y652A and F656C). beta-Blockers were selected based on the receptor subtype. Wild-type, Y652A and F656C mutants of HERG channel were stably expressed in HEK293 cells, and the current was recorded by using whole-cell patch-clamp technique (23 degrees C). Carvedilol (nonselective), propranolol (nonselective) and ICI 118551 (beta(2)-selective) inhibited HERG current in a concentration-dependent manner (IC(50) 0.51, 3.9 and 9.2 microM, respectively). The IC(50) value for carvedilol was a clinically relevant concentration. High metoprolol (beta(1)-selective) concentrations were required for blockade (IC(50) 145 microM), and atenolol (beta(1)-selective) did not inhibit the HERG current. Inhibition of HERG current by carvedilol, propranolol and ICI 118551 was partially but significantly attenuated in Y652A and F656C mutant channels. Affinities of metoprolol to Y652A and F656C mutant channels were not different compared with the wild-type. HERG current block by all beta-blockers was not frequency-dependent. Drug affinities to HERG channels were different in beta-blockers. Our results provide additional strategies for clinical usage of beta-blockers. Atenolol and metoprolol may be preferable for patients with type 1 and 2 long QT syndrome. Carvedilol has a class III antiarrhythmic effect, which may provide the rationale for a favourable clinical outcome compared with other beta-blockers as suggested in the recent COMET (Carvedilol Or Metoprolol European Trial) substudy.

Blockade of HERG cardiac K+ current by antifungal drug miconazole.

1. Miconazole, an imidazole antifungal agent, is associated with acquired long QT syndrome and ventricular arrhythmias. Miconazole increases the plasma concentration of QT-prolonging drugs by inhibiting the hepatic cytochrome P450 metabolic pathway, but whether it has direct effects on cardiac ion channels has not been elucidated. 2. To determine the mechanism underlying these clinical findings, we investigated the effect of miconazole on human ether-a-go-go-related gene (HERG) K+ channels. 3. HERG channels were heterologously expressed in human embryonic kidney 293 (HEK293) cells and whole-cell currents were recorded using a patch-clamp technique (23 degrees C). 4. Miconazole inhibited HERG peak tail current in a concentration-dependent manner (0.4-40 microM) with an IC50 of 2.1 microM (n=3-5 cells at each concentration, Hill coefficient 1.2). HERG block was not frequency-dependent. It required channel activation, occurred rapidly, and had very slow dissociation properties. 5. The activation curve was shifted in a negative direction (V(1/2): -9.5+/-2.3 mV in controls and -15.3+/-2.4 mV after 4 microM miconazole, P<0.05, n=6). Miconazole did not change other channel kinetics (activation, deactivation, onset of inactivation, recovery from inactivation, steady-state inactivation). 6. The S6 domain mutation, F656C, abolished the inhibitory action of miconazole on HERG current indicating that miconazole preferentially binds to an aromatic amino-acid residue within the pore-S6 region. 7. Our findings indicate that miconazole causes HERG channel block by binding to a common drug receptor, and this involves preferential binding to activated channels. Thus, miconazole prolongs the QT interval by direct inhibition of HERG channels.

Clinical advantage of neutral anode positioning feature in recent pacemaker generator.

Recent advances in pacemaker technology such as a thinner lead body, smaller size of pacemaker generators and pacemaker pulse generators with the neutral anode positioning (NAP) feature, have made pacemaker implantation easier. To date, however, the clinical disadvantages of this NAP feature have not been investigated. We investigated whether there are any clinically disadvantages in pacing and sensing thresholds, myopotential tracking thresholds and myopotential inhibition thresholds in 62 pacemaker patients with the NAP feature. All measured data from the NAP devices when the pacemaker was set to the bipolar system were acceptable and normal. In the unipolar system with NAP feature, no differences were observed in the numerous parameters measured compared to previously reported measured data in the unipolar system without the NAP feature. We concluded that the physician can also benefit from this feature since any pulse generator with the NAP feature is suitable for implant on either side of the body, without any disadvantages. Therefore, left- or right-sided pacers need no longer be ordered, stocked, or specified at the time of implant.

Relationship between exercise tolerance and muscle strength following cardiac rehabilitation: comparison of patients after cardiac surgery and patients with myocardial infarction.

BACKGROUND AND PURPOSE: Previous studies have demonstrated that cardiac rehabilitation (CR) improves exercise tolerance and muscle strength in patients with myocardial infarction (MI) and in patients after cardiac surgery. However, the association between exercise tolerance and muscular strength following CR and the comparison of relationships among various disease categories has not been fully examined. The purpose of the present study was to assess the relationship between exercise tolerance and muscle strength following CR in patients after cardiac surgery and patients with MI. METHODS AND RESULTS: One hundred and four patients who participated in CR for 6 months were enrolled [post-cardiac valve surgery (VALVE), n=28; post-coronary artery bypass grafting (CABG), n=42; post-acute MI, n=34]. The exercise tolerance, thigh/calf circumferences, and muscle strength were measured before and after CR. At the baseline, the thigh circumference was significantly smaller in the VALVE group than in the MI group. There were significant positive correlations between peak VO(2) and muscle torques of the lower muscles in all groups. After 6 months, peak VO(2) and muscle torque were significantly increased in all groups (p<0.001). A positive significant correlation between percent increases in peak VO(2) and muscular strength was observed in the VALVE group (r=0.51, p<0.01), but not in the other groups. In addition, the changes in peak VO(2) and calf circumference after CR were significantly higher in the VALVE group than in the MI group. CONCLUSIONS: These data suggest that exercise intolerance in patients after heart valve surgery may in part depend on decreased muscular strength. Further studies are needed to assess whether the strategy of increasing muscular strength of lower limb by programmed resistance training could be effective for improving exercise intolerance in patients after heart valve surgery and symptomatic patients with heart failure.

Effects of a phase III cardiac rehabilitation program on physical status and lipid profiles in elderly patients with coronary artery disease: Juntendo Cardiac Rehabilitation Program (J-CARP).

BACKGROUND: Limited data are available regarding the effects of phase III cardiac rehabilitation on the physical status and risk factors in elderly patients with coronary artery disease (CAD). METHODS AND RESULTS: Thirty-four male CAD patients (>65 years old) were randomly assigned to an intervention group (n=18) or a control group (n=16). The intervention group participated in a phase III cardiac rehabilitation program consisting of exercise training, diet therapy, and weekly counseling for 6 months. In the control group, usual outpatient care was provided. In the intervention group, body mass index, waist size and fat weight significantly decreased; peak VO2 and anaerobic threshold VO2 were maintained; isokinetic peak torques of knee extensor and flexor muscles significantly increased; anterior trunk flexibility was significantly improved. In the control group, all parameters were unchanged except for peak VO2, which significantly decreased. In the intervention group, serum total cholesterol levels significantly decreased after cardiac rehabilitation. However, high-density lipoprotein-cholesterol and apoA-I levels also decreased. In the control group, no significant change in lipid profile was observed. CONCLUSIONS: The results suggest that phase III cardiac rehabilitation could be beneficial for elderly patients with CAD.

Successful treatment of severe orthostatic hypotension with erythropoietin.

A 71-year-old man, who was diagnosed with familial amyloidosis type I, was admitted for treatment of severe orthostatic hypotension associated with recurrent syncopal attacks. Head-up tilt testing demonstrated severe orthostatic hypotension (114/72 mmHg in the supine position and 62/34 mmHg in the upright position) with syncope or presyncope. Oral midodorine and fludrocortisone therapies failed to prevent his symptoms. After administration of subcutaneous erythropoietin, his blood pressure drop in the upright position was decreased and symptoms disappeared unassociated with improvement of anemia. Although previous reports have shown that the mechanism by which erythropoietin improves orthostatic hypotension is related to improvement in anemia, other mechanisms may also play a role.

Effects of phase III cardiac rehabilitation programs on health-related quality of life in elderly patients with coronary artery disease: Juntendo Cardiac Rehabilitation Program (J-CARP).

The purpose of this prospective randomized controlled trial was to assess the impact of phase III comprehensive cardiac rehabilitation (CR) on health-related quality of life (HRQOL) in elderly patients with coronary artery disease (CAD). Thirty-eight elderly males (mean age, 70 years) with CAD were stratified as the intervention group (n=20) and the control group (n=18). In the intervention group, patients participated in CR for 6 months, whereas in the control group, they received standard care. Validated questionnaires were obtained to evaluate HRQOL using the Medical Outcome Study Short-Form 36 Health Status Survey (SF-36), State-trait anxiety inventory questionnaire (STAI) and Self-rating Depression Scale (SDS) at baseline and after 6 months. At baseline, scores of SF-36 except for general health, STAI and SDS were not different in either group. After 6 months, in the intervention group, scores of bodily pain, general health, vitality and mental health of SF-36 improved significantly compared with baseline. State anxiety scores also improved significantly (p<0.01), but SDS depression scores were not improved. In the control group, none of the parameters significantly changed. These results indicate that elderly patients with CAD should be vigorously encouraged to pursue CR even in chronic phase III.