Diffusion-weighted whole-body magnetic resonance imaging with background body signal suppression was useful in a patient with isolated myocardial abscess confined to the right atrial wall: a case report.

BACKGROUND: Myocardial abscess is often associated with infective endocarditis (IE), and isolated myocardial abscess without IE is rare. Echocardiography and computed tomography (CT) are often used to diagnose myocardial abscess; however, to the best of our knowledge, diffusion-weighted whole-body magnetic resonance imaging with background body signal suppression (DWIBS) has not been used. Here, we present a case of myocardial abscess without IE that was diagnosed using DWIBS. CASE PRESENTATION: A 72-year-old Japanese man with a history of hypertension, dyslipidemia, and retinitis pigmentosa presented to our hospital with malaise and a fever lasting 10 days. Blood test results showed elevated inflammatory marker levels (white blood cell count 18,700/µL and C-reactive protein level 23.0 mg/dL). Infection was suspected; however, the source of the infection could not be identified. DWIBS, which was performed on day 7 of admission to determine the source of infection, showed a high signal surrounding the right wall, suggesting inflammation. Contrast-enhanced CT performed on day 1 of hospitalization revealed a low-density area in the same region; however, the pathological implications of this finding could not be determined. Based on DWIBS findings, we concluded that the condition presented as a myocardial abscess that was confined specifically to the right atrial wall. Three sets of blood cultures revealed negative findings, and echocardiography showed no vegetation or valve regurgitation. Therefore, the patient was diagnosed with an isolated myocardial abscess uncomplicated with IE. An electrocardiogram on admission showed no P waves, and the patient had a junctional rhythm. However, on day 20 of hospitalization, he developed a complete atrioventricular block. After complete myocardial abscess healing following antibiotic treatment was confirmed, the patient underwent pacemaker implantation. Ten months after surgery, the patient had no signs of infection recurrence. CONCLUSIONS: Based on history and physical examination alone, diagnosis of an isolated myocardial abscess can be challenging. In addition to CT and echocardiography, DWIBS might be helpful for the diagnosis of myocardial abscesses.

Computed tomography values of pericardial effusion may predict chylopericardium: a case report.

BACKGROUND: Idiopathic chylopericardium is a rare disease characterized by filling of the pericardial cavity with chylous fluid and has no evident cause. Secondary chylopericardium usually results from injury or damage to the thoracic duct. The most common causes of secondary chylopericardium are trauma, thoracic or cardiac surgery, and congenital lymphangiomatosis. Conservative or surgical treatment can be pursued; however, surgical treatment is required if conservative treatment is unsuccessful. Pericardiocentesis plays a crucial role in the definitive diagnosis of chylopericardium. However, although a serious complication, its occurrence is infrequent. Non-invasive methods, such as computed tomography (CT), could be useful in predicting the color or characteristics of pericardial effusion. CASE PRESENTATION: A 37-year-old Japanese woman presented to our hospital with a cough that persisted for 1 week. Echocardiography revealed pericardial effusion, which was diagnosed as acute pericarditis and treated with loxoprofen. However, pericardial effusion increased, and the patient presented to the emergency room with cardiac tamponade 1 month later. Pericardiocentesis was performed, which confirmed that the pericardial effusion was chylopericardium. Lymphatic scintigraphy did not show any connection between the thoracic duct and pericardial cavity, and the patient was diagnosed with idiopathic chylopericardium. The patient underwent continuous drainage for 11 days. After completion of cardiac drainage, the patient was discharged from the hospital without any exacerbation. The CT attenuation value of the pericardial fluid was 11.00 Hounsfield units (HU). Compared with the other causes of pericardial effusions encountered at our hospital, the HU on CT scan of pericardial effusion was low in our study and similar to the values on CT scan of chylous ascites reported in previous studies. CONCLUSIONS: Although idiopathic chylopericardium is rare, it should be considered an important cause of pericardial effusion. Pericardiocentesis is necessary for definitive diagnosis; however, the CT findings of pericardial effusion may help predict the presence of chylous fluid.

Congenital Isolated Unilateral Agenesis of Pulmonary Arteries with 3-Year Follow-Up after Initiation of Treatment.

Background and objective: Unilateral agenesis of pulmonary arteries (UAPA) is a rare disease, with approximately 400 cases reported to date. UAPA is often associated with congenital heart disease, and the uncomplicated form is isolated UAPA, which accounts for approximately 30% of all cases of UAPA. The incidence of pulmonary hypertension due to UAPA has been reported to range from 19 to 44%. There is no consensus treatment for pulmonary hypertension associated with UAPA. We present the first reported case in which a three-drug combination, comprising of iloprost inhalation, riociguat, and ambrisentan, was administered to a patient with UAPA, and was followed-up for 3 years post-diagnosis. Case presentation: A 68-year-old Japanese woman presented to our hospital with dyspnea and chest discomfort. She underwent chest radiography, blood tests, and echocardiography; however, the cause of the patient's symptoms could not be identified. During regular follow-up, an echocardiography 21 months after the initial visit revealed elevated right ventricular pressure (peak tricuspid regurgitation velocity: 5.2 m/s and right ventricular systolic pressure: 120 mmHg) and a diagnosis of pulmonary hypertension was made. Contrast-enhanced computed tomography (CT) of the chest and a pulmonary blood flow scintigram were performed to investigate the cause of pulmonary hypertension, and isolated UAPA was diagnosed. The patient was treated with a three-drug combination of iloprost inhalation, riociguat, and ambrisentan and followed up for 3 years with good therapeutic outcomes. Conclusions: We present a case of pulmonary hypertension caused by isolated UAPA. Although rare, this disease can lead to pulmonary hypertension and should be treated cautiously. While there is no consensus regarding the treatment of this disease, a three-drug combination of iloprost inhalation, riociguat, and oral ambrisentan proved effective.

Hereditary Congenital Methemoglobinemia Diagnosed at the Age of 79 Years: A Case Report.

Background: Cardiopulmonary disorders are the most common cause of central cyanosis, and methemoglobinemia is often overlooked in the differential diagnosis of patients with central cyanosis. In most cases, methemoglobinemia is acquired and hereditary congenital methemoglobinemia is rare. Only a few case reports of congenital methemoglobinemia can be found in PubMed. To date, only four cases of congenital methemoglobinemia diagnosed after the age of 50 years have been reported. Case Presentation: A 79-year-old Japanese woman presented at our hospital with the chief complaints of dyspnea and cyanosis. She exhibited cyanosis of the lips and extremities, and her SpO2 was 80%, with oxygen administration at 5 L/min. Blood gas analysis revealed a PaO2 of 325.4 mmHg and methemoglobin level of 36.9%. The SpO2 and PaO2 values were dissociated, and methemoglobin levels were markedly elevated. Genetic analysis revealed a nonsynonymous variant in the gene encoding nicotinamide adenine dinucleotide cytochrome (NADH) B5 reductase 3 (CYB5R3), and the patient was diagnosed with congenital methemoglobinemia. Conclusions: It is important to consider methemoglobinemia in the differential diagnosis of patients with central cyanosis. At 79 years of age, our patient represents the oldest patient with this diagnosis. This report indicates that it is crucial to consider the possibility of methemoglobinemia regardless of the patient's age.

Respiratory Collapse of the Inferior Vena Cava Reflects Volume Shift and Subsequent Fluid Refill in Acute Heart Failure Syndrome.

BACKGROUND: Fluid redistribution rather than fluid accumulation plays an important role in the development of acute heart failure (HF) syndrome. Patients with fluid redistribution develop acute HF without prominent volume overload. We investigated volume status by measuring the diameter of the inferior vena cava (IVC) and examining variations in hemoglobin and hematocrit. METHODS AND RESULTS: Seventy-four consecutive patients admitted for acute HF syndrome were analyzed. Blood tests and measurement of IVC diameter after stabilization of respiratory distress were performed on admission and were repeated after 24 h. IVC collapsibility index (IVC-CI) was calculated as (maximum IVC-minimum IVC)/maximum IVC. According to the initial IVC-CI, the patients were divided into the collapse group (IVC-CI ≥0.5: n=34) and the non-collapse group (IVC-CI <0.5: n=40). Initial blood pressure was higher in the collapse group (P<0.001). Although 24-h urine volume did not differ between the groups, hemoglobin (P<0.001) and hematocrit (P<0.001) decreased significantly in the collapse group but not in the non-collapse group after 24 h. Furthermore, IVC-CI significantly decreased in the collapse group after 24 h (P=0.003). CONCLUSIONS: In acute HF syndrome, IVC-CI ≥0.5 on admission suggests a volume shift from the central vein into the pulmonary vasculature. Fluid refill occurs within 24 h after admission. This observation could be helpful in selecting strategies for diuretic use. (Circ J 2016; 80: 1171-1177).

Bailout Strategy for Paclitaxel-Coated Nitinol Self-Expanding Stent Deployment Failure: The Cut and Peel Technique.

The patient received endovascular therapy for a superficial femoral artery occlusion. Placement of a SMART stent distal to the lesion was successful, but deployment issues occurred with the Innova stent, requiring forceful retraction and causing elongation. The "cut and peel technique" was developed as a bailout strategy for such cases.

Implementation of the kissing balloon technique using a perfusion balloon in acute myocardial infarction: a case report.

Background: Prolonged antiplatelet-agent administration associated with stenting for acute myocardial infarction is not ideal in young patients. We successfully performed a perfusion balloon-based kissing balloon technique in the left anterior descending artery ostium in a young patient with acute myocardial infarction. Case summary: A 34-year-old female presenting with recurrent chest pain was diagnosed with ST-segment elevation acute myocardial infarction. Emergency coronary angiography revealed 90% stenosis of the left anterior descending artery ostium. Considering her age, lesion dilation using a perfusion balloon was preferred. This inadvertently impinged the left circumflex artery, causing chest pain and ischaemia-related hypotension with only a 10 s perfusion dilation balloon. We transitioned to an alternative 7 Fr guiding catheter and performed the kissing balloon technique using a perfusion balloon. This allowed prolonged inflation for 120 s, without complications. Optical coherence tomography of the lesion revealed layered plaques. Based on the patient's age and medical history, coronary spasm may be the aetiological factor underlying acute ST-segment elevation myocardial infarction. Coronary angiography 3 months post-discharge revealed no restenosis. Discussion: Regarding acute myocardial infarction, prolonged inflation with a perfusion balloon had higher frequency of non-stent-related interventions than that of semi-compliant or non-compliant balloons. In this case, the perfusion balloon resulted in chest pain and hypotension. Perfusion balloon-based kissing balloon technique was useful in this setting. Optical coherence tomography revealing the responsible lesions can help determine the cause of acute myocardial infarction in young patients; in our case, a layered plaque was observed. Layered plaques are associated with coronary spasm; therefore, initiating treatment of coronary spasm was considered herein.

Early and short-term use of proprotein convertase anti-subtilisin-kexin type 9 inhibitors on coronary plaque stability in acute coronary syndrome.

Aims: Proprotein convertase anti-subtilisin-kexin type 9 inhibitors (PCSK9Is) improve plaque volume and composition and reduce major adverse coronary events in chronic coronary artery disease. We evaluated the effects of the short-term use of PCSK9Is on coronary plaque stability in patients with acute coronary syndrome (ACS) using optical coherence tomography (OCT). Methods and results: This is a multicentre, open-label randomized controlled trial. The enrolled 80 subjects met the inclusion criteria. Of these, 52 patients (age 60 ± 11 years, 38 men, 14 women) with ST-elevated ACS had undergone successful primary percutaneous coronary intervention with LDL-cholesterol (LDL-C) levels > 70 mg/dL while receiving high-intensity statins. Participants were randomly assigned to the PCSK9I group (evolocumab 420 mg for 3 months, n = 29) or the standard of care (SoC) group (n = 23). Optical coherence tomography was performed at baseline (BL) and 3 and 9 months after randomization to assess lipid-rich plaques in non-culprit lesions. The change in the minimum fibrous cap thickness (MFCT) from BL to 9 months was the primary endpoint. The percentage change in LDL-C levels from BL to 3 months was significantly greater in the PCSK9I group (-67.8 ± 21.5% in the PCSK9I group vs. -16.3 ± 21.8% in the SoC group; P < 0.0001), and the difference between the two groups disappeared from BL to 9 months (-20.0 ± 37.8% in the PCSK9I group vs. -6.7 ± 34.2% in the SoC group; P = 0.20). The changes in MFCT from BL to 9 months were significantly greater in the PCSK9I group, even after PCSK9I discontinuation {100 µm [interquartile range (IQR): 45-180 µm] vs. 50 µm [IQR: 0-110 µm]; P = 0.032}. Conclusion: Combination treatment with PCSK9Is and statins resulted in more marked plaque stabilization after ACS than SoC alone, and this effect persisted for 6 months after PCSK9I discontinuation. Registration: Adage-Joto study, UMIN ID No. 26516.

Treatment for aortoiliac bifurcation disease by balloon-expandable covered stent; "Double-D" molding technique.

Appropriate endovascular treatment for aortic bifurcation lesions remains unclear. Incomplete apposition and radial mismatch have not been resolved to date. We treated two cases of aortic bifurcation lesions including common iliac aneurysms with balloon-expandable covered stents with "Double-D molding technique (DDMT)." This is the method. First, standard kissing stent technique with two balloon-expandable covered stents for aortic bifurcation lesions is performed. Second, either covered stent post-dilated with a larger size percutaneous transluminal angioplasty (PTA) balloon before the other covered stent also post-dilated with the same larger size PTA balloon. Kissing balloon technique was performed with the two previous size PTA balloons. Good double-D shape configuration is observed. This DDMT could improve the radial mismatch of the kissing covered stents to distal aortic wall. 〈Learning objective: The treatment of aortoiliaic bifurcation disease including iliac aneurysms with balloon expandable covered stents using "double D-shape molding technique" is safe and effective.〉.

Infective Endocarditis with No Underlying Disease for Which Bacterial Endophthalmitis Have Been the First Symptom.

Bacterial endophthalmitis is a rare complication of infective endocarditis (IE). We herein report a case of IE with no underlying disease for which endophthalmitis could have been the first symptom. A 58-year-old man was admitted to our hospital with a fever, vision disturbances, and pain in the left hand joint. His left eye was removed because fusion on the cornea progressed. Streptococcus agalactiae was detected in blood cultures, fluid cultures from his left hand joint, and the removed eye. Bacterial endophthalmitis may present as the first symptom of IE and develop without underlying disease due to S. agalactiae infection.