Effect of neointimal tissue morphology on vascular response to balloon angioplasty in lesions with in-stent restenosis after drug-eluting stent deployment: an optical coherence tomography analysis.

This study aimed to evaluate the vascular response to balloon angioplasty for drug-eluting stent (DES) in-stent restenosis (ISR) lesions based on our novel optical coherence tomography (OCT) classification to establish the optimal treatment strategy for ISR lesions after DES implantation. A total of 104 ISR lesions after DES implantation were imaged by OCT and categorized into the following six patterns: type I-homogeneous high-intensity tissue, type II-heterogeneous tissue with signal attenuation, type III-speckled heterogeneous tissue, type IV-mixed tissue containing poorly delineated region with invisible strut, type V-mixed tissue containing sharply delineated low-intensity region, and type VI-bright protruding tissue with an irregular surface. Serial volumetric OCT analysis was performed before and after balloon dilation to evaluate the vascular response to balloon angioplasty. After balloon dilation, the minimal decrease in neointimal volume was noted in type I lesions and maximal in type III lesions. In contrast, the increase in stent volume was significantly more in type I lesions than others. Neointimal tissue characterization by OCT allows us to provide useful information about the vascular response to balloon dilation, which can influence the therapeutic strategy for DES ISR lesions.

Utility and Validity of Intracoronary Administration of Nicorandil Alone for the Measurement of Fractional Flow Reserve in Patients With Intermediate Coronary Stenosis.

BACKGROUND: Intracoronary (IC) administration of nicorandil has been proposed as an alternative choice of hyperemic agent for fractional flow reserve (FFR) measurements. This study evaluated the utility and validity of IC nicorandil administration alone to induce maximal hyperemia.Methods and Results:Two-hundred-seven patients with coronary artery disease listed for coronary angiography with FFR were prospectively enrolled. FFR was measured after (1) IC administration of nicorandil 2 mg (ICNIC2 mg); (2) continuous intravenous (IV) adenosine triphosphatase (ATP) infusion at 150 µg/kg/min (IVATP150); (3) IV ATP infusion at 210 µg/kg/min (IVATP210); (4) IC administration of 0.5 mg nicorandil during IVATP150 (ICNIC0.5 mg+IVATP150); (5) IC administration of 1 mg nicorandil during IVATP150 (ICNIC1 mg+IVATP150); and (6) IC administration of 2 mg nicorandil during IVATP150 (ICNIC2 mg+IVATP150). The average FFR values and the rate of achieving maximum hyperemia after ICNIC2 mg, IVATP150, IVATP210, ICNIC0.5 mg+IVATP150, ICNIC1 mg+IVATP150, and ICNIC2 mg+IVATP150 were 0.85±0.08, 0.89±0.08, 0.85±0.09, 0.84±0.08, 0.83±0.08, 0.83±0.08 (P<0.01), and 92%, 54%, 91%, 96%, 99%, 99% (P<0.01), respectively. The incidence of systolic aortic pressure drop, chest discomfort, and transient atrioventricular block increased in a dose-dependent manner after IV ATP infusion, but almost no adverse effects were observed after ICNIC2 mg. CONCLUSIONS: ICNIC2 mg produced a more pronounced hyperemia than continuous IV ATP, and might be the preferred method for assessment of FFR.

Should we emergently revascularize occluded coronaries for cardiac arrest?: rapid-response extracorporeal membrane oxygenation and intra-arrest percutaneous coronary intervention.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) and percutaneous coronary intervention (PCI) may be useful in cardiopulmonary resuscitation. However, little is known about the combination of ECMO and intra-arrest PCI. This study investigated the efficacy of rapid-response ECMO and intra-arrest PCI in patients with cardiac arrest complicated by acute coronary syndrome who were unresponsive to conventional cardiopulmonary resuscitation. METHODS AND RESULTS: This multicenter cohort study was conducted with the use of the database of ECMO in Hiroshima City, Japan. Between January 2004 and May 2011, rapid-response ECMO was performed in 86 patients with acute coronary syndrome who were unresponsive to conventional CPR. The median age of the study patients was 63 years, and 81% were male. Emergency coronary angiography was performed in 81 patients (94%), and intra-arrest PCI was performed in 61 patients (71%). The rates of return of spontaneous heartbeat, 30-day survival, and favorable neurological outcomes were 88%, 29%, and 24%, respectively. All of the patients who received intra-arrest PCI achieved return of spontaneous heartbeat. In patients who survived up to day 30, the rate of out-of-hospital cardiac arrest was lower (58% versus 28%; P=0.01), the intra-arrest PCI was higher (88% versus 70%; P=0.04), and the time interval from collapse to the initiation of ECMO was shorter (40 [25-51] versus 54 minutes [34-74 minutes]; P=0.002). CONCLUSIONS: Rapid-response ECMO plus intra-arrest PCI is feasible and associated with improved outcomes in patients who are unresponsive to conventional cardiopulmonary resuscitation. On the basis of these findings, randomized studies of intra-arrest PCI are needed.

Three-year follow-up of sirolimus-eluting stents vs. bare metal stents for acute myocardial infarction.

BACKGROUND: The long-term safety and efficacy of drug-eluting stents for patients with acute myocardial infarction (AMI) remain controversial. METHODS AND RESULTS: A total of 143 consecutive patients who presented between August 2004 and July 2006 with AMI and who underwent primary percutaneous coronary intervention (PCI) using sirolimus-eluting stents (SES), were compared with a historical control cohort of 129 consecutive patients who presented between August 2002 and July 2004 and who underwent primary PCI using bare metal stents (BMS). The rate of major adverse cardiovascular events at 3 years was significantly lower in the SES group than in the BMS group (20.3% vs. 33.1%, respectively; P=0.01). This reduction was mainly driven by a decrease in the rate of target vessel revascularization (12.3% vs. 22.4%, respectively; P=0.02). There was no significant difference in the rate of cardiovascular death (4.5% vs. 5.7%, respectively; P=0.67), non-fatal myocardial infarction (4.5% vs. 9.2%, respectively; P=0.16), coronary artery bypass grafting (2.3% vs. 2.5%, respectively; P=0.93), stroke (2.4% vs. 0.8%, respectively; P=0.35), and stent thrombosis (2.9% vs. 2.3%, respectively; P=0.80) between the 2 groups. CONCLUSIONS: SES can be used safely and effectively in patients with AMI.

Usefulness of Lipoprotein (a) for predicting progression of non-culprit coronary lesions after acute myocardial infarction.

BACKGROUND: The serum lipoprotein (a) [Lp(a)] level is genetically determined and remains consistent during a person's life. Previous cohort studies have reported that subjects with a high Lp(a) level are at high risk of cardiac events. METHODS AND RESULTS: This study consisted of 410 patients who underwent primary percutaneous coronary intervention within 24h of the onset of acute myocardial infarction (AMI). Lp(a) was measured 1 week after AMI and patients were divided into 2 groups based: high Lp(a) group (>40mg/dl, n=95) and low Lp(a) group (≤40mg/dl, n=315). A major adverse cardiac event (MACE) was defined as cardiac death, myocardial infarction and/or revascularization for new lesions. The incidence of MACE during 5 years was significantly higher in the high Lp(a) group than in the low Lp(a) group (34.7% vs. 16.5%, P<0.001). This difference was primarily driven by a higher incidence of new lesions requiring revascularization in the high Lp(a) group (31.6% vs. 15.2%, P<0.001). Multivariate analysis showed that Lp(a) was an independent predictor for MACE (odds ratio [OR] 1.64, 95% confidence interval [CI] 1.31-2.06, P<0.001) and revascularization of a new lesion (OR 1.61, 95%CI 1.32-2.13, P<0.001). CONCLUSIONS: Lp(a) levels could predict the progression of the non-culprit coronary lesions after AMI.

Late peri-stent contrast staining appearance due to rupture of atherogenic neointima following drug-eluting stent.

The development of peri-stent contrast staining (PSS) after coronary intervention with implantation of a stent is observed in approximately 1-3% of patients treated with drug-eluting stent. Although the cumulative incidences of late in-stent restenosis and stent thrombosis are significantly higher in lesions with PSS than in those without the finding, the mechanisms for the development of PSS have not yet been fully elucidated. In this report, we describe a case of rapid development of PSS with ulcer formation caused by rupture of atherogenic neointima, which was observed by serial optical coherence tomography examinations over 6 months. Protrusion of the stent-jailed underlying necrotic core toward the lumen by the contracting force might have resulted in formation of atherogenic neointima within the stent. Subsequently, rupture of this necrotic core induced by iatrogenic neointimal injury due to balloon dilation and dissolution of the accumulated necrotic core may have resulted in PSS formation 6 months after the procedure. These findings may be helpful for consideration of etiology and therapeutic strategy for lesions with PSS. .

Acute myocardial infarction in a patient with uncorrected tetralogy of Fallot accompanied by coronary artery ectasia: A case report.

A 63-year-old male with a medical history of uncorrected tetralogy of Fallot (TOF) presented to our hospital due to acute myocardial infarction (AMI). Emergency coronary angiography (CAG) was performed and it showed a severe thrombotic stenosis in the middle right coronary artery (RCA) and total thrombotic occlusion of the posterior descending branch of the RCA. Subsequently, percutaneous coronary artery intervention (PCI) under the guidance of intravascular ultrasound (IVUS) was performed. He was discharged on the 14th day in stable condition. Nine months after the PCI procedure, coronary computed tomography angiography was performed for follow-up, which revealed tetralogy of Fallot and complete resolution of the thrombus and ectasic coronary artery without stenosis. When he was 70 years old, he was transferred to our hospital because of recurrent AMI. As emergency CAG showed total thrombotic occlusion of the middle RCA, IVUS-guided PCI was performed. We experienced a very rare case of AMI in an adult patient with uncorrected TOF accompanied by coronary artery ectasia (CAE). To the best of our knowledge, this is the first case of AMI in an adult patient with uncorrected TOF accompanied by CAE. .

Effect of prodromal angina pectoris on the infarct progression in patients with first ST-elevation acute myocardial infarction.

BACKGROUND: Prodromal angina pectoris (AP) has a cardioprotective effect by the mechanism of ischemic preconditioning, and the QRS score on the admission electrocardiogram (ECG) reflects myocardial damage at presentation. This study was undertaken to investigate the effect of prodromal AP on infarct progression after the onset of acute myocardial infarction (AMI). METHODS AND RESULTS: The study group comprised 291 patients with a first ST-elevation AMI who underwent coronary angiography within 24 h of symptom onset. QRS score was calculated from the admission ECG. Patients were divided into 3 groups according to elapsed time from onset of AMI to angiography: early group (<2 h), intermediate group (2-6 h) and late group (6-24 h). Prodromal AP was defined as angina occurring 24 h before the onset of AMI. Patients with prodromal AP (n=101; 35%) had a significantly lower QRS score than those without (2.4+/-2.4 vs 3.2+/-3.0, P=0.02). In patients without prodromal AP, the QRS score linearly increased as elapsed time increased: 2.6+/-2.8, 3.0+/-3.0 and 5.5+/-2.9 in the early, intermediate and late groups, respectively. In patients with prodromal AP, the QRS score remained low until 6 h after onset and then increased: 2.0+/-1.8, 2.0+/-2.1, and 4.1+/-3.3, respectively. CONCLUSIONS: The findings suggested that prodromal AP might delay infarct progression during the early hours after the onset of AMI and extend the window of time for reperfusion therapy.

Who benefits most from mild therapeutic hypothermia in coronary intervention era? A retrospective and propensity-matched study.

INTRODUCTION: The aim of the present study was to investigate the impact of the time interval from collapse to return of spontaneous circulation (CPA-ROSC) in cardiac arrest patients and the types of patients who will benefit from therapeutic hypothermia. METHODS: Four hundred witnessed adult comatose survivors of out-of-hospital cardiac arrest of cardiac etiology were enrolled in the study. The favorable neurological outcome was defined as category 1 or 2 on the five-point Pittsburgh cerebral performance scale at the time of hospital discharge. A matching process based on the propensity score was performed to equalize potential prognostic factors in the hypothermia and normothermia groups, and to formulate a balanced 1:1 matched cohort study. RESULTS: The rate of favorable neurological outcome was higher (P < 0.05) in the hypothermia group (n = 110) than in the normothermia group in patients with CPA-ROSC of 15 to 20 minutes (64% vs. 17%), 20 to 25 minutes (70% vs. 8%), 25 to 30 minutes (50% vs. 7%), 35 to 40 minutes (27% vs. 0%) and 40 to 45 minutes (29% vs. 2%). A similar association was observed in a propensity-matched cohort, but the differences were not significant. There was no significant difference in the rate of favorable neurological outcome between the hypothermia-matched group and the normothermia-matched group. In the patients whose CPA-ROSC was greater than 15 minutes, however, the rate of favorable neurological outcome was higher in the hypothermia-matched group than in the normothermia-matched group (27% vs. 4%, P < 0.001). In multivariate analysis, the CPA-ROSC was an independent predictor of favorable neurological outcome (every 1 minute: odds ratio = 0.89, 95% confidence interval = 0.85 to 0.92, P < 0.001). CONCLUSIONS: The CPA-ROSC is an independent predictor of neurological outcome. Therapeutic hypothermia is more beneficial in comatose survivors of cardiac arrest with CPA-ROSC greater than 15 minutes.

Successful percutaneous removal of dislodged ring-marker of optical coherence tomography catheter using the twisted wire technique with a guide-extension catheter: A case report.

An 81-year-old male with diabetes and hypertension was admitted to our hospital due to chest pain on exertion. Coronary angiography revealed a severe stenosis at the middle of right coronary artery (RCA). We performed percutaneous coronary intervention under the guidance of optical coherence tomography (OCT) to the lesion in the middle RCA. After balloon dilations, a drug-eluting stent was deployed to the lesion. Then, OCT examination was performed. At that time, fluoroscopy revealed a foreign body over the 0.014-inch guidewire in the distal RCA, which was the ring-marker of OCT catheter. As RCA blood flow was well preserved, percutaneous removal of the dislodged ring-marker was immediately attempted. At first, we tried to remove the dislodged ring-marker with the guide-extension catheter trapping technique. However, it failed and advanced balloon catheter made the dislodged ring-marker migrate more distally. Therefore, we tried the twisted wire technique with the guide-extension catheter and finally the dislodged ring-marker was removed with it. To the best of our knowledge, this is the first case report of a successful percutaneous removal of a dislodged ring-marker of OCT catheter using the twisted wire technique with a guide-extension catheter. .

Therapeutic hypothermia in combination with percutaneous coronary intervention in out-of-hospital cardiac arrest due to left main coronary artery disease.

A 59-year-old man had a witnessed collapse while driving a car. Approximately 10 min after the call to emergency services, paramedics arrived and initiated cardiopulmonary resuscitation. The first electrocardiogram (ECG) obtained by paramedics showed pulseless electrical activity. Review of his prehospital records documented that he experienced approximately 13 min of no flow or low flow before return of spontaneous circulation. On admission, he was still comatose with midrange dilated pupils. Electrocardiogram showed sinus rhythm, ST segment elevation in lead aVR, and ST segment depression in leads I, II, and V4-6. Coronary angiography showed 99% narrowing of the left main coronary artery (LMCA), but did not show any disease in the right coronary artery. A bare-metal stent was placed in the LMCA, and postdilated at 20 atmospheres. Immediately after return to the coronary care unit, therapeutic hypothermia was initiated. Hypothermia with a target temperature of 33.0 degrees C was maintained for 30 h. During this period, no significant hemodynamic instability occurred under intra-aortic balloon pumping (IABP) and intravenous catecholamines. Subsequently, he was slowly rewarmed at a rate of 0.3 degrees C/h up to 36.0 degrees C. Next day, the neurological condition improved and IABP was stopped. Creatine kinase increased to 2182 IU/l. Stent thrombosis did not occur despite the ad hoc loading of antiplatelet drugs. Follow-up echocardiography 9 days later showed mild hypokinesia of the anterior wall with an ejection fraction of 77%. He was discharged with no neurologic complications 18 days later.

Electrocardiographic prediction of short-term prognosis in patients with acute myocardial infarction associated with the left main coronary artery.

PURPOSE: The purpose of this study was to assess the usefulness of electrocardiogram on admission to predict short-term prognosis in patients with acute myocardial infarction (AMI) associated with left main coronary artery (LMCA). METHODS: Electrocardiogram was obtained on admission in 41 patients with AMI associated with LMCA who underwent reperfusion therapy. Electrocardiographic findings were compared between nonsurvivors and survivors. RESULTS: There were 24 nonsurvivors and 17 survivors during 30-day follow-up. Nonsurvivors had ST-segment elevation in both leads aVR and aVL (54% vs 18%, P < .05), left anterior fascicular block (83% vs 41%, P < .05), and right bundle-branch block (54% vs 18%, P < .05) more frequently, and ST-segment depression in lead V(5) (17% vs 59%, P < .05) less frequently than survivors among patients with AMI associated with LMCA. CONCLUSIONS: Our data suggested that electrocardiogram on admission might be useful to predict short-term prognosis in patients with AMI associated with LMCA.

The decrease in QRS amplitude after aortic valve replacement in patients with aortic valve stenosis.

PURPOSE: The purpose of this study was to evaluate the effect of aortic valve replacement on electrocardiogram (ECG) in patients with aortic valve stenosis. METHODS: Serial 12-lead ECGs were obtained in 15 patients with aortic valve stenosis who underwent aortic valve replacement. Three ECG indexes for left ventricular hypertrophy were manually measured in each ECG: Sokolow-Lyon index (sum of S wave in V(1) and R wave in V(5)), Cornell voltage index (sum of R wave in aVL and S wave in V(3)), and Gubner index (sum of R wave in I and S wave in III). RESULTS: After aortic valve replacement, Sokolow-Lyon index gradually decreased during 2 years (51.1 +/- 17.9 to 34.8 +/- 12.5 mm, P < .01). Cornell voltage index (25.6 +/- 7.0 to 15.0 +/- 4.8 mm, P < .01) and Gubner index (15.8 +/- 7.6 to 10.3 +/- 5.5 mm, P < .01) also gradually decreased during 2 years. ST depression in V(6) was found in 14 patients (93%) before aortic valve replacement. It resolved in 9 of 14 patients during 2 years. CONCLUSIONS: Electrocardiographic evidence of left ventricular hypertrophy gradually resolved after aortic valve replacement in patients with aortic valve stenosis.

Therapeutic hypothermia after out-of-hospital cardiac arrest due to Brugada syndrome.

A 56-year-old man was admitted to our hospital after successful resuscitation for out-of-hospital cardiac arrest. Electrocardiogram on admission showed right bundle branch block and ST segment elevation in leads V1-3. Subsequent intravenous infusion of isoproterenol rapidly resolved ST segment elevation, suggesting Brugada syndrome. Therapeutic hypothermia, that was performed with a target temperature of 34.0 degrees C did not induce ST segment elevation in leads V1-3. The J-ST segment elevation rather became much more normal, suggesting a beneficial effect of mild therapeutic hypothermia. Serial ECG showed the temporal variation of ST segment elevation, and pilsicainide challenge test showed the occurrence of ST segment elevation, confirming the diagnosis of Brugada syndrome. Clinical observation suggested that mild therapeutic hypothermia reversed the Brugada phenotype through the prevention of fever as well as being indicated for cerebral protection after cardiac arrest. In conclusion, therapeutic hypothermia with a temperature of 34.0 degrees C can be used safely in Brugada syndrome.

Pulmonary vein volume predicts the outcome of radiofrequency catheter ablation of paroxysmal atrial fibrillation.

PURPOSE: Catheter ablation of atrial fibrillation (AF) is an effective therapy for selected groups of patients. We evaluated whether quantification of left atrium (LA) or pulmonary vein (PV) by using multi-detector computed tomography (MDCT) may predict the success rate of PV isolation procedure. METHODS: We included 118 patients younger than 65 years with symptomatic AF (73 paroxysmal, PAF; 45 non-paroxysmal, non-PAF). All patients underwent 256-slice MDCT prior to circumferential PV isolation to evaluate anatomy, volume and dimensions of LA and PV. RESULTS: After a mean follow-up of 14 months, complete success was achieved in 50 patients (68.5%) of PAF and in 26 patients (57.8%) of non-PAF. In the PAF group, total PV volume was found to be an independent predictor of AF recurrence, whereas LA volume was not. Logistic regression analysis showed that the probability of AF recurrence was higher in patients with total PV volume greater than 12.0 cm3/BSA (m2) (AUC 0.682, 95%CI 0.541-0.822). In the non-PAF group, no independent risk factor of LA or PV size was observed for the postoperative recurrence. CONCLUSIONS: The PV volume quantification may predict the success of AF ablation in PAF patients.

Comparison of radial, brachial, and femoral accesses using hemostatic devices for percutaneous coronary intervention.

Some studies have suggested that radial access (RA) for percutaneous coronary intervention (PCI) reduces vascular complications and bleeding compared to femoral access (FA). The purpose of this study was to investigate the routine use of hemostatic devices and bleeding complications among RA, brachial access (BA), and FA. Between January 2015 and December 2015, 298 patients treated for PCI with RA were compared with 158 patients using BA and 206 patients using FA. The radial sheath was routinely removed with ADAPTY, the brachial sheath with BLEED SAFE, and the femoral sheath with Perclose ProGlide. In-hospital bleeding complications were investigated. Cardiogenic shock was most frequent in patients in the femoral group (RA 1.3%, BA 2.5%, FA 9.2%, p < 0.0001). The rate of major bleeding was highest in the femoral group (RA 1.0%, BA 2.5%, FA 5.3%, p = 0.01). Blood transfusion rates were highest in the femoral group (RA 0.7%, BA 1.3%, FA 4.4%, p = 0.01). Retroperitoneal bleeding was observed in 1.9% of patients in the femoral group. Patients in the brachial group had large hematomas (RA 0.7%, BA 4.4%, FA 1.5%, p = 0.01). Pseudoaneurysm formation needing intervention occurred most frequently in the brachial group (RA 0%, BA 1.3%, FA 0%, p = 0.04). In conclusion, compared to the brachial and femoral approaches, the radial approach appears to be the safest technique to avoid local vascular bleeding complications. The brachial approach has the highest risk of large hematoma and pseudoaneurysm formation among the three groups.

Impact of admission hyperglycemia and diabetes mellitus on short- and long-term mortality after acute myocardial infarction in the coronary intervention era.

The influence of admission hyperglycemia and diabetes on short- and long-term mortality of patients with acute myocardial infarction (AMI) in the percutaneous coronary intervention (PCI) era was investigated. From 1996 to 2003, a total of 802 consecutive patients with AMI underwent coronary angiography. Primary PCI was performed in 724 patients (90%). Three-year mortality curves were constructed using the Kaplan-Meier method. Cox proportional hazard regression was used to identify independent predictors of 30-day mortality and mortality from 30 days to 3 years. There were 261 patients with admission hyperglycemia (admission glucose>or=11.1 mmol/L) and 212 patients with diabetes. Admission hyperglycemia was associated with a significantly higher 30-day mortality rate (8.4% vs 2.4%, p<0.001). However, there was no significant difference in 30-day mortality rates between diabetic and nondiabetic patients (5.7% vs 3.9%, p=0.29). Conversely, diabetes significantly increased mortality from 30 days to 3 years (10.0% vs 5.5%, p=0.03), but admission hyperglycemia did not (8.4% vs 5.9%, p=0.19). Multivariate analysis showed that hyperglycemia was an independent predictor of 30-day mortality (odds ratio [OR] 1.71, 95% confidence interval [CI] 1.13 to 2.61, p=0.01), but diabetes was not (OR 0.84, 95% CI 0.55 to 1.27, p=0.42). Diabetes was independently associated with mortality from 30 days to 3 years (OR 1.43, 95% CI 1.02 to 1.97, p=0.04), but hyperglycemia had a neutral effect (OR 0.98, 95% CI 0.70 to 1.36, p=0.92). In conclusion, in the PCI era, admission hyperglycemia was associated with short-term mortality, whereas diabetes increased long-term mortality after convalescence in patients with AMI. Admission hyperglycemia and diabetes should be treated as 2 distinct disease states.

Pressure tracings in obstructive Tako-Tsubo cardiomyopathy.

A 70-year-old female experienced severe anxiety due to an incident with a stranger when she was home alone at night. Immediately after the event, she had an oppressive chest sensation; 16 h later she was admitted to hospital. Left ventriculography showed akinesia of the mid-to-distal portion and hyperkinesia of the basal portion of the left ventricular chamber. However, coronary angiography showed no significant coronary artery disease. We diagnosed her as having Tako-Tsubo cardiomyopathy. Subsequently, left ventricular and central aortic pressures were recorded simultaneously. Initial recording showed a peak systolic gradient of 60 mm Hg. On the first sinus beat after a premature ventricular contraction, the peak systolic gradient increased to 130 mm Hg, and the pulse pressure decreased. Shortly after intravenous administration of nitroglycerin (0.5 mg), central aortic pressure decreased and the peak systolic gradient increased to 100 mm Hg. On the first sinus beat after a premature ventricular contraction, the peak systolic gradient increased to 160 mm Hg, and the pulse pressure decreased. Five minutes after intravenous nitroglycerin, the peak systolic gradient returned to 70 mm Hg. Follow-up transthoracic echocardiography 13 days later showed normal left ventricular wall motion with no pressure gradient through the left ventricular outflow tract.

Myocardial perfusion and fatty acid metabolism in patients with tako-tsubo-like left ventricular dysfunction.

OBJECTIVES: We sought to assess myocardial perfusion and metabolism in patients with peculiar transient asynergy, which consisted of basal normokinesia and apical akinesia of the left ventricle (LV) at the same time. BACKGROUND: This asynergy has been widely called "tako-tsubo-like LV dysfunction" in Japan, but little is known about its pathophysiology. METHODS: We performed rest tallium-201 ((201)Tl) and iodine-123-beta-methyl-p-iodophenyl penta-decanoic acid ((123)I-BMIPP) dual-isotope myocardial single-photon emission computed tomography (SPECT) in 14 patients with tako-tsubo-like LV dysfunction. The LV was divided into 17 segments, and each segment was graded with scores between normal uptake (0) and defect (4). We also measured the Thrombolysis in Myocardial Infarction trial (TIMI) frame count in 28 patients and 20 control subjects. RESULTS: Early SPECT (5 +/- 3 days) revealed that the total defect score value with BMIPP was significantly higher than reduced uptake with (201)Tl (p < 0.01). Reduced uptake of BMIPP was observed in parallel with an apical akinetic region and usually involved uptake of (201)Tl. This discrepancy improved gradually during the follow-up period (29 +/- 6 days) (p = 0.36). Compared with control subjects, patients had a TIMI frame count that was significantly higher in all coronary arteries immediately after onset. This higher TIMI frame count decreased but was sustained even after resolution of tako-tsubo-like LV dysfunction. CONCLUSIONS: Our data suggest that myocardial fatty acid metabolism is more severely impaired than myocardial perfusion, in parallel with an apical akinetic region during the early phase, and that impaired multivessel coronary microcirculation is involved, at least in part, in tako-tsubo-like LV dysfunction.

Comparison of the cardioprotective effect of prodromal angina pectoris and collateral circulation in patients with a first anterior wall acute myocardial infarction.

To compare the cardioprotective effect of prodromal angina pectoris and collateral circulation, 245 patients with first anterior acute myocardial infarction who underwent coronary angioplasty within 12 hours of symptoms were studied. Prodromal angina pectoris and collateral circulation were independently associated with higher predischarge left ventricular ejection fraction (LVEF), and a combination of prodromal angina pectoris and collateral circulation afforded cumulative improvement in LVEF in patients without diabetes mellitus. In patients with diabetes mellitus, collateral circulation, but not prodromal angina pectoris, was associated with higher predischarge LVEF.