Cardiomegaly and Low Voltage Suggest Cardiac Involvement in a Patient With Hypereosinophilic Syndrome: A Case Report.

Hypereosinophilic syndrome is a heterogeneous group of disorders, the majority of which are idiopathic. Cardiac manifestations, particularly eosinophilic myocarditis and endomyocardial fibrosis, are a typical course of morbidity and mortality in hypereosinophilic syndrome. We present a case of a patient with asthma and idiopathic eosinophilia who presented with dyspnea and edema. Cardiac ultrasonography showed pericardial effusion and reduced left ventricular motion, which persisted despite heart failure therapy, although pulmonary congestion improved. The peripheral blood eosinophil count was markedly elevated four days after admission, even though eosinophilia was not present at admission. Parasitic disease, autoimmune disease, and drug-induced cardiomyopathy were excluded as possibilities. A high dose of steroid therapy was started due to eosinophilic myocarditis. Cardiac function improved soon after therapy, along with a reduction in eosinophils. Upon retrospective examination, cardiomegaly and low voltage were observed, along with an elevation in the eosinophil count 15 months before admission. Monitoring chest radiography and electrocardiograms according to fluctuations in eosinophils may enable early detection and treatment of cardiac involvement in patients with hypereosinophilic syndrome, as demonstrated by this case.

Perforation of the Brachial Artery During Percutaneous Lower Extremity Angioplasty via the Brachial Artery Approach Resulting in Difficulties in Balloon Catheter Removal: A Case Report.

Percutaneous endovascular treatment of peripheral vascular disease with small-caliber short sheaths may lead to device removal difficulties. A 50-year-old woman on hemodialysis underwent endovascular intervention for right common femoral artery stenosis, via the right brachial artery. A 4-Fr short sheath was used for the procedure owing to a previous hematoma at the puncture site. However, the balloon catheter could not cross the calcified lesion and was difficult to remove. A microcatheter was inserted and withdrawn, but the guidewire was kinked and could not be retrieved. Surgical retrieval of the guidewire and balloon catheter was performed. The kinked guidewire and microcatheter had migrated outside the vessel. In peripheral vascular intervention, the use of a long sheath in the brachial artery approach is important. Forcible removal of a difficult-to-remove catheter may cause further vascular damage. Therefore, it is essential to stop immediately and consider surgical treatment.

Irrelevant B-type natriuretic peptide levels in patients with mechanical prostheses in the mitral position presenting with congestive heart failure.

BACKGROUND: Plasma B-type natriuretic peptide (BNP) level is reported to be a strong marker of congestive heart failure (CHF). Heterogeneity of the BNP levels among individuals with CHF, however, can cause confusion in interpreting the results. The influence of mitral mechanical prostheses on BNP levels in patients presenting with CHF is not well known. METHODS AND RESULTS: In the present study 214 consecutive patients with CHF diagnosed using the Framingham criteria were enrolled and divided into 2 groups with and without mitral mechanical prostheses (prosthesis group, n=31; native group, n=183). The plasma BNP levels were measured, and clinical examinations including echocardiography were performed at the same time to assess cardiac performance. There was no difference in the left ventricular ejection fractions between the 2 groups. Despite having a lower body mass index, larger prevalence ratio of atrial fibrillation and larger size of the left atrium, the prosthesis group had a significantly lower logBNP level than the native group (prosthesis group vs native group: 5.12+/-1.01 vs 6.21+/-0.92, P<0.001; BNP level: 167+/-324 pg/ml vs 498+/-380 pg/ml). On multivariate analysis the presence of a mitral mechanical prosthesis was extracted as an independent predictor for decreased BNP level in patients with CHF. CONCLUSIONS: Plasma BNP level cannot correctly reflect the severity of CHF in patients with mechanical prostheses in the mitral position.

Prevalence of childhood obesity from 1978 to 2007 in Japan.

BACKGROUND: There are few cross-sectional and longitudinal studies on identification of the age of onset of obesity. The purpose of the present study was therefore to investigate 30 years of cross-sectional and longitudinal changes in the prevalence of obesity from 1978 to 2007 in Japanese children and adolescents between 5 and 17 years of age, using population-based samples. METHODS: Subject data were obtained from the Annual Reports of the School Health Survey published by the Ministry of Education, Culture, Sports, Science and Technology, Japan. Obesity was defined as a body mass index (BMI) at or above the 95th percentile for age and gender based on the reference years from 1979 to 1981 in Japan. The BMI was calculated as weight in kg/(height in m)(2). RESULTS: Cross-sectional analysis of 5-, 8-, 11-, 14-, and 17-year-olds showed that the prevalence of obesity has gradually decreased since the early 2000s, with the highest prevalence in the late 1990s to early 2000s, except for in 17 year-old boys. Longitudinal studies showed that the critical periods for developing obesity were in late infancy (between 5 and 6 years of age) and in the high school period in boys, and mainly in late infancy in girls. CONCLUSIONS: Intervention to prevent obesity should be focused on late infancy in both genders and male adolescents in Japan.

Long-term survivor diagnosed with arrhythmogenic right ventricular cardiomyopathy/dysplasia.

The subject was a 70 year-old man who survived for 31 years after being diagnosed with right ventricular cardiomyopathy, having undergone right ventricular (RV) aneurysmectomy at the age of 39. His arrhythmia and syncopal attacks were effectively abolished after the original aneurysmectomy. Although he frequently suffered from right heart failure, hemodialysis improved his status. However, the patient died due to worsening anasarca caused by RV low output syndrome. Autopsy results indicated extensive replacement of the RV myocardium with fibrous and fatty tissues. This case suggests that patients with arrhythmogenic RV cardiomyopathy, but without left ventricular abnormalities and rapid ventricular arrhythmia, have a relatively favorable prognosis, although RV abnormalities may be progressive.

Primary leiomyosarcoma of the pulmonary artery: a case of a 20-month survivor after incomplete surgical resection.

We report a 53-year-old man who presented with dyspnea and low-grade fever. Cardiac ultrasound showed pulmonary hypertension and an ill-defined echogenic mass within the pulmonary trunk. Computed tomography scan revealed an inhomogeneous mass which filled the main pulmonary trunk with near-total occlusion, and extended into both pulmonary arteries. Anticoagulant therapy was administered based on a presumptive diagnosis of pulmonary thromboembolism. Positron-emission tomography scan was useful for differentiating the mass, which was determined as a pulmonary artery sarcoma by surgical resection. Although complete resection was impossible, the patient survived for 20 months with adjuvant chemotherapy and medical treatment.

Successful treatment of spontaneous coronary bypass rupture using a polytetrafluoroethylene-covered stent.

A 57-year-old man with coronary bypass surgery experienced spontaneous rupture of a vein graft 16 months following his operation. Multislice computed tomography revealed a perforation of the saphenous vein graft to the obtuse marginal branch. 3D imaging was useful for diagnosis and in planning treatment. Hesitation to perform surgical treatment occurred due to inflammation in the patient, therefore we successfully implanted a polytetrafluoroethylene-covered stent to occlude the site of perforation. The use of a covered stent for a patient showing clear leakage of dye during angiography should be considered as an alternative to surgical intervention for a ruptured vein.

Rapid progression of aortic regurgitation with thoracic aortic aneurysm due to Takayasu arteritis associated with ulcerative colitis.

A 25-year-old woman with ulcerative colitis developed heart failure due to severe aortic regurgitation. Although chest X-ray 18 months previously showed a normal cardiac shadow, thoracic aortic aneurysm progressed due to Takayasu arteritis. Aortic valve and ascending aorta replacement were performed successfully, but re-valve replacement for severe aortic regurgitation due to prosthetic valve detachment and aortic root replacement for valsalva sinus rupture were required. Human leukocyte antigen analysis showed B35 and B52, the typical haplotype in cases with coexistence of both diseases and associated sustained inflammation. Close observation and early aortic root replacement were needed in this case.

Mid-term mortality of very elderly patients with acute myocardial infarction with or without coronary intervention.

BACKGROUND: The risk benefit of percutaneous coronary intervention (PCI) in very elderly patients with acute myocardial infarction (AMI) is currently unclear. Here, we aim to identify the characteristics of these patients and clarify their mid-term mortality rate with or without PCI. METHODS AND RESULTS: 77 patients (> or =80 years) were chosen from 506 patients with AMI, and treated with (n=32) or without (n=45) PCI. The mean age and time from onset to admission increased in patients having undergone no PCI. The reasons for PCI refusal were patient/family preference (40%), renal dysfunction (17.8%), or cognitive impairment (13.3%). Patients treated with PCI had lower mid-term mortality than those without PCI (34.4% vs 62.2%; p=0.02), while patients taking beta-blockers displayed a significantly lower mortality rate than those without (18.2% vs 63.6%; p=0.0003). Cognitively impaired patients had a higher mortality rate compared with cognitively normal patients (80.0% vs 46.3%; p=0.005). Multivariate analysis indicated that systolic blood pressure on admission, PCI, and beta-blocker therapy independently decreased mid-term mortality in these patients. CONCLUSIONS: PCI and beta-blocker therapy displayed significantly beneficial effects on mid-term mortality in very elderly AMI patients. Elderly-specific trials concerning coexisting disorders are needed to further examine the treatment-related benefits.

Impact of decreased renal function on coagulation and fibrinolysis in patients with non-valvular atrial fibrillation.

BACKGROUND: The prothrombotic state in non-valvular atrial fibrillation (NVAF) increases the risk of thromboembolic events. It is also well known that a prothrombotic state exists in renal failure. Hemostatic disorders play a role in thromboembolic mortality in both NVAF and renal failure. However, little is known about the influence of renal function on hemostasis in patients with NVAF. METHODS AND RESULTS: A total of 190 consecutive outpatients with NVAF who were not receiving anticoagulant therapy were enrolled in the present study. Patients were stratified in groups based on estimated glomerular filtration rate (eGFR). Plasma concentrations of thrombin-antithrombin complex (TAT) and D-dimer were measured and the influence of renal function on coagulation and fibrinolysis was assessed. A relatively weak and inverse relationship of eGFR to TAT and D-dimer was observed (r=0.28, P=0.0001; r=0.30, P<0.0001). Both mean TAT and D-dimer concentrations in groups gradually and significantly increased as eGFR decreased (P<0.0001). On multivariate regression analysis, decreased eGFR concentration was a significant predictor for elevation of TAT (P<0.05) and D-dimer (P<0.01) in patients with NVAF. CONCLUSIONS: The enhanced coagulation activation appeared to be related to a reduction in residual renal function in patients with NVAF. This suggests that decreased renal function might be a candidate predictor of thromboembolic events in patients with NVAF.

Relationship between weather and onset of acute myocardial infarction: can days of frequent onset be predicted?

BACKGROUND: The aim of this study was to clarify the relationship between onset of acute myocardial infarction (AMI) and weather conditions, to determine whether days in which AMI onset is likely can be predicted. METHODS AND RESULTS: Of the 929 patients admitted to our hospitals in Kagoshima prefecture with AMI, subjects comprised 611 patients. Days of frequent onset (F-days) were defined as days with > or = 3 patients/day admitted for AMI, with days of non-frequent onset (N-days) defined as days with < 3 patients/day. Meteorological factors were measured, and daily differences in all parameters and intraday temperature differences on the onset day, and 1 and 2 days before onset were calculated. F-days were significantly associated with intraday temperature differences on the onset day (10.3 degrees C vs. 7.9 degrees C, p=0.005), 1 day before onset (10.7 degrees C vs. 7.9 degrees C, p=0.002), and 2 days before onset (11.3 degrees C vs. 7.9 degrees C, p=0.0001). A cutoff intraday temperature difference of > or = 9.4 degrees C on 1 and 2 days before onset was predictive of F-days with 89% sensitivity and 87% specificity. CONCLUSIONS: Intraday temperature differences offer a powerful predictor of F-days. Onset of AMI can be predicted based on weather conditions over the preceding 1-2 days.

Case of transient mid-ventricular ballooning syndrome with a rapid and uncommon recovery.

A 60-year-old woman presented with acute pulmonary edema followed by cardiopulmonary arrest due to idiopathic ventricular fibrillation. Owing to immediate cardioversion, her electrocardiogram showed sinus rhythm and echocardiography did not show any wall motion abnormalities. The next day, echocardiographic re-examination was characterized by akinesis of both apical and mid segments of the left ventricle. One hour later, subsequently performed coronary angiography revealed non-occlusive coronary artery disease, but left ventriculography demonstrated only akinesis of mid-ventricular segment with hypercontractile other segments. Further echocardiographic investigation on the following day showed total resolution of left ventricular wall motion abnormalities. The diagnosis of mid-ventricular ballooning syndrome was made according to the findings of left ventriculography. In this case, the time course changes of both patient's pathophysiological condition and echocardiographic wall motion from the onset to recovery are rapid and uncommon.

[Multiple atrial ball thrombi with stalk mimicking myxoma without valve disease: a case report].

A 77-year-old man with atrial tumors was admitted to our hospital. He had no history of dyspnea, palpitation, or chest pain. He had a history of hypertension and atrial fibrillation without valve disease. Transthoracic and transesophageal echocardiography showed floating ball tumors with stalks from the right atrium (28 X 31 mm), the interatrial septum (16 X 11 mm), and the left atrial appendage (14 X 8 mm). The tumors were surgically removed and histologic examination of these tumors confirmed organization thrombus. This case of multiple atrial ball thrombi illustrates the problems with differentiation of myxoma and thrombus.