[A case of deep vein thrombosis in an elderly patient whose symptoms were exacerbated after applying catheter-based thrombolytic therapy].

We herein report a 99-year-old woman with hypertension and dyslipidemia. From the beginning of August 20XX, significant edema from the left thigh to the toes had been observed, so she had consulted her previous doctor. She had been suspected of having cellulitis and was given antibiotics, but no improvement in her symptoms was noted, so she was transferred to our hospital. The edema of the lower leg was localized to the left lower leg only, and the D-dimer level was as high as 16.6 µg/mL at her visit to the emergency room, so deep vein thrombosis (DVT) was suspected, and the patient received immediate hospitalization. Continuous administration of undifferentiated heparin was started, and lower extremity venous ultrasound was performed. As a result, central-type DVT extending from the left iliac vein to the common iliac vein bifurcation was observed. However, despite administering inferior vena cava (IVC) filter into under the renal vein, and changing heparin to edoxaban 30 mg, no improvement in the lower limb edema was observed. Therefore, catheter-based thrombolysis (CDT) was started on day 11 of illness, and continuous administration of urokinase was started via the catheter. Heparin and edoxaban were not used in combination in order to reduce the risk of bleeding. The edema gradually improved, and after confirming that the thrombus had completely disappeared on lower extremity venous ultrasound, the catheter was removed on day 14 (day 24 of illness) after starting CDT. The IVC filter was also removed, and prescription of edoxaban 30 mg was restarted. Since the patient had used a walking frame at home, she started rehabilitation from the initiation of CDT therapy and was discharged once she was able to use a self-sustaining portable toilet. The basic treatment for DVT is anticoagulant therapy; however, a large amount of thrombosis was observed in the present case, and no marked improvement was observed with conventional anticoagulant therapy. As the patient was particularly elderly, and considering that it was important to improve the edema promptly in order to maintain her activities of daily living, we performed CDT treatment and concluded that it was very effective in this case. However, the CDT procedure for DVT has yet to be standardized, and there are few cases of CDT treatment, especially for such super-elderly patients. In the current aging society, the incidence of DVT diseases is increasing, and in cases such as the present case, anticoagulation therapy alone and CDT therapy should be considered and implemented after careful consideration of the bleeding risk.

Minor ST-T changes on electrocardiograms are associated with reduced constructive myocardial work in hypertensive patients with a preserved ejection fraction.

Minor ST-T changes on electrocardiograms are observed in patients with hypertensive heart disease with a preserved left ventricular ejection fraction (LVEF); however, the relationship between minor ST-T changes and global myocardial work on echocardiograms remains unclear. We evaluated the global longitudinal strain (GLS), global work index (GWI), global constructive work (GCW), global wasted work (GWW), and global work efficiency (GWE) in 186 hypertensive patients with preserved LVEF (>50%) using an offline analysis system (View Pal, GE). Minor ST-T changes as well as major ST-T changes (depression in ST in lead V5 > 1 mV) were also evaluated by electrocardiography. The mean age was 79.4 ± 8.2 years (men 37.6%). Patients with minor and major ST-changes had a smaller absolute GLS (-20.3 ± 3.1, -18.2 ± 3.7, and -15.2 ± 5.0%, P < 0.001) and a smaller constructive workload [GWI (2148 ± 486, 1938 ± 462, and 1685 ± 701 mmHg%, P = 0.002) and GCW (2419 ± 510, 2185 ± 466, and 1865 ± 702 mmHg%, P < 0.001)] than those with no ST-T changes. Additionally, patients with minor and major ST-T changes had increased wasted myocardial work [GWW (87 ± 61, 105 ± 56, and 127 ± 75 mmHg%, P = 0.045)], which resulted in reductions in the myocardial work efficiency [GWE (95 ± 4, 94 ± 3, and 89 ± 12%, P < 0.001)]. Even after adjustments for confounding factors, including EF, diastolic function parameters, LV hypertrophy, history of heart failure and atrial fibrillation, patients with minor ST-T changes had significantly smaller LV global constructive work in comparison to those without [GWI (2260 ± 33 vs. 2025 ± 76 mmHg%, P = 0.007) and GCW (2501 ± 45 vs. 2210 ± 105 mmHg%, P = 0.003)]. In conclusion, in hypertensive patients with preserved LVEF, minor ST-T changes on electrocardiograms were associated with reduced constructive work in the LV.

Hypoxemia found after hospitalization with right hemiplegia due to cerebral infarction: platypnea-orthodeoxia syndrome in the older people.

An 89-year-old woman was admitted to our hospital for subacute onset of right upper and lower limb weakness and was diagnosed with acute cerebral infarction. During rehabilitation, close observation revealed that her oxygen saturation decreased in the sitting position and improved in the recumbent position without any subjective symptoms of dyspnea. Transthoracic and transesophageal echocardiography and cardiac catheterization revealed a large patent foramen ovale with an atrial septal aneurysm with right-to-left shunting through the defect, and she was diagnosed with platypnea-orthodeoxia syndrome. Her right hemiplegia caused the trunk to collapse, so the patient slumped when in sitting position, and the trunk tilted to the right forward, resulting in an increased right-to-left shunt. Her peripheral capillary oxygen saturation improved in the upright sitting position supported by therapists. This case suggests that right hemiplegia may exacerbate the symptoms of platypnea-orthodeoxia syndrome. .

Prevalence and Determinants of Cognitive Impairment in Elderly Patients With Heart Failure　- Pilot Study in a Geriatric Hospital.

Background: Elderly patients admitted to hospital with heart failure (HF) often have cognitive impairment, but the association between these conditions is unclear. Methods and Results: We enrolled 43 patients admitted to a geriatric hospital with HF. We evaluated echocardiography, Mini Mental State Examination (MMSE), and extracellular water/total body water (ECW/TBW) ratio (Inbody S10). Mean age was 85.1±8.0 years (range, 60-99 years) and 44.2% of the patients were men. Mean MMSE score was 20.5±5.4, with 66.7% of the patients showing cognitive impairment (MMSE ≤23). There was a significant negative correlation of MMSE score with age (r=-0.344, P=0.032), regular alcohol drinking (r=0.437, P=0.007), uric acid level (r=0.413, P=0.010), and ECW/TBW ratio (r=-0.437, P=0.007). On stepwise regression analysis including these covariates, MMSE score was significantly associated with the ECW/TBW ratio (ß=0.443, P=0.009). When several echocardiography parameters (i.e., end-diastolic left ventricular volume, r=0.327, P=0.048; left atrial volume index, r=-0.411, P=0.012; and transmitral inflow A wave velocity, r=-0.625, P=0.001) were added to the model, MMSE score was found to be related to the A wave (P=0.001) and to atrial volume index (P=0.015), which are measures of diastolic function. Conclusions: In elderly patients with HF, cognitive function might be influenced by body water distribution and diastolic heart function.

Case report of non-ST-segment elevation myocardial infarction diagnosed in spectral detector-based computed tomography performed for the diagnosis of acute pulmonary embolism.

BACKGROUND: Contrast-enhanced spectral detector-based computed tomography (SDCT) allows for the comprehensive and retrospective analysis. We report a case of pulmonary thromboembolism (PE) accompanied by non-ST-segment elevation myocardial infarction (NSTEMI) diagnosed by SDCT. CASE SUMMARY: A 72-year-old man with diabetes mellitus, hypertension, and prostate cancer suddenly developed chest and back pain and had difficulty in breathing at rest. Electrocardiography showed a right bundle branch block without significant ST-segment change. The initial serum troponin I level was 0.05 ng/mL, and the d-dimer level was 14.7 µg/mL. Spectral detector-based computed tomography showed bilateral scattered PE. After admission, his chest pain persisted, and the serum troponin I level 3 h after admission was elevated to 0.90 ng/mL. Reconstruction of SDCT images showed a perfusion defect of the posterolateral left ventricle myocardium. A coronary angiogram showed total occlusion of the obtuse marginal branch (OM); percutaneous coronary intervention was performed. Furthermore, we administered him with oral anticoagulants (OACs) for PE. Spectral detector-based computed tomography tests performed 6 months after the treatment was initiated, until when the dual antiplatelet therapy and OAC therapy were continued, showed improvement in perfusion defects of both pulmonary fields and the myocardium. His treatment was deescalated to single antiplatelet therapy and OAC, and the patient has had a good course. DISCUSSION: Non-ST-segment elevation myocardial infarction is sometimes difficult to diagnose accurately, especially in the hyper-acute phase or in the OM branch. The reconstruction of spectral images from enhanced SDCT was helpful to diagnose this unique combination of PE and NSTEMI and may be useful for evaluating therapeutic effects in such patients.

Gender Differences Among Patients With Acute Pulmonary Embolism.

Gender differences in patients with acute pulmonary embolism (APE) remain unclear and controversial. We aimed to understand the gender differences in patients with APE treated in the cardiovascular care units. The registry database of 1,428 patients with APE treated at the Tokyo cardiovascular care unit Network institutions from 2010 to 2014 was retrieved for analysis. In all, 795 women (55.7%) and 633 men (44.3%) were included in this study. The women were older than men (68.0 ± 16.1 vs 60.9 ± 15.6 years, p < 0.0001). Compared with men, women had more complaints of dyspnea and disturbed consciousness, lesser complaints of leg symptoms, and chest pain. Pulmonary arterial systolic pressure (51.5 ± 22.2 mm Hg vs 47.4 ± 22.4 mm Hg, p = 0.012) and the serum B-type natriuretic peptide level (180.4 [50.7 to 526.1] pg/ml vs 107.0 [25.0 to 306.8] pg/ml, p < 0.0001) on admission, was higher in women than in men. Severe cases with massive embolism were seen more in women compared with men (14.6% vs 9.2%, p = 0.0002). The use of inferior vena cava filters were lower in women than in men (31.9% vs 37.3%, p = 0.029). Furthermore, 30-day PE-related mortality was higher in women than in men significantly (5.0% vs 2.8%, p = 0.043). In conclusion, women APE patients were older with higher severity than men APE patients, resulting in poor prognosis.

Crossover stenting across the deep femoral artery entry: a multicenter retrospective study.

Crossover stenting of femoral bifurcation raises the concern of jeopardizing the deep femoral artery (DFA) entry, thereby increasing future risk of limb-threatening ischemia and amputation. This retrospective multicenter study compared clinical outcomes of crossover stenting and non-crossover stenting for ostial superficial femoral artery (SFA) lesions. We reviewed 125 limbs in 103 patients with successful stent implantation for ostial SFA lesions and allocated them to two groups, based on whether the stent crossed over the DFA orifice (CO, n = 54) or not (NC, n = 71). The decision of applying whether CO or NC was at the operators' discretion. Primary endpoints were incidences of major amputation and acute limb ischemia (ALI) at 24 months, and secondary endpoints were incidences of death, target lesion revascularization (TLR), composite of amputation or death, and major adverse limb events which was a composite of major amputation, ALI, TLR, or death at 24 months. Baseline characteristics were similar between the groups. Major amputation occurred only in the NC group, while ALI occurred only in the CO group. Kaplan-Meier estimation showed no significant differences in incidences of major amputation (NC: 3.0% vs. CO: 0.0%, p = 0.21), ALI, or any of the secondary endpoints. However, there was a trend towards higher incidence of ALI in the CO group (NC 0.0% vs. CO 3.9%, p = 0.11). Crossover stenting did not result in a significant difference in major amputation compared to non-crossover stenting within 24 months. However, it showed a trend towards higher incidence of ALI.