Influence of meal intake on pulse wave indices in type 2 diabetes.

Augmentation index (AI), brachial-ankle pulse wave velocity (baPWV) and cardio-ankle vascular index (CAVI) are available for the assessment of arterial stiffness in clinical practices. However, influences of meal intake on these indices are still poorly understood. The aim of this study is to elucidate the effects of daily meal intake on pulse wave indices in patients with type 2 diabetes. We studied 17 patients with type 2 diabetes. AI was measured at fasting, 60 and 120 min after a commercial mixed meal (500 kcal) intake. The baPWV and CAVI were measured at fasting and 80-100 min after meal intake. All pulse indices decreased significantly after meal intake (AI, 89.3+/-9.7% to 77.9+/-9.4%, 82.0+/-8.4%, P<0.001; baPWV, 1652+/-286-1586+/-240 cm s(-1), P=0.002; CAVI, 9.52+/-0.92-9.20+/-0.89, P=0.037). Delta(120) (value 120 min after meal intake-fasting value) AI correlated significantly with age, body weight, Delta(120) systolic blood pressure (SBP), Delta(120) diastolic blood pressure, Delta(120) pulse pressure, Delta(120) heart rate and fasting AI. Delta (postprandial value-fasting value) baPWV correlated significantly with fasting baPWV, Delta SBP, Delta pulse pressure and HbA1c. In contrast, Delta CAVI did not correlate with any clinical variables. In conclusion, postprandial decreases in AI, baPWV and CAVI can lead to underestimate arterial stiffness in patients with type 2 diabetes. Postprandial changes in AI and baPWV, but not CAVI, are associated with changes in hemodynamic variables after daily meal intake.

A case of pulmonary stenosis after a repair for tetralogy of Fallot treated with percutaneous pulmonary valvuloplasty using a triple-balloon technique.

The patient was a 37-year-old female who had undergone a repair for tetralogy of Fallot (TOF) at the age of 4 years. Postoperative pulmonary stenosis remained, but she continued to be managed medically. Approximately 3 years ago, at the age of 34, she exhibited a worsening of fatigue and dyspnea during exertion (New York Heart Association III), and was therefore hospitalized for a detailed examination. In cardiac catheterization, a right ventricle to pulmonary artery peak-to-peak gradient of about 90 mmHg was observed. Since it appeared that medical treatment alone would not sufficiently control her heart failure, pulmonary valvuloplasty using a triple-balloon technique was performed for the pulmonary stenosis. The peak-to-peak gradient immediately after the procedure decreased to 13 mmHg. There were no indications of restenosis approximately 6 months after the procedure, and the symptoms of heart failure in her daily life improved thereafter.

The lurking potential of tangential forces: A case of an arteriovenous shunt developed by percutaneous coronary intervention for the septal branch.

We describe the case of a 59-year-old male. His first percutaneous coronary intervention (PCI) using a bare metal stent was performed for a 90% stenosis in the mid portion of the left anterior descending artery (LAD). However, we performed re-PCI because in-stent restenosis developed during a chronic stage. After the first dilatation of the restenotic lesion, using a cutting balloon, the stenosis at the ostium of the septal branch, which takes off from the stent strut, became exacerbated. Therefore, after selective guidewire insertion to the septal branch, we performed balloon inflation. Unfortunately, a coronary dissection and perforation developed in the septal branch and a coronary arteriovenous shunt was also formed. Additional inflation for in-stent restenosis with a perfusion balloon provided successful occlusion of the ostium of the septal branch and the shunt flow disappeared. After careful re-selection of a guide wire into the septal branch, the perforated portion was then dilated using a small-sized conventional balloon. Finally, reperfusion of the septal branch was accomplished without any angiographic sign of coronary dissection, perforation or shunt. We herein report a rare case of coronary arteriovenous shunt formation due to the dissection and perforation of a coronary artery.

Serum markers of angiogenesis and myocardial ultrasonic tissue characterization in patients with dilated cardiomyopathy.

BACKGROUND AND AIMS: It has been proven that a disturbance in angiogenesis contributes to the progression of myocardial interstitial fibrosis in idiopathic dilated cardiomyopathy (DCM). This study was designed to evaluate the relationship between serum activity of angiogenic factors and myocardial ultrasonic tissue characterization in patients with DCM. METHODS AND RESULTS: We studied 30 patients with DCM and 15 healthy control subjects. Serum levels of vascular endothelial growth factor (VEGF), interleukin (IL)-4 and IL-13 were measured using enzyme-linked immunosorbent assay. We determined calibrated myocardial integrated backscatter (IB) as the value of myocardial interstitial fibrosis using ultrasonic tissue characterization and also quantified the magnitude of cyclic variations in IB (CV-IB). Serum levels of VEGF and IL-13 were significantly higher in patients with DCM than in control subjects (both P<0.05). Calibrated IB was significantly higher and CV-IB was markedly lower in patients with DCM than in control subjects (both P<0.01). In patients with DCM, the levels of IL-13 significantly correlated with calibrated IB (r=0.520, P=0.018). In addition, there was a significant negative correlation between levels of VEGF and CV-IB (r=-0.611, P=0.007). CONCLUSION: The increase in serum VEGF and IL-13 may be closely related to alterations in myocardial texture in DCM.

Circulating levels of heart-type fatty acid-binding protein and its relation to thallium-201 perfusion defects in patients with hypertrophic cardiomyopathy.

Myocyte loss and replacement fibrosis have been observed in patients with hypertrophic cardiomyopathy (HC) with heart failure. This study was designed to elucidate whether heart-type fatty acid-binding protein (H-FABP), a sensitive biochemical marker for myocardial damage, indicates ongoing myocardial damage in patients with HC. We studied 48 patients with HC and 17 control subjects. Patients with HC were divided into 2 groups according to the New York Heart Association (NYHA) functional class: NYHA I + II (n = 40) and NYHA III + IV (n = 8). Serum H-FABP and myoglobin levels were measured, and extent score was used to assess the extent of thallium-201 perfusion defect. Serum H-FABP levels were significantly higher in patients with HC than in control subjects (3.8 +/- 1.6 vs 2.6 +/- 0.7 ng/ml, p = 0.0032). Furthermore, serum H-FABP levels were significantly higher in NYHA III + IV than in NYHA I + II (5.2 +/- 1.3 vs 3.5 +/- 1.5 ng/ml, p = 0.0043). Serum myoglobin levels showed no significant difference among the 3 groups (control, 46.6 +/- 15.0 ng/ml; NYHA I + II, 55.5 +/- 26.4 ng/ml; NYHA III + IV, 65.1 +/- 33.6 ng/ml, p = 0.2115). Extent score correlated positively with serum H-FABP levels (r = 0.420, p = 0.0026) and negatively with fractional shortening (r = -0.542, p <0.0001). Increased H-FABP levels indicate ongoing myocardial damage, which could result in clinical deterioration in patients with HC.

Assessment of flow velocity in a bypass graft of the gastroepiploic artery by contrast-enhanced transabdominal Doppler echocardiography: a case report.

An 81-year-old man with effort angina pectoris underwent coronary artery bypass grafting operation using the bilateral internal thoracic arteries and the right gastroepiploic artery (GEA). Angiography after operation showed that the bilateral internal thoracic arteries were patent. Abdominal angiography showed severe ostial stenosis in the celiac trunk. The GEA was not opacified by the celiac trunk but by the superior mesenteric artery, by collaterals. GEA flow could be detected from the epigastric lesion by contrast-enhanced Doppler echocardiography, and moreover, the flow velocity reserve of the graft was 2.4. This case suggests that the GEA graft can provide sufficient blood flow to the coronary artery despite ostial stenosis of the celiac trunk.

Assessment of intermediate stenosis in the left anterior descending coronary artery with contrast-enhanced transthoracic Doppler echocardiography.

BACKGROUND: Visual or quantitative assessment of coronary angiography may not exactly predict the physiological significance of intermediate (40-70%) coronary stenosis. Coronary flow reserve is a well-established marker of the functional significance of coronary stenosis. OBJECTIVES: The aim of this study was to compare the coronary flow velocity reserve (CFVR) using contrast-enhanced transthoracic Doppler echocardiography (CE-TTDE) with thallium-201 imaging in assessment of intermediate lesions in the left anterior descending coronary artery (LAD). METHODS: A consecutive series of 50 patients with intermediate stenosis in the LAD underwent pharmacological stress thallium-201 imaging and CFVR measured by CE-TTDE. RESULTS: CFVR could be measured in 49 of 50 patients by the present method. A CFVR <2.0 predicted the presence of a stress thallium defect in 12 of 14 patients (agreement=90%, kappa=0.76, P < 0.001). The sensitivity and specificity of CFVR for stress thallium-201 results were 86 and 91%, respectively. In contrast, significant stenosis (>50% by diameter) showed fair agreement for stress thallium defects (agreement=59%, kappa=0.28, P < 0.05). CONCLUSIONS: In the evaluation of intermediate lesions in the LAD, CFVR as assessed by CE-TTDE could accurately predict the presence of ischemia on stress thallium imaging, whereas angiographic stenosis did not yield reliable results.

Usefulness of an echo-contrast agent for assessment of coronary flow velocity and coronary flow velocity reserve in the left anterior descending coronary artery with transthoracic doppler scan echocardiography.

BACKGROUND: This study assessed the feasibility of transthoracic Doppler scan echocardiography (TTDE) combined with echo-contrast agent in measuring coronary flow velocity (CFV) and coronary flow velocity reserve (CFVR) in the left anterior descending artery. METHODS: In 68 consecutive patients who underwent cardiac angiography, TTDE was recorded before and after induction of a hyperemic condition with intravenous administration of adenosine triphosphate (0.14 mg/kg/min). After CFV values returned to baseline, the same measurements were repeated while an echo-contrast agent was continuously infused. CFVR was assessed as the ratio of hyperemic to basal CFV. The pulsed wave Doppler scan quality was graded from 1 to 3 (TTDE score: 1, no signal detection; 2, poor definition of outline; 3, optimal outline definition). RESULTS: Before enhancement, CFVR could not be measured in 20 patients. Prevalence of delayed stenosis (Thrombolysis In Myocardial Infarction [TIMI] II grade flow) in these patients (30%) was significantly greater than in those whose CFVRs could be measured without enhancement (2%; P <.01). TTDE scores both at baseline and after hyperemia were significantly improved with contrast enhancement (before, 2.8 +/- 0.6; after, 3.0 +/- 0.3; P <.01; before, 2.6 +/- 0.7; after, 3.0 +/- 0.3; P <.01; respectively). Overall contrast enhancement increased the rate of successful CFVR measurement from 70% to 97% (P <.01). Sensitivity and specificity of significant left anterior descending artery stenosis detection with CFVR of <2.0 were 94.4% and 87.8%, respectively. CONCLUSION: These data suggest that administration of echo-contrast agent improves pulse wave Doppler scan quality and thus the feasibility of measuring CFVR.