Adolescent Persistent Atrial Fibrillation Concomitant with Pectus Excavatum.

A 19-year-old man with pectus excavatum developed symptomatic persistent atrial fibrillation (AF). He had no remarkable medical history or comorbidities and had not exercised intensely during childhood. Electrical cardioversion and pre-treatment with amiodarone for two months failed to maintain sinus rhythm. Computed tomography before ablation revealed compression of the right and left atria between the sternal bone and vertebral bodies. Voltage mapping revealed that the right and left atrial voltages were preserved within the normal limit. However, radiofrequency catheter ablation successfully eliminated recurrent persistent AF. No recurrence was observed during eight months of follow-up.

[Contrast-enhancement Effects of Dual-peak Contrast Medium Injection Method Using Bolus-tracking Technique in Coronary and Aorta CT Angiography].

OBJECTIVE: We compared the contrast-enhancement effects of the coronary arterial phase and the aortic phase in coronary and aorta computed tomography angiography (CA-CTA) using the bolus-tracking technique-based single-peak contrast medium injection (BT-SPI) method and the bolus-tracking technique-based dual-peak contrast medium injection (BT-DPI) method. METHOD: CA-CTA images were acquired from 30 patients, using BT-SPI and BT-DPI. Regions of interest were selected in the right ventricle and ascending aorta during the coronary arterial phase, and in the aorta during the aortic phase to obtain mean CT values. The mean CT values were used to compare the contrast-enhancement effects of BT-SPI and BT-DPI. RESULTS: The mean CT value of the right ventricle during the coronary arterial phase obtained using BT-SPI (320 Hounsfield unit [HU]) and BT-DPI (83 HU) was significantly different (p<0.05). Using BT-SPI and BT-DPI, the mean CT values of the ascending aorta during the coronary arterial phase were 361 HU and 379 HU, respectively, and those of the aorta during the aortic phase were 436 HU and 437 HU, respectively. The difference in the mean CT values for the aorta between BT-SPI and BT-DPI during the coronary arterial and aortic phases was insignificant. CONCLUSION: The retention of the contrast medium in the right ventricle during the coronary arterial phase using BT-DPI was lower than that using BT-SPI. BT-DPI showed substantial contrast-enhancement effects in both the coronary arterial and aortic phases.

J-wave change during rewarming therapy for accidental hypothermia.

BACKGROUND: J waves are abnormal electrocardiogram findings that indicate an elevation at the junction between the QRS complex and the ST segment. Hypothermia is associated with fetal arrhythmia, along with the increase of J-wave manifestation. CASE PRESENTATION: A 68-year-old woman with a medical history of old cerebral infarction and dementia was admitted to the emergency department with accidental hypothermia. An admission, electrocardiogram (ECG) showed prominent J waves with the highest amplitude recorded in limb and precordial leads. Continuous ECG monitoring was recorded during the rewarming therapy. As the body temperature increased, the amplitude of J waves became lower and disappeared. This case clearly showed that the degree of core body temperature is related to the height of the J-wave amplitude. There was no fatal arrhythmia during rewarming therapy. CONCLUSION: This case describes serial changes in the J-wave amplitude and morphology during rewarming therapy. Continuous ECG monitoring is important in a patient with severe hypothermia.

Dynamicity of hypothermia-induced J waves and the mechanism involved.

BACKGROUND: J waves develop during hypothermia, but the dynamicity of hypothermia-induced J waves is poorly understood. OBJECTIVE: The purpose of this study was to investigate the mechanism of the rate-dependent change in the amplitude of hypothermia-induced J waves. METHODS: Nineteen patients with severe hypothermia were included (mean age 70 ± 12 years; 16 men [84.2%]). The rectal temperature at the time of admission was 27.8° ± 2.5°C. In addition to prolonged PR, QRS complex, and corrected QT intervals, the distribution of prominent J waves was widespread in all 19 patients. RESULTS: Nine patients showed changes in RR intervals. When the RR interval shortened from 1353 ± 472 to 740 ± 391 ms (P = .0002), the J-wave amplitude increased from 0.50 ± 0.29 to 0.61 ±0.27 mV (P = .0075). The J-wave amplitude increased in 7 patients (77.8%) and decreased in 2 patients (22.2%) after short RR intervals. The augmentation of J waves at short RR intervals was associated with a significant prolongation of ventricular activation time (35 ± 5 ms vs 46 ± 5 ms; P = .0020), suggesting accentuated conduction delay. Increased conduction delay at short RR intervals was suggested to accentuate the phase 1 notch of the action potential and J waves in hypothermia. None developed ventricular fibrillation, and in 2 of 9 patients with atrial fibrillation, atrial fibrillation persisted after rewarming to normothermia. CONCLUSION: J waves in severe hypothermia were augmented after short RR intervals in 7 patients as expected for depolarization abnormality, whereas 2 patients showed a bradycardia-dependent augmentation as expected for transient outward current-mediated J waves. Increased conduction delay at short RR intervals can be responsible for the accentuation of the transient outward current and J waves during severe hypothermia.

Reliability of ST-segment shifts in the synthesized V3R-V5R leads after coronary balloon inflations during percutaneous coronary intervention.

Obtaining a right-chest electrocardiogram is essential for diagnosing concomitant right ventricular infarction in patients with inferior wall acute myocardial infarctions. A software program to synthesize right-chest electrocardiographic waveforms from 12-lead electrocardiographic waveforms is available in Japan. However, its reliability has not been fully investigated. Accordingly, the aim of this study was to examine the reliability of ST-segment shifts in the synthesized V3R to V5R leads. ST-segment shifts in actual and synthesized V3R to V5R leads were compared during the last 10 seconds of 131 balloon inflations while performing elective percutaneous coronary intervention in 56 patients with coronary artery disease. ST-segment shifts in the actual and synthesized V3R, V4R, and V5R leads were correlated (r = 0.96, p <0.001, r = 0.94, p <0.001, and r = 0.91, p <0.001, respectively). A Bland-Altman analysis showed that the bias between ST-segment shifts in the actual and synthesized V3R to V5R leads was -3.1, -5.4, and -4.2 µV, respectively, while the limits of agreement between the ST-segment shifts in the actual and synthesized V3R to V5R leads were -59.2 to 52.9, -61.9 to 51.1, and -59.7 to 51.3 µV, respectively. The κ coefficients for ST-segment elevation of ≥50 and ≥100 µV in the actual and synthesized V3R, V4R, and V5R leads were 0.83 and 0.81, 0.66 and 0.83, and 0.57 and 0.80, respectively. In conclusion, these results indicate that ST-segment shifts in the synthesized V3R to V5R leads have acceptable reliability, suggesting that synthesized right-chest electrocardiography can be used to diagnose concomitant right ventricular infarction in patients with inferior wall acute myocardial infarctions.

Takotsubo cardiomyopathy triggered by lateral wall ST-segment elevation myocardial infarction.

We herein report the case of a 72-year-old female with a lateral wall acute myocardial infarction (MI) complicated by takotsubo cardiomyopathy (TC). The patient presented with "severe" chest pain lasting for one hour. She did not experience any obvious emotional or physical stress preceding the chest pain. An admission electrocardiogram showed ST-segment elevation in leads I, aVL, and V6 and ST-segment depression in leads II, III, aVF, and V1. Emergent coronary angiography showed total occlusion of the obtuse marginal branch. Subsequently, primary percutaneous old balloon angioplasty followed by everolimus-eluting stenting was performed. Left ventriculography performed immediately after final coronary angiography revealed hypokinesis in the lateral wall and mid-ventricular ballooning. The electrocardiographic findings and left ventricular wall motion later normalized. Cardiac magnetic resonance imaging showed late gadolinium enhancement in the lateral wall. In conclusion, to the best of our knowledge, this is the second case report of TC triggered by an acute MI, which provides further evidence that an acute MI can potentially trigger TC. .

Gender differences in symptoms during 60-second balloon occlusion of the coronary artery.

Previous investigations have demonstrated the presence of gender differences in the symptoms of angina pectoris and acute coronary syndrome. However, most of these investigations have had certain limitations, including being retrospective, an interview-related bias, a various duration of myocardial ischemia, and a lack of multivariate analysis, all of which would have affected the results. Accordingly, we prospectively examined the presence or absence of chest pain and non-chest pain symptoms during a 60-second balloon inflation in the setting of percutaneous coronary intervention, which provides a unique model of transient myocardial ischemia, in 110 men and 80 women with coronary artery disease. Chest pain and/or non-chest pain symptoms (occipital pain, jaw pain, neck/throat pain, shoulder pain, upper arm pain, back pain, and nausea) were observed during the balloon inflation in 72 men and 52 women. In the 124 patients with any symptoms during the balloon inflation, non-chest pain symptoms were more common in women than in men (31% vs 14%, p = 0.02); however, the incidence of chest pain did not differ between the men and women. After adjustment for covariables, including age, body mass index, hypertension, diabetes mellitus, current smoking, previous myocardial infarction, target vessels, ß-blocker use, and calcium antagonist use, female gender remained significantly associated with non-chest pain symptoms (odds ratio 3.3, 95% confidence interval 1.2 to 9.9, p = 0.02). In conclusion, non-chest pain symptoms during the 60-second balloon occlusion of the coronary artery were more common in women than in men, supporting the presence of the gender difference in myocardial ischemic symptoms.

A new electrocardiographic criterion to differentiate between Takotsubo cardiomyopathy and anterior wall ST-segment elevation acute myocardial infarction.

Several studies have examined the ability of electrocardiography to differentiate between takotsubo cardiomyopathy (TC) and anterior wall acute ST-segment elevation myocardial infarction (AA-STEMI). In those studies, the magnitude of ST-segment elevation was not measured at the J point. The American Heart Association, American College of Cardiology Foundation, and Heart Rhythm Society guidelines recommend that the magnitude of ST-segment elevation should be measured at the J point. Accordingly, the aim of this study was to retrospectively examine whether electrocardiography, using the magnitude of ST-segment elevation measured at the J point, could differentiate 62 patients with TC from 280 with AA-STEMI. Patients with AA-STEMI were divided into following subgroups: 140 with left anterior descending coronary artery occlusions proximal to the first diagonal branch (AA-STEMI-P), 120 with left anterior descending occlusions distal to the first diagonal branch and proximal to the second diagonal branch (AA-STEMI-M), and 20 with left anterior descending occlusions distal to the second diagonal branch (AA-STEMI-D). TC had a much lower prevalence of ST-segment elevation ≥1 mm in lead V(1) (19.4%) compared to AA-STEMI (80.4%, p <0.01), AA-STEMI-P (80.7%, p <0.01), AA-STEMI-M (80%, p <0.01), and AA-STEMI-D (80%, p <0.01). ST-segment elevation ≥1 mm in ≥1 of leads V(3) to V(5) without ST-segment elevation ≥1 mm in lead V(1) identified TC with sensitivity of 74.2% and specificity of 80.6%. Furthermore, this criterion could differentiate TC from each AA-STEMI subgroup, with similar diagnostic values. In conclusion, using the magnitude of ST-segment elevation measured at the J point, a new electrocardiographic criterion is proposed with an acceptable ability to differentiate TC from AA-STEMI.

Incidental detection of cancers and other non-cardiac abnormalities on coronary multislice computed tomography.

The investigators prospectively examined 625 consecutive patients who underwent coronary multislice computed tomography (MSCT) for suspected coronary artery disease (CAD) and evaluated the presence or absence of cancers and other noncardiac abnormalities on the original transverse sectional images of MSCT. Eight patients with known cancers were excluded from the analysis. The remaining 617 patients (344 men, 273 women; mean age 66 +/- 12 years) were analyzed. Cancers were found in 7 patients (1.13%) on the multislice computed tomographic images, including 4 lung cancers (0.65%), 2 thyroid cancers (0.32%), and 1 hepatic cancer (0.16%). In addition, nonmalignant abnormalities (nodules, tumors, or lymphadenopathies) were also found in 142 patients (23.01%), consisting of 58 postinflammatory lung nodules (9.40%), 49 hepatic cysts or hemangiomas (7.94%), 18 benign thyroid tumors (2.92%), 12 mediastinal lymphadenopathies (1.94%), 4 benign mammary gland tumors (0.65%), and 1 esophageal submucosal tumor (0.16%). In conclusion, cancers and other noncardiac abnormalities are often found in patients who undergo coronary MSCT for suspected CAD. Because patients who undergo coronary MSCT for suspected CAD are mostly elderly and therefore may have unrecognized cancers or other noncardiac abnormalities, care should thus be taken not to overlook these abnormalities when analyzing the multislice computed tomographic images.

The collateral pathway from the left internal thoracic artery to the left external iliac artery detected by multislice computed tomography.

It is important to evaluate the presence or absence of the collateral pathway from the left internal thoracic artery in aortoiliac occlusive disease. This case report indicates that multislice computed tomography is a very useful method for detecting this collateral pathway.

Circadian variation in symptomatic subacute stent thrombosis after bare metal coronary stent implantation.

The present study examined whether onset of symptomatic subacute stent thrombosis (SAT) varies in a circadian manner after bare metal coronary stent implantation. Among 2,305 patients who underwent bare metal coronary stent implantation, 21 (0.9%) developed symptomatic SAT. Results of the present study indicate that onset of symptomatic SAT is more frequent between 6:00 A.M. and 12:00 P.M. than at any other measured 6-hour period during the day.

Aortic valve lipomatous hamartoma in a young woman.

We present a rare case of lipomatous hamartoma of the aortic valve. A 17-year-old woman was admitted with cardiac murmur. Echocardiography demonstrated severe aortic regurgitation and a highly echoic mass on the right cusp of the aortic valve. Surgery was performed with a differential diagnosis of chronic infective endocarditis or aortic valve tumor. At operation, a yellowish bead-shaped tumor was detected on the right cusp of the aortic valve, and aortic valve replacement was performed. Histopathological examination confirmed a lipomatous hamartoma. To the best of our knowledge, this is the first reported case of a lipomatous hamartoma located on the aortic valve.