Mesenteric phlebosclerosis associated with long-term oral intake of geniposide, an ingredient of herbal medicine.

BACKGROUND: Idiopathic mesenteric phlebosclerosis (IMP) is a rare disease, characterised by thickening of the wall of the right hemicolon with calcification of mesenteric veins. However, the aetiology remains unknown. AIM: To investigate the possible association of herbal medicines with IMP. METHOD: The clinical data of four of our own patients were collected. Furthermore, we searched for previous reports about similar patients with detailed descriptions of herbal prescriptions that they had taken. We compared herbal ingredients to identify the toxic agent as a possible aetiological factor. RESULTS: Clinical data on a total of 25 patients were summarised. Mean age was 61.8 years and there was female predominance (6 men and 19 women). The used Kampo prescription, the number of cases, and the mean duration of use were as follows: kamisyoyosan in 12 cases for 12.8 years, inshin-iseihaito in 5 cases for 13.4 years, orengedokuto in 4 cases for 14.3 years, inchinkoto in 1 case for 20 years, kamikihitou in 1 case for 19 years, seijobofuto in 1 case for 10 years and gorinsan in 1 case for an unknown duration. Only one ingredient, sansisi, was common to the herbal medicines of all 25 patients. This crude drug called geniposide in English is a major constituent of the Gardenia fruits. CONCLUSION: The long-term use of geniposide in herbal medicines appears to be associated with mesenteric phlebosclerosis.

Corticosteroid enhances TNF-alpha-mediated leukocyte adhesion to pulmonary microvascular endothelial cells.

BACKGROUND: Some severe asthma patients are characterized by elevated levels of tumor necrosis factor alpha (TNF-alpha) and neutrophilic inflammation in the airways. Although such phenotypic changes in asthma might contribute to corticosteroid refractoriness, the role of TNF-alpha in the process remains unclear. TNF-alpha exerts its biological effects mainly by acting on the vascular endothelium, and thereby upregulates leukocyte recruitment into inflamed tissues. The aim of this study was to investigate the effects of dexamethasone (DEX) on the TNF-alpha-mediated responses of human microvascular endothelial cells from lung blood vessels (HMVEC-LBl) in vitro. METHODS: HMVEC-LBl were cultured with TNF-alpha in the presence and absence of DEX. The effects of DEX on various TNF-alpha-mediated responses, such as the expressions of chemokines and cellular adhesion molecules, leukocyte adhesion were determined. RESULTS: TNF-alpha significantly induced growth-related oncogene alpha (GRO-alpha), interleukin 8 (IL-8), regulated on activation, normal T-cell expressed and secreted (RANTES) and interferon-inducible protein 10 (IP-10) productions and cell surface expressions of intracellular adhesion molecule 1 (ICAM-1) and vascular cell adhesion molecule 1 (VCAM-1) on HMVEC-LBl. TNF-alpha-induced GRO-alpha and IL-8 were slightly attenuated by DEX treatment (reaches to 89% and 79%, respectively), whereas expressions of IP-10, ICAM-1 and VCAM-1 were significantly enhanced by the same treatment (up to 172%, 152% and 139%, respectively). Correspondingly, in vitro adhesion of eosinophils and neutrophils to TNF-alpha-treated HMVEC-LBl were significantly enhanced by DEX. CONCLUSIONS: Some proinflammatory effects of DEX, a corticosteroid, were found in TNF-alpha-mediated in vitro reactions of pulmonary microvascular endothelial cells, i.e. chemokine productions and leukocyte adhesion. These in vitro results may explain, at least in part, the corticosteroid refractoriness accompanied by a marked increase in TNF-alpha production that is seen in severe asthmatic patients.

Composite large cell neuroendocrine carcinoma and adenocarcinoma of the common bile duct.

Large cell neuroendocrine carcinoma (LCNEC) is a high grade type of neuroendocrine tumour with an aggressive clinical course. This report describes the first case of LCNEC combined with an adenocarcinoma component in the common bile duct. A 68 year old man presented with jaundice. Severe stenosis of the bile duct was revealed by endoscopic retrograde cholangiography, and adenocarcinoma cells were detected by brush cytology. Pancreaticoduodenectomy was performed, and the patient died of disease three months after surgery. A tumour measuring 2.0 cm in diameter was located in the intrapancreatic portion of the bile duct. Histologically, the tumour consisted of a LCNEC component and a well differentiated adenocarcinoma component. There were transitional areas between the two components. Immunohistochemically, LCNEC cells were reactive for neuroendocrine markers, but no specific hormonal expression was found. Chromogranin A positive cells were found in some areas of the adenocarcinoma component. These findings are consistent with the theory that both of the carcinoma components originated from a common pluripotent stem cell.

Clinical and immunomodulatory effects of fun-boi, an herbal medicine, on collagen-induced arthritis in vivo.

OBJECTIVE: Crude preparations of Fun-boi (Stephania tetrandra), a traditional antirheumatic herb, have been reported to have immunomodulatory effects on both cell-mediated and humoral immunity in vitro, but little is known about the mode of action in vivo. The objective of this study was therefore to evaluate the efficacy of Fun-boi against arthritis and its effect on the immune system. METHODS: Mice were divided into the following 3 groups of 7 mice each: 1) a normal group, not treated to cause collagen-induced arthritis (CIA), received water orally; 2) a control group with CIA received water orally; and 3) the Fun-boi group with CIA, received Fun-boi (3 mg/g body weight/day) orally. We analyzed the arthritis score, the serum anti-type II collagen (CII) antibody level, and the percentage of the following lymphocyte subsets from lymphoid organs: B220, CD3/CD4, CD3/CD8 and CD40L/CD4 lymphocytes from blood or lymph nodes; and CD4-CD8-, CD4+CD8+, CD4+CD8- and CD4-CD8+ from the thymus. RESULTS: Fun-boi therapy markedly reduced the severity of arthritis (p < 0.001) and tended to reduce the serum anti-CII antibody level (p = 0.06). Whereas CII immunization of DBA/1J mice caused a significant redistribution of CD3/CD8 lymphocytes from blood or lymph nodes, Fun-boi therapy caused significant normalization of the same types of lymphocyte subsets from lymph nodes, but did not affect the CD4 or CD4/CD40L lymphocyte subsets. CONCLUSION: These results demonstrate that Fun-boi therapy exerts therapeutic effects in CIA mice, possibly by causing immunomodulatory effects at specific sites.

Effect of interleukin 2 on killer cell inhibitory receptors in patients with rheumatoid arthritis.

OBJECTIVE: The genes for killer cell inhibitory receptors (KIRs) have been cloned and their functions and responses to other molecules, including cytokines, have been partially clarified. However, the expression of KIRs has not been analysed in patients with autoimmune diseases, such as rheumatoid arthritis (RA), who are highly susceptible to microbial infection. Therefore, KIR expression on lymphocytes in patients with RA, and the regulation of KIR expression by interleukin 2 (IL2) in RA was investigated. METHODS: CD158a/b expression on peripheral blood mononuclear cells (PBMC) obtained from 25 patients with RA and 14 healthy subjects was analysed by flow cytometry. Additionally, PBMC from the two groups of subjects were cultured in RPMI 1640 medium with or without IL2 for 48 hours, and then their CD158a/b expression was analysed. RESULTS: The rate of CD158a expression on the CD8+ cells was lower in patients with RA than in healthy subjects, though there was no significant difference in the CD158a/b expression on the CD16+ cells between the two groups. The upregulation of CD16+CD158a/b+ cells in response to IL2 was significantly reduced in patients with RA compared with healthy subjects. CONCLUSION: The reduced induction of KIR expression in response to IL2 may provide insight into the reason for the high susceptibility of patients with RA to microbial infection.

A case of papillary muscle rupture caused by acute myocardial infarction.

A 63-year-old female was admitted because of cardiogenic shock due to complete rupture of the posterior papillary muscle. The diagnosis was made by echocardiography. She was treated successfully by an emergency replacement of the mitral valve. Early diagnosis and surgical treatment are mandatory and life-saving in the case of complete papillary muscle rupture.

Analysis of autoantibodies to cell cycle-associated antigens.

Abstract To determine the specificities of autoantibodies targeting cell cycle-associated antigens in rheumatic diseases, we studied 30 sera which were obtained from patients visiting our hospital and which exhibited a variegated speckled pattern in indirect immunofluorescence (IF). The immunoreactivities of the sera were analyzed by Western blotting (WB) and IF. Various reactivities to cellular components were observed in IF. The sera reacted with proteins of various molecular weights in WB. Serum OH from a patient with rheumatoid arthritis showed fine speckled nucleoplasmic and nucleolar staining at interphase, discrete dot staining associated with chromosomes and the midbody at mitosis, and reacted with a 34-kD polypeptide in WB. The target antigen was different from proliferating cell nuclear antigen (PCNA). The 34-kD antigen was characterized by IF using double staining procedures and cell synchronization. The results showed that the expression of the antigen was mainly observed between the late G1 and M-phases. This study indicated that various cell-cycle-associated antigens were recognized in sera from patients with rheumatic diseases, and suggested that a 34-kD antigen recognized by serum OH was a novel cell cycle-associated autoantigen.

Patient with atrioventricular node reentrant tachycardia with eccentric retrograde left-sided activation: treatment with radiofrequency catheter ablation.

We describe a patient with supraventricular tachycardia with triple atrioventricular (AV) node pathway physiology. A discontinuous curve was present in the antegrade AV nodal function curves. During right ventricular pacing, the earliest retrograde atrial activation was recorded at the left-sided coronary sinus electrode. The retrograde ventricular-atrial interval was long and had decremental conduction. We induced a slow-slow AV node reentrant tachycardia (AVNRT) with eccentric retrograde left-sided activation. After slow pathway ablation, dual AV nodal pathway physiology was present. AVNRT with eccentric retrograde left-sided activation is relatively rare, and our findings suggest that eccentric retrograde left-sided atrial inputs consist partially of a slow pathway and disappear with slow pathway ablation.

Clinical and Immunomodulatory Effect of Fun-boi, an Herbal Medicine, in Rheumatoid Arthritis.

Crude preparations of Fun-boi (Fen-fan-ji in Chinese), a traditional anti-rheumatic herb, have been used safely over millennia. To begin to study the efficacy of Fun-boi on the disease activity and the peripheral lymphocyte subsets, we performed a 12-week, open-label trial of Fun-boi extract (a decoction of Fun-boi 10 g/day) in 29 patients with rheumatoid arthritis (RA). Most clinical and immunological variables: swollen joint count, physician's and patient's assessment, pain score and IgM rheumatoid factor, showed statistically significant improvement. Seven (24%) of the enrolled patients met the American College of Rheumatology (ACR) criteria for a 20 percent improvement in measures of disease activity (ACR20) and 3 (10%) met those for ACR50. The CD3+CD8+ lymphocytes were increased significantly. Accordingly, the CD4/CD8 ratio was decreased; however, these changes did not show any clear correlation with clinical response. Two patients (7%) experienced some minor transient adverse events. In conclusion, Fun-boi is safe and showed beneficial effect in some patients for the treatment of the relatively mild RA seen in the patients studied. Further controlled studies are indicated. Clinicians should keep an open mind about possible benefits of these still incompletely studied herbal agents.

Killer-cell inhibitory receptors, CD158a/b, are upregulated by interleukin-2, but not interferon-gamma or interleukin-4.

Although it is now accepted that killer-cell inhibitory receptors (KIRs), which were molecularly cloned in 1995, deliver negative signals to natural killer (NK) cells regarding the recognition of target cells, it is still unclear how the expression of these receptors on lymphocytes is regulated. Therefore, we investigated the regulation of expression of representative KIRs, CD158a and CD158b, by cytokines such as interleukin-2 (IL-2), IL-4 and interferon-gamma (IFN-gamma). Neither IL-4 nor IFN-gamma affected the expression of CD158a/b, but incubation for 48 h with IL-2, which enhances the killer activity of NK cells, upregulated the expression of the KIRs. This upregulation by IL-2 was also observed in CD16-positive cells sorted from total lymphocytes. In contrast, IL-4, which is a down-regulator of IL-2-induced killer responses, did not change the level of CD158a/b expression when added after the IL-2 treatment. These findings suggest that IL-2 plays an important role in the regulation of CD158a/b expression, and might be involved in controlling NK activity via regulating expression of these molecules.

Rheumatoid arthritis complicated by mycobacterium tuberculosis are there characteristics predisposing to this association?

Several studies have reported that the emergence of mycobacterium tuberculosis (TB) is increasing, and that it may be a critical complication of rheumatoid arthritis (RA). Thus, we assessed the clinical and immune status of RA patients with TB to look for features that might favor infection. Seven RA patients with a history of TB and 62 RA patients without TB were compared in terms of background, RA disease activity, and the concentrations of serum soluble cell surface markers (sCD4, sCD8 and sCD23). There were no differences in RA activity between the two groups. It is noteworthy that the RA patients with TB had not been treated with immunosuppressives. Counts of lymphocytes, but not neutrophils, were significantly less in the RA patients with previous TB than in those without TB. The serum concentration of sCD23, a marker of B cell activation, was significantly higher in the RA with TB group. There was also a nonsignificant but considerable difference in the mean sCD8 concentration between the two groups. These results suggest that B cell and possibly also T cell activation is prominent in the RA patients with a history of TB, and that lymphocyte activation might explain in part the high susceptibility of RA patients to TB.

Characteristics of coronary flow velocity in constrictive pericarditis.

A 50-yr-old man developed constrictive pericarditis following an episode of acute pericarditis. Cardiac catheterization revealed a typical early diastolic dip and plateau configuration in both the right and left ventricular pressure curves. The coronary flow velocity pattern determined using an intracoronary Doppler guidewire showed an abrupt decrease in peak velocity at early diastole and followed by plateau until late diastole, the so-called dip and plateau configuration. After a successful pericardiectomy, cardiac catheterization no longer showed the dip and plateau configuration, but the early diastolic dip in the coronary flow velocity persisted probably because of infiltration of the organic involvement into the myocardium.

Coronary flow velocity patterns immediately after reperfusion reflect the pathologic characteristics of reperfused myocardium in canine models of acute myocardial infarction.

BACKGROUND: It is difficult to evaluate the extent of myocardial injury after successful reperfusion following acute myocardial infarction (AMI). We investigated the relationship between the coronary flow velocity pattern immediately after reperfusion and pathologic characteristics after myocardial reperfusion injury in dogs. METHODS: We measured distal coronary flow velocity variables in the left circumflex coronary artery in a canine model of AMI (n = 12) 10 min after the release of a clamp (3-10 h clamp procedure) using a 0.35 mm Doppler guide-wire. Dogs were divided into two groups according to presence or absence of early systolic retrograde coronary flow. Hearts were excised 2 h after reperfusion and examined histopathologically. RESULTS: The clamping time tended to be longer in dogs with early systolic retrograde coronary flow. Neutrophil infiltration was observed in the myocardium of dogs without systolic retrograde flow (n = 9); hemorrhage was rarely detectable and the myocardium maintained a bundle form. However, the bundle form of the myocardium became rough, and the severity of the incidence of hemorrhage tended to increase as the ratio of the diastolic coronary flow velocity to systolic velocity (DSVR) decreased. Vacuolar degeneration of the myocardium was also observed in hearts with a relatively low DSVR. In the group with systolic retrograde flow (n = 3), hearts were characterized by coagulation necrosis, marked vacuolar degeneration of the myocardium and diffusely distributed red cells in the intermyocytes. Systolic antegrade flow velocity was much reduced in this group, resulting in a markedly increased DSVR. These findings appeared to be related to severe myocardial damage. CONCLUSIONS: Coronary flow velocity patterns immediately after successful reperfusion appear to reflect the pathologic characteristics of the reperfused myocardium in dogs with AMI.

Right and left ventricular wall motion velocities as diagnostic indicators of constrictive pericarditis.

The purpose of this study was to examine the usefulness of pulsed tissue Doppler imaging for diagnosing constrictive pericarditis. Motion velocities of the ventricular septum (VS) and left ventricular (LV) posterior wall along the short axis, and those of the anterior right ventricular (RV) wall, VS, and LV posterior wall along the long axis were recorded using pulsed tissue Doppler imaging in 12 patients with constrictive pericarditis, who were diagnosed by cardiac catheterization, and also in 20 normal subjects. Peak early diastolic and atrial systolic velocities (Ew and Aw, respectively) were calculated, and the time between the aortic component of the second heart sound and the peak of the early diastolic velocity (IIA-Ew) was determined. The peak Ew and II A-Ew along the short and long axes were significantly higher and shorter, respectively, in the patient group than in the normal group. In the patient group, the motion velocity of the VS along the short axis showed a "backward" motion with a sharp and marked peak velocity immediately before Ew, or a biphasic early diastolic wave; a clear "downward" motion immediately after Ew was observed in the motion velocities of the anterior RV wall, VS, and LV posterior wall along the long axis. These distinctive backward and downward motions were not observed in any of the ventricular walls of the normal subjects. In conclusion, the early diastolic RV and LV wall motion velocity patterns along the short and long axes as measured by pulsed tissue Doppler imaging provide important information for the diagnosis of constrictive pericarditis.

Electrophysiologic effects of quinaprilat in dogs during acute myocardial ischemia and following reperfusion.

BACKGROUND: There have been few studies concerning the electrophysiologic changes associated with the use of angiotensin-converting enzyme inhibitors in patients with acute myocardial infarction. We examined the electrophysiologic effects of quinaprilat in dogs during acute myocardial ischemia and following reperfusion. METHODS: The left anterior descending coronary artery was occluded for 10 min and reperfused for 10 min. Animals received intravenous quinaprilat (3 micrograms/kg per min, quinaprilat group) or saline (control group). We measured the ventricular effective refractory period and intra-myocardial conduction time within the left anterior descending coronary artery region (ischemic region) during myocardial ischemia and following reperfusion, and determined the frequency of ventricular fibrillation. RESULTS: The effective refractory period in the ischemic region decreased during myocardial ischemia and decreased further immediately after reperfusion in the control group. The intra-myocardial conduction time in the ischemic region increased during myocardial ischemia but rapidly shortened after reperfusion in the control group. In the quinaprilat group, however, no significant differences were evident between the ischemic and non-ischemic regions in either the effective refractory period or the intra-myocardial conduction time during myocardial ischemia or following reperfusion. The percentage shortening of the effective refractory period and the percentage prolongation of the intra-myocardial conduction time in the ischemic region were significantly lower in the quinaprilat group than in the control group during myocardial ischemia and following reperfusion. The frequency of ventricular fibrillation during myocardial ischemia and following reperfusion was significantly lower in the quinaprilat group (21%) than in the control group (74%; P < 0.01). CONCLUSIONS: Quinaprilat protects against electrophysiologic abnormalities, and may decrease arrhythmias during acute myocardial ischemia and following reperfusion.

Systemic lupus erythematosus complicated by disseminated intravascular coagulation: the role of serum soluble cell surface markers.

We describe a 31-year-old Japanese female patient with systemic lupus erythematosus (SLE), who developed disseminated intravascular coagulation (DIC), fever, erythema on the hands, and aphthous stomatitis despite the absence of circulating anticoagulant. Since no other cause for DIC besides SLE could be demonstrated, she was treated with prednisolone and anticoagulants, which rapidly corrected the DIC as well as the other manifestations of SLE. During the episode of DIC, elevated serum anti-DNA antibody titers and decreased serum complement concentrations were not observed. In contrast, the serum concentration of soluble CD8 (sCD8) paralleled SLE disease activity. In addition, the concentration of plasma thrombomodulin was also increased. These observations suggest that the serum concentration of sCD8 is related to the clinical aspects of SLE, and that vasculitis might contribute to the development of SLE-associated DIC.

Presence and localization of endothelin receptor in the rat ovary and its regulation by pituitary gonadotropins.

In the present study we examined the regulation of receptors for endothelin 1 (ET-1) in rat granulosa cells. We examined the localization and regulation of ET receptors in immature rat ovary and the effects of ET-1 on steroidogenesis in cultured rat granulosa cells. The ovaries used in autoradiography were derived from pregnant mare serum gonadotropin and human chorionic gonadotropin-treated immature rats. Granulosa cells were obtained from diethylstilbestrol-treated immature rats and incubated with 125I-ET-1. Granulosa cells were cultured with ET-1 in the presence or absence of ovine follicle-stimulating hormone. The concentrations of sex steroid hormones in conditioned media were measured by radioimmunoassay. The binding site for ET-1 was localized in the granulosa cells, but not in thecal and luteal cells. Follicle-stimulating hormone (FSH) induced a dose-dependent increase in specific binding for ET-1 to cultured rat granulosa cells. In contrast, luteinizing hormone (LH) induced a dose-dependent decrease in specific binding for ET-1 to cultured rat granulosa cells. Conversely, treatment with prolactin and several sex steroid hormones had no effects on the specific binding of ET-1. Treatment with ET-1 inhibited FSH-stimulated accumulation of progesterone and estradiol in cultured rat granulosa cells. The results indicate that both FSH and LH influence the expression of ET-1 receptor, and that ET-1 may play a regulatory role in the ontogeny of the granulosa cell.

Work and power outputs determined from pedalling and flywheel friction forces during brief maximal exertion on a cycle ergometer.

Work and power outputs during short-term, maximal exertion on a friction loaded cycle ergometer are usually calculated from the friction force applied to the flywheel. The inertia of the flywheel is sometimes taken into consideration, but the effects of internal resistances and other factors have been ignored. The purpose of this study was to estimate their effects by comparing work or power output determined from the force exerted on the pedals (pedalling force) with work or power output determined from the friction force and the moment of inertia of the rotational parts. A group of 22 male college students accelerated a cycle ergometer as rapidly as possible for 3 s. The total work output determined from the pedalling force (TWp) was significantly greater than that calculated from the friction force and the moment of inertia (TWf). Power output determined from the pedalling force during each pedal stroke (SPp) was also significantly greater than that calculated from the friction force and the moment of inertia. Percentage difference (% diff), defined by % diff = ¿(TWp - TWf)/TWf¿ x 100, ranged from 16.8% to 49.3% with a mean value of 30.8 (SD 9.1)%. It was observed that % diff values were higher in subjects with greater TWp or greater maximal SPp. These results would indicate that internal resistances and other factors, such as the deformation of the chain and the vibrations of the entire system, may have significant effects on the measurements of work and power outputs. The effects appear to depend on the magnitudes of pedalling force and pedal velocity.

[Initial and short-term results of percutaneous transluminal coronary angioplasty in patients over 70 years old: recent improvements in effectiveness].

Elderly patients have a higher incidence of procedure-related complications and recurrent angina after percutaneous transluminal coronary angioplasty (PTCA). However, early success rates seem to have improved. To determine whether outcome of PTCA in the elderly has changed recently, we compared initial results and short-term outcome in patients over 70 years old in two groups; 64 patients with 70 PTCA lesions who underwent first elective PTCA in 1982-1989 (early group) and 140 patients with 153 PTCA lesions in 1990-1993 (late group). The mean age of the late group was significantly older than that of the early group (74 +/- 3 vs 73 +/- 2 years, p < 0.01). The two groups had similar clinical characteristics including sex, prior myocardial infarction and multivessel disease. The overall success rate of PTCA was significantly higher in the late group than in the early group (92.8% vs 82.8%, p < 0.05). The rate of abrupt closure was similar in the two groups (2.9% vs 2.6%). Major complications (procedural myocardial infarction, emergency bypass surgery, hospital death) occurred in 4.7% of the early group and in 3.6% of the late group. Angiographic restenosis occurred in 41.5% of the early group and in 33.6% of the late group. Cardiac events (cardiac death and/or myocardial infarction) occurred in 6.6% of the early group and in 1.5% of the late group (p = 0.06). The initial success rate of PTCA has improved in the elderly as well as younger patients (< 70; 92.8% vs 91.6%). We conclude that PTCA can be performed with high initial success and satisfactory short-term outcome in patients over 70 years old.

[Efficacy and safety of percutaneous transluminal coronary angioplasty of other coronary arteries in patients with chronic total occlusion of the left anterior descending artery].

The acute and long-term outcomes of percutaneous transluminal coronary angioplasty (PTCA) of the right coronary artery (RCA) or left circumflex branch (LCS) in patients with chronic occlusion of the left anterior descending branch (LAD) (group A) were compared with those of sex and age matched patients undergoing PTCA of the RCA or LCX with a normal LAD (group B). Before the procedure, group A had more frequent prior myocardial infarction (96% vs 33%, p < 0.001), and a lower left ventricular ejection fraction (LVEF) (49 +/- 14% vs 71 +/- 13%, p < 0.001). The acute results were similar in the two groups with respect to primary success (group A 90%, group B 91%) and major complications (group A 6%, group B 2%). At 3 months, the rate of restenosis was 33% in group A and 27% in group B. In group A, LVEF increased significantly in patients without restenosis (53 +/- 11% vs 62 +/- 11%, p < 0.01). At long-term follow-up, group A had higher rates of persistent angina but there was no difference in outcome between the two groups. In patients with chronic total occlusion of LAD, PTCA for RCA or LCX can be performed with a low complication rate and provides a significant improvement in LVEF at 3 months in the absence of restenosis. However, at short-term follow-up, these patients have a greater incidence of persistent angina.