Effectiveness of Saireito, a Traditional Japanese Kampo Herbal Medication, on Pacemaker-Related Pleural Effusion: A Case Report.

BACKGROUND Post-cardiac injury syndrome, including pleural effusion as a delayed complication of permanent pacemaker implantation, has rarely been reported. To resolve pleural effusion, prolonged chest tube placement is often required. Anti-inflammatory agents combined with diuretics are also often prescribed. Saireito, a Japanese herbal medication, which is a combination of Goreisan and Shousaikoto, has both anti-inflammatory and water-modulation properties and has been used for edema (lymph edema, cerebral edema) and inflammation (chronic nephritis). CASE REPORT We describe a 71-year-old woman with a history of syncope and bradycardia who underwent dual permanent pacemaker implantation (placed in the right chest because of a persistent left superior vena cava) without complications. Two months later, she came to the hospital as an outpatient with a dry cough, and was diagnosed with right-sided pleural effusion. A pleural fluid analysis revealed exudative effusion, according to Light's criteria. The fluid was negative for infectious etiology. Chest X-ray, computed tomography, and echocardiography revealed no signs of pericardial effusion or perforation of the pacemaker lead to outside the heart. The pleural effusion persisted despite use of anti-inflammatory medication for several weeks and diuretics for a short period. Saireito was administered with good response; the pleural effusion resolved completely and there was no deterioration of renal function. CONCLUSIONS The present case highlights the clinical significance of Saireito as an effective therapeutic agent for late-onset pacemaker-related pleural effusion, without adverse effects such as renal dysfunction.

Optimal timing of echocardiography for heart failure inpatients in Japanese institutions: OPTIMAL Study.

AIMS: Guidelines for the diagnosis and treatment of acute and chronic heart failure (HF) provided by the European Society of Cardiology state that echocardiography is recommended for the assessment of the myocardial structure and function of subjects with suspected HF including HF with reduced (HFrEF), mid-range (HFmrEF), and preserved ejection fraction (HFpEF) as class I of recommendation and level C of evidence. However, the impact of timing of echocardiography on survival for hospitalized HF patients or the prevalence of echocardiography during their stay has not yet been fully investigated. Therefore, we designed and conducted a prospective multicentre study, Optimal Timing of Echocardiography for Heart Failure Inpatients in Japanese Institutions (OPTIMAL) study, to investigate and evaluate the prevalence of echocardiography during the in-hospital stay of HF patients, and the impact of timing of echocardiography on their survival. METHODS AND RESULTS: OPTIMAL was based on a nationwide, prospective, multicentre registry at 10 institutions in Japan endorsed by the Japanese Society of Echocardiography. A total of 601 patients hospitalized with HF were enrolled between August 2016 and July 2018 at the participating centres. Their mean age was 73.9 ± 13.0 years, left ventricular ejection fraction was 37.0% (26.0-50.0), and 256 patients (42.6%) were female. Admission echocardiography (admission echo) was categorized as either standard or point-of-care echocardiography performed within 3 days of admission, as was pre-discharge echocardiography (pre-discharge echo) within 3 days of discharge. The primary endpoint was defined as cardiovascular death over a median follow-up period of 18.9 months (9.3-26.5 months). Admission echo was performed for 476 patients (79.2%) and pre-discharge echo for 216 patients (35.9%). The primary endpoint of cardiovascular death occurred in 65 patients (10.8%). Kaplan-Meier curve findings indicated that survival of patients with pre-discharge echo was significantly better than that of patients without it (log-rank P < 0.001), and the same findings were obtained for patients with HFrEF, HFmrEF, and HFpEF. However, survival of patients with and without admission echo was similar (log-rank P = 0.33). CONCLUSIONS: This OPTIMAL study prospectively showed the importance of pre-discharge echo for hospitalized HF patients. Careful attention is needed regarding the haemodynamic status of HF patients by administering pre-discharge echo to avoid HF re-hospitalization after discharge, and pre-discharge echo may provide additional information for deciding the appropriate discharge time. Our findings may thus offer a new insight into the management of hospitalized HF patients.

A Case of Takotsubo Cardiomyopathy with a Rare Transition Pattern of Left Ventricular Wall Motion Abnormality.

BACKGROUND Takotsubo cardiomyopathy is characterized by apical ballooning and excessive constriction of the base of heart. However, reverse takotsubo cardiomyopathy, wherein ballooning from the mid-ventricle to the base of the heart occurs with excessive constriction of the apex, has also been reported. We report a case of a transition from atypical wall motion abnormality to a typical takotsubo cardiomyopathy pattern. CASE REPORT A 54-year-old woman was following excessive sugar and dietary restrictions because of concerns regarding her blood sugar levels while receiving treatment for diabetes at another hospital. She presented at our hospital with general malaise and chest discomfort after several days of significantly increased workload. On admission, blood tests showed elevated cardiac enzymes. Electrocardiogram showed ST elevation of V2-V3 and poor R-wave enhancement of the anterior precordial lead. Coronary angiography showed no significant stenosis; however, left ventricular (LV) angiography showed a decrease in mid-ventricular wall motion. On the basis of these findings, she was diagnosed with a reverse takotsubo cardiomyopathy. We initiated conservative treatment for her condition. During her treatment, the LV wall motion showed a typical pattern of the apical ballooning that is characteristic of takotsubo cardiomyopathy. This LV wall motion was normalized on day 22 of the onset. CONCLUSIONS We observed a rare case of takotsubo cardiomyopathy where the pattern of LV wall motion abnormality changed over time. This case suggests that it is necessary to follow up LV abnormality over time rather than rely on single-point observations in cases with takotsubo cardiomyopathy.