Hemodynamic response during standing test after blood donation can predict the late phase vasovagal reaction.

A major complication of blood donation is vasovagal reaction (VVR) with or without syncope. VVR occurs not only in the early phase, but also in the late phase after blood donation. We previously reported the hemodynamic characteristics of blood donors susceptible to early phase VVR. In the present study, we investigated the hemodynamic characteristics of those who developed late VVR. Ninety-six healthy volunteers donating 400 ml of whole blood were studied. After asking about their physical condition or routine questions for blood donation, blood pressure (BP) and heart rate (HR) were recorded while the donors were kept standing up for 3 min before and after blood collection. Questionnaires were distributed to all donors for reporting late VVR symptoms within 24 h. Those with younger age and lower diastolic blood pressure were more susceptible to late VVR (both p < 0.05). Furthermore, we identified the increase in HR during the standing test after blood collection as a good predictor of late VVR (odds ratio 1.063, 95 % CI 1.005-1.124; p = 0.031). Also, analysis of questions asked before donation revealed that significantly more donors considered themselves as sensitive to pain in the late VVR group (Odds ratio 0.070, 95 % CI 0.008-0.586; p = 0.014). Excessive HR response to standing after blood collection and subjective sensitivity to pain as well as younger age and lower diastolic BP may be useful to detect donors at high risk for late VVR.

Onset Time of Ischemic Events and Antiplatelet Therapy after Intracranial Stent-assisted Coil Embolization.

BACKGROUND: Stent-assisted coil embolization is effective for intracranial aneurysms, especially wide-necked aneurysms; however, the optimal antiplatelet regimens for ischemic events that develop after coil embolization have not yet been established. We aimed to determine the onset time of such postoperative ischemic events and the relationship between these events and antiplatelet therapy. METHODS: We performed coil embolization using a vascular reconstruction stent for 43 cases of intracranial aneurysms and evaluated the incidence of postoperative ischemic events in these cases. RESULTS: Nine patients showed postoperative ischemic events during the follow-up period (13 ± 7 months). Two patients developed cerebral infarction within 24 hours. Five patients developed transient ischemic attack within 40 days while they were receiving dual antiplatelet therapy. In addition, 1 patient showed cerebral infarction 143 days postoperatively during single antiplatelet therapy, and a case of transient visual disturbance was reported 191 days postoperatively (49 days after antiplatelet therapy had been discontinued). We increased the number of antiplatelet agents in 4 of these patients. The other 5 patients were under strict observation with dual antiplatelet therapy. All these patients were shifted to single antiplatelet therapy 3-13 months postoperatively. No recurrence of ischemic events was noted. CONCLUSIONS: Postoperative ischemic events are most likely to occur within 40 days postoperatively. For patients with postoperative ischemic events, additional ischemic events can be prevented by increasing the number of antiplatelet agents; subsequently, they can be shifted to single antiplatelet therapy after the risk of recurrence has decreased.

Intracranial tuberculoma in non-immunosuppressive state.

The rise in the incidence of tuberculosis is generally related to human immunodeficiency virus infection. However, intracranial tuberculoma, a complication of tuberculosis considered to be a critical disease, can develop even in the absence of immunosuppressive state. Here, we describe 2 cases of intracranial tuberculoma occurring in patients with no evidence of immunosuppressive state or past history of tuberculosis. In Case 1, lesions were observed in the right lateral ventricle, with histological examination revealing granulomatous lesions. In Case 2, scattered lesions were observed in the cranium and the lung fields. In both cases, the QuantiFERON Test (QFT) was positive, and improvements were observed in the symptoms following administration of antituberculous drugs. Intracranial tuberculoma cannot be considered rare, and needs to be included in the differential diagnosis of intracranial lesions. Diagnosis can be tricky since this disease can develop in a patient in a non-immunosuppressive state or without a past history of tuberculosis. The QFT is an effective test to enable the diagnosis of tuberculomas in atypical patients.

Cilostazol reduces periprocedural hemodynamic depression in carotid artery stenting.

The clinical effects of two different types of antiplatelet drugs, cilostazol and thienopyridine drugs, were compared in patients treated by carotid artery stenting (CAS). Two hundred patients scheduled for CAS were randomized to either cilostazol or a thienopyridine drug (ticlopidine or clopidogrel). The study was conducted in open-label design. Aspirin was also given to all patients. All episodes of periprocedural hemodynamic instability (bradycardia, hypotension) were recorded together with all instances of stroke, cardiac morbidity, and death within 30 days of the procedure. Angiographic follow-up studies were conducted about 6 months after CAS. Finally, 197 patients were enrolled in this study; 97 were treated with cilostazol (cilostazol group) and 100 with a thienopyridine drug (thienopyridine group). In the 30-day follow-up period, the incidence of stroke, cardiac adverse effects, and death was not significantly different between the 2 groups (cilostazol group 7.2%, thienopyridine group 11.0%; p = 0.85). The incidence of intra- and postprocedural bradycardia was significantly lower in the cilostazol group (cilostazol group 18.6% and 2.1%, thienopyridine group 40.0% and 18.0%, respectively; p < 0.01). Although the incidence of intraprocedural hypotension did not significantly differ between the 2 groups, postprocedural hypotension was significantly lower in the cilostazol group (16.5% vs. 34.0%, p < 0.01). In-stent restenosis on follow-up angiograms was lower in the cilostazol group but not significantly (0% vs. 4.4%, p = 0.12). This small open-label study shows that cilostazol may reduce periprocedural bradycardia and hypotension compared with thienopyridine drugs in patients treated by CAS.

Histological examination of expanded polytetrafluoroethylene artificial dura mater at 14 years after craniotomy: case report.

Expanded polytetrafluoroethylene (ePTFE) porous material (GORE(®) PRECLUDE(®) Dura Substitute) does not degenerate or deteriorate in vivo, and is currently used as artificial dura mater. This material does not adhere well to the surrounding tissues, but cerebrospinal fluid leakage along the suture line has been observed in several cases. We describe a case of craniotomy for tumor resection performed 14 years after dural repair with ePTFE sheet. Histological examination of the ePTFE sheet revealed that the sheet was structurally intact, with no evidence of tissue adhesion or cellular infiltration. However, collagen deposition was observed around the suture thread. When the suture thread was removed the collagen was also removed, and the original needle hole appeared again. No significant changes were observed in the features of the ePTFE sheet even 14 years postoperatively. The formation of fibrous tissue around the needle hole was important in preventing cerebrospinal fluid leakage.

Intraprocedural prediction of hemorrhagic cerebral hyperperfusion syndrome after carotid artery stenting.

Hyperperfusion syndrome (HPS) is a rare but severe complication after carotid artery stenting (CAS). Reliable methods for predicting HPS remain to be developed. We aimed to establish a predictive value of hemorrhagic HPS after CAS. Our retrospective study included 136 consecutive patients who had undergone CAS. We determined the cerebral circulation time (CCT) by measuring the interval between the point of maximal opacification of the terminal portion of the internal carotid artery and the cortical vein. We calculated intraprocedural CCT changes (ΔCCT) by subtracting postprocedural CCT values from preprocedural CCT values. The mean ΔCCT was 0.9 ± 0.9 seconds; 3 patients (2.2%) with prolonged ΔCCT (2.7, 5.4, and 5.8 seconds) developed HPS. The cutoff time of 2.7 seconds predicted hemorrhagic HPS retrospectively with 100% sensitivity and 99% specificity. Our findings suggest that post-CAS HPS can be predicted by using the ΔCCT value obtained by intraprocedural digital subtraction angiography. Patients with a ΔCCT >2.7 seconds require careful intensive hemodynamic and neurologic monitoring after CAS.

Enhancement of cardiac performance by bilevel positive airway pressure ventilation in heart failure.

BACKGROUND: Recent studies have reported the clinical usefulness of positive airway pressure ventilation therapy with various kinds of pressure support compared with simple continuous positive airway pressure (CPAP) for heart failure patients. However, the mechanism of the favorable effect of CPAP with pressure support can not be explained simply from the mechanical aspect and remains to be elucidated. METHODS AND RESULTS: In 18 stable chronic heart failure patients, we performed stepwise CPAP (4, 8, 12 cm H(2)O) while the cardiac output and intracardiac pressures were continuously monitored, and we compared the effects of 4 cm H(2)O CPAP with those of 4 cm H(2)O CPAP plus 5 cm H(2)O pressure support. Stepwise CPAP decreased cardiac index significantly in patients with pulmonary arterial wedge pressure (PAWP) <12 mm Hg (n = 10), but not in those with PAWP ≥12 mm Hg (n = 8). Ventilation with CPAP plus pressure support increased cardiac index slightly but significantly from 2.2 ± 0.7 to 2.3 ± 0.7 L min(-1) m(-2) (P = .001) compared with CPAP alone, regardless of basal filling condition or cardiac index. CONCLUSIONS: Our results suggest that CPAP plus pressure support is more effective than simple CPAP in heart failure patients and that the enhancement might be induced by neural changes and not simply by alteration of the preload level.

Diagnostic performance of cardiac fusion images from myocardial perfusion imaging and multislice computed tomography coronary angiography for assessment of hemodynamically significant coronary artery lesions: an observational study.

BACKGROUND: In detecting coronary artery disease (CAD), fusion images obtained by combining myocardial perfusion imaging (MPI) and computed tomography coronary angiography (CTCA) have shown a higher accuracy and clinical usefulness than these modalities used separately or a simple comparison of individual images. However, the clinical use of fusion images has been restricted by the necessity of obtaining images with an integral type device or with devices made by the same manufacturer. Thus, we evaluated the detection of hemodynamically significant CAD by fusion images created with a newly developed general-purpose application that can be used with any type of device. METHODS AND RESULTS: In 49 patients, MPI during exercise and at rest and CTCA were obtained separately and combined into fusion images using the new application. As the reference standard, a comparative interpretation of MPI and the conventional coronary arteriography (CAG) was adopted. Hemodynamically significant CAD were diagnosed when MPI showed a reversible perfusion defect in a region with greater than 50% luminal stenosis on CAG. The capability of fusion images to detect CAD was compared with that of CTCA images alone. Fusion images showed a higher ability to detect CAD (sensitivity 80%, specificity 94%, positive predictive value 77%, and negative predictive value 95%) than CTCA alone (77, 77, 46, and 93%, respectively; fusion vs. CTCA: specificity P=0.0002, positive predictive value P=0.0001). CONCLUSION: Fusion images obtained with a general-purpose application were superior to CTCA images alone for detecting hemodynamically significant CAD.

Experience of step-wise protocol using noninvasive positive pressure ventilation for treating cardiogenic pulmonary edema.

Initiating and weaning procedure of noninvasive positive pressure ventilation (NIPPV) on acute cardiogenic pulmonary edema (ACPE) has been determined empirically, and the total time of its use has been sometimes prolonged unnecessarily. A simple protocol for its use may facilitate initiation and avoids prolongation of the NIPPV treatment. We designed a step-wise protocol for NIPPV use and retrospectively examined the clinical outcome of our protocol for initiation and weaning of NIPPV in 45 patients with ACPE. Almost all patients recovered from respiratory distress successfully. There was no intubation nor complication related to NIPPV. In most of the cases, maximal-end expiratory pressure was less than 7-cm H2O. The mean duration of NIPPV was 19.5±28.0 h and the median duration was 8.0 h (interquartile range=14.0 h). This simple step-wise NIPPV protocol for ACPE can facilitate quick and safe initiation and termination of the treatment.

Effects of the L/N-type calcium channel antagonist cilnidipine on morning blood pressure control and peripheral edema formation.

The L/N-type calcium channel blocker cilnidipine has unique effects including sympathetic nerve suppression and the balanced vasodilatation of arteries and veins that may alleviate morning hypertension (MHT) or peripheral edema caused by calcium channel antagonists. We used ambulatory blood pressure monitoring (ABPM) and a unique peripheral edema measurement to evaluate the effect of morning and bedtime cilnidipine in patients with MHT. Forty-three patients with MHT (60 ± 12 years) were randomly assigned to a morning or bedtime cilnidipine (10-20 mg/day). MHT was defined as a mean systolic blood pressure (SBP) ≥ 135 mm Hg by ABPM within 2 hours after awaking. After 3 months, greater SBP reductions were observed in the bedtime administration group (versus the morning administration group) at 3:30-6:00 AM (-24 ± 20 mm Hg vs. -10 ± 4 mm Hg; P < .05) and at 6:30-9:00 AM (-26 ± 15 mm Hg vs. -14 ± 17 mm Hg; P < .05). Although physical examinations showed leg edema in 16% of the patients, quantitative evaluations did not reveal significant volume gains. Cilnidipine had a greater effect on MHT, without causing significant leg edema, when administered at bedtime.

Instantaneous restoration of cardiac output by noninvasive positive pressure ventilation in a patient with obesity hypoventilation syndrome.

We report a 30-year-old man with severe obesity hypoventilation syndrome (OHVS) complicated by right-sided heart failure. Polysomnography revealed severe obstructive sleep apnea with apnea-hypopnea index (AHI) 70.4/h and gradual decrease in minimum oxygen saturation (SpO2) from 86% before sleep to 36% during sleep. Cardiac output (CO) was suppressed from 3.9 L/min before sleep to 2.5 L/min during sleep. Noninvasive positive pressure ventilation (NPPV) treatment drastically restored CO to the level before sleep, and improved AHI to 9.4/h and minimum SpO2 to 87%. NPPV may provide rapid and powerful symptom relief in patients with OHVS complicated with right sided heart failure.

Radiofrequency catheter ablation of ventricular tachyarrhythmia under navigation using EnSite array.

BACKGROUND: EnSite array (EA) provides virtual activation of ventricular tachycardia (VT) and premature ventricular contraction (PVC) on a beat-to-beat basis. METHODS AND RESULTS: Fifty-five consecutive patients (age 52+/-16 years) with 79 VTs/PVCs undergoing EA-guided radiofrequency catheter ablation (RFA) were studied, of whom 7 patients had organic heart diseases. A virtual activation map showed that 66 VTs/PVCs originated from the right ventricle (RV), including the RV outflow tract in 57, lateral wall of RV in 4, His bundle region in 3 and tricuspid annulus in 2. Ten VTs/PVCs originated from the left ventricle (LV), including the LV endocardium in 7 and aortic sinus cusp in 3. The origins of 3 PVCs, one each in 3 patients, were not identified. Six of 38 VTs were sustained and the remaining 32 VTs were non-sustained. RFA eliminated all but 3 focal PVCs, and all macroreentrant VTs at a critical conducting pathway, which was identified by the combined use of contact voltage and virtual activation maps. There were 11+/-9 applications, and the radiofrequency energy and fluoroscopy time were 11,354+/-13,360 J and 30+/-21 min, respectively. All patients with acute success were free of any symptoms during a follow up of 21+/-11 months. CONCLUSIONS: EA-guided RFA is safe and effective for VT/PVC, irrespective of its origin, mechanism, sustainability, hemodynamic condition, and underlying heart disease.

Characterization of bipolar electrograms during sinus rhythm for complex fractionated atrial electrograms recorded in patients with paroxysmal and persistent atrial fibrillation.

AIMS: Complex fractionated atrial electrogram (CFAE) has been reported to relate to maintain atrial fibrillation (AF). The aims of this study were to investigate the relationship between CFAE and background conditions during sinus rhythm (SR). METHODS AND RESULTS: Electroanatomical mapping using an EnSite Array was performed in 20 patients (paroxysmal AF:persistent AF = 16:4) who underwent pulmonary vein antrum isolation (PVAI). Contact bipolar electrograms were recorded before PVAI, during SR, and subsequently during induced AF. Peak-to-peak voltages and morphologies of the electrograms during SR were compared between sites with and without CFAE during AF. Among 1947 points obtained during SR, 974 (50%) were included in CFAE sites and 973 (50%) in non-CFAE sites. Electrogram amplitude during SR was higher at the CFAE sites than at the non-CFAE sites (2.4 +/- 1.7 vs. 1.9 +/- 1.9 mV; P < 0.0001), whereas fractionated or double electrograms were found in a similar range between the two areas (2 vs. 3%; P = 0.21). When analysed further in terms of AF termination by PVAI followed by confirmation of non-inducibility, the voltage of electrograms at the CFAE sites was lower (2.1 +/- 1.7 vs. 2.6 +/- 1.8 mV; P = 0.0001) and the morphology was more complex in patients without AF termination compared with those with AF termination. CONCLUSION: Our results suggest that in paroxysmal and persistent AF with minimally damaged LA, the CFAE sites in patients with AF termination by PVAI alone represent healthy atrial tissue with rapid electrical activity in response to an AF driver located in the pulmonary vein. However, in patients without AF termination, they represent more damaged tissue responsible for maintaining AF.

Radiofrequency catheter ablation of atrial tachycardia under navigation using the EnSite array.

BACKGROUND: Atrial tachycardia (AT) is sometimes difficult to eliminate by radiofrequency ablation (RFA), but the EnSite array (EA) visualizes the beat-to-beat virtual activation of any tachycardia. METHODS AND RESULTS: The 51 patients with 74 ATs (mean age 57+/-18 years, 28 males) undergoing EA-guided RFA were included; 14 patients had had previous open heart surgery and 5 had organic heart disease. RFA was performed at the AT focus for focal AT (n=48) with an endpoint of AT termination and subsequent non-inducibility. RFA was performed at a critical conducting pathway for reentrant AT (n=26) with creation of a block line in the critical reentry circuit. EA revealed that 57 ATs originated in the right atrium (77%) and 17 originated in the left atrium (23%); all but 1 were successfully eliminated. Fluoroscopic time was 19+/-11 min, the number of RFA applications was 8+/-7, and the radiofrequency energy was 10,711+/-12,655 J. No complications were noted. All but 2 patients were free of any symptoms during a follow-up of 16+/-9 months. CONCLUSIONS: EA-guided RFA is safe and effective for AT, irrespective of its mechanism, sustainability or origin, and regardless of underlying heart disease. (Circ J 2010; 74: 59 - 65).

Bipolar electrogram amplitudes in the left atrium are related to local conduction velocity in patients with atrial fibrillation.

AIMS: It is unclear how the amplitude of bipolar electrogram relates to the local conduction velocity (CV) in patients with atrial fibrillation (AF). For 50 AF patients (paroxysmal/persistent AF: 40/10 patients), contact bipolar voltage maps of the left atrium (LA) were constructed during sinus rhythm using EnSite version 6.0J in a point-by-point recording fashion. Patients were divided into Groups A (n = 16), B (n = 19), and C (n = 15) according to the level of the lowest electrogram amplitudes: <0.5, 0.5-0.75, and 0.75-1.0 mV, respectively. Low-voltage zone (LVZ) was defined separately for these groups as a bipolar electrogram amplitude of <0.5, 0.5-0.75, and 0.75-1.0 mV, respectively. The local CV through the LVZ and non-LVZ was calculated along the direction of local activation within each zone for all groups. METHODS AND RESULTS: Low-voltage zone was consistently found at the septal, anterior, and posterior LA in all groups. In Group A, CV through the LVZ was significantly slower compared with the non-LVZ (0.8 +/- 0.5 vs. 1.4 +/- 0.6 m/s, P = 0.004), but those through the LVZ and non-LVZ were similar in Group B (1.2 +/- 0.5 vs. 1.3 +/- 0.5 m/s, P = 0.07) and Group C (1.5 +/- 0.5 vs. 1.4 +/- 0.6 m/s, P = 0.79). The percentage of points showing fractionated or double potentials in the LVZ was significantly more in Group A (76/293 points, 26%) than in Group B (11/185 points, 6%), and Group C (7/135 points, 5%) (P < 0.0001 and P < 0.0001, respectively). CONCLUSION: There was a significant slowing of local conduction in the LVZ defined as <0.5 mV and was frequently associated with fractionated or double potentials in patients with AF.

Real-time 3-dimensional imaging of the esophagus and left atrium with a noncontact mapping system.

BACKGROUND: Recognizing the relative location of the esophagus to the left atrial posterior wall (LAPW) is required to avoid esophageal injury during atrial fibrillation ablation. METHODS AND RESULTS: The 24 patients undergoing circumferential pulmonary vein isolation (CPVI) each had the geometry of their left atrium (LA) and esophagus constructed by a noncontact mapping system with EnSite version 6.0J. The esophageal course relative to the LAPW was found to be to the left in 12, middle in 8, right in 2, and obliquely left-to-right in 2 patients, and in 13 patients (54%) it was located on or near either the left or right CPVI line. The mean distance between the esophagus and LAPW was shorter at the bottom line of the LAPW connecting both inferior pulmonary veins (3 +/- 3 mm) than at the LA roof line connecting both superior pulmonary veins (6 +/- 6 mm, P<0.01). CONCLUSIONS: The location of the esophagus relative to the LAPW varies with the patient, but a close location to either CPVI line was found in approximately 50% and a close location between the esophagus and LAPW was found in the inferior and middle locations in most patients.