Acute coronary syndrome with simultaneous two-vessel occlusion De Winter ST-segment depression or reciprocal change?

We discuss a case of acute coronary syndrome (ACS) with simultaneous two-vessel occlusions in a man in his 20s. The serial electrocardiograms (ECG) showed very early dynamic changes of ST-T configuration resulting from ischemic zone depth or area between anterior wall versus inferior wall. The upsloping ST depression along with tall tentorial T waves in the precordial leads, as shown in the index ECG, raises the possibilities of a de Winter pattern. The retrospective assessment of the index ECG identified prominent T waves and a mild degree of ST-segment elevations in the inferior leads, given the electrocardiographic findings previously recorded at his workplace medical examination obtained at a later date. If the subtle ST-segment elevations in leads II, III, and aVF and the tall T waves were not overlooked in the index ECG, the probability of reciprocal ST-segment depressions in the precordial leads should also be taken into account. We recognize our ECG findings as intriguing ST-T deviation patterns that can change depending on the time sequence and anatomical dominancy of two infarct-related arteries. We finally suggest physicians should bear in mind the possibility of simultaneous multiple vessel occlusions when they encounter ACS patients with hemodynamic instability as in this present case.

A Case of Chronic Heart Failure Complicated by Primary Biliary Cholangitis and Skeletal Myopathy.

Several autoantigens related to inflammatory myopathy have been identified. Antimitochondrial antibody M2 (AMA-M2) is known as one of the serologic hallmarks of primary biliary cholangitis (PBC). There have been several reports on the association between AMA-M2 and various types of inflammatory myopathy, including cardiomyopathy. We report a case of a 58-year-old man with decompensated heart failure who also had PBC and skeletal inflammatory myopathy. Endomyocardial biopsy revealed severe fibrotic replacement of the myocardium without massive inflammatory infiltration, which was pathologically similar to what happens in dilated cardiomyopathy (DCM). Although the potential relationship between chronic autoimmune inflammation and DCM has been discussed, the concept of the inflammatory DCM has not yet been established. When we see elevated liver enzymes, and which is not simply due to congestive hepatopathy, we should consider the coexisting disease such as PBC.

CVIT expert consensus document on primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) update 2022.

Primary Percutaneous Coronary Intervention (PCI) has significantly contributed to reducing the mortality of patients with ST-segment elevation myocardial infarction (STEMI) even in cardiogenic shock and is now the standard of care in most of Japanese institutions. The Task Force on Primary PCI of the Japanese Association of Cardiovascular Interventional and Therapeutics (CVIT) society proposed an expert consensus document for the management of acute myocardial infarction (AMI) focusing on procedural aspects of primary PCI in 2018. Updated guidelines for the management of AMI were published by the European Society of Cardiology (ESC) in 2017 and 2020. Major changes in the guidelines for STEMI patients included: (1) radial access and drug-eluting stents (DES) over bare-metal stents (BMS) were recommended as a Class I indication, (2) complete revascularization before hospital discharge (either immediate or staged) is now considered as Class IIa recommendation. In 2020, updated guidelines for Non-ST-Elevation Myocardial Infarction (NSTEMI) patients, the followings were changed: (1) an early invasive strategy within 24 h is recommended in patients with NSTEMI as a Class I indication, (2) complete revascularization in NSTEMI patients without cardiogenic shock is considered as Class IIa recommendation, and (3) in patients with atrial fibrillation following a short period of triple antithrombotic therapy, dual antithrombotic therapy (e.g., DOAC and single oral antiplatelet agent preferably clopidogrel) is recommended, with discontinuation of the antiplatelet agent after 6 to 12 months. Furthermore, an aspirin-free strategy after PCI has been investigated in several trials those have started to show the safety and efficacy. The Task Force on Primary PCI of the CVIT group has now proposed the updated expert consensus document for the management of AMI focusing on procedural aspects of primary PCI in 2022 version.

Possible Coronary Sequelae of Kawasaki Disease in an Elderly Man.

Kawasaki disease (KD) is an acute self-limited syndrome that predominantly affects children. Coronary sequelae have been identified to be responsible for a small, but significant percentage of young adults who present with myocardial ischemia. In this study, we present a case of an elderly patient with possible coronary sequelae of KD. A 76-year-old man was referred to our outpatient department for silent myocardial ischemia. Axial images of coronary computed tomography showed multiple lumens in the proximal left anterior descending (LAD) artery. Coronary angiography demonstrated braid-like appearance in the proximal and distal segment of the LAD. Coronary intervention was successfully performed for the proximal LAD lesion using directional atherectomy (DCA) catheter. Microscopic examination of the DCA specimens showed the following histological features: tissues in densely hyalinized fibrosis with occasional microcalcification, or those containing a number of smooth muscle cells (SMCs) with myxoid extracellular matrix. There was paucity of cholesterin crystals and aggregation of foamy cells. In addition, scarcely any inflammatory cell filtration was identified. In the section of SMC-containing samples, formation of multiple re-canalized vessels embracing endothelial cells was confirmed. These histopathologic findings indicated that the present coronary artery lesion has a high possibility of very late cardiovascular sequelae caused by arteritis due to KD, rather than arteriosclerosis. This is the oldest adult case with coronary artery disease possibly resulting from KD sequelae. This case highlights that KD sequelae must be considered as a cause of coronary artery lesion even in older patients.

Pueraria mirifica, an estrogenic tropical herb, unveiled the severity of Type 1 LQTS caused by KCNQ1-T587M.

After taking an estrogen-containing supplement derived from a tropical plant Pueraria mirifica, a 24-year-old woman presented marked QT prolongation and repetitive torsade de pointes. The patient was found to carry a heterozygous KCNQ1-T587M mutation. This is the first report on Pueraria mirifica-related acquired long QT syndrome.

Unstable angina complicated with dynamic left ventricular outflow tract obstruction.

Left ventricular outflow tract obstruction (LVOTO) complicated with unstable angina (uAP) has not been described widely, but patients with these two conditions have several problems. Differentiation of the two conditions is also often difficult because the chest symptoms are similar. Moreover, nitrates are commonly used for ischemic heart disease, but have the effect of worsening LVOTO. We experienced three cases of dynamic LVOTO with a sigmoid-shaped septum, and without typical hypertrophic obstructive cardiomyopathy, that were complicated with uAP. In all cases, LVOTO was improved after initial percutaneous coronary intervention (PCI) for the left anterior descending artery lesion. Next, a dobutamine stress test was performed and LVOTO was provoked again in two cases, but not in a case with small acute myocardial infarction of the basal septum during PCI. All cases remained asymptomatic with beta-blocker therapy. Therefore, PCI and beta-blocker administration for LVOTO with uAP resulted in favorable clinical courses in all three cases. These outcomes suggest that revascularization including PCI should have priority in the therapeutic strategy for a case of acute coronary syndrome with LVOTO.

The effect of the debulking by excimer laser coronary angioplasty on long-term outcome compared with drug-coating balloon: insights from optical frequency domain imaging analysis.

This study evaluated the 1-year efficacy of excimer laser coronary angioplasty (ELCA) before drug-coated balloon (DCB) dilatation for the treatment of in-stent restenosis (ISR). Forty consecutive patients with ISR were treated by DCB with or without the use of ELCA (ELCA plus DCB, N = 20; DCB alone, N = 20). Debulking efficiency (DE) value was defined as the neointima area on optical frequency domain imaging (OFDI) debulked by ELCA. The patients in the ELCA plus DCB group were divided into two groups (greater DE (GDE), N = 10; smaller DE (SDE), N = 10) based on the median value of DE. Thereafter, the ISR segment was prepared with a scoring balloon, followed by DCB. At follow-up, binary restenosis and target lesion revascularization (TLR) were evaluated. There were no significant differences in baseline characteristics such as age, comorbidity, and ISR type. Overall, the incidence of neoatherosclerosis in the ISR segment was 17.5%. Post-PCI, acute gain of minimum lumen diameter on quantitative coronary angiography and of minimum lumen area on OFDI was numerically higher in the GDE than in the SDE and the DCB alone group. At follow-up, the occurrences of binary restenosis and TLR in the ELCA plus DCB group were 20.0% and 10.0%; these values in the DCB alone group were 20.0% and 20.0%, respectively. Two patients from the SDE and none from the GDE developed TLR. DCB alone treatment was inferior to ELCA plus DCB treatment. However, greater ELCA debulking might be required to obtain optimal outcomes.

Impaired glucose tolerance and future cardiovascular risk after coronary revascularization: a 10-year follow-up report.

AIMS: Practical management guidelines for impaired glucose tolerance (IGT) have not been established. Although IGT is a potent marker of cardiovascular disease (CVD), it is still controversial whether its magnitude of CVD risk is comparable to that of frank diabetes. Moreover, information on long-term clinical outcomes of IGT patients undergoing coronary revascularization is limited. The aim of the present work was to investigate the 10-year prognostic impact of IGT in comparison with diabetes in patients with CAD undergoing coronary revascularization. METHODS: This cohort recruited from two Japanese clinical sites included patients with coronary artery disease (CAD) undergoing percutaneous coronary intervention (PCI) between 2004 and 2008. Patients were categorized into previously known diabetes (PKD, n = 197), newly diagnosed diabetes (NDD, n = 51), and IGT (n = 50) groups according to oral glucose tolerance test results except for PKD. The primary end point was defined as a composite of cardiovascular death, myocardial infarction, stroke, repeat revascularization, and heart failure hospitalization. RESULTS: The cumulative risk of the primary outcome was significantly higher in the PKD and IGT than in the NDD (log-rank test p = 0.017). A Cox proportional hazards model demonstrated that IGT (hazard ratio [HR], 7.91; 95% confidence interval [CI], 1.84-27.58) and creatinine clearance (HR, 7.89, 95% CI, 2.73-19.10) were predictors of long-term CVD risk, while NDD and PKD were not. CONCLUSIONS: IGT significantly increased the long-term risk of developing CVD in patients with CAD after PCI compared with diabetes.

Impact of glycemic variability on myocardial infarct size in patients with ST-segment elevation myocardial infarction: quantitative assessment of left ventricular wall motion severity.

Glycemic variability (GV) is relevant to impaired myocardial salvage in acute ST-elevation myocardial infarction (STEMI). Severity of hypokinesis at the infarct site as assessed from contrast left ventriculography can reportedly predict infarct size in STEMI. We prospectively studied 58 consecutive patients (mean age, 63 ± 11 years) with anterior or inferior STEMI who underwent successful reperfusion therapy. Mean amplitude of glucose excursion (MAGE) was obtained from continuous glucose monitoring system. Patients were divided into the upper tertile of MAGE as Group H, and the other two-thirds as Group L. Serial regional wall motion severity at the infarct site was computed postprocedure and at follow-up using a quantitative left ventricular analysis system. Impaired myocardial salvage was defined as severity recovery ratio < 20%. Significantly shorter onset-to-balloon time (196.9 vs. 279.0 min, p = 0.033) and relatively lower postprocedural wall motion severity (2.4 vs. 2.9, p = 0.096) were observed in Group H, but absolute severity recovery was significantly smaller in Group H (0.5 vs. 1.3, p = 0.017). Multivariate analysis showed higher MAGE as predictive of impaired myocardial salvage (OR, 406.10; 95% CI, 4.41-37,366.60; p = 0.009). Recovery of reginal wall motion severity at the infarct site was compromised in STEMI patients with higher MAGE. Our results suggest that final infarct size is potentially larger than expected in STEMI patients with higher GV.

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.

CVIT expert consensus document on primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) in 2018.

While primary percutaneous coronary intervention (PCI) has significantly contributed to improve the mortality in patients with ST segment elevation myocardial infarction even in cardiogenic shock, primary PCI is a standard of care in most of Japanese institutions. Whereas there are high numbers of available facilities providing primary PCI in Japan, there are no clear guidelines focusing on procedural aspect of the standardized care. Whilst updated guidelines for the management of acute myocardial infarction were recently published by European Society of Cardiology, the following major changes are indicated; (1) radial access and drug-eluting stent over bare metal stent were recommended as Class I indication, and (2) complete revascularization before hospital discharge (either immediate or staged) is now considered as Class IIa recommendation. Although the primary PCI is consistently recommended in recent and previous guidelines, the device lag from Europe, the frequent usage of coronary imaging modalities in Japan, and the difference in available medical therapy or mechanical support may prevent direct application of European guidelines to Japanese population. The Task Force on Primary Percutaneous Coronary Intervention of the Japanese Association of Cardiovascular Intervention and Therapeutics (CVIT) has now proposed the expert consensus document for the management of acute myocardial infarction focusing on procedural aspect of primary PCI.

Significance of Sarcopenia Evaluation in Acute Decompensated Heart Failure.

In patients with chronic heart failure (HF), the clinical importance of sarcopenia has been recognized in relation to disease severity, reduced exercise capacity, and adverse clinical outcome. Nevertheless, its impact on acute decompensated heart failure (ADHF) is still poorly understood. Dual-energy X-ray absorptiometry (DXA) is a technique for quantitatively analyzing muscle mass and the degree of sarcopenia. Fat-free mass index (FFMI) is a noninvasive and easily applicable marker of muscle mass.This was a prospective observational cohort study comprising 38 consecutive patients hospitalized for ADHF. Sarcopenia, derived from DXA, was defined as a skeletal muscle mass index (SMI) two standard deviations below the mean for healthy young subjects. FFMI (kg/m2) was calculated as 7.38 + 0.02908 × urinary creatinine (mg/day) divided by the square of height (m2).Sarcopenia was present in 52.6% of study patients. B-type natriuretic peptide (BNP) levels were significantly higher in ADHF patients with sarcopenia than in those without sarcopenia (1666 versus 429 pg/mL, P < 0.0001). Receiver operator curves were used to compare the predictive accuracy of SMI and FFMI for higher BNP levels. Areas under the curve for SMI and FFMI were 0.743 and 0.717, respectively. Multiple logistic regression analysis showed sarcopenia as a predictor of higher BNP level (OR = 18.4; 95% CI, 1.86-181.27; P = 0.013).Sarcopenia is associated with increased disease severity in ADHF. SMI based on DXA is potentially superior to FFMI in terms of predicting the degree of severity, but FFMI is also associated with ADHF severity.

Impact of Institutional and Operator Volume on Short-Term Outcomes of Percutaneous Coronary Intervention: A Report From the Japanese Nationwide Registry.

OBJECTIVES: The aim of this study was to assess the volume-outcome relationship for PCI within the nationwide registration system in Japan. BACKGROUND: The effect of site and operator case load for percutaneous coronary intervention (PCI) on outcomes has not been investigated thoroughly in non-Western regions. METHODS: In the present study, PCI procedural data recorded between January 2014 and December 2015 in the Japanese PCI registry, a nationwide registration system, were analyzed. Institutions and operators were categorized into deciles based on the number of PCIs performed per year. Odds ratios (ORs) for in-hospital mortality and the composite endpoint (in-hospital death and periprocedural complications) were estimated for each decile (with the lowest volume group as a reference group). RESULTS: A total of 323,322 PCIs (at 625 hospitals [median PCI cases/year: 216; quartiles: 121 to 332] by 4,211 operators [median PCI cases/year: 28; quartiles: 10 to 56]) were analyzed, of which 2,959 patients (0.9%) and 7,205 patients (2.2%) experienced in-hospital mortality and the composite endpoint after PCI, respectively. The adjusted risk for in-hospital mortality and the composite endpoint was significantly higher in hospitals included in the lowest decile (<150 PCIs/year); the risk remained consistently low across the remaining deciles. Contrastingly, no significant volume-outcome relationship was observed between operator volume and outcomes. A similar trend was observed when the analysis was confined to emergency/urgent PCI cases. CONCLUSIONS: In contemporary Japanese PCI practice, lower institutional volume was related inversely to in-hospital outcomes, but the association of annual operator volume with outcomes was less clear.

Relationship Between Glucose Fluctuations and ST-Segment Resolution in Patients With ST-Elevation Acute Myocardial Infarction.

This study was conducted to assess whether any relationships exist between glucose fluctuations and electrocardiographic surrogate markers of reperfusion injury in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI).We prospectively studied 63 consecutive patients with STEMI undergoing primary PCI. Patients had either diabetes (n = 30), impaired glucose tolerance (n = 26), impaired fasting glucose (n = 1), or normal glucose tolerance (n = 6). STsegment resolution (STR, %) was measured using electrocardiograms recorded 60 minutes after PCI. STR was categorized as ≥ 30% and < 30%. Glucose fluctuations were assessed by the following parameters obtained from a continuous glucose monitoring system: mean amplitude of glucose excursion (MAGE, mg/dL); and area under curve with reference to mean blood glucose (AUCMBG, mg/ dL/day).Both MAGE and AUCMBG were significantly higher in STR < 30%. In univariate analysis, MAGE ≥ 70 mg/dL (OR = 17.0; 95%CI, 1.93-150.12; P < 0.01), AUCMBG ≥ 20 mg/dL/day (OR = 10.9; 95%CI, 1.92-61.77; P < 0.01), and reperfusion arrhythmias (OR = 7.6; 95%CI, 1.32-44.29; P < 0.05) were significantly associated with suboptimal STR. Multiple logistic regression analysis showed only MAGE ≥ 70 mg/dL was predictive of suboptimal STR (OR = 22.5; 95%CI, 2.43-208.66, P < 0.01).Parameters of glucose fluctuations correlated with electrocardiographic surrogate markers of impaired myocardial salvage in STEMI after reperfusion therapy. Our results suggest that glucose fluctuations may represent a potential therapeutic target to reduce myocardial reperfusion injury in STEMI.

Right coronary artery stenosis associated with tricuspid valve ring annuloplasty.

A 70-year-old man with severe symptomatic functional mitral valve regurgitation underwent successful mitral valve repair combined with tricuspid valve ring annuloplasty. Pre-operative coronary angiography (CAG) showed no significant stenosis. One-and-a-half years later, the patient presented with an acute exacerbation of heart failure. Repeat CAG demonstrated tight stenosis in the right coronary artery (RCA) with arterial kinking that corresponded to the same point as the stenosis where the RCA is the closest to the tricuspid valve ring. The new lesion probably occurred as a consequence of the tricuspid valve ring annuloplasty.

Manifestation of Latent Left Ventricular Outflow Tract Obstruction in the Acute Phase of Takotsubo Cardiomyopathy.

Objective Left ventricular outflow tract (LVOT) obstruction is a complication in 15-25% of patients with Takotsubo cardiomyopathy and sometimes leads to catastrophic outcomes, such as cardiogenic shock or cardiac rupture. However, the underlying mechanisms have not been clarified. Methods and Results We experienced 22 cases of Takotsubo cardiomyopathy during 3 years, and 4 of these 22 cases were complicated with LVOT obstruction in the acute phase (mean age 79±5 years, 1 man, 21 women). The LVOT pressure gradient in the acute phase was 100±17 mmHg. Transthoracic echocardiogram (TTE) revealed left ventricular hypertrophy (LVH) in one case and sigmoid-shaped septum without LVH in three cases. The complete resolution of the LVOT obstruction was achieved in a few days with normalization of the left ventricular wall motion following administration of beta-blockers. A dobutamine provocation test after normalization of the left ventricular wall motion reproduced the LVOT obstruction in all cases and revealed the presence of latent LVOT obstruction. Conclusion The manifestation of latent LVOT obstruction in the acute phase of Takotsubo cardiomyopathy is one potential reason for the complication of LVOT obstruction with Takotsubo cardiomyopathy.

Efficacy of multidetector computed tomography for diagnosis of unroofed coronary sinus.

The patient was a 62-year-old woman with a chest X-ray abnormality. Transthoracic echocardiography (TTE) showed a dilated right ventricle and right atrium and an enlarged coronary sinus (CS), but definite diagnosis was not possible. Using contrast-enhanced 64-slice multidetector computed tomography (MDCT), curved planar reconstruction along the CS showed a direct connection of the left atrium and CS, in addition to the CS to right atrium connection. Unroofed CS is a rare congenital cardiac anomaly that is difficult to diagnose with TTE alone. Our case indicates that MDCT is useful for determining structural information that cannot be obtained from TTE. .

Historical changes in the ecosystem condition of a small mountain lake over the past 60 years as revealed by plankton remains and Daphnia ephippial carapaces stored in lake sediments.

To examine if changes in species composition of a plankton community in the past due to anthropogenic activities can be clarified in lakes without any monitoring data, we analyzed genetically ephippial carapaces of Daphnia with plankton remains stored in the bottom sediments of Lake Hataya Ohunma in Japan. In the lake, abundance of most plankton remains in the sediments was limited and TP flux was at low levels (2-4 mg/m2/y) before 1970. However TP flux increased two-fold during the period from 1980s to 1990 s. In parallel with this increase, abundance of most plankton remains increased although abundance of benthic testate amoebae's remains decreased, indicating that the lake trophic condition had changed from oligo- to mesotrophic for the past 60 years. According to cluster analysis, the stratigraphic sediments were divided into two periods with different features of the phytoplankton composition. Chronological comparison with events in the watershed suggested that eutrophication occurred because of an increase in visitors to the watershed and deposition of atmospheric dust. In this lake more than 50% of resting eggs produced by Daphnia over the past 60 years hatched. However, genetic analysis of the ephippial carapaces (remains) showed that the Daphnia population was originally composed of D. dentifera but that D. galeata, or its hybrid with D. dentifera, invaded and increased the population density when the lake was eutrophied. Subsequently, large D. pulex established populations in the 1980s when largemouth bass were anonymously introduced. These results indicated that the Lake Hataya Ohunma plankton community underwent significant changes despite the fact that there were no notable changes in land cover or land use in the watershed. Since increases in atmospheric deposition and release of fish have occurred in many Japanese lakes, the changes in the plankton community described here may be widespread in these lakes.

Manifestation of latent left ventricular outflow tract obstruction caused by acute myocardial infarction: An important complication of acute myocardial infarction.

BACKGROUND: Although transient left ventricular outflow tract (LVOT) obstruction is reported as a complication with acute myocardial infarction (AMI), the mechanisms and features of LVOT obstruction in AMI are unclear. METHODS AND RESULTS: Herein, we present two cases of transient LVOT obstruction with anteroseptal AMI. The features of these two cases were one-vessel disease (1-VD) of the left anterior descending artery (LAD) and maintenance of blood flow to the major septal branch (SB). Moreover, LVOT obstruction was revealed after dobutamine infusion in the chronic phase and the aorto-septal angle was low in these two cases, meaning that latent LVOT obstruction was due to sigmoid-shaped septum. CONCLUSIONS: Latent LVOT obstruction would be manifested in the acute phase of AMI. 1-VD of LAD and the maintenance of major SB blood flow are important factors with respect to the manifestation of latent LVOT obstruction.