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Acute purulent pericarditis is a rare infection in developed countries. We herein report a case with diabetic nephropathy under maintenance hemodialysis who suffered from acute purulent pericarditis caused by methicillin-resistant Staphylococcus aureus (MRSA). The treatment of purulent pericarditis mainly involves rapid administration of appropriate antibiotics and drainage. However, in this case, the patient was unresponsive to vancomycin and performing early surgical intervention was challenging due to highly pathogenic MRSA. Therefore, we performed pericardial fenestration in the chronic phase to suppress the risk of fatal secondary infections after daily irrigation for one month to reduce bacterial load mechanically. Learning objective: In a case of purulent pericarditis caused by highly pathogenic methicillin-resistant Staphylococcus aureus resistant to antibiotics and resulting in constrictive pericarditis, it was possible to perform pericardial fenestration in the chronic phase, while mitigating the risk of fatal secondary infections, by controlling the inflammation through daily irrigation for a long time to reduce the bacterial load mechanically.
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BACKGROUND: Neuromodulation through spinal cord stimulation (SCS) is a therapeutic option for relieving leg pain and improving the chances of limb salvage in patients with intractable chronic limb-threatening ischemia (CLTI); however, there is no consensus on its indications. OBJECTIVE: The aim of this study was to assess the clinical outcomes of SCS in patients with intractable leg pain caused by various diseases treated in the department of cardiovascular medicine in Japan. METHODS: This was a retrospective study of patients who underwent SCS for pain management. Patients were considered eligible for the therapy if they met the following criteria: (1) intractable leg pain (numerical rating scale [NRS] score of 10), (2) no revascularization option, and (3) no septicemia. RESULTS: Twenty patients (mean age: 77 years; men/women: 11/9) were included in this study. The NRS score of the patients significantly reduced from 10 ± 0 before procedure to 4 ± 3 at discharge (p < 0.001). The clinical response rate of the entire cohort was 65% (13/20) at 17 ± 14 months after implantation; however, patients with intractable CLTI showed a low response rate (45%), whereas those with subacute limb ischemia showed a high response rate (100%). A multivariable regression analysis showed that hemoglobin level was significantly associated with treatment response, even after adjusting for age and sex (p = 0.026). The area under the receiver operating characteristic curve for the correlation between hemoglobin level (cutoff, 11.4 g/dL) and clinical response to SCS was 0.824 (0.619-1). CONCLUSIONS: SCS can reduce clinical symptoms in majority of patients with intractable leg pain. Although implantation of an SCS device has been shown to improve microvascular perfusion insufficiency, the correlation between hemoglobin level and the clinical effect of SCS indicates that a preserved microcirculatory vascular bed is essential for the therapy to be effective.
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Pierna , Dolor Intratable , Estimulación de la Médula Espinal , Humanos , Femenino , Masculino , Estimulación de la Médula Espinal/métodos , Anciano , Estudios Retrospectivos , Japón , Resultado del Tratamiento , Anciano de 80 o más Años , Dolor Intratable/terapia , Persona de Mediana Edad , Manejo del Dolor/métodos , Dimensión del Dolor/métodosRESUMEN
OBJECTIVE: We aim to clarify the differences in the association between re-admission for heart failure (HF) and left atrial (LA) overload indices by sex in heart failure and a preserved ejection fraction (HFpEF). METHODS: We analyzed 898 HFpEF patients hospitalized for acute decompensated HF. Blood tests and transthoracic echocardiography were performed before discharge. The primary endpoint was re-admission for HF during the first year. RESULTS: The ratio of diastolic elastance to arterial elastance (p = 0.014), a relative index of LA pressure overload, in men and LA volume index (LAVI, p = 0.020) in women were significant for re-admission for HF during the first year in the multivariable Fine-Gray analysis. Stroke volume (SV)/LA volume (LAV), another index for LAV overload, was not a significant prognostic factor of re-admission for HF during this time. CONCLUSION: LA overload was an important prognostic factor for HF re-readmission during the first year after enrolment in patients with HFpEF, but the indices relating to LA overload differed by sex.
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OBJECTIVES: The prognostic significance of an afterload-integrated diastolic index, the ratio of diastolic elastance (Ed) to arterial elastance (Ea) (Ed/Ea=[E/e']/[0.9×systolic blood pressure]), is valid for 1 year after discharge in older patients with heart failure with preserved ejection fraction (HFpEF). We aimed to clarify the association with changes in Ed/Ea from enrolment to 1 year and prognosis thereafter in patients with HFpEF. SETTING: A prospective, multicentre observational registry of collaborating hospitals in Osaka, Japan. PARTICIPANTS: We enrolled 659 patients with HFpEF hospitalised for acute decompensated heart failure (men/women: 296/363). Blood tests and transthoracic echocardiography were performed before discharge and at 1 year after. PRIMARY OUTCOME MEASURES: All-cause mortality and/or re-admission for heart failure were evaluated after discharge. RESULTS: High Ed/Ea assessed before discharge was a significant prognostic factor during the first, but not the second, year after discharge in all-cause mortality or all-cause mortality and/or re-admission for heart failure. When re-analysis was performed using the value of Ed/Ea at 1 year after discharge, high Ed/Ea was significant for the prognosis during the second year for both end points (p=0.012 and p=0.033, respectively). The poorest mortality during 1â2 years after enrolment was observed in those who showed a worsening Ed/Ea during the first year associated with larger left ventricular mass index and reduced left ventricular ejection fraction. In all-cause mortality and/or re-admission for heart failure, the event rate during 1â2 years was highest in those with persistently high Ed/Ea even after 1 year. CONCLUSIONS: Time-sensitive prognostic performance of Ed/Ea, an afterload-integrated diastolic index, was observed in older patients with HFpEF. TRIAL REGISTRATION NUMBER: UMIN000021831.
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Insuficiencia Cardíaca , Anciano , Femenino , Insuficiencia Cardíaca/complicaciones , Insuficiencia Cardíaca/diagnóstico por imagen , Ventrículos Cardíacos , Humanos , Masculino , Pronóstico , Estudios Prospectivos , Volumen Sistólico/fisiología , Función Ventricular Izquierda/fisiologíaRESUMEN
OBJECTS: We aimed to clarify the differences in the of the ratio of diastolic elastance (Ed) to arterial elastance (Ea), [Ed/Ea=(E/e')/(0.9×systolic blood pressure)], anafterload-integrateddiastolic index that reflects left atrial pressure overload, on prognosis between patients with heart failure with preserved ejection fraction (HFpEF) with and without atrial fibrillation (AF). METHODS: We studied 552 HFpEF patients hospitalized for acute decompensated heart failure (sinus rhythm/AF:352/200).Blood testing and transthoracic echocardiography were performed before discharge. Primary endpoint was all-cause mortality after discharge. RESULTS: During a median follow-up of 508 days, 88 patients (sinus rhythm/AF: 54/34) had all-cause mortality. In the subgroup with sinus rhythm, but not AF, Ed/Ea was significantly higher in patients with than without all-cause mortality. In a multivariate Cox hazard analysis, Ed/Ea was significantly associated with all-cause mortality independent of N-terminal pro-brain natriuretic peptide level in patients with sinus rhythm, but not with AF. CONCLUSIONS: Ed/Ea providedlesser important information for predicting all-cause mortality in HFpEF patients with AF than with sinus rhythm. The prognostic risk factors may differ between elderly HFpEF patients with and without AF.
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BACKGROUND: Atrial fibrillation (AF) may cause cerebral and systemic embolism. An increased D-dimer level indicates hyperactivation of secondary fibrinolysis, resulting in predilection for thrombosis. To clarify the differential effects of anticoagulation therapy, we compared the D-dimer levels in peripheral and left atrial (LA) blood of atrial fibrillation patients scheduled for ablation. METHODS: We analyzed 141 patients with non-valvular AF (dabigatran, n = 30; apixaban, n = 47; edoxaban, n = 64; mean age: 68 years, male: 60%). Peripheral venous blood and LA blood was collected before pulmonary vein isolation. We examined the laboratory and echocardiographic parameters. RESULTS: After adjusting for baseline characteristics, D-dimer level in the LA was significantly higher in patients treated with edoxaban than that in those on apixaban (0.77 ± 0.05 vs. 0.60 ± 0.05 µg/mL, P = 0.047), although there were no significant differences in peripheral D-dimer levels. We classified the D-dimer value of the LA into a normal group (< 0.9) and a high value group (≥ 1.0); the peripheral prothrombin fragment F1 + 2 level (odds ratio [OR] 1.012; 95% confidence interval [CI]: 1.003-1.022; P = 0.008) and left ventricular ejection fraction (LVEF) (OR, 0.947; 95% CI, 0.910-0.986; P = 0.008) were potential predictors of high LA D-dimer levels. CONCLUSIONS: In apixaban-treated patients, the D-dimer level in the left atrium was lower than in edoxaban-treated patients on the day of ablation, suggesting that the anticoagulant effect of apixaban on the left atrium is better than that of edoxaban in patients with AF.
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Antitrombinas/administración & dosificación , Fibrilación Atrial/tratamiento farmacológico , Dabigatrán/administración & dosificación , Inhibidores del Factor Xa/administración & dosificación , Productos de Degradación de Fibrina-Fibrinógeno/metabolismo , Pirazoles/administración & dosificación , Piridinas/administración & dosificación , Piridonas/administración & dosificación , Tiazoles/administración & dosificación , Administración Oral , Anciano , Antitrombinas/efectos adversos , Fibrilación Atrial/sangre , Fibrilación Atrial/diagnóstico , Biomarcadores/sangre , Dabigatrán/efectos adversos , Inhibidores del Factor Xa/efectos adversos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Pirazoles/efectos adversos , Piridinas/efectos adversos , Piridonas/efectos adversos , Tiazoles/efectos adversos , Resultado del TratamientoRESUMEN
OBJECTIVES: The severity of diastolic dysfunction is assessed using a combination of several indices of left atrial (LA) volume overload and LA pressure overload. We aimed to clarify which overload is more associated with the prognosis in patients with heart failure and preserved ejection fraction (HFpEF). SETTING: A prospective, multicenter observational registry of collaborating hospitals in Osaka, Japan. PARTICIPANTS: We enrolled hospitalised patients with HFpEF showing sinus rhythm (men, 79; women, 113). Blood tests and transthoracic echocardiography were performed before discharge. The ratio of diastolic elastance (Ed) to arterial elastance (Ea) was used as a relative index of LA pressure overload. PRIMARY OUTCOME MEASURES: All-cause mortality and admission for heart failure were evaluated at >1 year after discharge. RESULTS: In the multivariable Cox regression analysis, Ed/Ea, but not LA volume index, was significantly associated with all-cause mortality or admission for heart failure (HR 2.034, 95% CI 1.059 to 3.907, p=0.032), independent of age, sex, and the serum N-terminal pro-brain natriuretic peptide (NT-proBNP) level. In patients with a higher NT-proBNP level, the effect of higher Ed/Ea on prognosis was prominent (p=0.015). CONCLUSIONS: Ed/Ea, an index of LA pressure overload, was significantly associated with the prognosis in elderly patients with HFpEF showing sinus rhythm. TRIAL REGISTRATION NUMBER: UMIN000021831.
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Insuficiencia Cardíaca , Anciano , Presión Atrial , Biomarcadores , Femenino , Humanos , Masculino , Péptido Natriurético Encefálico , Fragmentos de Péptidos , Pronóstico , Estudios Prospectivos , Volumen Sistólico , Función Ventricular IzquierdaRESUMEN
OBJECTIVE: During follow-up time, the value of prognostic factors may change, especially in the elderly patients, and the altered extent may affect the prognosis. We aimed to clarify the significance of the ratio of diastolic elastance (Ed) to arterial elastance (Ea), (Ed/Ea=(E/e')/(0.9×systolic blood pressure)), an afterload-integrated diastolic index, in relation to follow-up periods and other laboratory factors, on the prognosis of elderly patients with heart failure with preserved ejection fraction (HFpEF). METHODS: We studied 552 HFpEF patients hospitalised for acute decompensated heart failure (men/women: 255/297). Blood testing and transthoracic echocardiography were performed before discharge. The primary endpoint was all-cause mortality. RESULTS: During a median follow-up of 508 days, 88 patients (men/women: 39/49) had all-cause mortality. During the first year after discharge, Ed/Ea (p=0.045) was an independent prognostic factor in association with albumin (p<0.001) and N-terminal pro-brain natriuretic peptide (NT-proBNP, p=0.005) levels after adjusting for age and sex in the multivariate Cox hazard analysis. However, at 1 to 3 years after discharge, no other significant prognostic factors, except for albumin level (p=0.046), were detected. In the subgroup analysis, albumin, but not NT-proBNP level, showed a significant interaction with Ed/Ea for prognosis (p=0.047). CONCLUSION: The prognostic significance of a haemodynamic parameter such as Ed/Ea may be valid only during a short-term period, but that of albumin was persisting during the entire follow-up period in the elderly patients. The clinical significance of prognostic factors in HFpEF patients may differ according to the follow-up period.
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Presión Sanguínea/fisiología , Insuficiencia Cardíaca/fisiopatología , Sistema de Registros , Volumen Sistólico/fisiología , Función Ventricular Izquierda/fisiología , Anciano de 80 o más Años , Diástole , Femenino , Estudios de Seguimiento , Insuficiencia Cardíaca/diagnóstico , Humanos , Masculino , Pronóstico , Estudios Prospectivos , Factores de TiempoRESUMEN
The relationship between alterations in left ventricular (LV) diastolic function and the incidence of recurrence, as well as the associated factors after cryoballoon (CB) and radiofrequency (RF) catheter ablation in patients with paroxysmal atrial fibrillation (Paf), require clarification. We enrolled 138 patients with Paf (RF/CB 69/69) who underwent the first catheter ablation and follow-up for 12 months. Transthoracic echocardiography was performed before and after ablation. An afterload-integrated index of LV diastolic function was calculated as diastolic elastance (Ed)/arterial elastance (Ea), Ed/Ea. No significant increases were observed in Ed/Ea 3 days after RF ablation in patients with (n=12) and without (n=57) recurrence. However, a significant increase was observed in recurrence-free patients with CB ablation (n=59; P<0.05), although this level was restored after 6 months. Ed/Ea 3 days after CB ablation was correlated with left atrial pressure immediately after (r=0.630, P<0.001), but not before (r=0.290, P=0.159), ablation. The increment of creatine kinase- myocardial band release was positively associated with that of Ed/Ea (r=0.388, P<0.05) after CB ablation. Thus, the transient manifestation of LV diastolic dysfunction after CB ablation, evaluated by a new echocardiographic index, was observed only in recurrence-free patients with Paf. Protracted impairment of left atrial compliance due to ablation-induced myocardial injury may be related to the lack of recurrence in patients after CB ablation.
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BACKGROUNDS: Tolvaptan significantly increases urine volume in acute decompensated heart failure (ADHF); serum sodium level increases due to aquaresis in almost all cases. We aimed to elucidate clinical factors associated with hypernatremia in ADHF patients treated with tolvaptan. METHODS: We enrolled 117 ADHF patients treated with tolvaptan in addition to standard therapy. We examined differences in clinical factors at baseline between patients with and without hypernatremia in the initial three days of hospitalization. RESULTS: Systolic (p = 0.045) and diastolic (p = 0.004) blood pressure, serum sodium level (p = 0.002), and negative water balance (p = 0.036) were significantly higher and serum potassium level (p = 0.026) was significantly lower on admission day in patients with hypernatremia (n = 22). In multivariate regression analysis, hypernatremia was associated with low serum potassium level (p = 0.034). Among patients with serum potassium level ≤ 3.8 mEq/L, the cutoff value obtained using receiver operating characteristic curve analysis, those with hypernatremia related to tolvaptan treatment showed significantly higher diastolic blood pressure on admission day (p = 0.004). CONCLUSION: In tolvaptan treatment combined with standard therapy in ADHF patients, serum potassium level ≤ 3.8 mEq/L may be a determinant factor for hypernatremia development. Among hypokalemic patients, those with higher diastolic blood pressure on admission may be carefully managed to prevent hypernatremia.
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Antagonistas de los Receptores de Hormonas Antidiuréticas/efectos adversos , Presión Sanguínea , Insuficiencia Cardíaca/tratamiento farmacológico , Hipernatremia/inducido químicamente , Potasio/sangre , Tolvaptán/efectos adversos , Enfermedad Aguda , Anciano , Anciano de 80 o más Años , Biomarcadores/sangre , Femenino , Insuficiencia Cardíaca/sangre , Insuficiencia Cardíaca/diagnóstico , Insuficiencia Cardíaca/fisiopatología , Hospitalización , Humanos , Hipernatremia/sangre , Hipernatremia/diagnóstico , Hipernatremia/fisiopatología , Masculino , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: Myocardial perfusion single-photon emission computed tomography (SPECT) imaging with stress is a useful examination for detecting coronary artery disease. Since the presence of artifacts is remaining challenges, we aimed to define the minimum intensity of low-grade exercise stress levels combined with drug stress to reduce undesired artifacts and their related factors. METHODS: We divided patients with suspicious coronary artery disease into 4 groups as follows: group A, adenosine triphosphate (ATP) for 6 min; group A + 25 W, ATP + 25 W exercise for 6 min; group A + 35 W, ATP + 35 W exercise for 6 min; group A + 45 W, ATP + 45 W exercise for 6 min) and enrolled only those whose summed stress scores were < 3. Undesired artifacts were evaluated on the basis of heart-to-liver activity (H/L) ratio and heart-to-10 pixels below the heart (H/below the H) ratio. RESULTS: The logarithmic values of H/L and H/below the H ratios were significantly higher in groups A + 35 W and A + 45 W than in group A (p < 0.05, each). In all the patients, the logarithmic values of H/L and H/below the H ratios positively correlated with the increment of rate pressure product (RPP, p = 0.002 and p = 0.005, respectively) after stress in the univariate analysis. The left ventricular end-diastolic volume (LVEDV) after stress (p = 0.002) negatively correlated with the logarithmic value of H/below the H ratio, but not H/L ratio. Although the increment of RPP was independently associated with the logarithmic values of both H/L (p = 0.001) and H/below the H ratios (p = 0.005), LVEDV was also independently associated with the logarithmic value of H/below the H ratio (p < 0.001) in multivariate regression analysis under adjusting with age and sex. CONCLUSION: ATP plus ≥35 W exercise stress for 6 min was useful for reducing undesired artifacts after stress in myocardial perfusion SPECT. LVEDV after stress in addition to the increment of RPP was independently associated with the H/below the H ratio, but not the H/L ratio.
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Adenosina Trifosfato/administración & dosificación , Artefactos , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Prueba de Esfuerzo , Imagen de Perfusión Miocárdica , Tomografía Computarizada por Tomografía Computarizada de Emisión de Fotón Único , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Compuestos Organofosforados/administración & dosificación , Compuestos de Organotecnecio/administración & dosificación , Valor Predictivo de las Pruebas , Radiofármacos/administración & dosificación , Reproducibilidad de los Resultados , Factores de TiempoRESUMEN
Purpose: To identify lower limb 2-dimensional (2D) perfusion angiographic parameters that are related to skin perfusion pressure (SPP), a predictor of wound healing in patients with chronic limb-threatening ischemia (CLTI) undergoing below-the-knee (BTK) endovascular treatment (EVT). Materials and Methods: Thirty-three consecutive patients (mean age 74.5 years; 18 men) with 47 isolated BTK lesions in 33 limbs (Rutherford category 3-5) underwent EVT. Dorsal and plantar SPPs were measured before EVT and the day after. The indexed blood flow below the ankle was measured using 2D perfusion angiography before and after EVT to determine changes in perfusion parameters [arrival time (AT), time to peak, wash-in rate, mean transit time, and width and area under the time-density curve] at rest vs during hyperemia induced with a 20-mg intra-arterial papaverine infusion. Correlations between the 2D perfusion parameters and SPPs were assessed using the Pearson coefficient. The cutoff points to predict mean SPPs >40 mm Hg were analyzed using a receiver operating characteristic curve; outcomes are reported as the area under the curve (AUC) with 95% confidence interval (CI). Results: After EVT at rest and during hyperemia, only AT was significantly changed, although hyperemia produced significant changes in all the pre-/post-EVT 2D perfusion parameters except the wash-in rate. Dorsal and plantar SPPs after EVT were significantly increased and correlated with hyperemic AT and the AT ratio (hyperemia/at rest values) below the ankle. Hyperemic ATs <6.3 seconds and AT ratios <0.78 were predictive factors for a mean SPP >40 mm Hg, with AUCs of 0.83 (95% CI 0.67 to 0.99) and 0.78 (95% CI 0.61 to 0.95), respectively. Conclusion: Hyperemic ATs <6.3 seconds or AT ratios <0.78 below the ankle may be essential to obtain sufficient SPPs for limb salvage in BTK lesions. Thus, the use of 2D perfusion angiography enabled the monitoring of lower limb tissue perfusion throughout EVT and may thereby optimize treatment of CLTI.
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Angiografía de Substracción Digital , Tobillo/irrigación sanguínea , Isquemia/diagnóstico por imagen , Imagen de Perfusión/métodos , Enfermedad Arterial Periférica/diagnóstico por imagen , Piel/irrigación sanguínea , Anciano , Anciano de 80 o más Años , Angioplastia de Balón , Velocidad del Flujo Sanguíneo , Femenino , Humanos , Isquemia/fisiopatología , Isquemia/terapia , Recuperación del Miembro , Masculino , Enfermedad Arterial Periférica/fisiopatología , Enfermedad Arterial Periférica/terapia , Valor Predictivo de las Pruebas , Estudios Prospectivos , Flujo Sanguíneo Regional , Factores de Tiempo , Resultado del Tratamiento , Cicatrización de HeridasRESUMEN
The index for a target that can lead to improved prognoses and more reliable therapy in each heterogeneous patient with heart failure with preserved ejection fraction (HFpEF) remains to be defined. We examined the heterogeneity in the cardiac performance of patients with HFpEF by clarifying the relationship between the indices of left atrial (LA) volume (LAV) overload and pressure overload with echocardiography. We enrolled patients with HFpEF (N = 105) who underwent transthoracic echocardiography during stable sinus rhythm. Relative LAV overload was evaluated using the LAV index or stroke volume (SV)/LAV ratio. Relative LA pressure overload was estimated using E/e' or the afterload-integrated index of left ventricular (LV) diastolic function: diastolic elastance (Ed)/arterial elastance (Ea) ratio = (E/e')/(0.9 × systolic blood pressure). The logarithmic value of the N-terminal pro-brain natriuretic peptide was associated with SV/LAV (r = -0.214, p = 0.033). The pulmonary capillary wedge pressure was positively correlated to Ed/Ea (r = 0.403, p = 0.005). SV/LAV was negatively correlated to Ed/Ea (r = -0.292, p = 0.002), with no observed between-sex differences. The correlations between the LAV index and E/e' and Ed/Ea and between SV/LAV and E/e' were less prominent than the abovementioned relationships. SV/LAV and Ed/Ea, showing relative LAV and LA pressure respectively, were significantly but modestly correlated in patients with HFpEF. There may be considerable scatter in the relationships between these indices, which could possibly affect the selection of medications or efforts to improve the prognoses of patients with HFpEF.
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Atrios Cardíacos/fisiopatología , Insuficiencia Cardíaca/fisiopatología , Volumen Sistólico , Función Ventricular Izquierda , Presión Ventricular , Anciano , Presión Sanguínea , HumanosRESUMEN
Background: In superficial femoral artery (SFA) stenosis, stenosis resistance may increase, but the relationship between stenosis resistance and stenotic severity remains to be seen. This study aimed to investigate the physiological response, through a hyperemic condition, and the pathophysiological significance of Doppler flow and stenosis resistance in SFA. Methods: Twenty-four limbs with focal stenosis of the SFA were analyzed. We assessed the fractional flow reserve (FFR), hyperemic stenosis resistance (h-SR), and vascular flow reserve (VFR) of the SFA with a pressure/Doppler flow sensor-tipped combination guidewire before and after endovascular therapy (EVT). Results: FFR, h-SR, and VFR changed significantly after EVT. h-SR was more strongly correlated with % area stenosis, measured by intravascular ultrasound than FFR (FFR: r=-0.716, h-SR: r=0.741, p<0.0001, respectively). However, VFR was not associated with % area stenosis. A receiver operating characteristic curve showed cut-offs h-SR >0.36 mmHg·sec/cm, and FFR <0.88 predicted >75% area stenosis with area under curves of 0.883 and 0.828, respectively. Conclusion: h-SR can indicate stenotic severity in an SFA focal lesion more prominently than FFR and may be a new physiological index to determine indication for EVT. VFR was not feasible for assessment in SFA focal stenosis.
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An 80-year-old woman presented with general fatigue and leg edema for several months. Ultrasonography and contrast-enhanced computed tomographic angiography revealed inferior vena cava thrombosis, ilio-iliac arteriovenous fistula (AVF), and iliac artery pseudoaneurysm. Furthermore, malignant cells were observed in the aspirated thrombus. Although thrombus aspiration and anticoagulant therapy were unsuccessful in reducing the thrombotic mass and alleviating her symptoms, endovascular therapy for AVF and pseudoaneurysm improved her leg edema without recurrence or any endoleak. These findings highlight that endovascular therapy can be effective in older adults with cancer because of its low invasiveness.
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BACKGROUND: We previously reported that an index of afterload-related left ventricular diastolic function, operant diastolic elastance (Ed)/effective arterial elastance (Ea) = E/e'/(0.9 × systolic blood pressure), was significantly higher in elderly hypertensive women. We aimed to determine sex-related differences in the E/e'-related indices for left ventricular diastolic function and their related factors during admission in patients with heart failure with preserved ejection fraction (HFpEF). HYPOTHESIS: Elderly HFpEF women exhibit severe left ventricular diastolic dysfunction associated with different left atrioventricular volume ratio. METHODS: We divided 267 patients with HFpEF (men/women, 116/151) into two groups by age (≥75 years, n = 212; <75 years, n = 55). We examined the alterations of E/e', E/e'/stroke volume index = Ed, and Ed/Ea, and cardiac structure during admission. RESULTS: Ed and Ea were significantly higher in women than in men, at admission, especially in patients ≥75 years. Before discharge, not only Ed and Ea but also Ed/Ea was significantly higher in women than in men, especially in patients ≥75 years. Elderly female patients had larger left atrial than left ventricular volume. CONCLUSIONS: Higher afterload-related left ventricular diastolic elastance, Ed/Ea, in association with higher arterial elastance, Ea, accompanied by left atrioventricular volume mismatch was observed in elderly HFpEF women.
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Arterias/fisiopatología , Insuficiencia Cardíaca/fisiopatología , Ventrículos Cardíacos/fisiopatología , Admisión del Paciente , Volumen Sistólico/fisiología , Resistencia Vascular/fisiología , Función Ventricular Izquierda/fisiología , Anciano , Anciano de 80 o más Años , Presión Sanguínea , Diástole , Ecocardiografía Doppler , Femenino , Insuficiencia Cardíaca/diagnóstico , Insuficiencia Cardíaca/epidemiología , Ventrículos Cardíacos/diagnóstico por imagen , Humanos , Incidencia , Japón/epidemiología , Masculino , Estudios Prospectivos , Factores SexualesRESUMEN
BACKGROUND: In patients with atrial fibrillation, ablation decreases left atrial (LA) compliance, which may lead to left ventricular (LV) diastolic dysfunction. We aimed to examine serial changes in LV diastolic function after 2 ablation procedures and their related factors in patients with paroxysmal atrial fibrillation (PAF). HYPOTHESIS: LV diastolic function is different after 2 ablation procedures. METHODS: We enrolled 132 patients with PAF (76 males, mean age 67 years; cryoballoon [CB] ablation/radiofrequency [RF] ablation 60/72) who underwent a single ablation procedure. The transthoracic echocardiographic parameters were obtained before, 3 days after, and 6 months after ablation. RESULTS: The afterload-related index of LV diastolic function, Ed/Ea = E/e' / (0.9 × systolic blood pressure), increased significantly at 3 days after ablation, especially after CB ablation (P <0.05), although no differences were observed in age, sex, LA size, LV size, and E/e' before ablation between CB ablation and RF ablation. Creatine kinase release after ablation was significantly higher in CB ablation than in RF ablation (P <0.001). The increment of Ed/Ea after CB ablation was positively correlated with LV ejection fraction (LVEF) before ablation (r =0.416; P <0.05). The elderly (age ≥ 75 years), females, and patients with hypertension were more likely to show impaired LV diastolic function transiently after 3 days of ablation, but the diastolic index was restored to baseline level after 6 months. CONCLUSIONS: The increased Ed/Ea after CB ablation represented transient manifestation of underlying LV diastolic dysfunction in PAF patients with preserved LVEF with older age, female sex, and a history of hypertension.
Asunto(s)
Fibrilación Atrial/cirugía , Ablación por Catéter/efectos adversos , Electrocardiografía , Ventrículos Cardíacos/fisiopatología , Complicaciones Posoperatorias , Taquicardia Paroxística/cirugía , Disfunción Ventricular Izquierda/etiología , Anciano , Fibrilación Atrial/fisiopatología , Diástole , Ecocardiografía , Femenino , Estudios de Seguimiento , Ventrículos Cardíacos/diagnóstico por imagen , Humanos , Masculino , Estudios Retrospectivos , Taquicardia Paroxística/fisiopatología , Disfunción Ventricular Izquierda/diagnóstico , Disfunción Ventricular Izquierda/fisiopatologíaRESUMEN
AIM: Maximal hyperemic response, leading to examination of microvascular resistance in lower-limb lesions is not well understood. This study aimed to investigate the infrainguinal arterial physiological response through a hyperemic condition and the pathophysiological significance of microvascular resistance in peripheral artery disease. METHODS: Sixteen limbs with focal stenosis of the superficial femoral artery (SFA) and 16 control limbs were analyzed. We assessed the fractional flow reserve (FFR), vascular flow reserve (VFR), and hyperemic microvascular resistance (h-MR) of the SFA with a pressure/Doppler flow sensor-tipped combination guidewire before and after endovascular therapy (EVT). Skin perfusion pressure (SPP) on both the dorsal and the plantar sides of the foot was measured at baseline before and after the endovascular procedures. RESULTS: FFR (pï¼0.05) and VFR (pï¼0.05), but not h-MR, improved after EVT. There was no association between h-MR and FFR or VFR before EVT. h-MR was negatively correlated with the dorsal SPP before EVT (r=ï¼0.589, pï¼0.05). h-MR in patients with high h-MR before EVT significantly decreased after EVT (pï¼0.05). Patients with high, but not those with low, h-MR before EVT exhibited a significant increase in dorsal and plantar SPP after EVT (pï¼0.05, each). CONCLUSION: EVT for SFA stenosis improved FFR and VFR comprehensively, with no apparent change in h-MR. However, high h-MR before EVT may play a predictive role for limb perfusion improvement associated with h-MR reduction after EVT.
Asunto(s)
Arteria Femoral/fisiopatología , Hiperemia/fisiopatología , Enfermedad Arterial Periférica/fisiopatología , Resistencia Vascular , Anciano , Velocidad del Flujo Sanguíneo , Estudios de Casos y Controles , Femenino , Estudios de Seguimiento , Humanos , Masculino , PronósticoRESUMEN
In Japan and worldwide, the increase in educational interventions about resuscitation training significantly increases favorable neurological survival in out-of-hospital cardiopulmonary arrest cases treated with bystander cardiopulmonary resuscitation (BCPR) each year. This case with Bland-White-Garland syndrome having high-quality BCPR by nurses demonstrates the importance of education about BCPR.
RESUMEN
Patients with persistent atrial fibrillation (AF) and a large left atrium are at a high risk for thromboembolisms. Recently, direct oral anticoagulants (DOACs) have mainly been used for the prevention of cardiac embolisms caused by AF. Transesophageal echocardiography (TEE) is performed in order to exclude any left atrial appendage (LAA) thrombi. We herein report two cases of persistent AF, both of which were treated with rivaroxaban for more than two years. Since TEE identified mobile LAA thrombi with this treatment, we switched from rivaroxaban to the direct thrombin inhibitor dabigatran. Dabigatran resolved the LAA thrombi that had been refractory to rivaroxaban.