Anomalous Right Coronary Artery Arising from the Left Sinus of Valsalva in a Young Athlete.

Cardiac events associated with congenital coronary abnormalities are rare but potentially life-threatening in a young population. Most of these patients are not diagnosed before their initial cardiac event. Amongst such coronary artery anomalies, sudden death is frequently seen in an anomalous origination of a coronary artery from the opposite sinus. We herein present the case of a patient who presented with sudden cardiac arrest associated with an anomalous right coronary artery originating from the left sinus of Valsalva. Surgical treatment was selected because there was evidence of reversible ischemia based on the findings of a stress test.

Intracoronary followed by intravenous administration of the short-acting ß-blocker landiolol prevents myocardial injury in the face of elective percutaneous coronary intervention.

BACKGROUND: Myocardial injury during elective percutaneous coronary intervention (PCI) is associated with higher subsequent cardiac events and mortality. ß-Blockers have been used to reduce myocardial injury during ischemia and reperfusion. We investigated whether intracoronary followed by intravenous administration of the short-acting ß-blocker landiolol prevents myocardial injury in the face of elective PCI. METHODS AND RESULTS: Patients undergoing elective PCI (n=70) were randomly assigned to the landiolol (n=35) or control (n=35) group. Landiolol or saline was administered into target vessels through a balloon catheter for 1min before and after first balloon inflation followed by continuous intravenous administration for 6h after PCI. The incidence of myocardial injury defined by cardiac troponin-I (cTnI) >/=0.05 ng/ml was 79% of the patients in the control group compared to 56% in the landiolol group (p=0.04). The cTnI level at 24h after PCI tended to be lower in the landiolol group (0.57 ± 1.14 versus 1.27 ± 2.48 ng/ml; p=0.07), while the CK-MB level was not significantly different between the landiolol and control groups. The incidence of peri-procedural myocardial infarction defined by cTnI >/=0.12 ng/ml was significantly (p=0.02) lower in the landiolol group (41%) compared to the control group (70%). There was no incidence of coronary spasm, hypotension, bradycardia or heart failure during and after PCI in the two groups. CONCLUSIONS: Brief intracoronary followed by continuous intravenous administration of landiolol is safe and effective for myocardial protection in the face of elective PCI.

Prognostic value of normal stress-only technetium-99m myocardial perfusion imaging protocol. Comparison with standard stress-rest protocol.

BACKGROUND: Patients with a normal stress image on technetium-99m (Tc-99m) single-photon emission computed tomography (SPECT) have a good prognosis for diagnosing coronary artery disease. However, current guidelines recommend stress and rest imaging to confirm that a stress image is normal. METHODS AND RESULTS: We determined all-cause of cardiac events (acute coronary syndrome and sudden death) in 1,939 patients undergoing stress myocardial perfusion SPECT with Tc-99m radiotracers. Patients with an abnormal stress image were excluded, so we focused on 1,125 patients in whom the stress SPECT study was interpreted as normal. A stress-only protocol was used in 726 patients (adenosine=339; exercise=387), whereas 399 had both stress and rest imaging (adenosine=294; exercise=105). Mean follow-up was 1,252 days. At the end of follow-up, there were 39 cardiac events in the stress-only cohort and 19 in the stress-rest cohort. Kaplan-Meier analysis revealed that there were no differences for the entire cohort of cardiac events not only between the stress-only and stress-rest protocols but also for stressor modality, despite the fact that the stress-rest cohort showed higher coronary risk factors. CONCLUSIONS: Patients determined as having a normal SPECT on the basis of stress imaging alone have a similar cardiac event rate as those who have a normal SPECT on the basis of evaluation of both stress and rest images. This imaging strategy will significantly reduce radiation exposure in a substantial number of patients.

Atypical morphology and myocardial perfusion of mid-ventricular ballooning: A case report.

Although some atypical types of transient left ventricular apical ballooning syndrome have been reported, only a few atypical types of transient mid-ventricular ballooning have been reported. A 70-year-old female underwent surgery for urothelial carcinoma. At day 5 after the surgery, she was admitted to our department without cardiac symptoms because of ST elevation in leads I, II, III, aVF and V1-V6 indicating acute coronary syndrome. She was diagnosed with stress induced cardiomyopathy based on an angiographically normal coronary artery, newly developed extensive wall motion abnormality (hyperbasal contraction and akinesis from the mid-left ventricle to the apex without hypercontraction of the small area adjacent to the apex) based on left ventriculography, and a small elevation of myocardial enzymes incongruous with the area of contraction abnormality. Myocardial scintigraphy with 99mTc-tetrofosmin showed a severely reduced myocardial perfusion in an extensive mid-ventricular area without a left ventricular base and top of apex, in accord with a wall motion abnormality different from typical apical ballooning or typical mid-ventricular ballooning previously diagnosed in our hospital. This is the first report presenting an atypical mid-ventricular ballooning based on the myocardial atypical perfusion findings.

Direct correlation between regional systolic function and regional washout rate of 99mTc-sestamibi in patients with idiopathic dilated cardiomyopathy.

OBJECTIVE: Although a higher washout of 99mTc-sestamibi (MIBI) from the ischemic myocardium was reported, little is known about it in idiopathic, nonischemic dilated cardiomyopathy (DCM). Using a quantitative electrocardiographic-gated single-photon emission computed tomography strategy, regional myocardial function may be obtained in conjunction with regional tracer perfusion. The aim of this study was to investigate the significance of regional washout of MIBI compared with regional systolic function in patients with DCM. METHODS: Rest quantitative electrocardiographic-gated single-photon emission computed tomography was performed in 20 patients with DCM who had no significant coronary stenosis on coronary angiogram and in five normal volunteers. single-photon emission computed tomography imaging was observed at 30 min and 4 h after 740 MBq of MIBI injection, and the regional washout rate (WR) was calculated using a 20-segment model. RESULTS: The mean global ejection fraction was 28.2 ± 12.4% and the mean end-diastolic volume was 177 ± 78 ml. The myocardial segments were divided into three groups on the basis of the mean WR of normal volunteers: group A (n=164): WR ≥ 25.4% (=mean+SD); group B (n=138): 19.6% ≤ WR < 25.4%; group C (n=98): WR<19.6% (=mean-SD). The regional wall thickening of group A segments was significantly less than that of the other groups (11.6 ± 0.7 vs. 14.0 ± 0.9 and 14.9 ± 0.7%, respectively, P<0.05). The global left ventricular ejection fraction showed significant negative correlation to the extent of group A segments per patient (R=-0.65, P<0.005), indicating that higher washout was the result of decreased systolic function in DCM hearts. CONCLUSION: Regional higher WR of MIBI may indicate a significant marker for myocardial damage in asymptomatic to mildly symptomatic patients with DCM.

Efficacy of intracoronary administration of a short-acting ß-blocker landiolol during reperfusion in pigs.

BACKGROUND: Although ß-blockers are used to prevent myocardial ischemia/reperfusion injury, the risk of heart failure has limited ß-blocker therapy in patients with acute myocardial infarction. This study evaluated efficacy of intracoronary administration of the short-acting ß-blocker, landiolol, during reperfusion in pigs with acute myocardial ischemia. METHODS AND RESULTS: In the non-ischemic model landiolol administered into the left anterior descending coronary artery (LAD) inhibited in a dose-dependent fashion segmental wall thickening (SWT) in the anterior LV wall without altering SWT in the posterior LV wall and without prolonged depression of global LV function except for the highest dose. In the ischemic model with 60 min LAD occlusion followed by reperfusion the medium dose landiolol administered into the LAD 1 min before and for 10 min during reperfusion inhibited initial recovery of SWT in the anterior LV wall but improved SWT in this region and global LV function late after reperfusion. Ultrastructural studies showed inhibition of sub-sarcolemmal bleb formation by treatment with landiolol 10 min after reperfusion associated with the inhibition of CK-MB release and the reduction of infarct size. There was no significant difference in CK-MB release and infarct size between landiolol treatment for 10 min and 180 min during reperfusion. CONCLUSIONS: Selective and brief intracoronary administration of landiolol during reperfusion enhances myocardial salvage without causing deterioration of global LV function.

Retrograde fast pathway ablation with the EnSite NavX mapping system for slow-fast atrioventricular node reentrant tachycardia and a prolonged PR interval during sinus rhythm.

An 84-year-old male had experienced palpitations. He was transported to our hospital for treatment of palpitations. A 12-lead electrocardiogram (ECG) showed regular tachycardia with a wide QRS complex of 153 bpm, and the P wave was not clear. The ECG after the tachycardia stopped showed a sinus rhythm, and there was a prolonged PR interval of 312 ms and complete right bundle branch block. We recorded a prolonged AH interval (235 ms) in electrophysiology study (EPS). As for the St-A interval (185 ms) by consecutive pacing from the right ventricular apex, it was short in comparison with the anterograde conduction. As a result of detailed EPS, we diagnosed the tachycardia as slow-fast atrioventricular nodal reentrant tachycardia. The anterograde conduction depended on the slow pathway (SP), and the fast pathway (FP) was considered to have only retrograde conduction. It was thought that a complete atrioventricular block been caused by the SP ablation. Therefore we carried out FP ablation with three-dimensional computed tomography and the EnSite NavX mapping system (St. Jude Medical, St Paul, MN, USA), which was superior in space resolution power, and were able to effect a radical cure without complications.

Percutaneous coronary intervention for left main trunk ostial stenosis in a patient with Takayasu's arteritis.

Takayasu's arteritis with coronary artery involvement is a rare event especially in men. We will report on a male case of Takayasu's arteritis undergoing stent implantation for left main trunk (LMT) ostial stenosis. The case was that of a 25-year-old man who had been diagnosed with Takayasu's arteritis but there was no significant large vessel involvement. He presented with effort angina and a multidetector computed tomography (MDCT) revealed severe ostial stenosis in the LMT. A coronary angiography confirmed this finding and a virtual histology intravascular ultrasound (VH-IVUS) showed fibrous thickening of the intima and media with little necrotic lipid core and calcification. We performed a bare metal stent implantation for this lesion. No restenosis was found in the MDCT at the 6 month follow-up. Our experience suggests that the VH-IVUS is useful for examining the gross structure and component of the coronary vascular wall and for determining the choice of treatment in patients with Takayasu's arteritis.

Clinical significance of ischemic electrocardiographic changes during stress myocardial perfusion imaging: sub-analysis of the J-ACCESS study.

OBJECTIVES: The cardiac event rate among the countries varies according to ethnicity. Some reports have identified that ischemic heart disease often occurs at a low incidence and is often milder in Japan compared to other countries. Therefore, the present study was designed to determine the clinical significance and prediction for cardiac events in patients who showed ischemic ECG changes during stress myocardial perfusion SPECT. METHODS: Among 4,670 registered patients for Japanese-assessment of cardiac event and survival (J-ACCESS) study, patients with conduction abnormality on baseline were excluded and revascularization within 60 days of SPECT study were censored from the prognostic portion of analysis. Stress and rest myocardial perfusion SPECT imaging with (99m)Tc-tetrofosmin were performed and occurrence and nature of cardiac events were investigated at 1, 2 and 3 years after registration. Both PCI and CABG, as well as recurrent angina and non-severe heart failure were classified as soft events. Cardiac death, non-fatal MI and heart failure requiring hospitalization were classified as major cardiac events, and hard events comprised cardiac death and non-fatal MI. RESULTS: A total of 3,125 patients performed exercise (n = 2,383) or vasodilator (n = 742) stress MPI and significant ischemic ECG changes were obtained in 538 during exercise and 35 during vasodilator stress. Kaplan-Meier analysis revealed that the patients with both ischemic ECG changes and reversible perfusion defect on MPI had significantly higher incidence for major cardiac events, such as cardiac death, non-fatal MI and severe heart failure (P = 0.0038), and for cardiac hard events, such as cardiac death and non-fatal MI (P = 0.0028), in exercise stress. Interestingly, patients without reversible perfusion defect showed significantly fewer events despite presence of ischemic ECG changes. CONCLUSIONS: Ischemic ECG changes during exercise stress are well associated with higher incidence of cardiac events in patients demonstrated reversible perfusion defect on MPI.

Non-invasive detection of ischemic left ventricular dysfunction using rest gated SPECT: expectation of simultaneous evaluation of both myocardial perfusion and wall motion abnormality.

OBJECTIVE: Although the accurate detection of ischemic etiology is important in the management of patients with severe left ventricular (LV) dysfunction, it is difficult to determine using a non-invasive strategy. The present study investigates whether perfusion and regional functional abnormalities identified by quantitative electrocardiographic gated single-photon emission computed tomography (QGS) at rest can detect ischemic LV dysfunction in patients with severe LV dysfunction. METHODS: Rest QGS with (99m)Tc-tetrofosmin was performed on 54 consecutive patients with LV ejection fraction of

Three-dimensional echocardiographic assessment of left ventricular function in takotsubo cardiomyopathy.

We evaluated left ventricular (LV) function by three-dimensional echocardiography (3DE) in a patient with takotsubo cardiomyopathy (TC). An 82-year-old man was admitted to our hospital with a suspicion of acute myocardial infarction but was diagnosed as TC by coronary angiography and left ventriculography (LVG). Three-dimensional echocardiography showed circular asynergy from the midventricle to the apex associated with hyperkinesis of the base and volumetric data very close to those obtained by LVG. Thus, 3DE is a useful tool in evaluating regional wall motion abnormalities and LV volume in patients with TC.

'Takotsubo' cardiomyopathy in a maintenance hemodialysis patient.

An 84-year-old woman undergoing maintenance hemodialysis presented with chest discomfort lasting several days and electrocardiographic abnormalities. She had stopped smoking 2 weeks earlier and was experiencing irritability. Upon admission, electrocardiography showed ST-segment elevation in leads I, II, aVF, and V2-6 and an abnormal Q wave in leads II, III, and aVF. Ultrasound cardiography showed left ventricular anteroapical akinesia and basal hyperkinesia. The chest discomfort disappeared without specific therapy. During hospital days 1-5, the ST-segment elevation gradually improved. Giant negative T waves then developed. The left ventricular asynergy resolved by day 8. Radionuclide imaging with iodine-123-beta-methyl-p-iodophenyl pentadecanoic acid, but not with technetium-99 m-sestamibi, showed an apical defect. Elective coronary angiography showed no stenosis. 'Takotsubo' cardiomyopathy was diagnosed. After discharge, the patient continued regular dialysis without cardiac symptoms. We concluded that endogenously activated sympathetic nerve action in hemodialysis patients, especially those under emotional or physical stress, might be a causative factor for Takotsubo cardiomyopathy.

Scintigraphic prediction of left ventricular functional recovery early after primary coronary angioplasty using single-injection quantitative electrocardiographic gated SPECT.

OBJECTIVE: The clinical usefulness of characterizing reperfused myocardium by perfusion/thickening assessment using electrocardiographic gated single photon emission computed tomography (SPECT) has not been investigated. We evaluated whether single-injection gated SPECT with 99mTc tetrofosmin early after primary percutaneous coronary intervention (PCI) can predict left ventricular (LV) functional recovery. METHODS: Gated SPECT was performed 3 days after primary PCI in 45 patients with acute myocardial infarction and revascularized segments were classified into perfusion/thickening mismatched segments, matched normal and matched abnormal segments. Gated SPECT was repeated 3 months later to evaluate the changes in LV ejection fraction (deltaLVEF). RESULTS: Among 332 revascularized segments, there were 83 mismatched segments, 163 matched abnormal segments and 86 matched normal segments. In all the patients, LVEF increased significantly from 3 days to 3 months after primary PCI (52+/-13 to 57+/-14%, P<0.0001). Patients were divided into two groups according to deltaLVEF: 24 patients with LV functional recovery (deltaLVEF > or = 5%) and 21 patients without LV functional recovery. The number of mismatched segments in patients with LV functional recovery was significantly greater than that in patients without (2.7+/-1.7 vs. 0.8+/-1.4, P<0.0003) despite no differences in the number of matched abnormal and matched normal segments. There was a significant correlation between deltaLVEF and the number of mismatched segments (r=0.56, P<0.0001) and LVEF at 3 months after primary PCI was related to the number of matched abnormal segments (r=-0.78, P<0.0001). CONCLUSION: Single-injection gated SPECT early after primary PCI can predict LV functional recovery.