[Successful Surgical Correction of Partial Atrioventricular Septal Defect in an Elderly Patient:Report of a Case].

There are only few reports on surgery for partial atrioventricular septal defect( pAVSD) in patients aged over 70 years. This report is about successful surgical correction of pAVSD in a 79-year-old women. Echocardiography showed left-sided atrioventricular valve regurgitation with cleft and ostium primum atrial septal defect, but without ventricular septal defect. Accordingly, she was diagnosed with pAVSD. Treatment plan included direct cleft closure, patch closure for the ostium primum atrial septal defect, and right atrioventricular annuloplasty. The postoperative course was uneventful. She was followed up without complications for four years. To the best of our knowledge, our patient is the oldest to undergo such surgical techniques in Japan to date.

Comparison of Diagnostic Accuracy between Pulse Volume Recording Parameters and Exercise-Ankle-Brachial Pressure Index in Patients with Ankle-Brachial Pressure Index above 0.9.

Objective: The objective of this study was to clarify whether or not pulse volume recoding (PVR) parameters have screening capability equivalent to ankle-brachial pressure index after walking (Ex-ABI) for patients with 0.91 or higher ABI. Patients and Methods: The subjects were 87 patients (147 limbs) with symptoms of lower extremities with 0.91 or higher ABI. In all patients, upstroke time (UT), percentage of mean artery pressure (%MAP) of PVR and Ex-ABI were measured, and computed tomographic angiography (CTA) was concomitantly performed. Results: Area under the curve (AUC) of receiver operating characteristics (ROC) curves of Ex-ABI, %MAP, and UT were 0.90, 0.70, and 0.81, respectively. A significant difference was noted in AUC between Ex-ABI and %MAP (p <0.001). When the cut-off values were set at %MAP ≥45% and UT ≥180 msec, the accuracies of %MAP and UT were markedly lower than that of Ex-ABI. When the cut-off values were corrected to the values determined from the ROC curves (%MAP ≥41, UT ≥164 msec), the diagnostic accuracy of UT increased markedly. Conclusion: In patients with 0.91 or higher ABI, screening capability of PVR parameters was markedly lower than that of Ex-ABI, but UT has screening capability close to that of Ex-ABI when the cut-off value is corrected downward.

Exercise-ankle brachial pressure index with one-minute treadmill walking in patients on maintenance hemodialysis.

BACKGROUND: The ankle-brachial pressure index (ABI) is widely used as a standard screening method for arterial occlusive lesion above the knee. However, the sensitivity of ABI is low in hemodialysis (HD) patients. Exercise stress (Ex-ABI) may reduce the false negative results. PATIENTS AND METHODS: After measuring resting ABI and toe-brachial pressure index (TBI), ankle pressure and ABI immediately after walking (Post-AP, Post-ABI) were measured using one-minute treadmill walking in 52 lower limbs of 26 HD patients. The definition of peripheral arterial occlusive disease (PAD) required an ABI value of less than 0.90, TBI value of less than 0.60, and decrease of more than 15% of the Post-ABI value and 20 mmHg of Post-AP in Ex-ABI. Computed tomographic angiography (CTA) was performed in 32 lower limbs of 16 HD patients. PAD is defined as presence of stenosis of more than 75% in the case of lesions from an iliac artery to knee on CTA. RESULTS: The accuracy of Ex-ABI (Sensitivity, 85.7%; Specificity, 77.7%) was higher than those of ABI (Sensitivity, 42.9%; Specificity, 83.3%) or TBI (Sensitivity, 78.6%; Specificity, 61.1%). CONCLUSION: Ex-ABI with one-minute treadmill walking is the most useful tool for the screening of arterial occlusive lesions above the knee in maintenance HD patients.

A slightly elevated level of N-terminal pro-brain natriuretic peptide can predict coronary artery disease in a population with normal left ventricular function.

The prognostic and diagnostic values of N-terminal pro-brain natriuretic peptide (NT-pro-BNP) in ischemic heart disease have already been investigated in many previous studies. Although NT-pro-BNP is affected by many factors, these previous studies did not strictly exclude them. This study included 110 patients who received coronary arteriography between November 2007 and September 2009. Excluded from the study were those patients who had clinical symptoms of heart failure, asynergy by echocardiography or left ventriculography (LVG), atrial fibrillation, prior myocardial infarction, valvular disease, lung disease, anemia or renal dysfunction. We compared the laboratory data, LVG and early transmitral-to-early diastolic annular velocity ratio (E/E (a)) in echocardiography between the group with coronary stenosis and the group without it. NT-pro-BNP and the low-density lipoprotein/high-density lipoprotein ratio (LDL/HDL) independently associated with the presence of coronary artery stenosis (odds ratio of NT-pro-BNP, each 50 pg/ml 2.367, 95% confidence interval 1.302-4.303, p = 0.005). The area under the curve of the receiver-operating characteristic (ROC) curve of NT-pro-BNP, used to predict coronary artery stenosis, was 0.801 (0.719-0.883, p < 0.001). According to the ROC curve, the optimal cut-off level for predicting coronary stenosis was 64.3 pg/ml (sensitivity 82.5%, false-positive 34%). NT-pro-BNP is an attractive supplemental marker to predict the presence of coronary artery stenosis in a population that strictly excluded any affecting factors. In the population without factors affecting NT-pro-BNP, a slight increase suggests the presence of ischemic heart disease. The normal criteria for NT-pro-BNP in the patients undergoing coronary angiography may be much lower than the one currently used.

Endovascular treatment of innominate artery stenosis via the bilateral brachial approach.

Endovascular treatment (stenting) has evolved as an effective and safe treatment modality for symptomatic subclavian and innominate artery disease. Most of these patients have comorbid conditions associated with atherosclerotic vascular disease, which is responsible for the access site and increased difficulty of procedure. We report a case of symptomatic innominate artery stenosis with concomitant atherosclerotic disease of the abdominal aorta successfully treated with using coronary devices and the pull-through technique via the bilateral brachial approach.

Aggressive statin therapy in multicenter and effectiveness for the reduction of intra-myocardial damage caused by non-ST elevation acute coronary syndrome: AMERICA study.

BACKGROUND: While preprocedural statin treatment for acute coronary syndrome (ACS) is widely regarded as beneficial, there has been no prospective randomized multicenter trial of patients with non-ST elevation ACS in the Japanese population to examine the efficacy of preprocedural aggressive statin use. The aim of this study was to confirm this effect by prospective randomized multicenter design. METHODS: Fifty patients who presented with non-ST elevation ACS were enrolled, and randomly assigned to aggressive statin administration before percutaneous coronary intervention (PCI). Troponin-T (TnT), creatine phosphokinase (CK), CK-myocardial band (CK-MB), high-sense C-reactive protein (hs-CRP), and brain natriuretic peptide (BNP) were measured at baseline and/ or after procedure. RESULTS: Three days after PCI, the statin group had significantly less CK elevation compared with the nonstatin group (84+/-17 IU/l versus 180+/-68 IU/l, respectively, p = 0.02). CK-MB elevation also tended to be lower in the statin group than in the nonstatin group (3.2+/-1.9 versus. 7.0+/-3.0, respectively, p = 0.07), as was BNP level (3.2+/-1.9 versus 7.0+/-3.0 pg/ml, respectively, p = 0.07). The change of serum LDL cholesterol was significantly correlated with CK (p = 0.01) and TnT (p = 0.02) at 1 day after PCI. CONCLUSIONS: Aggressive statin usage before PCI to Japanese patients with non-ST elevation ACS appears to reduce myocardial damage after procedure. The degree of serum lipid level reduction may reflect the vulnerability of atheromatous plaques that could cause cardiac damage after PCI.

Distribution of ultrasonic radiofrequency signal amplitude detects lipids in atherosclerotic plaque of coronary arteries: an ex-vivo study.

BACKGROUND: Accumulation of lipids within coronary plaques is an important process in disease progression. However, gray-scale intravascular ultrasound images cannot detect plaque lipids effectively. Radiofrequency signal analysis could provide more accurate information on preclinical coronary plaques. METHODS: We analyzed 29 zones of mild atheroma in human coronary arteries acquired at autopsy. Two histologic groups, i.e., plaques with a lipid core (group L) and plaques without a lipid core (group N), were analyzed by automatic calculation of integrated backscatter. One hundred regions of interest were set on the target zone. Radiofrequency signals from a 50 MHz transducer were digitized at 240 MHz with 12-bit resolution. The intensity of integrated backscatter and its distribution within each plaque were compared between the two groups. RESULTS: Although the mean backscatter was similar between the groups, intraplaque variation of backscatter and backscatter in the axial direction were larger in group L than in group N (p = 0.02). Conventional intravascular ultrasound showed extremely low sensitivity for lipid detection, despite a high specificity. In contrast, a cut-off value>32 for the total variance of integrated backscatter identified lipid-containing plaque with a high sensitivity (85%) and specificity (75%). CONCLUSION: Compared with conventional imaging, assessment of the intraplaque distribution of integrated backscatter is more effective for detecting lipid. As coronary atheroma progresses, its composition becomes heterogeneous and multi-layered. This radiofrequency technique can portray complex plaque histology and can detect the early stage of plaque progression.

Impact of statin therapy on coronary intervention for non-ST elevation acute coronary syndrome with decreased low-density lipoprotein cholesterol.

OBJECTIVES: The benefits of treating patients with acute coronary syndrome (ACS) with statins are well established. This study investigated the effects of statins on patients who presented with low levels of low-density lipoprotein (LDL) cholesterol, were diagnosed with non-ST elevation ACS, and subsequently underwent percutaneous coronary interventions (PCI). METHODS: From 2000 to 2003, 87 patients(mean age 68 +/- 10 years, 69 males, 18 females) underwent PCI because of non-ST elevation ACS, and had low LDL cholesterol on presentation. These patients were divided into two groups: those who had been taking statins (S-group, n = 46), and those not taking statins, or controls (C-group, n = 41). Only patients whose LDL cholesterol was < 100 mg/dl at admission (average: 82 +/- 12 mg/dl) were included in the study. Troponin-T (TnT), creatine kinase (CK), CK-MB, and high-sense C reactive protein (hs-CRP) were measured before and 6 hr after PCI. The two groups were evaluated at 6 months clinical follow-up. RESULTS: There was no difference in these markers before PCI in both groups. TnT and CK-MB in the S-group at 6 hr post-PCI were significantly decreased compared to those of the C-group (0.45 +/- 1.34 vs 1.40 +/- 2.37 ng/ml, respectively, for TnT, p = 0.04; 17.2 +/- 45.5 vs 81.3 +/- 157.2 IU/l, respectively, for CK-MB, p = 0.02). Major adverse cardiac events (MACE) defined as death, myocardial infarction, congestive heart failure and target lesion revascularization were evaluated after 6 months. There was no difference in MACE between the two groups. CONCLUSIONS: Statin treatment before PCI in patients with non-ST elevation ACS demonstrated beneficial effects such as less myocardial damage, even though both groups presented with low LDL cholesterol levels. However, no significant effect on MACE was seen at 6 months after PCI.

[Initial and long term outcomes of stent implantation for iliac compression syndrome].

OBJECTIVES: The initial and long term outcome of stenting in the iliac vein were investigated in patients with iliac compression syndrome. METHODS: Iliac compression syndrome was diagnosed with venography and intravascular ultrasonography that demonstrated severe stenosis at the iliac venous compression site. Fourteen patients with symptomatic iliac compression syndrome were treated with stent implantation. The patency of the stents was examined at short and long term follow-up examinations. RESULTS: Thirteen patients presented with left iliac venous compression and only one patient presented with right iliac venous compression. Twelve of the 14 patients had acute deep venous thrombosis, so temporary vena cava filter implantation was performed during the procedure in these 12 patients. Procedural success was defined as less than 50% stenosis after stent implantation with good flow and without major complication (death, surgical repair for vein, or symptomatic pulmonary embolization). Procedural success was achieved in 13 of 14 patients, and these 13 patients showed improvement of symptoms. In the unsuccessful case, the compression site was resolved by stenting, but good flow was not obtained due to remaining femoral vein occlusion. The self-expandable stent was used for 6 patients, and the balloon-expandable stent was used for 8 patients. Angiographic or ultrasonographic follow up was performed in 10 patients at mean follow up of 8 months, but no restenosis was documented. CONCLUSIONS: Stent implantation for symptomatic iliac compression syndrome is a safe and effective procedure to resolve venous disease symptoms. Despite the small number of patients, long term outcome has been excellent in this study.

Case report: Focal ablation for atrial fibrillation originating from the inferior vena cava and the posterior left atrium.

We identified a case of paroxysmal atrial fibrillation (AF) originating from inferior vena cava (IVC) and the low-posterior left atrium (LA). Both foci, the IVC and the low-posterior LA, simultaneously served not only as trigger but also as driver for maintenance of AF. During AF, the IVC and the low-posterior LA continuously demonstrated the rapid and fractionated potentials that exit into both atria with conduction block. Focal ablation for ectopic beats within the IVC and the low-posterior LA completely eliminated the storm of AF.

Two atrial reentrant tachycardias originating from the superior vena cava: electrophysiological characteristics and radiofrequency ablation.

A case with two different types of atrial reentrant tachycardia of superior vena cava (SVC) origin is presented. Recent clinical studies have shown that the origin of focal atrial tachycardia typically lies in the venous structures connecting to both atria--the coronary sinus, the superior and inferior vena cava, and the pulmonary vein. These foci have atrial muscle fiber extensions which have electrophysiological characteristics essential to generation of focal ectopic firing. However, little is known about reentrant mechanism of these venous structures. In this report, we present a case of two atrial tachycardias (SVT1 and SVT2) independently originating from the SVC. SVT1 had 430 ms of tachycardia cycle length, and SVT2 had 390 ms of tachycardia cycle length. Both of them showed the character of reentry, and their earliest activations were recorded in the SVC. They were successfully eliminated by focal radiofrequency ablation in the SVC.

Catheter ablation for an incessant form of antiarrhythmic drug-resistant ventricular fibrillation after acute coronary syndrome.

A 77-year-old man was admitted with an acute coronary syndrome (ACS), severe heart failure (HF), and repeated ventricular fibrillation (VF) episodes. A single premature ventricular complex (PVC) induced ventricular tachycardia (VT), which degenerated to VF reproducibly. This PVC was eliminated by catheter ablation at the left ventricular posteroseptal region where double Purkinje potentials preceding the ventricular wave had been recorded. The electrical storm disappeared, and programmable stimulation failed to induce any tachyarrhythmias after the ablation. A Purkinje fiber network-related PVC served as a trigger and as a substrate for VT and VF in a case of ACS with HF.

Comparison of coronary arterial finding by intravascular ultrasound in patients with "transient no-reflow" versus "reflow" during percutaneous coronary intervention in acute coronary syndrome.

Previous studies have shown that transient no-reflow during coronary intervention but with Thrombosis in Myocardial Infarction (TIMI) grade 3 flow at the completion of the procedure is associated with increased in-hospital and 6-month mortality. We hypothesized that the use of intravascular ultrasound before intervention could identify morphologic features that were predictive of transient no-reflow in patients who had acute coronary syndrome (ACS). We analyzed 220 patients with ACS who had suitable intravascular ultrasound images that were acquired before intervention. We defined "transient no-reflow" as TIMI grade 0, 1, or 2 flow during the procedure and TIMI grade 3 flow at the completion of the procedure. We defined "reflow" as good coronary flow (TIMI grade 3 flow) during and after the procedure. Patients were categorized to a transient no-reflow group (n = 20) or a reflow group (n = 200). In the transient no-reflow group, vessel area and amount of plaque burden in the culprit lesion were significantly greater than in the reflow group (vessel 20.8 +/- 5.4 vs 16.4 +/- 6.2 mm(2), p < 0.01; plaque burden 0.90 +/- 0.03 vs 0.83 +/- 0.08, p < 0.001). The presence of ruptured plaque, lipid pool-like images, and thrombus formation were significantly higher in the transient no-reflow group than in the reflow group. Multivariate analysis identified the presence of thrombus formation (odds ratio 4.53, 95% confidence interval 1.03 to 20.0, p = 0.04) and larger plaque burden (odds ratio 1.79, 95% confidence interval 1.01 to 3.23, p = 0.05) as independent predictors of transient no-reflow. In conclusion, lesion morphologies are different for transient no-reflow and reflow. These findings suggest that the presence of thrombus formation and large plaque burden increase the risk for developing transient no-reflow during coronary intervention for ACS.