Pulmonary hemorrhage in a middle-aged woman as a complication of treatments for acute myocardial infarction.

A 49-year-old woman complaining of anterior chest pain underwent emergent coronary angiogram and thrombotic obstruction in the proximal left anterior descending artery was discovered. Deployment of a bare metal stent recovered good coronary flow and congestive heart failure was soon relieved. However, on day 3 of hospitalization, chest radiography suddenly showed newly emergent bilateral pulmonary infiltration shadow mimicking congestive heart failure. Chest computed tomography and clinical findings suggested bilateral alveolar hemorrhage. The patient received dual antiplatelet therapy, aspirin 100 mg/day and clopidogrel 75 mg/day and continuous 15,000 U/day heparin infusion, after percutaneous coronary intervention. Therapies that minimize bleeding risk while maintaining an antithrombotic effect are required for patients with acute coronary syndrome (ACS). Due to concern about the increased risk of early stent thrombosis induced by discontinuation of antiplatelet therapy, we continued to administer dual antiplatelet therapy. Pulmonary hemorrhage complicated with ACS without abciximab is a rare clinical entity, and we successfully overcame this potentially life-threatening complication with conservative therapy.

Subacutely progressed extensive aortic dissection complicated with catheter-induced dissection in left main coronary artery.

A 64-year-old man complaining of resting angina underwent emergent coronary angiogram and significant stenosis in the mid-left anterior descending artery was discovered. Although deployment of the drug-eluting Cypher stent relieved the stenosis, the guiding catheter accidentally induced coronary dissection in the left main coronary artery (LMCA). Then, deployment of another Cypher stent at the lesion successfully managed the complication. 20 days later, although asymptomatic, extensive aortic dissection was detected from the coronary sinus of Valsalva to the femoral artery. 64-Row multidetector computed tomography demonstrated that the dissection originated from the LMCA and retrogradely expanded to the aorta. This type of dissection is a rare complication related to coronary intervention and even in such a clinical setting, asymptomatic delayed progression of retrograde aortic dissection has not previously been reported to our knowledge.

Fatal splenic laceration in a young woman caused by idiopathic isolated splenic vein thrombosis.

A 38-year-old woman died of hemorrhagic shock caused by idiopathic bleeding in the abdominal cavity. At autopsy, more than 5,000 mL hemoperitoneum was detected. There was no remarkable bleeding site except for a small tear in the surface of the spleen. Microscopic examination suggested that isolated splenic vein thrombosis induced coagulative necrosis of the spleen and subsequently caused splenic laceration. Whenever a case of hemoperitoneum is encountered, splenic rupture should be included in the differential diagnosis; it is imperative to manage such cases as promptly as possible.

Clinical utility of evaluating intracranial artery stenosis and silent brain infarction to predict the presence of subclinical coronary artery disease in ischemic stroke patients.

OBJECTIVE: We have recently reported the prevalence of subclinical cardiovascular diseases and the association between the presence of subclinical coronary artery disease (CAD) and vascular risk factors in ischemic stroke patients. The relationship between the presence of subclinical CAD and elements of brain ischemia including intracranial artery stenosis, silent brain infarction (SBI), and white matter lesions remains unclear. We determined the usefulness of elements of brain ischemia to predict the presence of subclinical CAD in ischemic stroke patients. METHODS: The study group comprised 100 patients with first-ever ischemic stroke who had no history of CAD. Intracranial artery stenosis on magnetic resonance angiography and SBI and white matter lesions on magnetic resonance imaging were investigated in comparison with CAD defined as > or =50% stenosis on coronary computed tomographic angiography. RESULTS: Thirty-six patients had subclinical CAD. Intracranial artery stenosis (78.1% vs 35.1%, p<0.0001) and SBI (69.4% vs 46.9%, p=0.03) were more prevalent in patients with subclinical CAD. Of the patients with both intracranial artery stenosis and SBI, 61% had subclinical CAD. Multiple regression analyses showed that the presence of subclinical CAD was independently associated with intracranial artery stenosis; <50% stenosis (OR 8.01 95%CI 2.02 to 31.9; p<0.01), > or =50% stenosis (OR 19.5 95%CI 2.77 to 137.4; p<0.01), and multiple SBI (OR 3.85 95%CI 1.23 to 12.0; p<0.05). CONCLUSION: The evaluation of intracranial artery stenosis and SBI may be useful to identify ischemic stroke patients at high risk for subclinical CAD.

Prevalence of coronary artery disease in Japanese patients with cerebral infarction: impact of metabolic syndrome and intracranial large artery atherosclerosis.

BACKGROUND: Patients with cerebral infarction have a high prevalence of asymptomatic coronary artery disease (CAD) and other vascular diseases, but there is a lack of such data for Japanese patients, so the present study investigated the prevalence of cardiovascular disease (CVD) in Japanese patients and determined the predictors of CAD. METHODS AND RESULTS: The study group comprised 104 patients with cerebral infarction who had no history of CVD. All patients underwent coronary computed tomographic angiography, and systematic evaluation was done on the basis of the presence of other vascular diseases, CVD risk markers, and the degree of atherosclerosis. Of the total, 39 patients (37.5%) had CAD, 9 (8.7%) had carotid artery stenosis, 9 (8.7%) had peripheral artery disease of the lower limbs, and 3 (2.9%) had atherosclerotic renal artery stenosis. Multiple regression analysis showed that the presence of CAD was independently associated with metabolic syndrome (odds ratio (OR) 5.008, 95% confidence interval (CI) 1.538-16.309; p<0.01) and intracranial large artery atherosclerosis (OR 4.979, 95% CI 1.633-15.183; p<0.01). CONCLUSION: Japanese patients with cerebral infarction have a high prevalence of CVD, especially asymptomatic CAD. Both metabolic syndrome and intracranial large artery atherosclerosis may be potential predictors for identifying patients with cerebral infarction who are at the highest risk of asymptomatic CAD.

[Prevention of contrast-induced nephropathy using cardiac catheterization combined with hydration, oral N-acetylcysteine, sodium bicarbonate and iso-osmolar contrast agents].

OBJECTIVES: Contrast-induced nephropathy (CIN) after coronary angiography is a serious complication with an unfavorable prognosis. If CIN is persistent in the chronic phase, the prognosis is much worsened. We evaluated the efficacy of a new clinical therapy consisting of cardiac catheterization combined with hydration, oral N-acetylcysteine, sodium bicarbonate and iso-osmolar contrast agents. METHODS: The clinical therapy was applied to patients with pre-existent chronic renal insufficiency who underwent elective coronary angiography between December 2005 and December 2006. The incidence of CIN (defined as an increase > or = 25% and/or > or = 0.5 mg/dl in serum creatinine) persisting in the chronic phase at 30-60 days was examined in therapy era patients and compared with non-therapy era patients treated between January 2004 and November 2005, as well as patients with creatinine clearance < 40 ml/min. RESULTS: The clinical therapy was applied to 31 of 517 consecutive patients who underwent coronary angiography. CIN persisting in the chronic phase at 30-60 days occurred in 28 of 808 consecutive non-therapy era patients and 8 of 517 consecutive therapy era patients (3.5% vs 1.8%, p < 0.05). Excluding emergent cases, it occurred in 23 of 752 non-therapy era patients and 5 of 466 therapy era patients (3.1% vs 1.1%, p < 0.05). The patients with pre-existent chronic renal insufficiency (creatinine clearance < 40 ml/min) included 66 non-therapy era patients, and 21 of 31 therapy patients. Serum creatinine increased in the non-therapy era group (p < 0.01), but not in the therapy group. CIN persisting in the chronic phase at 30-60 days occurred in 21 non-therapy era group but in none of the therapy group. CONCLUSIONS: Therapy for patients with renal failure consisting of cardiac catheterization combined with hydration, oral N-acetylcysteine, sodium bicarbonate and iso-osmolar contrast agents is effective to prevent CIN in the chronic phase.

[Survivor of blow out type of free wall rupture: multislice computed tomographic detection of myocardial rupture in a case of small myocardial infarction].

A 73-year-old man was admitted to the emergency room because of shock and loss of consciousness. Electrocardiography and echocardiography revealed myocardial infarction of the inferoposterior wall and cardiac tamponade. However, laboratory data showed mild inflammation without elevation of any cardiac enzymes. Under percutaneous cardiopulmonary support, coronary angiography showed stenosis of only a small posterior descending branch of the right coronary artery. Multislice computed tomography provided a definite diagnosis of free wall rupture of the left ventricle, clearly showing the tear of the inferior wall. After surgical repair and rehabilitation, he returned to a normal life. Small inferior wall infarction rarely causes the blow out type of left ventricular free wall rupture. Multislice computed tomography is a fast and noninvasive tool for the detection of ventricular rupture as well as acute dissection of ascending aorta, both of which may result in cardiac tamponade and may not be visualized by echocardiography.

Morphology of protonated methanol clusters: an infrared spectroscopic study of hydrogen bond networks of H+(CH3OH)n (n = 4-15).

Infrared spectroscopy of large-sized protonated methanol clusters, H(+)(MeOH)(n) (n = 4-15), was carried out in the OH stretch region to characterize the development of the hydrogen bond network with the cluster size, n. The band intensity of the free OH stretching mode decreased with n, and the band finally disappeared at n = 7. On the other hand, the broad absorption band due to hydrogen-bonded OH stretches exhibited a remarkable shift with the cluster size, and it finally converged on 3300 cm(-1) for n >/= approximately 10. The size dependence of the infrared spectra was morphologically interpreted in terms of the formation of the bicyclic hydrogen-bonded structure of the clusters.

Electronic and infrared spectroscopy of [benzene-(methanol)(n)](+) (n = 1-6).

The microsolvation structure of the [benzene-(methanol)(n)](+) (n = 1-6) clusters was analyzed by electronic and infrared spectroscopy. For the n = 1 and 2 clusters, further spectroscopic investigation was carried out by Ar atom attachment, which has been know as a useful technique for discriminating isomers of the clusters. The coexistence of multiple isomers was confirmed for the n = 1 and 2 clusters, and remarkably, preferential production of the specific isomers occurred in the Ar attachment. The most stable isomer of the n = 1 cluster was suggested to be of the "on-ring" structure where the nonbonding electrons of the methanol moiety directly interact with the pi orbital of the benzene cation moiety. This is a sharp contrast to [benzene-(H(2)O)(1)](+), exhibiting the "side" structure, where the water moiety is bound to the C-H sites of the benzene cation moiety. The structure of the n = 2 cluster was discussed with the help of density functional theory calculations. Spectral signatures of the intracluster proton-transfer reaction were found for n > or = 5. The intracluster electron-transfer reaction leading to the (methanol)(m)()(+) fragment was also seen upon vibrational and electronic excitation of n > or = 4.