Influence of Serum Cholinesterase Levels on Patients Suspected of Having Stable Coronary Artery Disease.

Objective The serum cholinesterase (ChE) level has been used for the evaluation of the nutritional status in daily practice. It has been reported that the serum ChE level is significantly more elevated in patients with three-vessel coronary disease than in normal subjects. Thus, the aim of this study was to assess the influence of serum ChE levels in patients suspected of having stable coronary artery disease (CAD). Methods The relationship between myocardial ischemia and the serum ChE levels was evaluated in 559 consecutive patients suspected of having stable CAD without a history of cardiovascular disease admitted to our hospitals to undergo coronary angiography. Results This study revealed that, in patients suspected of having stable CAD, 1) the frequency of myocardial ischemia was significantly increased in accordance with the serum ChE levels (p<0.001); 2) higher ChE levels were associated with a higher body mass index (p<0.001) and the co-existence of dyslipidemia (p<0.001), including higher values of low-density lipoprotein-cholesterol (p<0.001) and triglycerides (p<0.001) and serum albumin (p<0.001), as well as a younger age (p<0.001); 3) the specificity and sensitivity of myocardial ischemia were 0.599 and 0.658 at the ChE level of 286 IU/L, respectively; and 4) an increased serum ChE (OR=1.66, p<0.001) was an independent risk factor for myocardial ischemia, in patients suspected of having stable CAD. Conclusion The serum ChE level may be an important diagnostic biomarker in patients suspected of having stable CAD.

Radiofrequency catheter ablation of premature ventricular contractions from near the His-bundle.

OBJECTIVE: This study aimed to investigate the effects of radiofrequency catheter ablation (RFCA) and clinical and electrophysiological characteristics in symptomatic patients with premature ventricular contractions (PVCs) from near the His-bundle (His-PVCs). METHODS: The patient characteristics, prevalence of complications with any life style related disease (ALSRD) including hypertension, dyslipidemia, or diabetes mellitus, and/or cardiovascular disease (CVD) including coronary artery disease, cerebrovascular disease, renal dysfunction, or cardiomyopathy, clinical status, frequency of PVCs evaluated by 24hour Holter monitoring, echocardiography including the left ventricular diastolic dysfunction (LVDD) parameters, and electrophysiological findings were evaluated in 14 consecutive symptomatic patients with His-PVCs. RESULTS: The prevalence of males, being elderly and/or slightly obese, current and/or history of smoking, ALSRD or CVD related complications, and LVDD probably resulting from ALSRD and/or CVD complications were higher in patients with His-PVCs. RFCA of His-PVCs steadily decreased the PVC frequency and improved the systolic function, LV dilation, and clinical status, but not the LVDD. There was a significant relationship between the accordance rate of the QRS polarity between sinus rhythm and His-PVCs and the distance between the successful ablation site and His-bundle. CONCLUSION: The analysis of the QRS duration and accordance rate of the QRS polarity between sinus rhythm and His-PVCs before the RFCA may help to determine the distance between the origin of the PVCs and His-bundle. Further, the appropriate ablation catheter may be selected during the RFCA procedure. Finally, RFCA may be one of the most effective, feasible, and safest therapies for symptomatic patients with His-PVCs.

Paroxysmal Atrial Fibrillation in Patients Successfully Treated by Radiofrequency Catheter Ablation with Severely Compression, Lateral Displacement, and Clockwise Rotation of Their Hearts due to Severe Pectus Excavatum.

Two cases with severe pectus excavatum and symptomatic atrial fibrillation (AF) underwent radiofrequency catheter ablation (RFCA). Their chest X-ray and computed tomography (CT) findings revealed lateral displacement and clockwise rotation of their hearts, and severe right atrial and mild right ventricular compression against the sternum, but no left atrium compression against the spinal column. The procedure was therefore carefully performed under guidance with CT, intra-cardiac echography, atriography, and a three-dimensions mapping system. Finally, the AF was successfully treated by RFCA without any complications. These findings underscore the importance of understanding cases of abnormal anatomy and carefully designing a strategy before performing any procedure.

A case of paroxysmal atrial fibrillation in a patient successfully treated by radiofrequency catheter ablation with a severely right-sided dislocation of the heart after a total right lung excision.

A 72-year-old woman with symptomatic and drug-refractory paroxysmal atrial fibrillation (AF) underwent radiofrequency catheter ablation (RFCA). She had a history of a total right lung excision. Her chest X-ray and computed tomography (CT) revealed a severely sight-sided dislocation of the heart. Thus, the procedure was carefully performed under guidance of a CT, intracardiac echogram, atriography, and 3D mapping system. Finally, the AF was successfully treated by RFCA without any complications.

Clinical benefits of deep sedation with a supraglottic airway while monitoring the bispectral index during catheter ablation of atrial fibrillation.

BACKGROUND: Pulmonary vein antrum isolation (PVAI) under sedation has proven to be a useful strategy for catheter ablation of atrial fibrillation (AF). METHODS: To evaluate the clinical benefits of respiratory management using supraglottic airways (SGAs) under deep sedation while monitoring the bispectral (BIS) index during the PVAI and the durations from admission to the catheterization room to starting the radiofrequency energy delivery (Time α), and from starting the radiofrequency energy delivery to completion of the PVAI (Time ß), X-ray time, frequency of dislocations of the three-dimensional maps (D3DM), procedure-related complications, and proportion of an AF-free rate 15 months after the PVAI (PAFFR) in patients who received deep sedation without SGAs (Group A: n=48) and those with SGAs (Group B: n=51) were evaluated. RESULTS: There were no significant differences in patient characteristics, Time α (77±3 versus 78±2 min; p=0.816), complications of cardiac tamponade (2% versus 2%; p=0.966), or PAFFR (81% versus 88%; p=0.313) between the two groups. However, the Time ß (84±4 versus 67±3; p=0.001), X-ray time (53±2 versus 34±2; p<0.001), and minor complications of nasal bleeding (25% versus 0%; p=0.001) were significantly shorter and lower in Group B than in Group A, in accordance with a reduction in the hypoxia (15% versus 0%; p=0.007) and D3DM (31% versus 8%; p=0.003). CONCLUSIONS: These results may demonstrate the clinical benefits of deep sedation with SGAs while monitoring the BIS index without any hypoxia during PVAI in patients with AF.

Inappropriate Sinus Tachycardia Diagnosed and Treated as Depression Successfully Treated by Radiofrequency Catheter Ablation.

We experienced a man in his 20s with inappropriate sinus tachycardia (IST) initially diagnosed and treated as depression who was steadily treated with radiofrequency catheter ablation (RFCA) using an EnSite™ system. The patient has remained well without any symptoms or medications, including antidepressants, for two years since the RFCA. To avoid missing IST and treating it as an emotional problem and/or mental illness such as depression, physicians - including cardiologists - should be aware of these conditions when examining patients with multiple and incapacitating complaints including palpitations and general fatigue and/or tachycardia, especially characterized by an elevated resting heart rate or a disproportionate increase in the heart rate with minimal exertion.

A case of premature ventricular complexes/ventricular tachycardia from the left ventricular outflow tract successfully ablated from the distal great cardiac vein.

We experienced a 41-year-old male with premature ventricular complexes/ventricular tachycardia from the left coronary cusp and distal great cardiac vein of the left ventricular outflow tract successfully treated by radiofrequency catheter ablation utilizing a 3D mapping system (EnSiteNavX/Velocity™ Cardiac Mapping System, St. Jude Medical, St. Paul, MN, USA) without any complications. .

Silent myocardial ischemia in asymptomatic patients with type 2 diabetes mellitus without previous histories of cardiovascular disease.

BACKGROUND: The number of patients with type 2 diabetes mellitus (T2DM) continues to increase all over the world. Cardiovascular disease (CVD), especially coronary artery disease (CAD), is a major cause of the morbidity and mortality in patients with T2DM. The prognosis of patients with silent myocardial ischemia (SMI) is worse than that in those without. METHODS AND RESULTS: Thus, to assess how many patients with SMI existed among those patients, CVD screening tests were performed in 128 asymptomatic patients with T2DM without previous histories of CVD. SMI could be detected in 24 patients (19%) by exercise stress tests and/or the coronary fractional flow reserve. Their 12-lead electrocardiogram and cardiac ultrasonography were both normal. Compared to those without SMI, those with had a statistically significant longer history of T2DM (17±1 versus 11±1years, p=0.006), and the co-existence of a family history of CVD (42% versus 21%, p=0.037). Furthermore, these factors were demonstrated as independent risk factors of SMI by a multivariate analysis (Odds ratio 1.060 and 4.000, respectively), and in accordance with the disease duration of T2DM, the prevalence of patients with SMI has been increasing (p=0.019). CONCLUSIONS: Physicians should be aware of these conditions when examining patients with T2DM, especially with a family history of CVD and/or long disease duration (>11years) of T2DM, even though they have no symptoms, previous histories of CVDs, and/or abnormal findings on the 12-lead electrocardiogram and cardiac ultrasonography. This may be an effective, safe, and attractive diagnostic strategy for those asymptomatic patients with T2DM.

A case of fulminant myocarditis treated with very long-term support by cardiopulmonary support system.

Fulminant myocarditis (FM) sometimes causes severe left ventricular dysfunction and lethal arrhythmias leading to cardiogenic shock and critical conditions. Thus, mechanical circulation support with intra-aortic balloon pumping and/or a cardiopulmonary support system (CPS) is sometimes needed to save lives. The special recommended therapies for FM for that classified as class I (evidence level C) in the guidelines of the Japanese Circulation Society are intra-aortic balloon pumping, CPS, percutaneous cardiac pacing, and a left ventricular assist device (LVAD), and they are well established in evidence-based medicine. We experienced a case of FM that we were able to save by long-term stable CPS support. Because, unfortunately, the LVAD was not commercially available in Japan at that time, intensive treatments including CPS were continued in our hospital. Finally, a good course of the illness was achieved without any adverse complications. Thus, these intensive treatments in the present case may be one of the optional effective strategies for FM, especially in hospitals and/or countries where the LVAD is not (commercially) available, and when an LVAD may not be suitable because of complications associated with infectious disease. .

Ebstein's anomaly in adult patients over 50 years of age.

Ebstein's anomaly (EA) is a rare congenital heart disease of the tricuspid valve, and less than 5% of patients with EA survive beyond the age of 50. We report two unoperated cases of EA in adult patients aged over 50 years. Two patients, a 70-year-old Japanese woman and a 59-year-old Chinese woman, were referred to us for tachyarrhythmias. Transthoracic echocardiography demonstrated apical displacement (>8 mm/m(2) body surface area) of the septal leaflet of the tricuspid valve from the atrioventricular ring with tricuspid regurgitation in both patients. The former suddenly expired 20 months later after suffering from repetitive supraventricular tachyarrhythmias and/or heart failure, and the latter is alive with minimal signs of heart failure 12 months after the diagnosis of EA. Although the natural history of EA is extremely variable, these two patients are exceptional in that they tolerated EA well for over 50 years without any surgical intervention.

Characteristics of the conduction of the left atrium in atrial fibrillation using non-contact mapping.

BACKGROUND: We evaluated the conduction properties of the posterior left atrium (LA) using a non-contact mapping (NCM) system as well as the significance of linear ablation at the roof of the posterior LA (LA roof) and inferior region of the posterior LA (LA bottom). METHODS AND RESULTS: In 133 patients with atrial fibrillation (AF) (83 paroxysmal type, 50 persistent/long-lasting persistent type), we performed complete isolation of the posterior LA including pulmonary veins (Box isolation) using NCM. Isochronal activation maps were analyzed during sinus rhythm (SR), during pacing from the proximal coronary sinus (CS), and during pacing within the posterior LA before and after ablation. In sinus rhythm, horizontal conduction along the LA roof line, but not into the posterior LA wall, was observed in 59% of the patients. During paroxysmal CS pacing, horizontal conduction along the LA bottom line was observed in 69% of the patients. Posterior wall pacing conducted vertically over the LA roof and bottom lines in 98% and 83% of the patients, respectively. During AF, rotor wave conduction into the posterior LA through the LA roof and bottom lines was observed in 85% of the patients. Heterogeneous conduction directions in the posterior LA at the LA roof and bottom lines were observed in 60% of the patients. CONCLUSIONS: Heterogeneous conduction was observed at the roof and inferior region of the posterior LA in most of these AF patients. The conduction properties of the posterior LA are affected by the direction of the wavefronts, and this may play an important role in the initiation and maintenance of AF. The complete isolation of the posterior LA may prevent AF.

Left ventricular oozing rupture following acute myocardial infarction.

We describe the case of an 85-year-old woman in whom pericardiocentesis, prolonged bed rest and blood pressure control were performed without surgery to successfully treat an oozing-type myocardial rupture due to myocardial infarction.

Isolated pulmonary arterial stenosis caused by Takayasu's arteritis in an elderly male.

Takayasu's arteritis has often been difficult to diagnose because of a lack of typical symptoms and other specific makers. We report here a case of Takayasu's arteritis in a 73-year-old man who was considered to exhibit isolated pulmonary artery involvement. Pulmonary hypertension and right heart failure and severe stenosis in the main trunk and left pulmonary artery were observed. There was nothing remarkable in his routine blood-sample tests other than increased CRP and ESR. There were neither infectious nor collagen diseases. Anti-cardiolipin antibody, Antiphospholipid Syndrome, PR3-ANCA and MPO-ANCA were negative. We diagnosed the patient as having Takayasu's arteritis based on chronic inflammation and the morphologic features of pulmonary artery lesion. However, other large vessels and the aorta were not involved. Treatment was started with glucocorticoids. The symptoms gradually improved, and pulmonary artery pressure estimated by echocardiography decreased along with inflammatiory markers. There were no remarkable changes in the stenotic lesions in the pulmonary artery but the flow limit in the left pulmonary artery was improved.

Effects of reconstituted HDL on charge-based LDL subfractions as characterized by capillary isotachophoresis.

Modified LDL in human plasma including small, dense LDL (sdLDL) and oxidized LDL carries a more negative charge than unmodified LDL and is atherogenic. We examined the effects of apolipoprotein A-I (apoA-I)/POPC discs on charge-based LDL subfractions as determined by capillary isotachophoresis (cITP). Three normal healthy subjects and seven patients with metabolic disorders were included in the study. LDL in human plasma was separated into two major subfractions, fast- and slow-migrating LDL (fLDL and sLDL), by cITP. Normal LDL was characterized by low fLDL, and mildly oxidized LDL in vitro and mildly modified LDL in human plasma were characterized by increased fLDL. Moderately oxidized LDL in vitro and moderately modified LDL in a patient with hypertriglyceridemia and HDL deficiency were characterized by both increased fLDL and a new LDL subfraction with a faster mobility than fLDL [very-fast-migrating LDL as determined by cITP (vfLDL)]. cITP LDL subfractions with faster electrophoretic mobility (fLDL vs. sLDL, vfLDL vs. fLDL) were associated with an increased content of sdLDL. Incubation of a plasma fraction with d>1.019 g/ml (depleted of triglyceride-rich lipoproteins) in the presence of apoA-I/POPC discs at 37 degrees C greatly decreased vfLDL and fLDL but increased sLDL. Incubation of whole plasma from patients with an altered distribution of cITP LDL subfractions in the presence of apoA-I/POPC discs also greatly decreased fLDL but increased sLDL. ApoA-I/POPC discs decreased the cITP fLDL level, the free cholesterol concentration, and platelet-activating factor acetylhydrolase activity in the sdLDL subclasses (d=1.040-1.063 g/ml) and increased the size of LDL. ApoA-I/POPC discs reduced charge-modified LDL in human plasma by remodeling cITP fLDL into sLDL subfractions.

Effects of edaravone on reperfusion injury in patients with acute myocardial infarction.

This clinical pilot study was a randomized, controlled, open-label study in 80 patients with acute myocardial infarction and was designed to examine the effects of a novel free radical scavenger, edaravone. Administration of edaravone before myocardial reperfusion was associated with smaller enzymatic infarcts and better clinical outcome.