Pulmonary embolism caused by ovarian vein thrombosis during cesarean section: a case report.

BACKGROUND: Ovarian vein thrombosis is a rare complication of pregnancy. The representative complaints of patients with ovarian vein thrombosis are abdominal pain and fever. In some cases, however, fatal pulmonary embolism may develop. We report a case of pulmonary embolism presenting with severe hypotension and loss of consciousness during cesarean section possibly caused by ovarian vein thrombosis. CASE PRESENTATION: A 25-year-old woman at 38 weeks 4 days of gestation was scheduled for repeat cesarean section. Her past history was unremarkable, and the progress of her pregnancy was uneventful. She did not experience any symptoms indicative of deep vein thrombosis. Cesarean section was performed under spinal anesthesia, and a healthy newborn was delivered. After removal of the placenta, she suddenly developed dyspnea, hypotension, and loss of consciousness with decreased peripheral oxygen saturation. Blood pressure, heart rate, and oxygen saturation recovered after tracheal intubation and mechanical ventilation with oxygen. Postoperative computed tomography revealed no abnormality in the brain or in the pulmonary artery, but a dilated right ovarian vein with thrombi, extending up to the inferior vena cava, was found. A diagnosis of pulmonary embolism caused by ovarian vein thrombosis was made, and heparin was administered. The tracheal tube was removed on the first postoperative day. Her postoperative course was uneventful, and she was discharged with no complications. CONCLUSION: Fatal pulmonary embolism might be caused by ovarian vein thrombosis during cesarean section. Careful and continuous observation of the patient after delivery and prompt treatment are important.

Use of desflurane during anesthesia for resection of extra-adrenal pheochromocytoma: a case report.

BACKGROUND: Although various agents are used during anesthesia for surgical resection of pheochromocytoma, application of desflurane has rarely been reported. We report the use of desflurane in a case receiving resection of extra-adrenal pheochromocytoma. CASE PRESENTATION: A 51-year-old female was transferred to our hospital for sustained hypertension. A diagnosis of extra-adrenal pheochromocytoma was made based on increased plasma catecholamine levels and radiographic findings. Surgical resection was planned after controlling blood pressure. General anesthesia was induced with propofol and fentanyl, followed by maintenance with desflurane 4.3% and remifentanil 0.2-0.4 µg/kg/min. Blood pressure and heart rate were stable during induction, tracheal intubation, and tumor manipulation. Blood pressure abruptly decreased to 62/40 mmHg after removal of the tumor, which was treated with noradrenaline. The surgery was completed uneventfully and the postoperative course was also uneventful. CONCLUSION: Desflurane was safely used in combination with remifentanil during anesthesia for resection of extra-adrenal pheochromocytoma.

Prediction of aortic stenosis-related events in patients with systolic ejection murmur using pocket-sized echocardiography.

BACKGROUND: We have previously reported the usefulness of our newly developed visual aortic stenosis (AS) score in screening for AS using pocket-sized echocardiography. The objective of this study was to investigate whether the visual AS score and/or conventional aortic valve calcification score derived from pocket-sized echocardiography can be used to predict AS-related events. METHODS: One hundred and nine patients with systolic ejection murmur (SEM) or known AS (64 males, age 75±9 years) were enrolled and a visual AS score and an aortic valve calcification score were assessed using pocket-sized echocardiography. The primary endpoint was defined as AS-related events, including cardiac death and aortic valve replacement, during the follow-up period. RESULTS: In a multivariate Cox proportional hazards analysis, AS-related events were independently predicted by an aortic valve calcification score ≥3 (HR, 3.5; 95% CI, 1.1-11; p=0.033) and a visual AS score ≥3 (HR, 15; 95% CI, 1.8-125; p=0.013). During 18±9 months of follow-up, the event-free survival rate was 98% in patients with both a visual AS score <3 and an aortic valve calcification score <3, 90% in patients with either a visual AS score ≥3 or an aortic valve calcification score ≥3 (p<0.0001), and 62% in patients with both a visual AS score ≥3 and an aortic valve calcification score ≥3 (p<0.0001). CONCLUSIONS: The combination of visual AS score and aortic valve calcification score derived from pocket-sized echocardiography is useful for predicting AS-related events in patients with SEM.

[Long-Term Survival after Multidisciplinary Treatment for Resected Pancreatic Adenocarcinoma with Recurrence of Pulmonary Metastases - A Case Report].

Recent studies indicated that isolated pulmonary metastases could define a favorable subgroup in metastatic pancreatic cancer. We report a case of isolated pulmonary metastases after curative resection of pancreas head cancer treated with chemotherapy and pulmonary metastasectomy survived for 79 months after recurrence. A 72-year-old male underwent pancreatoduodenectomy for pancreas head cancer. Adjuvant chemotherapy was done with gemcitabine hydrochloride (GEM)for 6 months and then S-1 for 2 months. Twenty-seven months after surgery, 2 small metastatic nodules in the left lung was detected. Chemotherapy with GEM was performed but the lesions grew larger very slowly. A new metastatic nodule was detected in the right lung 40 months after surgery and pleural effusion was detected 52 months after surgery. Then combination chemotherapy with GEM and S-1 was performed for 3 months followed chemotherapy with S-1 alone. Seventytwo months after surgery, chemotherapy with GEM was performed again because of patient's intolerance to S-1. Ninety months after initial surgery, pulmonary metastasectomy of the right lung was performed because of its resistance to chemotherapy. Chemotherapy with GEM was started again 4 months after pulmonary metastasectomy but serum levels of tumor markers remained increase. Combination chemotherapy with GEM and nab-paclitaxel was started 8 months after pulmonary metastasectomy but the patient died 16 months after pulmonary metastasectomy.

Right coronary artery perforation by an active-fixation atrial pacing lead resulting in life-threatening tamponade.

Cardiac tamponade resulting from perforation of a cardiac chamber is a relatively rare complication of pacemaker implantation. We report the first case of perforation of the right coronary artery related to the implantation of a screw-in atrial pacing lead, presenting as life-threatening cardiac tamponade. We report the case of a 72-year-old woman with complete atrioventricular block and dyspnea on exertion. A permanent pacemaker was implanted with bipolar Medtronic active-fixation leads positioned in the right atrial appendage and at the right ventricular basal septum without any difficulty. Approximately 3.5 h after the procedure, the patient complained of nausea, and the systolic blood pressure decreased to less than 60 mmHg. Echocardiography revealed a large pericardial effusion. Because the effects of pericardiocentesis lasted for less than an hour, the patient underwent a thoracotomy. After evacuation of a massive hemopericardium, bright red blood was seen gushing out from the right coronary artery, which was located on the opposite site of the right atrial appendage where a small portion of the screw tip was observed to be penetrating the atrial wall. The right coronary artery perforation was repaired using autologous pericardium-reinforced 7-0 prolene mattress sutures. Perforation of the right coronary artery is a potential complication and should be part of the differential diagnosis of cardiac tamponade after pacemaker implantation.

Intravascular findings of fibromuscular dysplasia on optical coherence tomography.

We present the case of a 29-year-old woman with right renal artery stenosis caused by fibromuscular dysplasia (FMD) who underwent optical coherence tomography (OCT)-guided percutaneous transluminal renal angioplasty. Using OCT, we could clearly observe intimal fibroplasia and medial hyperplasia that was indicative of FMD. Based on diagnosis of FMD by OCT, this patient was treated with plain old balloon angioplasty that resulted in adequate luminal opening without intimal dissection confirmed on final angiography and OCT. .

Gender-specific correlation between plasma myeloperoxidase levels and serum high-density lipoprotein-associated paraoxonase-1 levels in patients with stable and unstable coronary artery disease.

OBJECTIVE: Low high-density lipoprotein (HDL) cholesterol is well-established as a negative risk factor for coronary artery disease (CAD) and its anti-oxidant property has been attributed mainly to the HDL-bound enzyme paraoxonase-1 (PON-1). Recently, myeloperoxidase (MPO), a pro-oxidant enzyme released from activated neutrophils, has been shown to alter the atheroprotective function of HDL to a dysfunctional form. This study investigated the relationship between plasma MPO and serum PON-1 levels in patients with stable (SAP) and unstable angina pectoris (UAP). METHODS: Plasma MPO levels and serum PON-1 concentration/activity were measured in patients with SAP (n = 226), UAP (n = 151) and in control subjects (n = 99). RESULTS: Plasma MPO levels in UAP patients were significantly higher than those in SAP patients or in control subjects (UAP, 21.6[16.7-44.6]; SAP, 19.3[15.7-29.1]; control, 15.9[14.7-18.7] ng/mL; P < 0.0001). Serum PON-1 concentrations in UAP and SAP patients were significantly lower than those in control subjects (UAP, 55.6[45.9-69.7]; SAP, 55.0[46.9-64.9]; control, 62.5[51.1-78.8] µg/mL; P = 0.0002). Plasma MPO levels showed a weak inverse correlation with serum PON-1 concentrations in all subjects (R = -0.163, P < 0.0005). Moreover, in women, plasma MPO levels showed a significant inverse correlation with serum PON-1 concentrations and PON-arylesterase activity in SAP (concentration: R = -0.537, P < 0.0001; arylesterase-activity: R = -0.469, P < 0.001) and UAP (concentration: R = -0.340, P < 0.05; arylesterase-activity: R = -0.350, P < 0.05) patients, but not in men. CONCLUSION: This study demonstrates that plasma MPO levels have a significant inverse correlation with PON-1 levels, especially in women, in SAP and UAP patients, and suggests that an imbalance between pro-oxidants and anti-oxidants may contribute to the progression of coronary plaque instability.

Association between hemoglobin scavenger receptor and heme oxygenase-1-related anti-inflammatory mediators in human coronary stable and unstable plaques.

Heme oxygenase-1 (HO-1) is a cytoprotective enzyme that is induced by intraplaque hemorrhage and degrades free heme and releases ferrous iron, which is rapidly sequestered by ferritin. In vitro studies have shown that binding of hemoglobin to hemoglobin scavenger receptor (CD163) induces HO-1 and the anti-inflammatory mediator interleukin (IL)-10. We immunohistochemically examined the relationship between CD163 expression in macrophages and intraplaque hemorrhage, HO-1, IL-10, and ferritin using coronary atherectomy specimens from patients with stable (SAP) or unstable angina pectoris (UAP). A total of 67 patients underwent atherectomy for SAP (n = 33) or UAP (n = 34). Samples were stained with antibodies against smooth muscle cells, macrophages, glycophorin-A (a protein specific to erythrocyte membranes), CD163, HO-1, IL-10, and ferritin. To identify cell types of HO-1-positive cells, double immunostaining was also performed. Double immunostaining for HO-1 and macrophages revealed that the vast majority of HO-1-positive cells were macrophages. Morphometric analysis demonstrated that CD163-positive macrophage score and the percentage of glycophorin-A-, HO-1-, IL-10-, and ferritin-positive areas were significantly higher in UAP than in SAP patients (CD163, P < .005; glycophorin-A, P < .0001; HO-1, P < .0001; IL-10, P < .005; ferritin, P = .0001). Moreover, CD163-positive macrophage score was positively associated with the percentage of glycophorin-A-, HO-1-, IL-10-, and ferritin-positive areas (glycophorin-A, r = 0.60, P < .0001; HO-1, r = 0.67, P < .0001; IL-10, r = 0.45, P < .0005; ferritin, r = 0.61, P < .0001). These findings suggest that enhanced expression of HO-1 and HO-1-related atheroprotective molecules plays an important role in exerting anti-inflammatory, antioxidant, and scavenging functions, which could contribute to plaque stabilization.

Relationship of thrombus characteristics to the incidence of angiographically visible distal embolization in patients with ST-segment elevation myocardial infarction treated with thrombus aspiration.

OBJECTIVES: This study sought to investigate the association between pathological characteristics of aspirated intracoronary thrombi and the incidence of angiographically visible distal embolization (AVDE) during primary percutaneous coronary intervention (p-PCI) in patients with ST-segment elevation myocardial infarction (STEMI) treated with thrombus aspiration. BACKGROUND: AVDE of atherosclerotic and thrombotic material has been shown to impair myocardial perfusion and contribute to poor clinical outcome in patients with STEMI. Recent studies have shown that thrombus composition and size are associated with the incidence of AVDE. METHODS: Aspirated thrombi from 164 STEMI patients within 12 h of symptom onset were investigated immunohistochemically using antibodies against platelets, erythrocytes, and inflammatory cells. RESULTS: The angiographic results showed that AVDE during p-PCI occurred in 22 (13.4%) patients. Pathological analysis revealed that thrombi from patients with AVDE had a greater erythrocyte-positive area (60 ± 15% vs. 43 ± 21%, p < 0.0005) and more myeloperoxidase-positive cells (943 ± 324 cells/mm(2) vs. 592 ± 419 cells/mm(2), p < 0.0005) than those from patients without AVDE. Thrombus size, quantified as the thrombus surface area, was positively correlated with the erythrocyte component (r = 0.362, p < 0.0001). Moreover, multivariate logistic analysis demonstrated that erythrocyte-positive area in the thrombi, glucose levels on admission, larger vessel diameter (≥ 3.5 mm), and pre-balloon dilation were independent predictors of the incidence of AVDE. CONCLUSIONS: This study demonstrated that the erythrocyte-rich component of aspirated thrombi may be associated with the incidence of AVDE during p-PCI in patients with STEMI.

Comparison of two-dimensional and real-time three-dimensional transesophageal echocardiography in the assessment of aortic valve area.

BACKGROUND: The accuracy of two-dimensional transesophageal echocardiography (2D-TEE) for the measurement of aortic valve area (AVA) in patients with aortic stenosis (AS) depends upon the cross-section selected for imaging. Real-time three-dimensional transesophageal echocardiography (3D-TEE) may overcome this limitation of 2D-TEE. The goal of this study was to compare 3D-TEE with 2D-TEE for the measurement of AVA. METHODS AND RESULTS: Twenty-five patients with AS underwent TEE. In 2D-TEE, the aortic valve image was obtained at the orifice level in the short-axis view, and AVA was measured by planimetry of the acquired images (2D-AVA). In 3D-TEE, 3D data containing the entire aortic valve were obtained. Then, a short-axis cross-section containing the smallest orifice in mid-systole was cut from the 3D data during image postprocessing, and the AVA was measured by planimetry (3D-AVA). The 3D-AVA was significantly smaller than the 2D-AVA (0.79±0.35cm(2) vs. 0.93±0.40cm(2), p<0.0001), but there was a strong correlation between 3D-AVA and 2D-AVA (R=0.94). Although the frame rate was lower in 3D-TEE than in 2D-TEE (17±6Hz vs. 58±16Hz), the 3D-AVA determined at each frame during systole showed that the difference between 3D-AVA and 2D-AVA was not explained by the lower frame rate. The time required for image acquisition of the aortic valve was shorter with 3D-TEE than with 2D-TEE (p=0.0005). CONCLUSIONS: The geometric AVA is smaller with 3D-TEE than with 2D-TEE, and the difference is not due to the lower frame rate of 3D-TEE. The improved accuracy of 3D-TEE along with reduced image acquisition time indicates that 3D-TEE is superior to 2D-TEE for the assessment of AVA.

Erythrocyte-rich thrombus aspirated from patients with ST-elevation myocardial infarction: association with oxidative stress and its impact on myocardial reperfusion.

AIMS: Recent studies have demonstrated that erythrocytes are a potential component in atheromatous lesions and thrombus formation in patients with ST-elevation myocardial infarction (STEMI). The purpose of this study was to determine the associations of red blood cell (RBC) component of coronary thrombi with oxidative stress and myocardial reperfusion. METHODS AND RESULTS: Aspirated thrombi from 178 STEMI patients within 12 h of symptom onset were investigated immunohistochemically using antibodies against platelets, RBCs, fibrin, macrophages, and neutrophils [myeloperoxidase (MPO)]. The thrombi were divided into tertiles according to the percentage of glycophorin-A-positive area: low (glycophorin-A-positive area <33%; n = 60), intermediate (<54 to 33%; n = 59), and high group (≥54%; n = 59). We also measured plasma MPO levels on admission. In the thrombi, the number of MPO-positive cells in the high-RBC group was significantly greater than that in the low-RBC group (high, 927 ± 385; intermediate, 765 ± 406; low, 279 ± 220 cells/mm(2); P< 0.0001). Plasma MPO levels were significantly higher in the high-RBC group than that in the low-RBC group [low 43.1 (25.0-71.6); intermediate 71.0 (32.9-111.2); high 74.3 (31.1-126.4)ng/mL; P< 0.005]. Distal embolization occurred more frequently in the high-RBC group (P= 0.0009). Moreover, the signs of impaired myocardial reperfusion, as indicated by incomplete ST-segment resolution (STR) and lower myocardial blush grades (MBG), and progression of left ventricular remodelling at 6 months were frequently observed in the high-RBC group (high vs. low: STR, P= 0.056; MBG, P< 0.01; remodelling, P< 0.01). CONCLUSION: The present study demonstrated that erythrocyte-rich thrombi contain more inflammatory cells and reflect high thrombus burden, leading to impaired myocardial reperfusion in STEMI patients.

Aortic aneurysm with severe aortic regurgitation in a patient with systemic lupus erythematosus.

A 37-year-old man was admitted to our hospital for precordial chest pain. He had taken prednisolone (5 mg/day) for systemic lupus erythematosus (SLE) and had been symptom free for the past 12 years. Echocardiography and contrast-enhanced CT of chest showed an enlarged ascending aortic aneurysm, which is rarely seen in SLE. Severe aortic regurgitation was also present, and surgical replacement of the ascending aorta and aortic valve was successfully accomplished by the Bentall procedure. Medial cystic necrosis in the ascending aorta, which is rarely seen in SLE angiopathy, was confirmed by histology. There were no significant histopathological findings in the aortic valve.

A decline in platelet activation and inflammatory cell infiltration is associated with the phenotypic redifferentiation of neointimal smooth muscle cells after bare-metal stent implantation in acute coronary syndrome.

AIM: This immunohistochemical investigation was to analyze the relationship between platelet activation/aggregation, inflammatory cell infiltration, the differentiation state of neointimal smooth muscle cells (SMCs), expression of platelet-derived growth factor (PDGF), and endothelial cell regeneration at sites of bare-metal stents (BMS) in patients with acute coronary syndrome (ACS). METHODS: Sixteen coronary arteries after stenting were obtained at autopsy from ACS patients. Serial frozen sections were stained with antibodies against SMCs (1A4, HHF-35, CGA-7), macrophages, neutrophils, endothelial cells, GP IIb/IIIa, P-selectin, PDGF-B, and PDGF-beta receptor. RESULTS: Up to 12 days after BMS, the stent sites contained P-selectin-positive activated platelets with neutrophil infiltration. From 24 to 55 days after BMS, parts of the platelet thrombi were still positive for P-selectin, and infiltration of neutrophils and macrophages was also found. Neointimal SMCs at these stages stained positive with 1A4 but negative with CGA-7, and PDGF-B and PDGF-beta receptor were expressed in macrophages and SMCs. At sites from 3 months onward, platelet thrombi and neutrophil infiltration were not detected, and the neointima contained increased numbers of highly differentiated SMCs with CGA-7 positivity. The P-selectin-positive area was positively correlated with the neutrophil count and macrophage-positive area (neutrophils, r=0.86, p<0.0005; macrophage, r=0.66, p<0.05). In contrast, the P-selectin-positive area was negatively correlated with the HHF-35-positive area and CGA-7-positive area (HHF-35, r=-0.90, p<0.0001; CGA-7, r=-0.82, p<0.005). CONCLUSION: These observations suggest that P-selectin-positive platelet thrombi in the neointima are positively associated with the inflammatory cell infiltration and reversely associated with the phenotypic redifferentiation of neointimal SMCs after BMS in ACS patients.

Relation of elevated levels of plasma myeloperoxidase to impaired myocardial microcirculation after reperfusion in patients with acute myocardial infarction.

Previous studies have shown that oxidative stress and endothelial dysfunction are related to impaired myocardial microcirculation after reperfusion. Moreover, elevated myeloperoxidase (MPO) levels are associated with endothelial dysfunction. Plasma MPO levels were measured in patients with ST-segment elevation acute myocardial infarction (n = 160) who had undergone percutaneous coronary stenting within 12 hours of symptom onset. We investigated whether the plasma MPO level at admission was associated with impaired myocardial microcirculation, as indicated by ST-segment resolution and myocardial blush grade after reperfusion, and left ventricular ejection fraction and remodeling at 6 months. The patients were divided into 2 groups according to the median MPO value for the entire cohort (low-MPO group < or =50 ng/ml, n = 80; high-MPO group >50 ng/ml, n = 80). ST-segment resolution and the myocardial blush grade were significantly lower in the high-MPO than in the low-MPO group (48 +/- 27% vs 61 +/- 24%, p <0.005; and 2.1 +/- 0.8 vs 2.4 +/- 0.7, p <0.01; respectively). Moreover, the percentage of increase in the left ventricular end-diastolic volume index was significantly greater and the left ventricular ejection fraction at 6 months was significantly lower in the high-MPO group than in the low-MPO group (8.2 +/- 24.7% vs -1.9 +/- 23.5%, p <0.05; and 46 +/- 9% vs 54 +/- 9%, p <0.0001, respectively). Multiple regression analysis showed that the plasma MPO level was an independent predictor of incomplete ST-segment resolution (odds ratio 6.94, 95% confidence interval 2.10 to 22.9, p = 0.0015). In conclusion, elevated plasma MPO levels at admission were associated with impaired myocardial microcirculation after reperfusion in patients with acute myocardial infarction.

A novel echocardiographic index of inefficient left ventricular contraction resulting from mechanical dyssynchrony.

OBJECTIVES: The purpose of this study was to explore the possibility of using our novel echocardiographic index of inefficient left ventricular (LV) contraction in patient selection for cardiac resynchronization therapy (CRT). METHODS: Forty consecutive patients with LV ejection fraction < or = 35% were divided into 2 groups, 9 CRT candidates and 31 non-CRT candidates based on conventional criteria. A global LV time-area curve and regional LV time-area curves in 6 radial sectors were obtained using two-dimensional echocardiography in the short-axis view with speckle tracking. Fractional inefficient contraction (FIC, %) was calculated as follows: (1-global LV area change/sum of regional LV area changes) x 100. LV dyssynergy and dyssynchrony were quantified as the standard deviations of minimal values of circumferential speckle-tracking strain and their timings in the 6 sectors, respectively. RESULTS: There was no significant difference in LV dyssynchrony between CRT candidates and non-CRT candidates (79 + or - 61 ms vs. 58 + or - 26 ms, respectively). In contrast, FIC was significantly larger in CRT candidates than in non-CRT candidates (15.7 + or - 11.0% vs. 5.4 + or - 3.5%, respectively, p=0.0018), with less overlap between groups. FIC showed a positive correlation with dyssynchrony (r=0.64) and a negative correlation with dyssynergy (r=-0.42). CONCLUSIONS: Our novel echocardiographic index of inefficient LV contraction, which increases with more dyssynchrony or less dyssynergy, may prove more useful in patient selection for CRT than other indices that focus on LV temporal dyssynchrony alone.

Stenting of right coronary ostial occlusion due to thrombosed type A aortic dissection: One-year follow-up results.

A 52-year-old man experienced acute chest pain and was transferred to our hospital. An electrocardiogram showed ST-segment elevation in leads II, III, aVf, and V1 through V3. The diagnosis at the emergency room was inferior acute myocardial infarction (AMI), and emergent coronary angiography (CAG) was performed. While CAG showed subtotal occlusion of the right coronary artery (RCA) ostium, aortic dissection was suspected due to staining of the contrast agent distal to the occluded site of RCA. Intravascular ultrasound showed compression of the RCA ostium due to aortic dissection. We performed bare metal stent implantation, and contrast-enhanced computed tomography (CT) after stenting showed a thrombosed type A aortic dissection. The patient received medical treatment along with repeated CT and echocardiographic examinations, and was discharged without any events one month after admission. CAG six months after stenting and 64-multislice CT angiography one year later showed a patent RCA. Contrast-enhanced CT at six months showed complete resorption of the ascending aortic intramural hematoma, and 64-multislice CT at one year showed a descending aortic intramural hematoma. The patient is doing well one year after the onset. This is a rare case of successful medical treatment for acute type A aortic dissection complicated with AMI.

Enhanced expression of haemoglobin scavenger receptor in accumulated macrophages of culprit lesions in acute coronary syndromes.

AIMS: Effective clearance of extracellular haemoglobin (Hb) is thought to limit systemic oxidative heme toxicity, which is presumed to contribute to the pathogenesis of plaque instability. We immunohistochemically examined the relationship between intraplaque haemorrhage, 4-HNE (4-hydroxy-2-nonenal), an index of lipid peroxidation, and the Hb scavenger receptor (CD163), using coronary atherectomy specimens from 74 patients with stable angina pectoris (SAP, n = 39) or unstable angina pectoris (UAP, n = 35). METHODS AND RESULTS: Atherectomy samples were stained with antibodies against glycophorin A (a protein specific to erythrocyte membranes), CD31, 4-HNE, and CD163. Quantitative analysis demonstrated that glycophorin A-positive areas, 4-HNE-positive macrophage score, and CD163-positive macrophage score in UAP patients were significantly higher (glycophorin A, P < 0.0001; 4-HNE-positive macrophage score, P < 0.0001; CD163-positive macrophage score, P < 0.0005) than in SAP patients. The percentage of the glycophorin A-positive area showed a significant positive correlation with the number of CD31-positive microvessels and the 4-HNE-positive macrophage score (microvessels, R = 0.59, P < 0.0001; 4-HNE, R = 0.59, P < 0.0001). Moreover, the CD163-positive macrophage score was positively correlated with glycophorin A-positive area and the 4-HNE-positive macrophage score (glycophorin A, R = 0.58, P < 0.0001; 4-HNE, R = 0.53, P < 0.0001). CONCLUSION: These findings suggest a positive association among intraplaque haemorrhage, enhanced expression of Hb scavenger receptor, and lipid peroxidation in human unstable plaques.

[Primary aldosteronism with ventricular fibrillation: a case report].

A 60-year-old female had sudden onset of syncope. The emergency service noticed that she suffered cardiopulmonary arrest (ventricular fibrillation: VF). After defibrillation in the ambulance, she was transported to our emergency department. Electrocardiography monitoring showed QT prolongation. Serum potassium level was extremely low at 1.8 mEq/l. Although potassium and lidocaine were administered, it was difficult to maintain appropriate electrolyte balance and prevent VF after admission, so temporary overdrive pacing was required. She was diagnosed as having primary aldosteronism after laboratory and imaging examinations. VF was otherwise uncontrollable so a cardioverter defibrillator was implanted on the 24th hospital day. Laparoscopic adrenalglandectomy was performed about 1 month later. After the surgery, serum potassium level remained at an appropriate level without medication. No severe neurological deficits were found at discharge from our hospital.

[Primary effusion lymphoma complicating cardiac tamponade: a case report].

A 76-year-old woman was admitted to our hospital because of exertional dyspnea and leg edema during the previous month. Her systolic blood pressure on admission was 80 mmHg with 12 mmHg of pulsus paradoxous, and her pulse rate was 110 beats/min. Chest radiography revealed marked cardiomegaly and echocardiography showed massive pericardial effusion mainly behind the left ventricle and collapse of the right ventricle. The initial diagnosis was pericardial tamponade. Pericardiocentesis and pericardial drainage revealed bloody pericardial effusion. After drainage, her vital signs improved and her symptoms immediately disappeared. The cytological analysis of the pericardial effusion revealed numerous lymphoma cells. Computed tomography of the neck, chest and abdomen showed no evidence of tumor masses, lymph node enlargement, or hepatosplenomegaly. Infectious disease, collagen disease and aortic dissection were excluded. The final diagnosis was primary effusion lymphoma. The prognosis of primary effusion lymphoma is generally unfavorable because it is frequently accompanied by immunodeficiency disease. However, there was no human immunodeficiency virus infection in this patient. Fortunately, the effect of chemotherapy was excellent and the patient is doing well 1 year after the diagnosis.

[Efficacy of percutaneous balloon pericardiotomy and intrapericardial instillation for the management of refractory pericardial effusion: a case report].

Percutaneous balloon pericardiotomy and intrapericardial instillation seemed to be less invasive and effective treatments for refractory pericardial effusion. A 65-year-old man who suffered from refractory pericardial effusion associated with gastric cancer and had been hospitalized three times for pericardiocentesis, complained of dyspnea at rest and visited our emergency room. Echocardiography showed a large amount of pericardial effusion all around the heart and signs of cardiac tamponade. Percutaneous balloon pericardiotomy was performed and pericardial effusion turned to pleural effusion. We performed left thoracocentesis. One week later, massive pericardial effusion localized only around the right heart appeared, and pericardiocentesis was performed again. After another month, pericardial effusion around right heart appeared again and intrapericardial instillation with OK-432 (Picibanil) was tried. After the procedure, the pericardial effusion did not increase, and he has had few symptoms for 2 months as an outpatient.