Complete Revascularization of Simultaneous Acute Occlusion of Three Major Coronary Arteries.

Our case demonstrates that rapid and complete revascularization by PCI can save a patient with acute myocardial infarction caused by simultaneous acute occlusion of the three major coronary arteries.

Asymptomatic abdominal aortic stenosis detected by unenhanced computed tomography before angiography in acute myocardial infarction.

Although rapid treatment is important, unenhanced computed tomography before angiography is quick and can detect myocardial infarction induced by aortic dissection and also asymptomatic abdominal aortic stenosis in acute myocardial infarction cases.

ST segment elevation in secondary cardiac cancer: a case report and review of the literature.

Secondary cardiac cancer most frequently originates from primary lung cancer and most commonly occurs in the pericardium. On electrocardiographic examination, patients with secondary cardiac cancer occasionally show ST segment elevation that mimics acute coronary syndrome, despite the absence of coronary artery occlusion. We herein describe a rare case of secondary cardiac cancer that presented with ST segment elevation and review the literature regarding ST segment elevation caused by secondary cardiac cancer. A 73-year-old Japanese woman was admitted to the hospital with chest pain. Electrocardiography showed abnormal ST segment elevation in the precordial and lateral leads, suggestive of ST-elevation myocardial infarction. Emergency coronary angiography showed occlusion of the distal left anterior descending coronary artery (LAD), and plain old balloon angioplasty of the LAD was performed. The ST segment elevation initially resolved after angioplasty, but recurred after 7 days. Contrast-enhanced chest computed tomography showed primary lung cancer in the left lower lobe, pericardial metastasis, and myocardial metastasis in the intraventricular septum and posterolateral wall of the left ventricle. Histopathological examination of the lung cancer was not performed. Patients with ST segment elevation due to secondary cardiac cancer may have symptoms and electrocardiographic changes mimicking anteroseptal or lateral infarction without the development of abnormal Q waves. These findings are frequently associated with posterolateral or anteroseptal invasion by primary lung cancer and may indicate a poor prognosis. In conclusion, physicians should be aware that secondary cardiac cancer may present with symptoms and ST segment elevation mimicking acute coronary syndrome, indicating a poor prognosis.

Capillary endothelial fatty acid binding proteins 4 and 5 play a critical role in fatty acid uptake in heart and skeletal muscle.

OBJECTIVE: Fatty acids (FAs) are the major substrate for energy production in the heart. Here, we hypothesize that capillary endothelial fatty acid binding protein 4 (FABP4) and FABP5 play an important role in providing sufficient FAs to the myocardium. APPROACH AND RESULTS: Both FABP4/5 were abundantly expressed in capillary endothelium in the heart and skeletal muscle. The uptake of a FA analogue, 125I-15-(p-iodophenyl)-3-(R,S)-methyl pentadecanoic acid, was significantly reduced in these tissues in double-knockout (DKO) mice for FABP4/5 compared with wild-type mice. In contrast, the uptake of a glucose analogue, 18F-fluorodeoxyglucose, was remarkably increased in DKO mice. The expression of transcripts for the oxidative catabolism of FAs was reduced during fasting, whereas transcripts for the glycolytic pathway were not altered in DKO hearts. Notably, metabolome analysis revealed that phosphocreatine and ADP levels were significantly lower in DKO hearts, whereas ATP content was kept at a normal level. The protein expression levels of the glucose transporter Glut4 and the phosphorylated form of phosphofructokinase-2 were increased in DKO hearts, whereas the phosphorylation of insulin receptor-ß and Akt was comparable between wild-type and DKO hearts during fasting, suggesting that a dramatic increase in glucose usage during fasting is insulin independent and is at least partly attributed to the post-transcriptional and allosteric regulation of key proteins that regulate glucose uptake and glycolysis. CONCLUSIONS: Capillary endothelial FABP4/5 are required for FA transport into FA-consuming tissues that include the heart. These findings identify FABP4/5 as promising targets for controlling the metabolism of energy substrates in FA-consuming organs that have muscle-type continuous capillary.

Peroxisome proliferator-activated receptor-γ in capillary endothelia promotes fatty acid uptake by heart during long-term fasting.

BACKGROUND: Endothelium is a crucial blood-tissue interface controlling energy supply according to organ needs. We investigated whether peroxisome proliferator-activated receptor-γ (PPARγ) induces expression of fatty acid-binding protein 4 (FABP4) and fatty acid translocase (FAT)/CD36 in capillary endothelial cells (ECs) to promote FA transport into the heart. METHODS AND RESULTS: Expression of FABP4 and CD36 was induced by the PPARγ agonist pioglitazone in human cardiac microvessel ECs (HCMECs), but not in human umbilical vein ECs. Real-time PCR and immunohistochemistry of the heart tissue of control (Pparg(fl/null)) mice showed an increase in expression of FABP4 and CD36 in capillary ECs by either pioglitazone treatment or 48 hours of fasting, and these effects were not found in mice deficient in endothelial PPARγ (Pparg(▵)(EC)(/null)). Luciferase reporter constructs of the Fabp4 and CD36 promoters were markedly activated by pioglitazone in HCMECs through canonical PPAR-responsive elements. Activation of PPARγ facilitated FA uptake by HCMECs, which was partially inhibited by knockdown of either FABP4 or CD36. Uptake of an FA analogue, (125)I-BMIPP, was significantly reduced in heart, red skeletal muscle, and adipose tissue in Pparg(▵)(EC)(/null) mice as compared with Pparg(fl/null) mice after olive oil loading, whereas those values were comparable between Pparg(fl/null) and Pparg(▵)(EC)(/null) null mice on standard chow and a high-fat diet. Furthermore, Pparg(▵)(EC)(/null) mice displayed slower triglyceride clearance after olive oil loading. CONCLUSIONS: These findings identified a novel role for capillary endothelial PPARγ as a regulator of FA handing in FA-metabolizing organs including the heart in the postprandial state after long-term fasting.

Activation of receptor for advanced glycation end products induces osteogenic differentiation of vascular smooth muscle cells.

AIM: Vascular calcification is prevalent in patients with diabetes and chronic kidney disease. Receptor for advanced glycation end products (RAGE) and its multiple ligands have been implicated in the pathogenesis of accelerated atherosclerosis; however, little is known about the effects of RAGE activation on vascular calcification. METHODS AND RESULTS: Cultured rat and human aortic smooth muscle cells (HASMC) were transduced with adenovirus expressing RAGE. Expression of myocardin and the SMC-marker genes was significantly repressed in these cells. RAGE activation inhibited myocardin-induced expression of the SMC genes in mouse embryonic mesenchymal C3H10T1/2 cells. Interestingly, RAGE activation induced alkaline phosphatase (ALP) expression, calcium deposition, and Msx2 expression, a crucial transcription factor for osteogenic differentiation, in HASMC. RAGE-induced osteogenic differentiation was significantly inhibited by endogenous secretory RAGE. RAGE-induced ALP and Msx2 expression was completely abrogated by DAPT, an inhibitor of the Notch signaling pathway. PD98059 (MEK inhibitor) effectively blunted RAGE-induced Notch1 and Msx2 gene expression. Simultaneous stimulation with bone morphogenetic protein 2 (BMP2) and RAGE signaling synergistically induced expressions of Msx2 and ALP in HASMC. Immunohistochemistry revealed that the human calcifying atherosclerotic plaque expressed RAGE, Notch components and Msx2. The ALP activity induced in RAGE-overexpressing HASMCs by human serum was positively correlated with the serum creatinine level, but not with phosphate and hemoglobin A1c levels. CONCLUSIONS: These results indicate that activation of RAGE not only inhibits myocardin-dependent SMC gene expression, but also induces osteogenic differentiation of vascular SMC through Notch/Msx2 induction. These results provide a novel insight into the role of RAGE axis in vascular calcification.

Endoscopic submucosal dissection for colorectal neoplasia.

AIM: Endoscopic submucosal dissection (ESD) has been positively applied to and gradually standardized for early gastric cancer; however, it is not widely used in the colorectum because of its technical difficulty. METHODS: To increase the safety and ease of carrying out colon ESD, we developed a new scissors-type device that we call the stag beetle knife (SBK). Here we report on our efforts to assess the efficacy and safety of colon ESD using the SBK. RESULTS: ESD was carried out using SBK in 25 patients with colorectal neoplasia. All lesions were treated safety and easily, without any unexpected incisions. No delayed hemorrhage and perforation occurred. An en-bloc resection and a negative resection margin were obtained in all cases. CONCLUSION: ESD using the SBK can be carried out with greater ease and safety for colorectal neoplasia.

[Carcinoma of the gallbladder which progress on the mucosa of choledochocolonic fistula].

A 70-year-old man was admitted to our hospital for further examination of pneumobilia and atrophy in the gallbladder. Abdominal CT scan and EUS revealed that the atrophic gallbladder was occupied by a tumor lesion. In addition, ERCP showed choledochocolonic fistula. Colonoscopy revealed an elevated lesion in the colonic side of fistula, and biopsy of the elevated lesion revealed adenocarcinoma. Cholecystectomy and right hemicolectomy was performed under a preoperative diagnosis of gallbladder carcinoma with choledochocolonic fistula. Pathologically, most of the tumor was localized in the gallbladder, and grew along the mucosa of choledchocolonic fistula. This case was of interest with regard to the relationship between the choledochocolonic fistula and gallbladder carcinoma.

Predominance of mother-to-child transmission of Helicobacter pylori infection detected by random amplified polymorphic DNA fingerprinting analysis in Japanese families.

BACKGROUND: Helicobacter pylori (H. pylori) is one of the most common bacterial pathogens in humans but the route of transmission remains unclear. We investigated transmission by DNA fingerprinting analysis of cultured H. pylori from pediatric patients and their family members. METHODS: Forty-two index patients with a mean age of 11.7 years (range, 4-19) were diagnosed as having H. pylori gastritis with or without duodenal/gastric ulcer disease. A total of 66 family members for whom the results of the H. pylori stool antigen test and/or serum H. pylori IgG test were positive underwent endoscopic examination and biopsy or aspiration of gastric juice for H. pylori culture. The extraction of H. pylori genomic DNA and PCR-based RAPD analysis were performed. RESULTS: Thirty-two (76%) of the 42 patients showed DNA fingerprint patterns identical to those of at least one of the respective family members. The patterns of 29 (69%) of the analyses of the H. pylori infected patients were identical to those of their mothers. The patterns for 7 patients were identical to those of their fathers, and those for 6 of the latter patients were also identical to those of their mothers. The rate of fingerprint patterns identical to those of the index patients was significantly higher in those of mothers compared with those of fathers (P < 0.01). CONCLUSIONS: Mother-to-child transmission is the predominant route of H. pylori infection in Japan.

Hemodynamic evaluation by endoscopic ultrasonography of esophageal varices resistant to injection sclerotherapy.

PURPOSE: Some esophageal variceal cases are resistant to endoscopic injection sclerotherapy (EIS) using 5% ethanolamine oleate (5% EO). We evaluated the hemodynamics of esophageal varices that were resistant to EIS using 5% EO. METHODS: Selected for this study were 290 consecutive patients who underwent hemodynamic evaluation using endoscopic color Doppler ultrasonography (ECDUS) and an ultrasonic microprobe (UMP) before EIS. EIS was performed using 5% EO with iopamidol (5% EOI) under fluoroscopy. We retrospectively evaluated the hemodynamic differences between patients resistant to and not resistant to EIS using 5% EOI. RESULTS: Nine patients were resistant to EIS using 5% EOI (group A). Various parameters were compared between the 281 patients who had been given EIS using 5% EOI for esophageal varices (group B) and the 9 patients in group A. The mean number of EIS treatments until shrinkage of esophageal varices was achieved in group A (6.8 ± 3.4) was significantly greater than that in group B (4.4 ± 2.1) (P < 0.01). The mean amount of 5% EOI used in group A (31.1 ± 17.4 ml) was significantly larger than that used in group B (14.9 ± 8.8 ml) (P < 0.001). The mean frequency shift of esophageal varices in group A (452.9 ± 106.6 Hz) was significantly higher than that in group B (313.0 ± 103.2 Hz) (P < 0.001) as determined by ECDUS. The mean diameter of esophageal varices as found by UMP was 8.0 ± 3.5 mm in group A and 4.6 ± 2.4 mm in group B, with the difference being significant (P < 0.01). Perforating veins inflowing from extramural to intramural regions were recognized in 8 (88.9%) of the 9 patients in group A and in 67 (24.1 %) of the 281 patients in group B. The mean diameter of the perforating vein was 3.8 ± 1.9 mm in group A and 2.1 ± 0.5 mm in group B, as shown by UMP, a difference that was statistically significant (P < 0.01). CONCLUSION: Hemodynamic evaluation revealed that the esophageal varices were of a higher grade in group A than in group B. By using ECDUS and UMP, this study shed light on the hemodynamics of esophageal variceal cases resistant to EIS using 5% EOI.

Improvement in symptoms after H2-receptor antagonist-based therapy for eradication of H pylori infection.

AIM: To investigate the therapeutic effects of triple therapy combining lafutidine with clarithromycin and amoxicillin on H pylori infection and the resolution of gastroesophageal symptoms after eradication. METHODS: We conducted a randomized, multicenter, open-label controlled trial to compare the effectiveness of a triple therapy of lafutidine, clarithromycin, and amoxicillin (lafutidine group) with that of a triple therapy of lansoprazole, clarithromycin, and amoxicillin (lansoprazole group) in patients with H pylori infection. The study group comprised 22 patients with gastric ulcers and 18 patients with duodenal ulcers who had H pylori infection. RESULTS: H pylori eradication rates were similar in the lafutidine group (14/20, 70%) and the lansoprazole group (14/20, 70%). Gastroesophageal reflux and abdominal symptoms improved after eradication therapy in both groups, whereas abdominal discomfort, diarrhea, and constipation were unchanged. H pylori status had no apparent effect on improvement of gastroesophageal reflux or abdominal symptoms after treatment. Adverse events were similar in both groups. CONCLUSION: The triple therapy including lafutidine is equivalent to triple therapy including lansoprazole in terms of H pylori eradication rates and improvement in gastroesophageal reflux and abdominal symptoms. These results are attributed to the fact that lafutidine has strong, continuous antisecretory activity, unaffected by CYP2C19 polymorphisms.

Hemodynamic changes in a patient with esophageal varices after endoscopic injection sclerotherapy evaluated by endoscopic color Doppler ultrasonography.

A 46-year-old man with alcoholic cirrhosis was admitted to our hospital for treatment of high-risk esophageal varices in February 2000. Images of the esophageal varices, paraesophageal veins and palisade veins were obtained by endoscopic color Doppler ultrasonography (ECDUS) before endoscopic injection sclerotherapy (EIS). Prophylactic EIS was performed six times per week for esophageal varices, and EIS was continued until the esophageal varices were completely eradicated. In July 2002, endoscopy revealed esophageal varices graded as Cb, F1, Lm, and RC(-), and color flow images of the palisade veins (hepatofugal flow), esophageal varices, and a developed paraesophageal vein were obtained with ECDUS. In April 2003, endoscopy showed esophageal varices graded as Cb, F1, Lm, and RC(-), and color flow images of the palisade veins and esophageal varices were obtained using ECDUS. The blood in the palisade veins flowed in an alternate direction on color flow images, and pulsatile waves were delineated at the gastroesophageal junction. In January 2004, endoscopy revealed esophageal varices graded as F0 and RC(-), and pulsatile waves were delineated in the lower esophagus with ECDUS. However, the esophageal varices and palisade veins had disappeared from color flow images. In conclusion, ECDUS was useful for evaluating hemodynamic changes after EIS.

Efficacy of color Doppler ultrasonography for the diagnosis of duodenal varices successfully treated with percutaneous transhepatic obliteration.

We treated a 74-year-old woman who complained of tarry stool. Neither endoscopic examination of the upper gastrointestinal tract nor colonoscopy revealed any finding indicative of bleeding, and (99m)Tc-HSA-D pool scintigraphic imaging showed no accumulation of blood in the digestive tract. Small tortuous collateral veins were observed on computed tomography (CT) in the distal third portion of the duodenum. Color Doppler ultrasonography obtained color flow images of varices in the distal third portion of the duodenum indicating turbulent flow, and color flow imaging showed the outflow vessel from duodenal varices. Duodenoscopy revealed tortuous varices, with erosions and blue in appearance, in the same area. Percutaneous transhepatic portography was carried out 18 days after the treatment of ascites, and hepatofugal blood flow was confirmed in the pancreatic duodenal vein originating near the junction between the splenic and inferior mesenteric veins with the passage of contrast medium into the duodenal varices, which drained into the left ovarian vein. We performed selective catheterization into the afferent vein of the varices, and injected 8 ml of a 5% solution of ethanolamine oleate containing iopamidol. Microcoil embolization using steel coils was added because the therapeutic effect resulting after the relatively rapid washout of sclerosant was insufficient. CT and color Doppler ultrasonography showed absence of blood flow in the varices 1 week after the therapy. This patient has had no episodes of rebleeding in the 24 months after therapy. Color Doppler ultrasonography was useful in diagnosing this case of duodenal varices and in evaluating therapeutic effect.

Hemodynamic evaluation of rectal varices by color Doppler ultrasonography: a case report.

A 69-year-old man with liver cirrhosis was admitted to our hospital with general fatigue. Colonoscopy revealed risky red color sign-positive enlarged tortuous rectal varices. Endoscopic injection sclerotherapy (EIS) was performed three times weekly using 5% ethanolamine oleate with iopamidol; the total amount of sclerosant was 7 ml. Images of rectal varices and the outflowing vessel from rectal varices were obtained via color Doppler ultrasonography before EIS, and fast Fourier transform analysis showed a continuous flow with a frequency shift of 276.6 Hz. We successfully performed EIS for this patient, having effective varicealography. After EIS, colonoscopy revealed shrinkage of the varices in the rectum, and color Doppler indicated an extreme decrease of blood flow in the rectal varices. In conclusion, color Doppler is a useful noninvasive modality for detecting rectal varices and for evaluating the therapeutic effects of EIS.

The value of the endoscopic therapies in the treatment of rectal varices: a retrospective comparison between injection sclerotherapy and band ligation.

This study consisted of 15 patients who had undergone endoscopic injection sclerotherapy (EIS) or endoscopic variceal ligation (EVL) for rectal varices. Ten of fifteen patients had histories of anal bleeding, and colonoscopy revealed signs of the risk of variceal rupture in the other five patients. EIS was perfomed in six of the fifteen patients, and the other nine patients underwent EVL. EIS was performed weekly from 2 to 4 times (mean, 3.0), and the total amount of sclerosant ranged from 3.2 to 5.8ml (mean, 4.9ml). After EIS, colonoscopy revealed shrinkage of the rectal varices in all six patients with no complications. EVL was performed weekly from 1 to 3 times (mean, 2.2), and bands were placed on the varices at 2-12 sites (mean, 8.0). After EVL, colonoscopy revealed both ulcers and shrinkage of the varices in the rectum in all nine patients. Eight of the nine experienced no operative complications. However, in the other case, colonoscopy revealed bleeding from ulcers after EVL. The average follow-up period after EIS or EVL was 30 months. The overall non-recurrence rate of rectal varices was 11 of 15 (73.3%); this includes five of the six patients (83.3%) receiving EIS and six of the nine who received EVL (66.7%). The non-recurrence rate was no difference between EIS group and EVL group statistically (P=0.57) by reason of small number of cases. In conclusion, EIS is some superior to EVL with regard to long-term effectiveness, complications on rectal varices.

Usefulness of electronic radial endoscopic color Doppler ultrasonography in esophageal varices: comparison with convex type.

BACKGROUND: Endoscopic color Doppler ultrasonography (ECDUS) is a method for detecting color flow images in blood vessels. We previously reported on the usefulness of ECDUS (convex-type scanning instruments with forward--oblique viewing) for evaluating the hemodynamics of esophageal varices. In the present study, we report the usefulness of new electronic radial ECDUS in cases of esophageal varices by comparison with convex-type ECDUS. METHODS: Twenty-six patients with esophageal varices were identified and studied. The underlying pathologies of portal hypertension included liver cirrhosis (15 patients) and cirrhosis associated with hepatocellular carcinoma (11 patients). Endoscopic findings of esophageal varices were as follows: Cb, F3, and Ls varices in four patients; Cb, F2, and Lm varices in 21 patients; and Cb, Lm, and F1 varices in one patient. RC1 was observed in the esophagus in 14 of the 26 patients. RC2 was noted in 11 cases, and RC0 was seen in one patient. ECDUS was performed using a Pentax EG-3630UR (forward view) with a distal tip diameter of 12 mm. The instrument (electronic radial array) has a curved array scanning transducer with variable frequency (5.0, 7.5, 10.0 MHz). A Hitachi EUB 6500,8500 was used for the display, providing 270 degrees images. We monitored the color flow images of esophageal varices, paraesophageal veins, palisade veins, perforating veins, and pulsatile waves using this technique. As a control, 110 patients were examined by convex-type ECDUS. RESULTS: (1) Color flow images of esophageal varices and paraesophageal veins were obtained in 26 of the 26 patients, whereas color flow images of perforating veins were obtained in 18 of the 26 patients (69.2%). Color flow images of palisade veins were obtained in 12 of the 26 patients (46.2%). (2) Color flow images of pulsatile waves were obtained in 10 of the 26 patients (38.5%). Color flow images of pulsatile waves were detected in zero (0%) of the 4 F3 varices, in nine (42.9%) of the 21 F2 varices, and in the 1 (100%) case of F1 varices. Also, color flow images of pulsatile waves were detected in seven (50.0%) of the 14 RC1 varices, in two (18.2%) of the 11 RC2 varices, and in the 1 (100%) case of RC0 varices. (3) As a control, 110 patients were examined by convex-type ECDUS. Color flow images of esophageal varices and paraesophageal veins were obtained in 110 of the 110 patients, whereas color flow images of perforating veins were obtained in 74 of 110 (67.3%) with convex-type ECDUS. The detection rate of palisade veins with electronic radial ECDUS (12 of the 26 patients, 46.2%) was significantly higher than with convex-type ECDUS (28 of the 110 patients, 25.5%) (P<0.05). The detection rate of pulsatile waves with electronic radial ECDUS (10 of the 26 cases, 38.5%) was significantly higher than with convex-type ECDUS (3 of the 110 cases, 2.7%) (P<0.0001). CONCLUSIONS: Electronic radial ECDUS provides clear color flow images of blood vessels in esophageal varices with the additional advantages of forward-view optics and extended 270 degrees views. Electronic radial ECDUS was superior to convex-type ECDUS in detecting palisade veins and pulsatile waves.