Circulating immunoreactive endothelin in patients undergoing percutaneous transluminal coronary angioplasty.

Circulating immunoreactive endothelin (ir-ET) in the coronary sinus (CS) and the femoral artery (Ao) was measured in patients who underwent percutaneous transluminal coronary angioplasty (PTCA). Plasma ir-ET level in the CS was significantly increased from 1.6 +/- 0.8 pg/mL to 2.0 +/- 1.0 pg/mL after PTCA (P less than .05). Plasma ir-ET level in the Ao tended to increase after PTCA, but it was not significant. Plasma ir-ET level in the CS was not related to the plasma thromboglobulin level, plasma thrombin-antithrombin complex level, mean blood pressure, or heart rate. These results suggest that the increase of plasma ir-ET level in the CS may be associated with the coronary endothelial injury by PTCA.

Resting 123I-BMIPP scintigraphy for detection of organic coronary stenosis and therapeutic outcome in patients with chest pain.

PURPOSE: Resting 123I-BMIPP scintigraphy can detect coronary artery disease based on persistent abnormality of myocardial fatty acid metabolism after transient ischemia. The present study aimed to determine the value of resting 123I-BMIPP scintigraphy in diagnosing coronary artery disease and predicting the therapeutic outcome in patients with chest pain symptom. METHOD: Five hospitals participated in this study, and scintigraphic and angiographic studies were performed in 104 patients without myocardial infarction. Twenty of them had non-coronary artery disease (chest pain syndrome), 26 had stable effort angina, 35 had unstable angina with organic coronary lesions, and 23 had vasospastic angina without significant organic stenosis. RESULTS: Overall sensitivity for diagnosing angina pectoris (stable, unstable and vasospastic) was 45%, and overall specificity for excluding non-coronary artery disease was 80%. The incidence of positive 123I-BMIPP was 54% among patients with organic coronary stenosis (50% in stable angina and 61% in unstable angina with organic stenosis), but it was low (22%) in vasospastic angina without organic stenosis. Patients with advanced coronary stenosis and multi-vessel disease were found to have a higher incidence of positive 123I-BMIPP. A positive 123I-BMIPP result was correlated with a higher rate of subsequent intervention therapy (catheter intervention or CABG) than a negative result (48% versus 27%, p = 0.03 at one month; and 63% versus 35%, p = 0.008 at one year). CONCLUSION: Resting 123I-BMIPP scintigraphy was valuable in detecting advanced coronary lesions in angina patients associated with a high incidence of subsequent intervention therapy.

[Clinical value of rapid clearance in resting sestamibi cardiac SPECT in patients with acute myocardial infarction].

Resting 99mTc sestamibi (MIBI) SPECT and exercise-reinjection thallium-201 (T1) SPECT were performed in fourteen patients with acute myocardial infarction (AMI). MIBI SPECT were obtained 90 min (MIBI-90) and 300 min (MIBI-300) after injection of 370 MBq of MIBI at rest. MIBI-90 and MIBI-300 were compared with exercise T1 imaging (T1-EX) and T1 reinjection imaging (REINJ). Each SPECT image was divided into 22 segments and myocardial uptake was scored visually. Abnormal perfusion defects were observed in 94 myocardial regions. Worsening of the score was observed in 79 segments (84%) on MIBI-300 compared with MIBI-90. Total MIBI-300 uptake score per person was significantly greater than that at MIBI-90 (14.8 +/- 8.6 vs. 7.7 +/- 7.9, p = 0.001). The concordance rate of defect score between MIBI-90 and REINJ was significantly higher than that between MIBI-300 and REINJ (55% vs. 17%, p = 0.001). In nine patients without recanalization of an infarct-related artery, perfusion defects were seen in 74 segments. The concordance rate of defect scores between MIBI-300 and T1-EX was significantly higher than that between MIBI-90 and T1-EX (45% vs. 16%, p = 0.001). In conclusion, rapid clearance of MIBI was observed frequently in patients with AMI. MIBI-90 and MIBI-300 may reflect myocardial viability and areas at risk for AMI, respectively.

[Malignant thymoma detected by thallium-201 myocardial scintigraphy].

We present two cases of malignant thymoma which showed a remarkable accumulation of thallium-201 chloride on myocardial scintigraphy. A 69 year-old man underwent stress 201Tl scintigraphy to evaluate myocardial ischemia and abnormal accumulation of thallium activity was observed in the anterior mediastinum by chance. It was more clearly visualized on delayed image. Moreover, abnormal uptake of 67Ga citrate was also observed in the same region. In another 68 year-old woman, there was high uptake on 201Tl scintigraphy, but no abnormal uptake using 67Ga. The diagnosis of malignant thymoma was confirmed by operation in each patient. These two cases had no abnormality in the mediastinum on the chest X-ray film and one of them had no uptake of 67Ga, 201Tl scintigraphy was more useful to detect malignant thymoma.

[Acute myocardial infarction and silent myocardial ischemia in the elderly--clinical features and effectiveness of therapy in an era of coronary intervention].

To elucidate the clinical features of acute myocardial infarction (AMI) and post-MI silent myocardial ischemia (SMI) in the elderly, and efficacy of therapy in an era of coronary intervention, a total of 10,607 patients with AMI who were enrolled in a multicenter survey between 1982 and 1992 were examined. The elderly had a higher ratio of females, noncardiac illness, atypical symptoms at the onset of AMI, severe pump failure at admission, cardiac rupture and multivessel disease. Hospital mortality was markedly higher in patients > or = 75 years, and it was 4-fold compared with patients < 65 years. In the last 5 years, the rate of application of coronary angiography and primary PTCA significantly increased even in the very elderly. In contrast, use of thrombolysis highly diminished. Hospital mortality declined (14.6 vs 11.9%, p < 0.001) in every age group compared with the first 5 years, although it was higher in the elderly even in the last 5 years. Investigation of 642 survivors after AMI admitted to one hospital showed that the elderly had a higher incidence of SMI and post-MI angina compared with the non-elderly. Clinical features of SMI were similar in both groups. However, medical treatment was more prevalent and recurrence of MI and cardiac death during follow-up (average 27 months) were more frequent in the elderly. In this retrospective study, characteristics of AMI and SMI, and effectiveness and limitation of therapy in the elderly were clearly demonstrated. It was evident that hospital mortality of the elderly had improved, although it was still higher than the non-elderly.

[Clinical significance of improved persistent defect by thallium-201 reinjection imaging in the subacute phase of myocardial infarction].

The clinical significance of new fill-in observed by thallium-201 (201Tl) reinjection in myocardial segments with persistent defect in the subacute phase of myocardial infarction was investigated. Seventy-five patients with subacute phase (mean 20th day) of first myocardial infarction underwent stress-redistribution-reinjection 201Tl single photon emission computed tomography (SPECT) imaging. Percentage 201Tl uptake was calculated and classified as persistent defect without fill-in even after reinjection (PD group, n = 26, 35%), persistent defect with new fill-in after reinjection [REINJ (+) group, n = 19, 25%] and reversible defect [RD (+) group, n = 24, 32%]. The clinical features and angiographic findings were assessed in the same phase in each group. Diameter stenosis of the infarction-related arteries by coronary angiography was 68 +/- 34% in the PD group, 31 +/- 23% in the REINJ (+) group and 83 +/- 27% in the RD (+) group [p < 0.01, REINJ (+) group vs PD group and RD (+) group]. Wall motion of the infarcted myocardial segments significantly improved and the mean left ventricular ejection fraction (EF) was higher in the REINJ (+) group than in the PD group (mean EF 51% vs 43%, p < 0.01). Post infarction angina was more frequent in the RD (+) group than in the REINJ (+) group (38% vs 5%, p < 0.05). Although new fill-in-after 201Tl reinjection has been considered to indicate severe myocardial ischemia in chronic coronary disease, these results indicate that this phenomenon in viable myocardium in patients with subacute phase of myocardial infarction is not always related to residual ischemia in the infarcted myocardial area.

Isolated lateral traumatic dislocation of the radial head in a boy: case report.

Lateral traumatic dislocation of the radial head occurred in a 9-year-old boy with cubitus varus. Reduction of the dislocation and immobilization of the arm in flexion and supination in a plaster cast for 4 weeks were done and after 6 months the boy returned to school, with no problems in daily living.

[Detection of left ventricular thrombi after acute myocardial infarction using Ga-67-DFO-DAS-fibrinogen].

Ga-67-DFO-DAS-fibrinogen (Ga-fbg) scintigraphy, a new radiopharmaceutical method, was performed for detecting intraventricular thrombi following acute myocardial infarction in five patients. The thrombi in four of them were detected by two-dimensional echocardiography (2DE) and that in the fifth patient was suspected during magnetic resonance imaging. Imaging of the heart was performed using a scinticamera with a medium energy collimator and multiple views (anterior, LAO 30 degrees, LAO 45 degrees, and lateral) three and four days after the intravenous administration of Ga-fbg. By Ga-fbg scintigraphy, intraventricular thrombi were detected in four patients. The size of the thrombi visualized by Ga-fbg appeared larger than those by 2DE. In one patient examined again after anticoagulant therapy, a thrombus was missed by 2-DE, but it was detected by Ga-fbg, though the radioactivity of the thrombus decreased. We concluded that Ga-fbg scintigraphy is a very simple method and sufficiently useful for detecting active left ventricular thrombi and for monitoring the effect of anticoagulant therapy. It could be more sensitive than 2DE for determining the extent of an active intraventricular thrombus.

[Estimation of myocardial viability and clinical significance of reverse redistribution in resting technetium-99m sestamibi myocardial single photon emission computed tomography in patients with acute myocardial infarction].

The clinical significance of reverse redistribution of technetium-99m sestamibi (MIBI) was investigated in 36 patients with acute myocardial infarction and angiographically confirmed single-vessel disease, but without previous infarction using resting MIBI myocardial single photon emission computed tomography (SPECT) and exercise-reinjection thallium-201 (Tl) myocardial SPECT. MIBI myocardial SPECT was performed 90 min and 300 min after injection of MIBI 370 MBq at rest. Four hours after exercise Tl imaging was completed, reinjection imaging was obtained. Wall motion abnormalities on left ventriculograms were analyzed at the onset of infarction and 1 month later. The severity scores on the MIBI early image, MIBI delayed image and Tl reinjection image were 98 +/- 18, 170 +/- 22 and 90 +/- 18, respectively. The reverse redistribution of MIBI was marked in acute infarction. A significant correlation of severity score was found between the MIBI early image and Tl reinjection image (r = 0.89). In 18 patients with significant stenosis of an infarct-related artery, there was a significant correlation between the degree of reverse redistribution and that of Tl redistribution (r = 0.826). A good correlation was found between the severity score on the MIBI early image and wall motion abnormality at 1 month after infarction (r = 0.816). There was a significant correlation between the degree of reverse redistribution and wall motion improvement (r = 0.782). Despite stenosis of the infarct-related artery, the wall motion abnormality was less in 22 patients with marked reverse redistribution (defect score on the MIBI delayed image was double that on the early image) than the other 14 patients. In conclusion, the MIBI early image may reflect myocardial viability and the reverse redistribution of MIBI was observed frequently in patients with acute myocardial infarction. Marked reverse redistribution was observed in patients with preserved left ventricular function. Because of the close correlation of reverse redistribution with Tl redistribution and wall motion improvement, reverse redistribution of MIBI is considered to occur in areas at risk for acute myocardial infarction.

A case of rest angina due to microvascular spasm.

A 66-year-old woman underwent elective cardiac catheterization for investigation of periodic attacks of chest pain at rest. During the examination, a chest pain attack occurred unexpectedly, resulting in ST elevation in the precordial leads on electrocardiography. Immediate coronary arteriography demonstrated no organic stenosis but markedly delayed contrast medium perfusion in the mild to distal portion of the left anterior descending artery. These phenomena spontaneously disappeared about 3 min later, and the patient was diagnosed as having angina pectoris due to microvascular spasm. The demonstration of angina pectoris due to microvascular spasm by coronary arteriography during a spontaneous attack is very rare.

Relationship between insufficient redistribution in exercise thallium-201 myocardial single-photon emission computed tomography and reverse redistribution at rest.

It is widely accepted that perfusion defects in 3 to 4-h delayed images in exercise thallium-201 (201Tl) myocardial scintigraphy underestimate the viability of myocardium in the infarct region. In the present study, to examine the contribution of the condition of myocardium which demonstrates reverse redistribution in resting scintigraphy to the insufficiency of redistribution in the 4-h delayed image in exercise scintigraphy, we performed exercise and resting 201Tl myocardial single-photon emission computed tomography in 58 patients with acute myocardial infarction and a single diseased coronary artery. Twenty eight patients demonstrated reverse redistribution (group RR) and 28 showed a fixed defect (group FD) in resting scintigraphy. Redistribution in the 4-h delayed image in exercise scintigraphy was significantly more insufficient in group RR than in group FD (p < 0.01), and the degree of the insufficiency of redistribution in exercise scintigraphy closely correlated with the degree of reverse redistribution in resting scintigraphy (r = 0.79, p < 0.001). We conclude that in patients with acute myocardial infarction, the condition of myocardium which demonstrates reverse redistribution in resting myocardial scintigraphy is related to the insufficiency of redistribution in the delayed image in exercise scintigraphy.

Two-dimensional and Doppler echocardiographic findings in a case of subaortic "fibrous sac".

We described a 37-year-old man with a subaortic "fibrous sac", admitted for congestive heart failure. On 2-dimensional echocardiography a saccular structure was seen to extend from the left coronary cusp of the aortic valve to the outflow tract of the left ventricle. By color Doppler imaging, a grade 3 aortic regurgitation was recognized. Aortic regurgitant flow was recorded from the left coronary cusp to the saccular lesion. When congestive heart failure became exacerbated, the repeat examination showed the regurgitant flow passing through the perforated bottom of this lesion and reaching the left ventricular cavity. On microscopic examination of the excised valve, capillary proliferation and inflammatory changes were recognized near the annular region of the left coronary cusp. The edge of the valve leaflet and the other 2 cusps were intact. It is likely that our patient had a mycotic aneurysm near the aortic ring. We speculate that aortic regurgitation followed inflammation. It dilated the left ventricular cavity and contributed to congestive heart failure. Inflammation also weakened the tissue near the annulus, causing it to protrude into the subaortic region thus forming a small aneurysm. It may have grown to become a large saccular structure under high aortic pressure. That is, it became a "giant" endocardial pocket with inflammatory process. Finally, the rupture of this sac caused a massive aortic regurgitation, exacerbating congestive heart failure.

Plasma levels of platelet-derived growth factor in normal subjects and patients with ischemic heart disease.

Plasma levels of platelet-derived growth factor (PDGF) were measured in 24 normal control subjects, 31 patients with stable angina pectoris, 25 patients with unstable angina pectoris, and 31 patients with acute myocardial infarction (AMI) by a sensitive direct radioimmunoassay. The plasma PDGF level in normal control subjects was 273 +/- 25 pg/ml; there was no significant correlation between the plasma PDGF level and age. Plasma PDGF levels in patients with unstable angina pectoris and acute myocardial infarction were significantly lower than those in normal control subjects and patients with stable angina pectoris (p less than 0.05). In patients with acute myocardial infarction the plasma PDGF level in the chronic phase was significantly higher than that in the acute phase (p less than 0.05). These observations raise the possibility that PDGF is involved in the pathophysiology of ischemic heart disease.

Assessment of superior vena caval blood flow velocity in ischemic heart disease.

In order to evaluate the right atrial function in patients with ischemic heart-disease, we studied the superior vena caval blood flow velocity using pulsed Doppler echocardiography. The subjects included 31 patients with anteroseptal infarction (ANT), 23 with inferior or inferoposterior infarction (INF + POS), 27 with effort angina pectoris (EAP) and 15 with vasospastic angina pectoris (VAP). The systolic peak flow velocity (PFVs) was significantly reduced only in INF + POS compared with those in ANT, EAP and VAP (36.8 +/- 1.8 cm/sec vs 46.9 +/- 2.1 cm/sec, 46.4 +/- 2.1 cm/sec and 42.6 +/- 1.9 cm/sec, p less than 0.05, respectively). No significant difference in diastolic peak flow velocity (PFVd) was found between the 4 groups. PFVs/PFVd was significantly reduced only in INF + POS compared with those in ANT, EAP, and VAP (1.39 +/- 0.05 vs. 1.75 +/- 0.08, 1.76 +/- 0.09, and 1.62 +/- 0.09, p less than 0.05, respectively). These results suggested that INF + POS caused impairment of the right atrial reservoir function.

Extensive specifically localized myocardial calcium deposition in a hemodialysis patient.

A 51-year-old female who was hospitalized for evaluation of frequent episodes of hypotension, died unexpectedly. At autopsy, there were many fine, white granular deposits in the myocardium, which were more prominent in the subepicardium of the left ventricle than in the subendocardium. Pathologic calcification is sometimes seen in chronic hemodialysis patients and in some organs the sites of calcium deposition are quite specific. There have been few reports concerning the pattern of calcium deposition in the myocardium and, to our knowledge, the reason for this characteristic distribution is unknown. However it may relate to hydrogen ion concentration in the myocardium.

Clinical significance of reverse redistribution on thallium-201 single-photon emission computed tomography in patients with acute myocardial infarction.

To determine the clinical significance of reverse redistribution (RR), resting thallium-201 myocardial single-photon emission computed tomography was performed once or twice in 80 patients in subacute phase (1 week to 2 months) of myocardial infarction. Thirty eight patients demonstrated RR on at least one study (group RR) and 32 a fixed defect only (group FD). Group RR had significantly smaller defects than group FD. Standardizing the relation of the severity of wall motion abnormality of left ventricle on echocardiogram with that of perfusion defect, in group RR wall motion abnormality in the acute and subacute phase reflected the defect of delayed image, while that in chronic phase, which was thought to reflect the viability of myocardium in the infarct region, reflected the defect of initial image. In serial thallium-201 studies, only the defect of delayed image of group RR improved on the second study, while the defect of initial image of group RR and defect of group FD did not improve. Wall motion of group RR improved with the disappearance of RR, and when RR remained, wall motion did not improve so much. We concluded that RR was thought to be demonstrated in viable myocardium with severe wall motion abnormality.

Influence of exercise on plasma atrial natriuretic factor levels in patients with myocardial infarction.

The influence of dynamic exercise on plasma atrial natriuretic factor (ANF) levels was studied in a group of 10 patients with myocardial infarction (MI) and five patients with atypical chest pain (control group). Exercise protocol consisted of three fixed workloads (25, 50, and 75 watts) every 4 minutes with the use of a supine bicycle ergometer. Plasma ANF levels and hemodynamic indices were measured before, during, and 10 minutes after exercise. In the MI group, plasma ANF levels significantly increased at the 75-watt workload and significantly decreased at 10 minutes after exercise, whereas in the control group, the increase in plasma ANP levels after a 75-watt workload, compared with those at rest, was not significant. Significant correlations of pulmonary artery wedge pressure, right atrial pressure, mean arterial pressure, and heart rate to plasma ANF levels were observed at four points obtained before and during each stage of exercise in the MI group. Furthermore, a significant correlation between maximal creatine kinase levels and plasma ANF levels at a 75-watt workload and a significant inverse correlation between left ventricular ejection fraction and plasma ANF levels at a 75-watt workload were observed. These results suggest that the increase in the circulating ANF level during exercise in MI is associated with elevated atrial pressure resulting from left ventricular dysfunction and that measurement of ANF during exercise may be an indication of the severity of MI and associated left ventricular dysfunction.