Washout rate of iodine-123 metaiodobenzylguanidine (MIBG) myocardial scintigraphy is correlated with the degree of myocardial damage. The aim of this study is to ascertain whether there is any relationship between QRS complex duration at right ventricle (RV) pacing and the degree of myocardial damage assessed by I-123 MIBG myocardial scintigraphy in normally functioning left ventricle.

Arteriovenous shunt is one of the causes of heart failure, but heart failure caused by common iliac arteriovenous fistula is relatively rare. A 64-year-old man who developed acute heart failure due to venous perforation of a common iliac aneurysm and also had bilateral aneurysms (diameter 58 mm) was referred to our department. On admission, the patient complained of dyspnea and swollen left leg, so diuretic agent was administered to treat the heart failure. Cardiac catheterization showed a shunt rate of 80.6%, as well as 5.0 Qp/Qs and O2 step-up across perforation of the common iliac vein. Despite the therapy, pleural effusion and ascites exacerbated, and the heart failure became difficult to control, so surgical treatment was performed. The aneurysm was replaced with an artificial vessel, and the fistula was closed by direct suturing. Postoperatively, the symptoms disappeared, and the patient is in good health.

A 76-year-old woman was urgently referred to our hospital 2 days after the onset of acute myocardial infarction with a harsh pansystolic murmur. She had hypertension and type II diabetes mellitus for several years. An electrocardiogram revealed deep Q waves and ST segment elevations in leads V1 through V4. Transthoracic echocardiography showed a huge cavity inside the septum and an interventricular communication located at the apex (Fig 1, Fig 2, Fig 3). Figure 1 is an apical view (LV = left ventricle; RA = right atrium; RV = right ventricle). Figure 2 is a short axis view (LV = left ventricle; RV = right ventricle). Figure 3 is a color Doppler apical view. Coronary cineangiography demonstrated a total occlusion of the proximal left anterior descending artery. She was taken to the operating room, and the left ventricular was opened through an anterior ventriculotomy while on conventional cardiopulmonary bypass with cardioplegic arrest. Extensive antero-septal necrosis complicated a septal dissection and interventricular communication was confirmed. A pericardial patch was successfully sutured to the endocardium of the left ventricle to exclude the infarct from the left ventricular cavity. The patient’s postoperative course was uneventful with a follow-up echocardiography demonstrating neither cavity in the septum nor interventricular shunt (Fig 4). Figure 4 is an apical view (post operation) (LA = left atrium; LV = left ventricle).Fig 2View Large Image Figure ViewerDownload (PPT)Fig 3View Large Image Figure ViewerDownload (PPT)Fig 4View Large Image Figure ViewerDownload (PPT)Interventricular septal dissection is a rare complication [1Nakata A. Hirota S. Tsuji H. Takazakura E. Interventricular septal dissection in a patient with an old myocardial infarction.Intern Med. 1996; 35: 33-35Crossref PubMed Scopus (12) Google Scholar]. A complex rupture with a huge septal dissection remote from the primary septal defect is usually observed in inferior acute myocardial infarction with high mortality as compared with anterior infarction [2Edwards B.S. Edwards W.D. Edwards J.E. Ventricular septal rupture complicating acute myocardial infarction identification of simple and complex types in 53 autopsied hearts.Am J Cardiol. 1984; 54: 1201-1205Abstract Full Text PDF PubMed Scopus (156) Google Scholar]. This type of rupture probably occurs from an infarct extension. Early diagnosis and surgical intervention are mandatory. A 76-year-old woman was urgently referred to our hospital 2 days after the onset of acute myocardial infarction with a harsh pansystolic murmur. She had hypertension and type II diabetes mellitus for several years. An electrocardiogram revealed deep Q waves and ST segment elevations in leads V1 through V4. Transthoracic echocardiography showed a huge cavity inside the septum and an interventricular communication located at the apex (Fig 1, Fig 2, Fig 3). Figure 1 is an apical view (LV = left ventricle; RA = right atrium; RV = right ventricle). Figure 2 is a short axis view (LV = left ventricle; RV = right ventricle). Figure 3 is a color Doppler apical view. Coronary cineangiography demonstrated a total occlusion of the proximal left anterior descending artery. She was taken to the operating room, and the left ventricular was opened through an anterior ventriculotomy while on conventional cardiopulmonary bypass with cardioplegic arrest. Extensive antero-septal necrosis complicated a septal dissection and interventricular communication was confirmed. A pericardial patch was successfully sutured to the endocardium of the left ventricle to exclude the infarct from the left ventricular cavity. The patient’s postoperative course was uneventful with a follow-up echocardiography demonstrating neither cavity in the septum nor interventricular shunt (Fig 4). Figure 4 is an apical view (post operation) (LA = left atrium; LV = left ventricle). Interventricular septal dissection is a rare complication [1Nakata A. Hirota S. Tsuji H. Takazakura E. Interventricular septal dissection in a patient with an old myocardial infarction.Intern Med. 1996; 35: 33-35Crossref PubMed Scopus (12) Google Scholar]. A complex rupture with a huge septal dissection remote from the primary septal defect is usually observed in inferior acute myocardial infarction with high mortality as compared with anterior infarction [2Edwards B.S. Edwards W.D. Edwards J.E. Ventricular septal rupture complicating acute myocardial infarction identification of simple and complex types in 53 autopsied hearts.Am J Cardiol. 1984; 54: 1201-1205Abstract Full Text PDF PubMed Scopus (156) Google Scholar]. This type of rupture probably occurs from an infarct extension. Early diagnosis and surgical intervention are mandatory.

We report a 57-yr-old woman with severe cardiac failure secondary to postnephrectomy arteriovenous fistula which was successfully removed. A review of the literature shows the rarity of this complication; only 72 cases have been reported in the world literature including 6 cases (including the present case) from Japan. Surgical intervention is generally the treatment of choice from a fistula and provides satisfactory results for cardiac failure which is the major complication of this fistula. A characteristic bruit was observed in all reported cases. Therefore, nonsurgical closure by percutaneous embolization for a small sized shunt may be possible if early diagnosis is obtained by careful auscultation of the loin. (Internal Medicine 31: 98-101, 1992)

Objectives: The exact role of pressure gradient across the prosthetic valve estimated from Doppler flow velocity remains controversial. This in-vivo study was designed to assess the actual discrepancy between Doppler and catheter measurements of the pressure gradients for small bileaflet prosthetic valves in the aortic position. Methods: Bileaflet prosthetic valves (19 mm-ATS) were implanted into the aortic position in pigs, and pressure gradients across the valves were examined by volume loading under right heart bypass. The pressure gradient obtained by catheter was defined as the conventional peak-to-peak gradient between the left ventricle and aorta. The peak Doppler gradients were calculated from the maximal instantaneous Doppler velocity with the ultrasound probe positioned on the diaphragm at the level of the cardiac apex. Results: There were strong correlations between pressure gradients and cardiac output. The Doppler gradient was constantly higher than the catheter values, and the resultant discrepancy between Doppler and catheter measurements was directly dependent on cardiac output (y=9.9x+0.6, r2=0.55). For cardiac output ≧5.0 L/min, the difference between Doppler and catheter gradients reached 40 mmHg, and maximum differences of up to 80 mmHg were observed. Conclusions: In view of the presence of striking overestimation of catheter gradient by Doppler measurement, Doppler ultrasound should be used cautiously to assess small-size bileaflet prosthetic valve function with consideration of the patient’s hemodynamic state.

To clarify whether inflammation is a cause or consequence of atrial fibrillation (AF), we measured high-sensitivity C-reactive protein (hs-CRP), interleukin-6 (IL-6), and tumor necrosis factor alpha (TNF-alpha) before and after pharmacological cardioversion in 15 patients with paroxysmal AF. Levels of hs-CRP, IL-6, and TNF-alpha after cardioversion were significantly higher than those in controls (P < 0.05). Furthermore, the levels of these indices did not differ significantly even at 24 hours and 2 weeks after cardioversion. These results suggest that inflammation is a causative agent of paroxymal AF.

Optimal atrioventricular (AV) delay (AVD) is important for AV sequential pacing. To verify whether optimal AVD can be determined using only Doppler index (DI), adult mongrel dogs with complete AV block were examined with pulsed Doppler echocardiography and hemodynamics measured by a cardiac catheter. After passive-fixation pacing leads were inserted into the right atrium and ventricle, complete AV block was achieved by radio-frequency catheter ablation. AV sequential pacing was then applied. Cardiac index (CI), isovolumic contraction time (ICT), isovolumic relaxation time (IRT), aortic ejection time (ET), and diastolic filling time (DFT) were measured, and DI was calculated as (ICT+IRT)/ET at AVDs of 50, 80, 100, 120, 150, and 200 ms. DI was minimal when AVD was set at 100 ms, and increased significantly when AVD was set at either above or below 100 ms. Optimal AVD determined from DI was the AVD at which DI was minimal. This optimal AVD was equal to the optimal AVD obtained from CI. On the basis of results in this study, DI is useful in determining optimal AVD in AV sequential pacing. (J. Jpn. Coll. Angiol., 2004, 44: 103–107)

A 76-year-old female had been followed in our hospital for dissecting aneurysm, cardiac failure, and cerebral infarction. Inguinal lymphadenopathy, anorexia, and weight loss were noted in June 1998. The histopathologic diagnosis of the biopsied lymph node was diffuse pleomorphic type non-Hodgkin's lymphoma with T-cellular phenotype, and the patient was referred to our department. She had human T-lymphotropic virus type I seropositivity, and PCR of the pX lesion disclosed a monoclonal band. She was ultimately diagnosed as having adult T-cell leukemia/lymphoma (ATL/L, stage IV). Since she had many severe complications, she was given low-dose etoposide (LD-ETP, 50 mg/day). Atypical cells disappeared from the blood, and lymphadenopathy regressed. No major adverse reaction was observed after LD-ETP. She continued to receive intermittent LD-ETP, but she developed pneumonia in June 2000, and died in August 2000. Autopsy disclosed no residual lymphomatous lesions. These findings suggest that LD-ETP is a well tolerable and effective treatment in patients with ATL/L even if there are severe complications.

To examine acute effects of olprinone hydrochloride (CAS 106730-54-0, Coretec) on pulmonary hypertension, hypoxic pulmonary hypertension was produced in 6 adult Beagle dogs. Using this pulmonary hypertension model, single intravenous bolus injections of olprinone at doses of 10, 30 and 100 micrograms/kg were administered at 5-min intervals and hemodynamic parameters were evaluated. Heart rate increased at doses of 30 and 100 micrograms/kg, but did not change at a dose of 10 micrograms/kg. Mean aortic pressure, mean pulmonary arterial pressure, pulmonary vascular resistance and systemic vascular resistance and right ventricular stroke work index did not change at doses of 10 and 30 micrograms/kg, but they decreased significantly at a dose of 100 micrograms/kg. On the other hand, cardiac index and the first derivative value of the left ventricular pressure did not show significant change at all doses. These results indicate the vasodilating effects on peripheral and pulmonary vessels in hypoxic model at high doses of olprinone. Its application in right heart failure accompanied by pulmonary hypertension therefore is expected to yield promising results.

We treated a case of ventricular septal perforation (VSP) who survived for 14 years after myocardial infarction, Nine years after the onset of myocardial infarction, an apparent cardiac murmur was discovered by chance, and following further examination, the patient was diagnosed as having VSP, The patient is still in the NYHA functional class I, and requiring no surgical treatment, In general, the prognosis of myocardial infarction complicated with VSP is so poor that there have only been 14 reported cases of long survival without surgical treatment. Among these patients, only 2 survived for more than 10 years. The present case is extremely rare, and evidently is the longest living survivor with this condition vet reported.

His‐bundle pacing gives a more physiological ventricular contraction in comparison to right ventricular apical pacing. However the problems of lead fixation and stability of long‐term His‐bundle pacing are yet unsolved. We used six adult beagles, in which a screw‐in lead was anchored in the His‐bundle region for observation of the pacing conditions and histopathologic changes of the conduction system over the course of 2 months. In the results, a satisfactory fixation was obtained using a conventional screw‐in lead and no histological influence on the conduction system was observed. The pacing threshold at the time of implantation was 1.15 ± 0.69V (3.23 ± 3.08 mA) in the pulse width of 0.5 ms. R wave amplitude, the impedance and slew rate were 7.28 ± 2.04 mV, 409 ± 102 Ohm, and 0.65 ± 0.41 V/s, respectively. Two months later, these parameters changed to 2.83 ± 1.06 V (10.4 ± 5.71 mA), 5.63 ± 1.62 mV, 310 ± 71.3 Ohm, and 0.49 ± 0.22 V/s, respectively. These results suggest the feasibility of clinical application of permanent His‐bundle pacing.

We evaluated a 68-year-old male patient with isolated levocardia without intracardiac anomaly. The patient's condition was complicated by the absence of the inferior vena cava, a lobulated spleen and sick sinus syndrome. Isolated levocardia without intracardiac anomaly is very rare and only 25 cases of this disease have been reported, to our knowledge. In general, it is accepted that cardiac rhythm disorder is frequently observed in cases of isolated levocardia and/or absence of inferior vena cava. However, there are few cases of isolated levocardia without intracardiac anomaly complicated by the absence of the inferior vena cava, a lobulated spleen and apparent sick sinus syndrome.

Objectives. To determine whether atrial fibrillation (AF) alone affects the fibrinocoagulation system, up examined the relation between fibrinocoagulation activity and duration of AF in patients viith paroxysmal AF (PAF).Background. Patients with chronic AP are at higher risk for stroke and a hypercoagulative state. It is not clear whether this hypercoagulative state is attributable to AF alone or to the underlying disease. There are no reports on the fibrinocoagulation properties in PAF.Methods. Fibrinocoagulation variables in 21 patients with PAF were measured during AF and 7 days after recovery of sinus rhythm. There were positive correlations between the duration of AF and beta-thromboglobulin, platelet factor 4, thrombin-antithrombin III complex and fibrinogen. These variables increased significantly 12 h after the occurrence of PAF; thus, patients were classified into two groups according to the duration of PAF: PAF-I group (<12 h, n = 10), PAF-II group (greater than or equal to 12 h, n = 11). Nine age-matched, healthy subjects formed the control group.Results. Levels of beta-thromboglobulin and platelet factor 4 were significantly higher (p < 0.001) by two-way repeated measures analysis of variance (ANOVA), and thrombin-antithrombin III complex and fibrinogen levels tended to be but sere not significantly higher (p = 0.06, ANOVA), in the PAF-II group than in the PAF-I group. There were no significant differences between groups in activated partial thromboplastin time, D-dimer or plasmin inhibitor complex.Conclusions. These results indicate that AF itself enhances platelet aggregation and coagulation, which are influenced by the duration of AF. The acceleration of platelet activity and coagulability occurred 12 h after the occurrence of AF.

A 64-year-old man visited our hospital with a complaint of exertional chest discomfort. Exercise electrocardiography revealed ST segment depression in the V4-V6 leads, and exercise thallium myocardial scintigraphy demonstrated myocardial ischemia in the area of the right coronary artery, suggesting effort angina. Diagnostic coronary angiography revealed an anomalous origin of the right coronary artery from the left sinus of Valsalva and 90% organic stenosis at the proximal portion. We performed percutaneous transluminal coronary angioplasty (PTCA), but repeat PTCA was required 3 months later because of restenosis. Follow-up angiography 1 year later showed regression of the stenotic lesion to less than 50% diameter compared with the data obtained 3 months after the second PTCA. However, exercise 99mtechnetium-tetrofosmin myocardial scintigraphy disclosed obvious myocardial ischemia in the inferior region. These results suggested that the myocardial ischemia in this particular patient was caused not only by the organic stenosis but also by the anatomic anomaly which might reduce coronary blood flow during exercise. Such patients should be followed up cautiously with much more sophisticated methodology.

We examined histologically whether the severity of arterial stretch injury is related to the degree of subsequent intimal hyperplasia. In six male New Zealand White rabbits, the common carotid artery was hyperextended with a 3F Fogarty balloon catheter. Two weeks later, no proliferative change was evident in the intima in the most hyperextended portion. Paradoxically, however, intimal hyperplasia due to smooth muscle cell proliferation was observed in the moderately extended portions. The intimal hyperplasia appeared to be exacerbated where the arterial stretching was more severe. It is concluded that the severity of arterial stretch injury is closely related to the intimal proliferation of smooth muscle cells.

We report an interesting case of aortic regurgitation. Phonocardiographically, the shape of the diastolic musical murmur in this case changed in each cardiac cycle despite being in sinus rhythm, in the same posture and in the same breathing phase. Experimentally, we were able to obtain a similar noise pattern using an artificial respirator and a hemispherical silicone membrane. We concluded that the irregular and chaotic change in the shape of the diastolic musical murmur in the present case occurred due to irregular swaying of the non-coronary cusp under the influence of the Venturi effect owing to a regurgitant jet stream.

Three months after implantation of endocardial pacing leads in 10 mongrel dogs, the tensile forces needed to remove 5 tined type and 5 screw-in type leads were compared experimentally. Mean maximum tensile force was 291 +/- 174 g with the screw-in type and 1174 +/- 369 g with the tined type (p < 0.01). Histopathologically, no changes suggesting any myocardial damage due to lead extraction were recognized in cases where screw-in type leads were used. These results support the clinical feasibility of safe and easy manual retraction of infected pacing leads of the screw-in type.