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Introduction: Although the prognostic efficacy of out-patient cardiac rehabilitation (OPCR) in patients with coronary artery disease (CAD) has been established in Western countries, it has not been studied in Japan, where both incidence and mortality of CAD are known to be much lower than in Western counties. Methods: To determine the prognostic efficacy of OPCR in Japan, a prospective, controlled, multicenter study of OPCR (J-REHAB) was conducted in 15 hospitals in Japan. A total of 1047 patients hospitalized with cardiac events were prospectively assigned to either OPCR group (n=848) or Non-OPCR group (n=199) according to patient’s preference at the time of hospital discharge. Patients in OPCR group were scheduled to participate in a comprehensive OPCR program for 3 months and Non-OPCR group received usual care. Event-free survivals for cardiac and all-cause death/rehospitalization were assessed according to the initial group assignment and the “prespecified” actual OPCR performance (attendance >=4 times/month and total exercise time >=150 min/week). Results: Patients were followed-up for 416days on average and the follow-up rate was 99.4%. At baseline, patients were 64±11years of age, 85% was male, 58% acute myocardial infarction, with preserved EF (53±13%). By Kaplan-Meier analysis, OPCR group had significantly better event-free survival for cardiac death/rehospitalization (p Conclusions: The first Japanese prospective multicenter J-REHAB study has demonstrated that active participation in OPCR is associated with better event-free survival in CAD patients, independent of baseline clinical characteristics.

Background When patients with severely depressed left ventricular function are treated, it is crucial to know in advance how much functional recovery is expected from coronary revascularization. Methods and Results We compared the results of 11 C acetate positron emission tomography (PET) with dobutamine infusion with changes in regional wall motion evaluated by left ventriculography in 28 patients with old Q-wave anterior myocardial infarctions. Dysfunctional but viable myocardium (group A, n=13) was separated from nonviable myocardium (group B, n=15) by echocardiographic assessments of regional wall motion before and after successful coronary revascularization. 11 C acetate PET was performed to characterize normalized myocardial blood flow and oxidative metabolism (the clearance rate constant, k mono). While the baseline k monos of the infarct areas of the two groups were different with overlap, the responses to dobutamine infusion were directionally different. In addition, relative perfusion by 11 C acetate PET could predict recovery of left ventricular function as well as or better than dobutamine 11 C acetate kinetics. The extent of the increase in k monos of the infarct area with dobutamine infusion correlated well ( P Conclusions 11 C acetate PET with dobutamine infusion can predict not only the reversibility of dysfunctioning myocardium after coronary revascularization but also the extent of improvement of regional wall motion in patients with old Q-wave infarction.

Left ventriculography with simultaneous pressure micromanometry was performed in 11 normal control subjects and 17 patients with dilated cardiomyopathy (DCM). Left ventricular silhouettes in the right anterior oblique projection were divided into eight areas, and regional wall stress was computed by Janz's method in each area excluding the two most basal areas. Wall stress was higher in DCM patients than in control subjects (p less than 0.01). The percent area changes from end diastole to end systole in each area were lower in DCM patients than in control subjects (mean for six areas, 22 +/- 14% versus 54 +/- 9%, respectively, p less than 0.01), but the coefficient of variation for the percent area changes in the six areas of the left ventricle in DCM patients was greater than that in control subjects (32 +/- 17% versus 15 +/- 4%, respectively, p less than 0.01), indicating regional differences in hypokinesis. There was a significant negative correlation between end-systolic regional wall stress and percent area change (r = -0.60 to -0.86, p less than 0.05) in each area. Thus, excessive regional afterload may play an important role in causing regional hypokinesis in DCM.

Background: The development of congestive heart failure (CHF) is associated with left ventricular (LV) remodeling. However, fundamental mechanisms that contribute to this remodeling process remain unclear. The matrix metalloproteinases (MMPs) and tissue inhibitors of MMPs (TIMPs) have been demonstrated to play a significant role in tissue remodeling through a number of pathological processes. Objectives: The purpose of this study was to investigate whether MMPs and TIMPs represent autocrine/paracrine factors and are accumulated in pericardial fluid. We previously reported that active MMP-2 levels in pericardial fluid served as more sensitive and accurate indicators of LV remodeling than did active MMP-2 levels in plasma. Methods: We measured the concentrations of the enzyme (active MMP-9) in both plasma and pericardial fluid in 20 patients during coronary artery bypass graft surgery. Results: The active MMP-9 level was significantly higher in pericardial fluid than in plasma (4.68 ± 1.17 vs. 2.58 ± 0.29 ng/ml, p Conclusions: Active MMP-9 levels in pericardial fluid serve as more sensitive and accurate indicators of LV remodeling than did active MMP-9 levels in plasma. Thus, active form of MMP-9 may be also secreted from the heart into the pericardial space with the progression of CHF, and it may have a pathophysiologic role in LV remodeling process as an autocrine/paracrine factor.

An 86-year-old woman was referred for treatment of a rapidly enlarging aortic arch aneurysm, which had been monitored for 2 years with serial computed tomography (CT) scans. The size of the aneurysm had been 65 mm 2 years previously, but it had enlarged to 110 mm at the most recent examination (Figure 1). The patient complained of hemosputum and back pain. The risk of rupture was considered very high if the aneurysm was left untreated; however, thoracotomy was considered high risk because of the patient’s age. After obtaining the informed …

Background Collateral growth is induced by chemical signals from the ischemic myocardium. We hypothesized that angiogenic growth factors are produced by cardiac tissue; they are diffusible, more concentrated in pericardial fluids, and are increased by myocardial ischemia. Methods and Results With the use of an enzyme-linked immunosorbent assay, we measured the concentrations of basic fibroblast growth factor (bFGF) and vascular endothelial growth factor (VEGF) in pericardial fluids of 12 patients with unstable angina (group 1) and of 8 patients with nonischemic heart diseases (group 2). The levels of protein in pericardial fluids were quite comparable between the two groups (34±2 versus 32±4 mg/mL). The concentration of bFGF in pericardial fluids in group 1 was 2036±357 pg/mL, significantly ( P P Conclusions This finding provides new evidence that bFGF plays an important role in mediating collateral growth in humans.

Background Accurate noninvasive determination of myocardial viability is of paramount importance for the clinical identification of patients who will benefit most from revascularization. The preserved metabolic activity in the myocardium, as studied with positron emission tomography (PET), has been considered a gold standard for this purpose. However, recent reports show that moderate hypoperfusion or stress-induced ischemia may represent reversible ischemia. The present study was undertaken to compare the value of perfusion and metabolic studies with PET for predicting improvement in wall motion after revascularization. Methods and Results Of 61 patients who had regional asynergy and underwent PET before revascularization, 43 patients who had successful revascularization were included in the study. Each patient underwent rest-stress 13 N-ammonia perfusion scans and 18 F-fluorodeoxyglucose (FDG) scan at rest while in a fasting state. Reversible ischemia was considered to be present when the resting perfusion was ≥50% of the peak value, stress-induced hypoperfusion was present, or an increase in FDG uptake was observed. Of 130 asynergy segments, 51 segments had improved wall motion after revascularization. The positive and negative predictive values for improvement in asynergy were 48% and 87% by the rest perfusion study, 63% ( P =.05 versus the rest value) and 87% by the rest-stress perfusion study, and 76% ( P Conclusions FDG PET provided the best predictive value for improvement in wall motion after revascularization. On the other hand, 13 N-ammonia PET is useful for predicting nonreversible myocardial scarring when it shows severe hypoperfusion at rest or hypoperfusion without stress-induced ischemia.