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Coronary flow velocity recordings were obtained in three patients with ampulla (Takotsubo) cardiomyopathy using Doppler guide wire. Immediately after admission, coronary angiography demonstrated no significant stenosis and normal coronary flow in the epicardial coronary artery. Left ventriculography showed abnormal wall motion of the left ventricle mimicking ampulla shape in all patients. The coronary flow velocity pattern was normal, but coronary flow reserve of the left anterior descending coronary artery was decreased by adenosine administration in all patients. The coronary flow reserve in the left circumflex and right coronary artery also decreased. Cardiac catheterization was performed during the follow-up period in two patients. Left ventriculography revealed almost normal wall motion of the left ventricle. The coronary flow reserve normalized in one patient.

Objectives: This study compared the hyperemic responses to adenosine triphosphate (ATP) administered by intravenous and by intracoronary injection in patients with impaired coronary microcirculation., Methods: The hyperemic responses to intravenous and intracoronary administration of ATP in 107 patients (mean age 63 +/- 10 years, 77 males, 30 females) with impaired coronary circulation [including myocardial infarction (n = 68), cardiomyopath (n = 20) and diabetes mellitus (n = 11)] were compared by measurement of coronary flow reserve (CFR) using the Doppler guide wire. Patients with chest pain syndrome were used as the normal controls. The coronary blood flow velocity was measured at rest and during peak hyperemic responses to intravenous infusion (150 micrograms/kg/min) and intracoronary infusion of ATP (50 micrograms in the left coronary artery, 25 micrograms in the right coronary artery). The CFR was calculated as the ratio of averaged peak velocity during hyperemia to baseline averaged peak velocity., Results: The CFR after intravenous administration of ATP (CFRi.v.) was well correlated with CFR by intracoronary administration of ATP(CFRic) (r = 0.77, p < 0.001). However, the CFRi.v. was also inversely correlated with the ratio of CFRic to CFRiv (CFRic/i.v.) (r = -0.36, p < 0.001). There were no relationships between the changes of hemodynamic parameters(blood pressure and heart rate) induced by ATP and CFRic/i.v. A lower CFRi.v. of less than 2.0 provided significantly greater CFRic/i.v. than that of CFRiv greater than 2.0., Conclusions: The maximal hyperemic response of coronary artery was not always induced by conventional intravenous administration of ATP, especially in patients with lower CFR than 2.0. High dose of intravenous ATP and/or intracoronary ATP should be administered in patients with lower CFR to attain maximum hyperemia in the impaired coronary circulation.

A 25-year-old woman was admitted to our hospital with goiter. The diagnosis was Grave's disease. Diagnostic transthoracic echocardiography revealed a hyperdynamic stage of the heart with right ventricular dilation. Doppler echocardiography showed mild to moderate tricuspid regurgitation and elevated systolic right ventricular pressure. Right heart catheterization revealed high cardiac output (9.49 l/min) and pulmonary hypertension (57 mmHg) with increased pulmonary vascular resistance and total pulmonary resistance. No intracardiac shunts were detected. Since neither thiomazole nor propylthiouracil was effective and both caused side effects, she underwent subtotal thyroidectomy. After the surgery, pulmonary hypertension improved and cardiac output normalized, but without normalization of pulmonary vascular resistance and total pulmonary resistance. Reversible pulmonary hypertension may occur in patients with hyperthyroidism. Increased pulmonary blood flow and sustained high pulmonary artery resistance were suspected as the causes of pulmonary hypertension. In addition, pulmonary endothelial dysfunction as a result of sustained increased pulmonary blood flow could be another cause of pulmonary hypertension.