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A 60-year-old man developed acute myocardial infarction from the total occlusion of the right coronary artery via metastatic squamous lung cancer and was treated with percutaneous coronary intervention (PCI). Computed tomography and transthoracic echocardiography (TTE) revealed a metastatic tumor, and three-dimensional TTE was useful for determining the size and location of the tumor in relation to the coronary artery. Six months after PCI, the patient died, and an autopsy confirmed extensive metastasis to the heart and nearby vessels as detected by three-dimensional TTE. Although rare, lung cancer metastasis to the heart may directly occlude the coronary artery.

A 59-year-old man presented with exertional dyspnoea and pretibial oedema that had lasted 6 months. He was referred to our hospital with suspected constrictive pericarditis (CP). Several examinations, including CT, echocardiography and cardiac catheterisation, indicated heart failure associated with CP that had been induced by trauma 13 years prior. The CP and heart failure were unresponsive to medical treatment, therefore, a surgical pericardiectomy was performed, which is considered the only definitive treatment. Pathological examination of the resected pericardium revealed a fatty texture and dense fibrous connective tissues, which are associated with old haemorrhage and focal calcification. The patient’s symptoms were improved to New York Heart Association Class I, and his peripheral oedema disappeared 6 months after leaving hospital.

A 72-year-old man presented to our hospital with a fever. Chest computed tomography showed typical coronavirus disease 2019 (COVID-19) pneumonia. The fever normalized after a few days, and the pneumonia was alleviated. However, the intermittent fever subsequently re-occurred and persisted for over a month. Various tests, including blood tests, culture tests, and image evaluations, were performed. However, the conclusion was that long COVID was the cause of the intermittent fever as an exclusion diagnosis. Many patients suffer from persistent symptoms of COVID-19, but the symptoms and their durations vary. Here we report a case of prolonged fever after COVID-19 pneumonia.

This study aimed to evaluate the clinical implication of the brachial-ankle pulse wave velocity (baPWV) for endovascular treatment (EVT). Eighty-four patients who underwent EVT for aortoiliac and femoropopliteal artery were included. In these patients, 36 (43 %) had an ABI improvement above 0.9 a day after EVT. The baPWV in patients who received re-EVT afterwards was significantly higher than that of patients who did not. The area under the receiver operating characteristic curve for the baPWV for predicting re-EVT was 0.788. The optimal cut-off values of the baPWV for re-EVT, specificity, and sensitivity were 2220 cm/s, 93.1 %, and 57.1 %, respectively.

Background: The ankle-brachial index (ABI), percentage of mean arterial pressure (%MAP), and upstroke time (UT) are indicators to diagnose lower-extremity peripheral artery disease (PAD). However, the respective relationship between these parameters is unknown. In this study, we analyzed the correlations between ABI, %MAP, and UT and examined their clinical usefulness for endovascular treatment (EVT). Methods: Sixty-three consecutive subjects who underwent successful EVT for aortoiliac to femoropopliteal artery diseases were analyzed. The ABI, %MAP, and UT were measured using an automated oscillometric device. Results: There were significant correlations between the ABI and %MAP (r = -0.425, P < 0.001), the ABI and UT (r = -0.304, P = 0.017), and %MAP and UT (r = 0.368, P = 0.003). In terms of lesion length, there was a significant difference in %MAP after EVT (focal, 42.6%; short, 44.5%; intermediate, 47.1%; long, 49.1%; P = 0.015). There was minimal %MAP improvement in the case of a long lesion length (focal, -8.83%; short, -5.10%; intermediate, -3.00%; long, -1.50%; P = 0.006). Excessive lesion calcification also hindered %MAP improvement (grade 0, -7.16%; grade 1, -5.52%; grade 2, -4.71%; grade 3, -2.80%; grade 4, -1.00%; P = 0.049). Patients who underwent re-EVT (an average of 10.1 months after initial EVT) had minimal %MAP improvement (-2.76% vs. -5.95%, P = 0.035) at the first outpatient visit (an average of 3.3 weeks after EVT). Conclusions: In conclusion, the ABI, %MAP, and UT are correlated with each other. If the length of the lesion is long and there is excessive calcification, %MAP improvement is minimal. Moreover, minimal %MAP improvement may be an indicator of future restenosis. Cardiol Res. 2020;11(6):392-397 doi: https://doi.org/10.14740/cr1146

Background Polysulfone (PS) dialyzers are most frequently used worldwide for chronic renal failure patients and they are produced by several manufacturers. Despite using the same materials, differences in biocompatibility among PS dialyzers have been reported. TORAYLIGHT NV (NV) is a PS dialyzer that was reported to have superior biocompatibility compared with other PS membranes (conventional PS membranes). Therefore, we examined whether biocompatibility of PS membranes would affect the occurrence of cardiovascular events in hemodialysis patients with diabetic nephropathy (DN). Methods Fifty hemodialysis patients with DN were enrolled. They were randomly divided into NV and PS groups and then followed up for 3 years. The number of patients who developed cardiovascular events and clinical data including laboratory tests and blood pressure was recorded. Results There were 13 and 14 patients who developed cardiovascular events during the 3-year follow-up of the NV and PS groups, respectively. There was no significant difference between the groups. There were no significant differences in most of the clinical data between the two groups. However, serum pentosidine concentrations in the PS group significantly increased throughout this study, while those in the NV group did not change. Additionally, the width of the systolic blood pressure drop, which was shown to be the difference between before and after dialysis session, in the PS group showed no change, while that in the NV group tended to decrease. Conclusions The superiority of using NV membrane compared with conventional PS membranes in reducing cardiovascular events in hemodialysis patients with DN remains unclear. However, our results suggested that PS membranes with superior biocompatibility would slow the progression of atherosclerosis and reduce the occurrence of intradialytic hypotension. Trial registration This study was retrospectively registered with the Clinical Trials Registry at the University Hospital Medical Information Network (UMIN-CTR) on March 17, 2017 (registration ID, UMIN 000026339). https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr.cgi?function=brows&action=brows&recptno=R000030259&type=summary&language=J

Graphical abstract, Highlights • ATTRwt is underdiagnosed, and sometimes coexists with AS. • ATTRwt with AS tends to result in a poor prognosis after TAVR. • Recognizing coexistent ATTRwt before TAVR is crucial. • STE and cardiac scintigraphy are useful in diagnosing ATTRwt. • Persistent wall thickening after TAVR suggests an occult ATTRwt.

ObjectivesThe severity of diastolic dysfunction is assessed using a combination of several indices of left atrial (LA) volume overload and LA pressure overload. We aimed to clarify which overload is more associated with the prognosis in patients with heart failure and preserved ejection fraction (HFpEF).SettingA prospective, multicenter observational registry of collaborating hospitals in Osaka, Japan.ParticipantsWe enrolled hospitalised patients with HFpEF showing sinus rhythm (men, 79; women, 113). Blood tests and transthoracic echocardiography were performed before discharge. The ratio of diastolic elastance (Ed) to arterial elastance (Ea) was used as a relative index of LA pressure overload.Primary outcome measuresAll-cause mortality and admission for heart failure were evaluated at >1 year after discharge.ResultsIn the multivariable Cox regression analysis, Ed/Ea, but not LA volume index, was significantly associated with all-cause mortality or admission for heart failure (HR 2.034, 95% CI 1.059 to 3.907, p=0.032), independent of age, sex, and the serum N-terminal pro-brain natriuretic peptide (NT-proBNP) level. In patients with a higher NT-proBNP level, the effect of higher Ed/Ea on prognosis was prominent (p=0.015).ConclusionsEd/Ea, an index of LA pressure overload, was significantly associated with the prognosis in elderly patients with HFpEF showing sinus rhythm.Trial registration numberUMIN000021831.

Background: Mycoplasma pneumoniae pneumonia (MPP) is generally a self-limiting disease, but it may become refractory. It is thought that refractory MPP is linked to the excessive immunologic responses of the host. Consequently, the use of adjunctive systemic corticosteroids may have beneficial effects. In this study, we compared the effects of high- and low-dose corticosteroid therapy in a pediatric population with refractory MPP. Methods: We retrospectively collected data from 91 pediatric MPP patients treated with adjunctive systemic corticosteroids between April 2014 and October 2016. The patients were divided into the following two groups: high-dose corticosteroid group (2 mg/kg/day or more of prednisolone equivalents; n = 38) and low-dose corticosteroid group (, ファイル公開：2020-05-01

BackgroundSubepicardial aneurysm (SEA) is an uncommon but potentially fatal complication of acute myocardial infarction (MI) associated with an increased risk of free wall rupture (FWR) leading to sudden death. We describe a rare case of a silent myocardial infarction complicated by SEA and subsequent FWR, resulting in cardiac tamponade.Case summaryA 68-year-old man with no previous chest symptoms presented with syncope. Cardiac computed tomography incidentally revealed a small aneurysmal cavity at the inferolateral wall of the left ventricle, which was overlooked on initial transthoracic echocardiography. Coronary angiography demonstrated a narrowed first obtuse marginal branch with coronary slow flow, suggesting that spontaneous recanalization of the occluded obtuse marginal branch induced SEA and subsequent FWR. The patient underwent an emergency left ventricular aneurysm repair. The post-operative course was uneventful, and the patient was discharged from the hospital on post-operative day 20.DiscussionThis case emphasizes the importance of prompt detection and surgical intervention for SEA. Subepicardial aneurysm should be suspected in patients with pericardial effusion and suspected MI. Cardiac computed tomography is not only useful in the detection of such cases but also facilitates the development of a successful surgical strategy.

Postoperative coronary artery complications after Bentall procedures are well recognised but are rare and potentially fatal. There have been only five cases documenting percutaneous coronary intervention (PCI) for right coronary artery (RCA) involvements after button Bentall procedures. We describe a case of postoperative silent myocardial ischaemia in a 72-year-old man who underwent the button Bentall procedure for a right sinus of Valsalva aneurysm. On postoperative day 15, an RCA complication was incidentally detected by follow-up multidetector CT. Coronary angiography showed proximal RCA kinking, which was not an anastomosis but a native coronary artery. The patient underwent a successful PCI with drug-eluting stent implantation. We reviewed six cases consisting of this case and five previous cases treated with PCI. These cases enhance the recognition of potential RCA complications after the button Bentall procedure.

Popliteal venous aneurysm (PVA) and antiphospholipid syndrome (APS) are under-recognised as potential causes of pulmonary embolism (PE). A 66-year-old woman presented with progressive shortness of breath. A contrast-enhanced CT revealed bilateral PE, a small renal infarction and bilateral PVAs. Direct oral anticoagulant (DOAC) therapy was initiated immediately for venous thrombosis. Given the positivity for serum antiphospholipid antibody (aPL) in an initial blood test, low-dose aspirin was included to prevent further arterial thrombosis. Her symptoms resolved and she was discharged 1 week later. Twelve weeks later, she was diagnosed with APS because of persistent aPL. Surgical resection of the right PVA was performed 1 year later from her hospitalisation. To the best of our knowledge, this is the first case of PE caused by the combination of bilateral PVAs and APS. This report emphasises the importance of careful screening to identify PE causes, and its optimal management.

Background: Ventricular waveforms are characterized by a dip-and-plateau pattern during diastole owing to an abrupt termination of ventricular filling because of pericardial constraint under conditions such as constrictive pericarditis (CP). However, constrictive hemodynamics is not specifically caused by CP. Therefore, this study aimed to evaluate whether patients with obesity exhibited constrictive hemodynamics. Methods: Overall, 60 consecutive Japanese patients (mean age, 69.5 years; 45% women) who underwent right heart catheterization at the Japan Community Healthcare Organization Osaka Hospital from July 2016 to September 2018 were examined. Two-dimensional echocardiography was used to measure the epicardial adipose tissue (EAT) in the standard parasternal long-axis view during end-diastole. Because patients who underwent open-heart surgery were highly likely to have CP, they were excluded. Results: Among the 60 patients, 11 (18%) exhibited a plateau pattern of the right ventricular waveform and had a mean EAT value of 4.2 mm, which was significantly higher than that of patients without such a pattern (2.1 mm, P < 0.001). Similarly, the mean body mass index (BMI) values were significantly higher in patients with a plateau pattern than in those without it (27.2 vs. 21.8 kg/m 2 , P < 0.001). EAT was significantly correlated with the BMI (r = 0.72, P < 0.001). In patients with a plateau pattern, the triglyceride (TG) and low-density lipoprotein cholesterol (LDL-C) levels were significantly higher (TG: 150 vs. 100 mg/dL, LDL-C: 121 vs. 95 mg/dL, P < 0.05) and the left atrial diameter (52.8 vs. 44.7 mm, P < 0.01) and left atrial volume index (58.7 vs. 47.6 mL/m 2 , P < 0.05) were significantly greater than those in the patients without it. The EAT was also significantly correlated with the TG level (r = 0.37, P < 0.01). Conclusions: Obese patients may present with constrictive hemodynamics, suggesting left ventricular diastolic dysfunction. EAT was significantly correlated with metabolic syndrome components, namely obesity and TG levels. Cardiol Res. 2019;10(3):165-171 doi: https://doi.org/10.14740/cr865

A 92-year-old woman was admitted to hospital for dyspnoea. She was diagnosed for the first time with congestive heart failure. Her medical history included hypertension and diabetes. Chest radiography and electrocardiography revealed an enlarged heart and paroxysmal atrial fibrillation, respectively

ObjectiveDuring follow-up time, the value of prognostic factors may change, especially in the elderly patients, and the altered extent may affect the prognosis. We aimed to clarify the significance of the ratio of diastolic elastance (Ed) to arterial elastance (Ea), (Ed/Ea=(E/e’)/(0.9×systolic blood pressure)), an afterload-integrated diastolic index, in relation to follow-up periods and other laboratory factors, on the prognosis of elderly patients with heart failure with preserved ejection fraction (HFpEF).MethodsWe studied 552 HFpEF patients hospitalised for acute decompensated heart failure (men/women: 255/297). Blood testing and transthoracic echocardiography were performed before discharge. The primary endpoint was all-cause mortality.ResultsDuring a median follow-up of 508 days, 88 patients (men/women: 39/49) had all-cause mortality. During the first year after discharge, Ed/Ea (p=0.045) was an independent prognostic factor in association with albumin (pConclusionThe prognostic significance of a haemodynamic parameter such as Ed/Ea may be valid only during a short-term period, but that of albumin was persisting during the entire follow-up period in the elderly patients. The clinical significance of prognostic factors in HFpEF patients may differ according to the follow-up period.

In Japan, methamphetamine accounts for the majority of illicit drug use and dependence is becoming a critical issue. Methamphetamine abuse induces cardiovascular complications, such as cardiomyopathy and heart failure. However, methamphetamine-associated cardiovascular complications are not common in Japan. We report the case of a young patient with hypertensive heart disease associated with habitual methamphetamine abuse. A 37-year-old man was admitted with congestive heart failure. He was a habitual methamphetamine abuser and developed chronic hypertension after he started methamphetamine abuse. His echocardiogram demonstrated left ventricular concentric hypertrophy with diffuse hypokinesis. An endomyocardial biopsy revealed histological evidence of a hypertensive heart. This case shows that habitual methamphetamine use may cause hypertensive heart disease because of chronic hypertension.

Background Immunoglobulin G4-related disease (IgG4-RD) is a systemic disease characterized by the tumefactive lesions and infiltration of IgG4-positive plasma cells. IgG4-RD has been described in various organs, but rarely the aortic valve. There are only a few reports of aortic stenosis, and none on significant aortic regurgitation. In addition, previous case reports relating to aortic valve lesions led to surgery as a first-line treatment. The effect of steroid treatment has not yet been determined. Case Summary A 62-year-old man, receiving steroid therapy, who presented with general malaise, shortness of breath, and bradycardia. He had suspected IgG4-RD because of pancreatitis, lacrimal gland enlargement, and retroperitoneal fibrosis. An examination revealed a thickened aortic valve extending to the left ventricular outflow tract with severe aortic regurgitation and complete atrioventricular block. He received intensive steroid therapy for a suspected IgG4-related aortic valve lesion. The complete atrioventricular block improved, but worsening aortic regurgitation caused congestive heart failure. He required replacement of the aortic valve. A histopathological examination of the excised aortic valve leaflets revealed IgG4-positive lymphoplasmacytic infiltration with fibrotic tissue. The prosthetic valve was functioning well without leakage around the valve at the 1-year follow-up. Discussion This case highlights the rare possibility that IgG4-RD of the aortic valve also causes significant aortic regurgitation. Conservative treatment with steroids may induce regression of the lesion and contribute to the stability of the prosthetic valve after surgery, but it may also exacerbate heart failure due to the progression of aortic regurgitation in patients with aortic valve lesions.

Atrial fibrillation (AF) is an irregular and often rapid heart rate that can increase the risk of stroke, heart failure, and other heart-related complications. Its incidence increases with age and the presence of concomitant heart disease. We present the cases of a 93-year-old woman, an 82-year-old man, and an 87-year-old woman who developed AF tachycardia. This report highlights the use of a bisoprolol transdermal patch to treat AF tachycardia in 3 adult elderly patients. In this paper, we report an initial treatment strategy using a bisoprolol transdermal patch and show heart rate trends for 24 hours.

In this study, we present a case of developmental delay, epilepsy and neonatal diabetes (DEND) syndrome in a young male patient with the R50P mutation located in the Kir6.2 subunit of the ATP-sensitive K(+) (KATP) channel. Whereas most patients with DEND syndrome are resistant to sulfonylurea therapy, our patient was responsive to sulfonylurea, lacked the most common neurological symptoms, such as epilepsy, but refused to drink water. His serum electrolytes and plasma osmolarity were normal but the serum vasopressin level was increased. To investigate the underlying mechanism of his water intake disorder, a 5 μL aliquot of 340 μM KATP channel opener diazoxide or 100 μM KATP channel inhibitor glibenclamide was injected into the third ventricle of the rat brain, and water intake was monitored. Although the injection of glibenclamide had no effect, injection of diazoxide significantly increased water intake by about 1.5 fold without affecting food intake. This result indicates that the KATP channel activity in the brain may have an influence on water intake. Here, we present the first case of a DEND syndrome-afflicted patient with water intake disorder and increased serum vasopressin level, possibly related to altered KATP channel activity.

Septic shock is a life-threatening condition that occurs when the blood pressure drops to a low level after an infection. Atrial fibrillation (AF) is the most common arrhythmia to complicate its course. Beta (β)-blockers are often administrated to manage supraventricular tachyarrhythmias observed in patients presenting with sepsis. A 74-year-old woman presenting with sepsis demonstrated AF tachycardia characterised by severe hypotension. She was refractory to conventional therapy including verapamil and digoxin; therefore, treatment using landiolol (an ultrashort-acting β-blocker) was initiated. Her clinical course was followed over 48 hours, and she showed a significant improvement in her heart rate and blood pressure without any adverse effect. Landiolol can rapidly control the accelerated heart rate associated with AF in critically decompensated patients presenting with septic shock.

BACKGROUND Nocturnal blood pressure (BP) is an independent risk factor of cardiovascular events. The NOCTURNE study, a multicenter, randomized controlled trial (RCT) using our recently developed information and communication technology (ICT) nocturnal home BP monitoring (HBPM) device, was performed to compare the nocturnal HBP-lowering effects of differential ARB-based combination therapies in 411 Japanese patients with nocturnal hypertension (HT).Methods and Results:Patients with nocturnal BP ≥120/70 mmHg at baseline even under ARB therapy (100 mg irbesartan daily) were enrolled. The ARB/CCB combination therapy (irbesartan 100 mg+amlodipine 5 mg) achieved a significantly greater reduction in nocturnal home systolic BP (primary endpoint) than the ARB/diuretic combination (daily irbesartan 100 mg+trichlormethiazide 1 mg) (-14.4 vs. -10.5 mmHg, P

Background Patient movement has been considered an important source of errors in cardiac PET. This study was aimed at evaluating the effects of such movement on myocardial blood flow (MBF) and perfusable tissue fraction (PTF) measurements in intravenous 15O-water PET. Methods Nineteen 15O-water scans were performed on ten healthy volunteers and three patients with severe cardiac dysfunction under resting conditions. Motions of subjects during scans were estimated by monitoring locations of markers on their chests using an optical motion-tracking device. Each sinogram of the dynamic emission frames was corrected for subject motion. Variation of regional MBF and PTF with and without the motion corrections was evaluated. Results In nine scans, motions during 15O-water scan (inter-frame (IF) motion) and misalignments relative to the transmission scan (inter-scan (IS) motion) larger than the spatial resolution of the PET scanner (4.0 mm) were both detected by the optical motion-tracking device. After correction for IF motions, MBF values changed from 0.845 ± 0.366 to 0.780 ± 0.360 mL/minute/g (P

Background and Purpose— Angiotensin-converting enzyme (ACE) inhibitor-based therapy reduces the recurrence of stroke. The present study assessed the effects of long-term ACE inhibitor therapy on cerebral circulation in patients with previous minor stroke. Methods— After a run-in period, 19 patients were randomized to ACE inhibitor therapy (n=9; 4 mg of perindopril daily; mean age, 64±8 years; mean systolic/diastolic blood pressure [BP]±SD, 133±12/77±9 mm Hg) or placebo therapy (n=10; mean age, 66±9 years; mean BP, 139±10/78±8 mm Hg). Cerebral blood flow (CBF) was measured during hypercapnia, normocapnia, and hypocapnia using a positron emission tomography with H 2 15 O at entry into the study and after 3 to 12 months. Cerebral perfusion reserve (CPR) was defined as percent CBF response to a 1 mm Hg change in arterial partial pressure of CO 2 between hypercapnia and hypocapnia. Results— Systolic/diastolic BP and CBF during normocapnia showed no significant changes between entry and completion of the trial in the perindopril and placebo groups. Mean value of CPR showed a significant increase in the perindopril group (from 3.7±1.7%/mm Hg to 4.8±1.7%/mm Hg; P P Conclusions— Long-term ACE inhibitor-based therapy had a beneficial effect on the cerebral circulation by improving CPR in patients with previous minor stroke.

Objectives The aim of this study was to elucidate whether the response of idiopathic dilated cardiomyopathy (DCM) patients to β-blockers can be predicted by positron emission tomography with fluorine-18 fluoro-2-deoxyglucose (FDG-PET). Background Patients with DCM often have a poor prognosis, and it is important to predict their response to β-blocker therapy, which may be effective in DCM. However, no accurate methods of predicting their response have been available. Methods In 22 DCM patients with reduced left ventricular (LV) systolic function, FDG-PET was performed. Uptake in the LV after glucose loading was evaluated based on the average global percent uptake of the injected dose (G%ID) and the coefficient of variance (CV) in 24 segments of the LV. Uptake during fasting was evaluated semiquantitatively on the basis of the total uptake score. The β-blocker was administered, and LV function was monitored by echocardiography. The histologic findings were assessed in the 18 patients who underwent endomyocardial biopsy. Results The β-blocker was effective in the majority of patients whose G%ID after glucose loading was >0.7%, and the sensitivity and specificity of G%ID as a predictor of β-blocker efficacy were 83.3% and 90.0%, respectively. Percent CV did not predict efficacy. Four groups, defined on the basis of the FDG uptake score during fasting and G%ID after glucose loading, had distinctive histologic findings and outcomes. Conclusions It has been shown that FDG-PET is a good predictor for the effectiveness of β-blockers.

Clinical studies using 18 F-fluorodeoxyglucose suggest that this tracer may overestimate myocardial viability. This study aimed to elucidate whether 2-deoxyglucose accurately indicates myocardial viability at the early phase of myocardial infarction. Autoradiography with 14 C-deoxyglucose was performed in fasting rats whose left coronary artery was occluded for 60 min and then reperfused. 14 C-deoxyglucose was injected 30 min after the reperfusion (acute; n=10) or 1 week later (subacute; n =9), Infarction and risk areas were identified by triphenyl tetrazolium chloride or haematoxylin-eosin staining and methylene blue, respectively. Immuno-histochemical staining using anti-glucose transporter 1 and 4 antibodies was performed. At the acute stage, the uptake of deoxyglucose was consistent with the grade of anti-glucose transporter 4 expression. At the subacute stage, the uptake of deoxyglucose in poorly viable myocardium (543.4 ± 343.7%: normalized with the uptake at the right ventricle) as well as in the viable one (335.2 ± 149.8%) in the risk area was significantly greater than that in the remote area (116.4 ± 94.9%, P < 0.01). Anti-glucose transporter 1 was expressed in the poorly viable area where inflammatory cells infiltrated. It is concluded that deoxyglucose uptake by inflammatory cells which express anti-glucose transporter 1 causes overestimation of myocardial viability at subacute stage.

This study investigated the clinical value of I-123 MIBG pulmonary accumulation and washout in patients with chronic heart failure (CHF). Nineteen patients with CHF and 15 normal volunteers (NL) were included. The uptake ratio of heart to mediastinum (H/M), that of lung fields to mediastinum (L/M), and washout rate (WR) of the heart and lung fields were calculated in anterior planar images and compared with results of echocardiography and cardiac catheterization. In the CHF group, the lung uptake in delayed images increased and lung WR was decreased, suggesting pulmonary endothelial lesions. Furthermore, there was a negative correlation between right and left lung WR and pulmonary arterial diastolic pressure (PA(D)) and pulmonary arterial systolic pressure (PA(s)) in the CHF group. Since the WR of MIBG reflected PA, it may be used as an index of severity of cardiac dysfunction.

Clinical investigations have suggested that the defects in SPECT images of a free fatty acid analog, I-123 beta-methyliodophenyl pentadecanoic acid (BMIPP) may indicate the ischemic risk area. To elucidate whether I-123 BMIPP can indicate the area at risk of ischemia, ex-vivo autoradiography was performed in rats whose left coronary artery was occluded for 60 min and then reperfused. I-123 BMIPP was injected at the acute stage (n = 10), or the subacute stage (7 days after reperfusion; n = 9). Infarction and the area at risk were identified by triphenyl tetrazolium chloride staining and injection of methylene blue during religation just before sacrifice, respectively. The BMIPP uptake in the risk area was significantly lower than that in the remote area at the acute (risk, 53.7+/-23.3% of the uptake at right ventricle, mean +/- SD; remote, 109.3+/-11.8%; p0.01) and subacute (risk, 52.5+/-11.5%; remote, 97.9+/-14.3%; p0.01) stages. In addition, the area with reduced uptake of I-123 BMIPP showed a significant correlation with the area at risk both at the acute (r = 0.98, p0.01) and subacute (r = 0.92, p0.01) stages. In conclusion, the area at risk can be evaluated by I-123 BMIPP both at the acute and subacute stages.

To elucidate the change in perfusion and aerobic metabolism in myocarditis, tissue counting and dual tracer ex vivo autoradiography with Tl-201 and a free fatty acid analog, I-123- or I-125-labeled (p-iodophenyl)-methyl-pentadecanoic acid (BMIPP), were performed in rats with myocarditis induced by immunization with cardiac myosin. Inflammatory damage was classified histologically. At the acute stage (2-4 weeks after the antigen-injection), total heart uptakes of Tl and BMIPP and the ratio (BMIPP/Tl) were significantly reduced in myocarditis rats (N = 15) compared with the controls (N = 12). Myocardial distribution of Tl and BMIPP was not homogeneous. Relative uptake of Tl and BMIPP (N = 9, 128 regions) was gradually decreased with the extent of inflammation, and the regional BMIPP/Tl was smaller than the control. At the subacute stage (7 weeks after the antigen-injection), total Tl uptake in myocarditis rats (N = 5) recovered to the control level (N = 4), but that of BMIPP was still significantly lower than the control. BMIPP/Tl was still significantly lower in myocarditis. Myocardial distribution of Tl and BMIPP recovered to be more homogeneous. Relative uptake of Tl and BMIPP (N = 6, 78 regions) still gradually but significantly decreased with the extent of inflammation. Regional BMIPP/Tl was still depressed in myocarditis. These results indicate that myocardial perfusion and aerobic metabolism were discrepant and heterogeneously suppressed with severe inflammation during the acute stages, but the difference decreases with time. Examination with Tl-201 and BMIPP may provide information about the severity of myocarditis.

To evaluate the ability to detect coronary artery disease (CAD) with a new iodine-123 labeled branched fatty acid analog, iodophenyl-9-methyl pentadecanoic acid (9MPA), we performed 9MPA, iodine-123 BMIPP and thallium-201 SPECT in patients with CAD. Twenty-four patients (11 with effort angina and 13 with myocardial infarction) were studied. In all patients, 9MPA SPECT was obtained at 15 min after injection. Twenty-three patients underwent stress-redistribution 201Tl SPECT and 9 patients also underwent BMIPP myocardial fatty acid imaging. The regional uptakes of 9MPA, BMIPP and 201Tl were scored semiquantitatively and the segmental agreements were compared among them. In the segment-to-segment comparison, 9MPA showed reduced activity in comparison to stress-redistribution 201Tl imaging. The defect score of 9MPA was significantly greater than that of redistribution 201Tl images (p0.001). In addition, segmental 9MPA uptake was lower than BMIPP and its defect score was significantly greater than that of BMIPP (p0.05). When coronary angiography was used as the criterion, 9MPA showed higher sensitivity and lower specificity than stress-redistribution 201Tl (p0.01). In conclusion, fatty acid metabolic imaging with 9MPA is a sensitive but nonspecific detector of CAD.

To elucidate the after-effect of exercise on left ventricular (LV) function, end-diastolic volume (EDV), end-systolic volume (ESV) and ejection fraction (LVEF) were evaluated at 1 h after exercise and at rest by technetium-99m tetrofosmin gated myocardial single-photon emission tomography (SPET) using an automated program in 53 subjects. The subjects were grouped as follows: normal scan (n = 16), ischaemia (n = 19) and infarction (n = 18), based on the interpretation of perfusion images. Postexercise LVEF did not differ from resting LVEF in the groups with normal scan and infarction. In patients with ischaemia, postexercise EDV (90+/-17 ml, mean +/-SD) and ESV (44+/-15 ml) were significantly higher than EDV (84+/-15 ml, P = 0.001) and ESV (36+/-14 ml, P0.0005) at rest. LVEF was significantly depressed 1 h after exercise (53%+/-9% vs 58%+/-9%, P0.0001). In ischaemic patients with depressed postexercise LVEF, LVEF difference between rest and postexercise showed a significant correlation with the sum of defect scores, which were reversible from exercise to rest perfusion images (r = 0.92, P0.0001). These results indicate that exercise-induced LV dysfunction (myocardial stunning) continues for at least 1 h in ischaemic patients and that the extent of LVEF depression is determined by the severity of ischaemia.

To elucidate the relation between glucose tolerance and myocardial uptake of F-18 fluorodeoxyglucose (FDG), FDG-PET with 75 g oral glucose loading was performed on 43 coronary artery disease patients (twice in 2 patients). The patients were divided into 4 groups based on the blood glucose level (BS) and the insulinogenic index (II): group 1, normal (n = 9); group 2, impaired glucose tolerance (IGT, n = 12); group 3, mild diabetes mellitus (DM) (II > 0.4, n = 12); and group 4, severe DM (II < 0.4, n = 12). Percent (%) dose uptake of FDG in the normal regions of the myocardium was not significantly different in groups 1,2, and 3, but it was much lower in group 4 than in groups 1 and 2. In groups 2,3, and 4, % dose uptake showed a definite negative correlation with BS 60 min after glucose loading (r = -0.450, p < 0.05), and a close positive correlation with II (r = 0.363, p < 0.05). These findings indicate that myocardial FDG uptake in normal regions is not greatly impaired in patients with IGT or mild DM. Myocardial viability can be assessed by oral glucose loading in patients with IGT and mild DM as well as in patients with normal glucose tolerance.

Comparative studies of thallium-201 (201Tl) and 99Tcm-tetrofosmin for the detection of ischaemic heart disease (IHD) have previously been reported. These 201Tl and 99Tcm-tetrofosmin studies were usually performed separately with different exercise loads at an interval of several days. Here, we used a dual-isotope technique with exercise myocardial SPET (single photon emission tomography) in 17 patients with IHD and 10 patients with normal coronary arteries. The triple-energy window (TEW) method was applied for cross-talk correction. SPET imaging was performed at 10 and 70 min (S1 and S2) after the injection of 99Tcm-tetrofosmin (222 MBq) and 201Tl (74 MBq) at peak exercise to determine the optimal imaging time of 99Tcm-tetrofosmin. The S2 value was obtained 35 min after the subject drank a glass of milk to accelerate hepatobiliary clearance. Twenty-five minutes after S2, 37 MBq of 201Tl were reinjected at rest and SPET imaging (S3) was performed. Immediately after S3, 666 MBq of 99Tcm-tetrofosmin were reinjected and SPET imaging (S4) was performed 50 min later. Representative short and vertical long axis tomograms were divided into 17 segments. Each segment was assessed using a 4-point scoring system. The defect score was defined as the sum of each segmental score. The defect scores for imaging at exercise were 14.3 +/- 11.4 for 201Tl at S1, 11.4 +/- 8 for 99Tcm-tetrofosmin at S1 and 9.7 +/-9.8 for 99Tcm-tetrofosmin at S2 (P < 0.01), respectively. The washout rate of 99Tcm-tetrofosmin for the first hour was 15.5 +/- 7.3% and 11.8 +/- 7.7% (P < 0.01), respectively, for the normal and ischaemic segments. The image quality of 201Tl at S1 was almost equivalent to that of 99Tcm-tetrofosmin at S1/S2. The overall sensitivity and specificity for the detection of ischaemia was 94% and 82% for 201Tl at S1, 89% and 86% for 99Tcm-tetrofosmin at S1, and 88% and 95% for 99Tcm-tetrofosmin at S2, respectively. The overall accuracy was 86%, 88% and 92%, respectively. The myocardial viability score was 7.4 +/- 7.1 for 201Tl at S3 and 5.8 +/- 7.0 for 99Tcm-tetrofosmin at S4 (P < 0.01). The results indicate that the diagnostic accuracy of 99Tcm-tetrofosmin for myocardial ischaemia is almost equivalent to that of 201Tl as assessed by dual SPET imaging, and that the optimal imaging time for 99Tcm-tetrofosmin is within 10-35 min (S1) after exercise.

Adjunctive intracoronary administration of nicorandil, an ATP-sensitive potassium channel opener, after successful coronary revascularization was performed in a 54-year-old patient with acute myocardial infarction. The `no-reflow' phenomenon disappeared after nicorandil administration and significant functional recovery of the infarcted myocardium was achieved. This suggests that nicorandil could eliminate the `no-reflow' phenomenon after successful coronary revascularization. (Jpn Circ J 1997; 61: 455 - 458)

Obturator hernia that is successfully diagnosed preoperatively has been increasingly reported with a recent progression of imaging techniques. We describe a case of the disease in which computed tomography (CT) was very useful to make the definite diagnosis preoperatively.An 83-year-old woman was admitted to the hospital because of nausea and vomiting. Obturator hernia was suspected by a gastrografin study using an ileus tube. The final diagnosis of obturator hernia was made by CT, which demonstrated a water density mass located between the internal and external obturator muscle. Emergency laparotomy was performed with enterectomy. The operative outcome was satisfactory.

A 24-year-old man visited our clinic with the chief complaint of weakness of the extremities. On the basis of clinical observations and tests, a hypokalemic periodic paralysis attack followed by Graves' disease was diagnosed. Potassium administration rapidly restored his muscle strength. On the next day, his serum potassium level was within normal limits with the restoration of his muscle strength, and the paralysis disappeared.Methimazole, propylthiouracil and iodine agents were not tolerable because of their side effects. The hyperthyroid state was satisfactorily controlled with β-blockers and adrenocortical hormones in a relatively short period before surgery. Therefore a subtotal thyroidectomy was successfully performed under general anesthesia. Although periodic paralysis is not common as an initial symptom of Graves' disease, this disease should be taken into consideration in patients with periodic paralysis.

We encountered a patient with mucocele of the appendix causing strangulation ileus. A 71-year-old female was admitted because of abdominal pain, abdominal distension and vomiting. The patient underwent emergency surgery with a diagnosis of strangulation ileus. The mucocele of the appendix had adhered to the ileum, producing strangulation of the ileum of 1.5m proximal to the cecum. The appendix and the necrotic ileum were resected. Strangulation ileus is a rare complication of mucocele of the appendix. This is the 14th case report in Japan.

In a 65-year-old man who had been diagnosed as having lung cancer, invasive thymoma was pointed out on chest computed tomography. First, he underwent a right upper lobectomy. The pathological diagnosis was squamous cell carcinoma of the lung. After a month of the first operation, he underwent a thymothymectomy including left diaphragmatic nerve resection. Nearly 3 years after the second operation, he was urgently admitted to our hospital because of respiratory failure. A diagnosis of respiratory muscle failure due to diaphragmatic paralysis was made. He received mechanical ventilation followed by daily training for respiration. Mechanical ventilation was needed only at night. Thus, we decided that home mechanical ventilation (HMV) was possible. His present condition has been steady using HMV at home. HMV is effective for achieving a better quality of life.

A 37-year-old female with complaints of lower abdominal pain and nausea was admitted to our hospital. An emergency operation was performed after a diagnosis of acute appendicitis was made. At laparotomy, a whitish, appendiceal tumor was found invading the cecum, and ileocecal resection was performed. The microscopic diagnosis of the tumor was mucinous cystadenocarcinoma of the appendix infiltrating the cecum. At a second look operation three days after the first operation, peritoneal calcinosis was found in the Douglas cavity but no regional lymph node metastasis was detected. Right hemicolectomy with lymph node dissection was then performed.Preoperative diagnosis of primary carcinoma of the appendix is difficult. Thus, intraoperative rapid histological diagnosis by frozen block is necessary, in addition to preoperative examinations, including echography and CT scans.

The aim of this study was to investigate changes in CD4(+)CD25(+)FOXP3(+) regulatory T cells (Tregs) throughout the clinical course of Kawasaki disease (KD) and correlations with response to intravenous immunoglobulin (IVIg) therapy. Participants comprised 18 patients who fulfilled the diagnostic criteria for KD and 20 healthy subjects. Expressions of CD25 and FOXP3 among all CD4(+) T cells in peripheral blood mononuclear cells were analyzed by flow cytometry before and 7 and 30 days after IVIg therapy. Before treatment, percentages of CD4(+)CD25(+)FOXP3(+) Tregs among total CD4(+) Tregs were significantly lower among KD patients (4.19 %; range, 0.16-8.11 %) than among healthy subjects (7.32 %; 4.18-13.42 %; P = 0.0001). Both percentages and absolute numbers of CD4(+)CD25(+)FOXP3(+) Tregs on day 7 after IVIg therapy were significantly increased compared with values before treatment (8.02 % (range, 0.51-12.6 %) vs. 4.19 % (range, 0.16-8.11 %), P = 0.0005; 93.25/ μL (range, 6.67-258.05) vs. 41.85/ μL (range, 0.44-160.62), P 0.0001, respectively). Moreover, percentages and absolute numbers of CD4(+)CD25(+)FOXP3(+) Tregs before treatment were significantly lower in the IVIg-resistant group than in the IVIg-sensitive group (0.18 % (range, 0.16-3.34 %) vs. 4.52 % (range, 2.8-8.11 %), P = 0.0022; 0.68/μL (range, 0.44-53.81) vs. 51.66/μL (range, 2.88-160.62), P = 0.0098, respectively). The frequency of CD4(+)CD25(+)FOXP3(+) Tregs in four of the five IVIg-resistant patients at diagnosis was more than 3 standard deviations below that in healthy subjects. Two of these four patients displayed coronary abnormalities, and one of these two patients developed coronary aneurysm.Lack of CD4(+)CD25(+)FOXP3(+) Tregs before treatment may predict resistance to IVIg therapy in patients with KD.

This paper presents a patient with Dieulafoy's ulcer of the ileum, with some discussion on the relevant literature. A 62-year-old man was admitted to the hospital because of abdominal distention and tarry stool. Since the bleeding point was not detected by upper gastrointestinal endoscopy and colonoscopy, the small intestine was suspected to be a source of bleeding. At an emergency laparotomy, it was found that the lower jejunum to the ileum contained blood coagula. A careful transillumination technique successfully identified the bleeding point, and the ileum by 10cm in length was resected. The resected specimen showed a ruptured artery in a minute ulcer. Microscopic examination showed a markedly enlarged artery under the minute ulcer (UI-II), which was neither a true aneurysm nor arteriosclerosis. Only five patients including this patient with Dieulafoy's ulcer of the small intestine have been reported in the world.