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The outcome of paradox splitting of the second heart sound (S2) after cardiac resynchronization therapy (CRT) has not been well defined. We present a case of right ventricular pacing induced heart failure with prominent paradox splitting of S2 which markedly improved after upgrading to CRT.

Thrombolysis in Myocardial Infarction Risk Score for Secondary Prevention (TRS2°P) is a contemporary risk scoring system for secondary prevention based on nine clinical factors. However, this scoring system has not been validated in other populations. The aim of this study was to validate the TRS2°P in patients with acute myocardial infarction (AMI) treated with primary percutaneous coronary intervention (PCI) in a nationwide registry cohort. Among 3283 consecutive patients with AMI enrolled in the Japanese registry of acute Myocardial INfarction diagnosed by Universal dEfiniTion (J-MINUET), a total of 2611 patients who underwent primary PCI were included in this study. The performance of the TRS2°P to predict major adverse cardiovascular events (MACE) composed of all-cause death, non-fatal MI, and non-fatal stroke up to 3 years in the present cohort was evaluated. The TRS2°P had modest discriminative performance in this J-MINUET cohort with a c-statistic of 0.63, similar to that in the derived cohort (TRA2°P-TIMI50, c-statistic 0.67). A strong graded relationship between the TRS2°P and 3-year cardiovascular event rates was also observed in the J-MINUET cohort. Age ≥ 75 years, Killip ≥ 2, prior stroke, peripheral artery disease, anemia, and non-ST-elevation myocardial infarction were identified as independent factors for the incidence of MACE. The TRS2°P modestly predicted secondary cardiovascular events among patients with AMI treated by primary PCI in a nationwide cohort of Japan. Further studies are needed to develop a novel risk score better predicting secondary cardiovascular events.

Background The prevalence of acute myocardial infarction (AMI) in elderly people is increasing worldwide. However, their characteristics and prognosis have been rarely investigated. This study aimed to investigate the characteristics and prognosis in elderly patients with cardiac troponin-positive AMI. Methods Consecutive patients with AMI from the J-MINUET study were divided into the following 3 groups: patients aged less than 65 years, those aged between 65 and 79 years, and those aged 80 years or over. Their characteristics and in-hospital outcomes were compared. Results Patients with AMI aged 80 years or over had the highest incidence of female gender, and the highest incidence of hypertension, chronic kidney disease, and cardiovascular disease, such as peripheral artery disease, atrial fibrillation, and stroke, whereas they had the lowest body mass index, and the lowest incidence of current smoker, diabetes mellitus, and dyslipidemia. Patients with AMI aged 80 years or over had significantly longer onset to door time and longer door to device time, and lower peak creatine kinase (CK). The incidence of ST-segment elevation myocardial infarction (STEMI) was the lowest in the AMI patients aged 80 years or over, but the patients had a higher incidence of in-hospital death and cardiac failure than the other two groups. In addition, the presentation with STEMI and non-ST-segment elevation myocardial infarction with CK elevation among patients aged 80 years or over showed the highest incidence of in-hospital death and cardiac failure. Conclusions J-MINUET showed different clinical characteristics between the aged and younger populations. The incidence of in-hospital death and cardiac failure in patients aged 80 years or over with AMI was poorer than their younger counterparts.

Discordant results have been reported on outcomes of acute myocardial infarction (AMI) patients who present during off-hours.We investigated 3283 consecutive patients with AMI who were selected from the prospective, nationwide, multicenter registry (J-MINUET) database comprising 28 institutions in Japan between July 2012 and March 2014 to determine the current impact of off-hours presentation (defined as weekends, holidays, and weekdays from 8:01 PM to 7:59 AM) at hospitals on long-term clinical outcomes. The primary endpoint was a composite of all-cause death, non-fatal MI, non-fatal stroke, cardiac failure, and urgent revascularization for unstable angina for up to 3 years from the index event.During off-hours, 52% of patients presented. Primary percutaneous coronary intervention was performed in 85% of patients, and the door-to-balloon time was comparable between off-hours and regular hours (74, interquartile range [IQR] 52 to 113 versus 75, IQR 52 to 126 minutes, P = 0.34). Rate of overall primary endpoint overall did not overall significantly differ (25.3% versus 23.5%, log-rank P = 0.26), in patients with ST-elevation myocardial infarction (STEMI) (log-rank P = 0.93) and in patients with non-ST-elevation myocardial infarction (NSTEMI) (log-rank P = 0.14). Multivariate Cox regression analysis showed that off-hours presentation was not significantly associated with long-term clinical events in all cohorts.The impact of presentation during off-hours or regular hours on the long-term clinical outcomes of Japanese patients with AMI is comparable in contemporary practice.

Unilateral pulmonary edema (UPE) is a rare entity and is usually associated with severe mitral regurgitation and more frequently occurs in the right lung. We herein report a case of unilateral left pulmonary edema caused by external compression of the right pulmonary artery and left pulmonary vein caused by the presence of hematoma due to type A acute aortic dissection (AAD), resulting in asymmetrically increased inflow and decreased outflow in the left pulmonary circulation. Physicians caring for patients with UPE should be aware that AAD leading to the external compression of the heart may be a possible underlying mechanism.

A woman in her 50s developed acute coronary syndrome with de Winter pattern electrocardiogram (ECG). A coronary angiography revealed diagonal branch lesion caused by spontaneous coronary artery dissection, whereas the left-anterior descending artery was intact. The ECG change was transient and returned to normal without treatment 2 h later. (Level of Difficulty: Beginner.), Graphical abstract, A woman in her 50s developed acute coronary syndrome with de Winter pattern electrocardiogram (ECG). A coronary angiography revealed diagonal branch…

A 52-year-old female developed acute idiopathic pericarditis, which was complicated with tamponade. Constrictive physiology persisted after pericardiocentesis, and effusive-constrictive pericarditis (ECP) was diagnosed. Constrictive physiology improved in 10 days with anti-inflammatory therapy. This case was remarkable because it showed that ECP may present in an acute and reversible form. (Level of Difficulty: Beginner.), Graphical abstract, A 52-year-old female developed acute idiopathic pericarditis, which was complicated with tamponade. Constrictive physiology persisted after…

It is known that incidence and short-term mortality rate of acute myocardial infarction (AMI) tend to be higher in the cold season. The aim of our study was to investigate the association of onset-season with patient characteristics and long-term prognosis of AMI. This was a prospective, multicenter, Japanese investigation of 3,283 patients with AMI who were hospitalized within 48 h of symptom onset between July 2012 and March 2014. Patients were divided into 3 seasonal groups according to admission date: cold season group (December–March), hot season group (June–September), and moderate season group (April, May, October, and November). We identified 1356 patients (41.3%) admitted during the cold season, 901 (27.4%) during the hot season, and 1026 (31.3%) during the moderate season. We investigated the seasonal effect on patient characteristics and clinical outcomes. Baseline characteristics of each seasonal group were comparable, with the exception of age, Killip class, and conduction disturbances. The rates of higher Killip class and complete atrioventricular block were significantly higher in the cold season group. The 3-year cumulative survival free from major adverse cardiac events (MACE) rate was the lowest in the cold season (67.1%), showing a significant difference, followed by the moderate (70.0%) and hot seasons (72.9%) (p

Beta-blockers are standard therapy for acute myocardial infarction (AMI). However, despite current advances in the management of AMI, it remains unclear whether all AMI patients benefit from β-blockers. We investigated whether admission heart rate (HR) is a determinant of the effectiveness of β-blockers for AMI patients. Methods and Results: We enrolled 3,283 consecutive AMI patients who were admitted to 28 participating institutions in the Japanese Registry of Acute Myocardial Infarction Diagnosed by Universal Definition (J-MINUET) study. According to admission HR, we divided patients into 3 groups: bradycardia (HR60 beats/min, n=444), normocardia (HR 60 to ≤100 beats/min, n=2,013), and tachycardia (HR100 beats/min, n=342). The primary endpoint was major adverse cardiac events (MACE), including all-cause death, non-fatal MI, non-fatal stroke, heart failure (HF), and urgent revascularization for unstable angina, at 3-year follow-up. Beta-blocker at discharge was significantly associated with a lower risk of MACE in the tachycardia group (23.6% vs. 33.0%; P=0.033), but it did not affect rates of MACE in the normocardia group (17.8% vs. 18.4%; P=0.681). In the bradycardia group, β-blocker use at discharge was significantly associated with a higher risk of MACE (21.6% vs. 12.7%; P=0.026). Results were consistent for multivariable regression and stepwise multivariable regression.Admission HR might determine the efficacy of β-blockers for current AMI patients.

A 60-year-old woman with cardiac sarcoidosis developed recurrent and refractory right heart failure 26 months after tricuspid valve replacement. Echocardiography revealed thickened and immobile cusp with increased diastolic tricuspid gradient of 8–10 mmHg, consistent with bioprosthetic tricuspid stenosis (TS). Prolonged intravenous injection of dobutamine and carperitide, with intermittent intravenous furosemide, was necessary at multiple times. Despite treatment, the patient died of refractory right heart failure. The explanted tricuspid bioprosthesis on autopsy revealed marked pannus formation, resulting in stiff and immobile cusps while the same mitral bioprosthesis, which was implanted on the same day, was normal. Sarcoid granulomas were not present either in tricuspid or mitral bioprostheses. Chronic valve inflammation associated with prolonged use of intravenous drugs and multiple episodes of line-associated bacteremia may have caused early onset bioprosthetic TS. Learning objectives: 1 Early onset bioprosthetic tricuspid stenosis (TS) is rare. 2 Elevated jugular venous pulse and pan-diastolic rumble with the Rivero–Carvallo sign are keys to the diagnosis of TS which is confirmed using echocardiography. 3 Repeated episodes of bacteremia associated with prolonged infusion of intravenous drugs might have contributed to the development of early onset bioprosthetic TS.

Thrombolysis in Myocardial Infarction Risk Score for Secondary Prevention (TRS2°P) is a contemporary risk scoring system for secondary prevention based on nine clinical factors. However, this scoring system has not been validated in other populations. The aim of this study was to validate the TRS2°P in patients with acute myocardial infarction (AMI) treated with primary percutaneous coronary intervention (PCI) in a nationwide registry cohort. Among 3283 consecutive patients with AMI enrolled in the Japanese registry of acute Myocardial INfarction diagnosed by Universal dEfiniTion (J-MINUET), a total of 2611 patients who underwent primary PCI were included in this study. The performance of the TRS2°P to predict major adverse cardiovascular events (MACE) composed of all-cause death, non-fatal MI, and non-fatal stroke up to 3 years in the present cohort was evaluated. The TRS2°P had modest discriminative performance in this J-MINUET cohort with a c-statistic of 0.63, similar to that in the derived cohort (TRA2°P-TIMI50, c-statistic 0.67). A strong graded relationship between the TRS2°P and 3-year cardiovascular event rates was also observed in the J-MINUET cohort. Age ≥ 75 years, Killip ≥ 2, prior stroke, peripheral artery disease, anemia, and non-ST-elevation myocardial infarction were identified as independent factors for the incidence of MACE. The TRS2°P modestly predicted secondary cardiovascular events among patients with AMI treated by primary PCI in a nationwide cohort of Japan. Further studies are needed to develop a novel risk score better predicting secondary cardiovascular events.

Although B-type natriuretic peptide (BNP) has gradually gained recognition as an indicator in risk stratification for patients with acute myocardial infarction (AMI), the prognostic impact on long-term clinical outcomes in patients with non-ST-segment elevation acute myocardial infarction (NSTEMI) without creatine kinase (CK) elevation remains unclear.This prospective multicenter study assessed 3,283 consecutive patients with AMI admitted to 28 institutions in Japan between 2012 and 2014. We analyzed 218 patients with NSTEMI without CK elevation (NSTEMI-CK) for whom BNP was available. In the NSTEMI-CK group, patients were assigned to high- and low-BNP groups according to BNP values (cut-off BNP, 100 pg/mL). The primary endpoint was defined as a composite of all-cause death, non-fatal myocardial infarction, non-fatal stroke, cardiac failure, and urgent revascularization for unstable angina up to 3 years. Primary endpoints were observed in 60 (33.3%) events among patients with NSTEMI-CK. Kaplan-Meier analysis revealed a significantly higher event rate for primary endpoints among patients with high BNP (log-rank P0.001). After adjusting for covariates, a higher BNP level was significantly associated with long-term clinical outcomes in NSTEMI-CK (adjusted hazard ratio, 4.86; 95% confidence interval, 2.18-12.44; P0.001).The BNP concentration is associated with adverse long-term clinical outcomes among patients with NSTEMI-CK who are considered low risk. Careful clinical management may be warranted for secondary prevention in patients with NSTEMI-CK with high BNP levels.

We herein report 3 cases of acute aortic dissection (AAD) in which the initial 12-lead electrocardiogram showed typical ST elevation consistent with acute pericarditis. All patients exhibited small pericardial effusion but did not suffer from rupture into the pericardium or clinical tamponade. Slow leakage or exudate stemming from the dissecting hematoma appeared to have caused inflammation, resulting in pericarditis. Therefore, we highlight the fact that AAD may masquerade as acute pericarditis. Physicians should be aware of the possibility of type A AAD as an important underlying condition, since the early diagnosis and subsequent surgical treatment may save patients' lives.

While prognoses in relation to myocardial infarction (MI) type have been elucidated in past reports, the results were not consistent, perhaps due to occurrence of Type 2 MI with CVS and its mortality. The Japanese registry of acute Myocardial Infarction diagnosed by Universal Definition (J-MINUET) is a prospective multicenter registry in Japan. In contrast to thromboembolic event-related Type 1 myocardial infarction (MI), clinical features of Type 2 MI, including coronary vasospasm (CVS), are varied due to the heterogeneous nature of its development. To elucidate the MI type-related all-cause mortality, 2989 consecutive patients with AMI were stratified as Type 1 MI, Type 2 MI with CVS, and Type 2 MI with non-CVS. Most patients (n = 2834, 94.8%) were classified as Type 1 MI and 155 patients (5.2%) were classified as Type 2 MI. Of the Type 2 MI patients, 87 (56% of Type 2 MI) were diagnosed as MI with CVS. Although the 3-year mortality was comparable between Type 1 and Type 2 MI patients, significant differences were observed between Type 2 MI with CVS and with non-CVS (3.4% and 22.1%, p &lt, 0.001). Among Japanese patients with AMI, mortality rates between Type 1 MI and Type 2 MI are comparable, but further stratification of Type 2 MI (with or without CVS) may be useful in predicting the prognosis of patients with Type 2 MI.

Discordant results have been reported on outcomes of acute myocardial infarction (AMI) patients who present during off-hours.We investigated 3283 consecutive patients with AMI who were selected from the prospective, nationwide, multicenter registry (J-MINUET) database comprising 28 institutions in Japan between July 2012 and March 2014 to determine the current impact of off-hours presentation (defined as weekends, holidays, and weekdays from 8:01 PM to 7:59 AM) at hospitals on long-term clinical outcomes. The primary endpoint was a composite of all-cause death, non-fatal MI, non-fatal stroke, cardiac failure, and urgent revascularization for unstable angina for up to 3 years from the index event.During off-hours, 52% of patients presented. Primary percutaneous coronary intervention was performed in 85% of patients, and the door-to-balloon time was comparable between off-hours and regular hours (74, interquartile range [IQR] 52 to 113 versus 75, IQR 52 to 126 minutes, P = 0.34). Rate of overall primary endpoint overall did not overall significantly differ (25.3% versus 23.5%, log-rank P = 0.26), in patients with ST-elevation myocardial infarction (STEMI) (log-rank P = 0.93) and in patients with non-ST-elevation myocardial infarction (NSTEMI) (log-rank P = 0.14). Multivariate Cox regression analysis showed that off-hours presentation was not significantly associated with long-term clinical events in all cohorts.The impact of presentation during off-hours or regular hours on the long-term clinical outcomes of Japanese patients with AMI is comparable in contemporary practice.

Background: The association between guideline adherence and long-term outcomes in patients with acute myocardial infarction in real-world clinical practice remains unclear. Methods: We investigated 3283 consecutive patients with acute myocardial infarction who were selected from a prospective, nation-wide, multicentre registry (J-MINUET) database covering 28 institutions in Japan between July 2012 and March 2014. Among the 2757 eligible patients, we evaluated the use of seven guideline-recommended therapies, including urgent revascularisation, door-to-balloon time of 90 minutes or less, and five discharge medications (P2Y12 inhibitors on aspirin, beta-blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, statins, lipid-lowering drugs). The primary endpoint was a composite of all-cause death, non-fatal myocardial infarction, non-fatal stroke, cardiac failure and urgent revascularisation for unstable angina up to 3 years. Results: The overall median composite guideline adherence was 85.7%. Patients were divided into the following three groups: complete (100%) adherence group (n=862); moderate adherence (75% to Conclusion: The use of guideline-based therapies for patients with acute myocardial infarction in contemporary clinical practice was associated with significant decreases in adverse long-term clinical outcomes. Trial registration: UMIN Unique trial Number: UMIN000010037

Previous studies have demonstrated that use of intravascular ultrasound (IVUS) during percutaneous coronary intervention (PCI) was associated with lower incidence of death, myocardial infarction, and target vessel revascularization. Recently, optical coherence tomography (OCT) has emerged as an alternative intravascular imaging device with better resolution. The aim of this study was to investigate frequency and prognostic impact of IVUS or OCT-guided PCI during urgent revascularization for acute myocardial infarction diagnosed by the universal definition. A total of 2788 patients who underwent urgent PCI were selected from a multicenter, Japanese registry of acute myocardial infarction diagnosed by universal definition (J-MINUET). Frequency, clinical characteristics and prognostic impact of the IVUS-, or OCT- guided PCI were investigated. Clinical endpoint was in-hospital death. Angiography-, IVUS-, and OCT-guided urgent PCI were performed in 689 (24.7%), 1947 (69.8%), and 152 (5.5%) patients. In-hospital death in each group was 10.4%, 5.1%, and 3.3%, respectively (P

It has been shown that the patency of an infarct-related artery (IRA) before primary percutaneous coronary intervention determines post-procedural success, better preservation of left ventricular function, and lower in-hospital mortality. However, the factors associated with pre-procedural Thrombolysis In Myocardial Infarction (TIMI) flow have not been fully investigated.The Japanese registry of acute Myocardial INfarction diagnosed by Universal dEfiniTion (J-MINUET) is a prospective multicenter registry conducted at 28 Japanese medical institutions between July 2012 and March 2014. We enrolled 3,283 consecutive patients with acute myocardial infarction who were admitted to a participating institution within 48 hours of symptom onset. There were 2,262 patients (68.9%) with ST-elevation myocardial infarction (STEMI), among whom 2,182 patients underwent emergent or urgent coronary angiography.Pre-procedural TIMI flow grade 3 was related to post-procedural TIMI flow grade 3 (P < 0.001), lower enzymatic infarct size (P < 0.001), lower ventricular tachycardia and ventricular fibrillation (P = 0.049), and lower in-hospital mortality (P = 0.020). A history of antiplatelet drug use was associated with pre-procedural TIMI flow.Antiplatelet drug use on admission was associated with pre-procedural TIMI flow. The patency of the IRA in patients with STEMI was related to procedural success and decreased enzymatic infarct size, fatal arrhythmic events, and in-hospital mortality.

Patients with peripheral artery disease (PAD) are at high risk of cardiovascular events, including myocardial infarction (MI), stroke, and cardiovascular death. However, the impact of PAD on prognosis in Japanese patients with acute MI remains unclear.The Japanese registry of acute Myocardial INfarction diagnosed by Universal dEfiniTion (J-MINUET) is a prospective multicenter registry that registered 3283 patients with acute MI. Among them, 2970 patients with available data of PAD were divided into the following 4 groups: 2513 patients without prior MI or PAD (None group), 320 patients with only prior MI (Prior MI group), 100 patients with only PAD (PAD group), and 37 patients with both previous MI and PAD (Both group). The primary endpoint was a composite of all-cause death, non-fatal MI, non-fatal stroke, cardiac failure, and urgent revascularization for unstable angina.The 3-year cumulative incidence of the primary endpoint was 26.9% in None group, 41.4% in Prior MI group, 48.0% in PAD group, and 60.3% in Both group (p 0.001). In multivariate analysis, hazard ratio using None group as reference was 1.55 (95% confidence intervals 1.25-1.91; p 0.001) for MI group, 2.26 (1.61-3.07; p 0.001) for PAD group, and 2.52 (1.52-3.90; p 0.001) for Both group.Concomitant PAD was associated with poor prognosis in Japanese patients with acute MI.

The association between patients with acute myocardial infarction (AMI) who present during off-hours and clinical outcomes has not been fully elucidated.We investigated 3283 consecutive patients with AMI who were selected from a prospective, nationwide, multicenter registry (J-MINUET) database comprising 28 institutions in Japan between July 2012 and March 2014 to determine the current impact of off-hours presentation on in-hospital mortality among Japanese patients with AMI.Among the patients, 52% presented in off-hours. Baseline characteristics were comparable, although those who presented during off-hours were younger and had a higher incidence of ST-elevation myocardial infarction and advanced Killip Class. The time from symptom onset to presentation time was shorter in off-hour patients (120min, interquartile range 60 to 256 vs. 215min, interquartile range 90 to 610, p0.0001). In contrast, 85% of patients underwent primary percutaneous coronary intervention (PCI) and door to balloon time was comparable between the groups (74min, interquartile range 52 to 113 vs. 75min, interquartile range 52 to 126, p=0.34). The rates of in-hospital mortality were comparable (6.2% vs 6.8%, p=0.39). Multivariate logistic regression analysis revealed that off-hours presentation was not significantly associated with in-hospital mortality [odds ratio (OR) 0.94; 95% CI, 0.68-1.30, p=0.70].The clinical impact of presenting during off-hours or regular hours on AMI patients in Japan is comparable in contemporary practice.UMIN Unique trial Number: UMIN000010037.

The ratio of serum eicosapentaenoic acid (EPA) to arachidonic acid (AA) is significantly associated with long-term clinical outcomes in patients with acute myocardial infarction (AMI). However, it has not been conclusively demonstrated that higher serum EPA/AA ratio fares better clinical outcomes in the early phase of AMI. The Japanese registry of acute Myocardial INfarction diagnosed by Universal dEfiniTion (J-MINUET) is a prospective multicenter registry conducted in 28 Japanese medical institutions between July 2012 and March 2014. We enrolled 3,283 consecutive AMI patients who were admitted to participating institutions within 48 h of symptom onset. A serum EPA/AA ratio was available for 629 of these patients. The endpoints were in-hospital mortality and major adverse cardiac events (MACE), defined as a composite of all cause death, cardiac failure, ventricular tachycardia (VT) and/or ventricular fibrillation (VF) and bleeding during hospitalization. Although similar rates of in-hospital mortality, cardiac failure, bleeding, and MACE were found in the lower serum EPA/AA group and higher serum EPA/AA group, the incidence of VT/VF during hospitalization was significantly higher in the low ratio group (p = 0.008). Receiver operating characteristic curve analysis showed that an EPA/AA ratio

Esophageal hiatus hernia has been known to cause symptoms of congestive heart failure or syncope after meal due to compression of the heart, mainly the left atrium. However, compression of the left ventricle resulting in syncope has never been reported. Seventy-one year old woman developed syncope after taking a lunch. A chest roentgenogram showed possible mass lesion behind the heart. An echocardiogram revealed a mass lesion posterior to the left ventricle, resulting in “banana-shaped” deformity. A CT scan revealed a giant esophageal hiatus hernia which compressed the left ventricle. Cardiac catheterization revealed marked pressure gradient in the left ventricle suggestive of intracavitary obstruction after isoproterenol infusion. Left ventricular compression due to enlarged giant hiatus hernia after meal resulted in intracavitary obstruction of the left ventricle, causing syncopal episode in this particular patient. Dehydration and diastolic dysfunction may also have contributed.

Background Aorto-cavitary fistula is a rare condition, and the most common underlying aetiology is infective endocarditis (IE) of the native or the prosthetic aortic valve. We report a case of aorto-right inferior pulmonary venous fistula following redo mitral valve replacement (MVR) for prosthetic mitral valve IE. Case summary A 74-year-old woman underwent urgent redo MVR for prosthetic mitral valve IE. The post-operative course was complicated with heart failure and mediastinal haematoma compressing the left atrium. The haematoma was surgically removed and laceration of the left atrial wall was suture ligated; this was attributed to the surgical trauma dissection of the adhesive tissues. One-week post-operatively, a continuous murmur emerged, which prompted an evaluation of the left to right shunt. Transthoracic echocardiography revealed an echolucent area posterior to the aorta, with continuous flow on colour Doppler. Three-dimensional computed tomography showed a fistula between the aorta and the right inferior pulmonary vein. There was a high risk involved in surgical management; therefore, she was managed medically. Fortunately, the continuous murmur and echolucent space disappeared after 6 months. The fistula was considered to be obstructed by spontaneous thrombus formation in the narrowed segment of the fistula tract. Discussion The cause of fistula was attributed to possible surgical trauma in the presence of infection. The present case was unique, as it showed spontaneous healing of an aorto-cavitary fistula, which is very rare. The patient was alive with good health status, 6 years after the MVR.

A 75-year-old woman, with a history of bilateral internal mammary artery–coronary artery bypass graft surgery, developed hypotension and pulmonary oedema posing as cardiogenic shock. Severe bilateral subclavian artery stenosis emerged to be the cause of ischaemic myocardial dysfunction and heart failure. An emergency endovascular treatment was successfully performed. The presence of simultaneous bilateral subclavian artery narrowing as the pathophysiologic mechanism of myocardial ischaemia makes this case remarkable.

Background Bioprosthetic tricuspid valve stenosis is a late sequela of tricuspid valve replacement (TVR); however, detailed information regarding its clinical picture is lacking. Case summary Thirty-one patients with bioprosthetic TVR (mean age: 60.5 ± 16.6 years, male/female: 11/20) were followed-up for 79.5 ± 49.1 months (14–188 months). Eleven patients developed bioprosthetic tricuspid valve stenosis (mean tricuspid gradient >5 mmHg) at a median interval of 96 months (interquartile range: 61–114 months). The mean tricuspid gradient at the time of tricuspid valve stenosis diagnosis was 10.9 ± 3.9 mmHg. Although the mid-term tricuspid valve stenosis-free survival was favourable (92.4% at 60 and 78.7% at 84 months), it had declined steeply to 31.5% by 120 months. Ten out of 11 tricuspid valve stenosis patients showed signs of right heart failure (RHF) as manifested by oedema and elevated jugular venous pressure, requiring moderate-to-high doses of diuretics. Diastolic rumble was audible in 10 patients. Five of the 11 tricuspid valve stenosis patients required redo TVR as a result of refractory RHF. Examination of the five excised bioprostheses showed pannus in four, fusion of the commissure in three, native valve attachment in two, and sclerosis in one. Detailed clinical pictures and pathology of the explanted valves in three cases that underwent surgery are presented in this case series. Discussion Bioprosthetic tricuspid valve stenosis is not uncommon after 8 years. Tricuspid valve replacement performed at the second surgery was associated with a higher incidence of bioprosthetic tricuspid valve stenosis.

High levels of blood urea nitrogen (BUN) have been demonstrated to significantly predict poor prognosis in patients with acute decompensated heart failure. However, this relationship has not been fully investigated in patients with acute myocardial infarction (AMI). We investigated whether a high level of BUN is a significant predictor for in-hospital mortality and other clinical outcomes in patients with AMI. The Japanese registry of acute Myocardial INfarction diagnosed by Universal dEfiniTion (J-MINUET) is a prospective, observational, multicenter study conducted in 28 institutions, in which 3,283 consecutive AMI patients were enrolled. We excluded 98 patients in whom BUN levels were not recorded at admission and 190 patients who were undergoing hemodialysis. A total of 2,995 patients were retrospectively analyzed. BUN tertiles were 1.5-14.4 mg/dL (tertile 1), 14.5-19.4 mg/dL (tertile 2), and 19.5-240 mg/dL (tertile 3). Increasing tertiles of BUN were associated with stepwise increased risk of in-hospital mortality (2.5, 5.1, and 11%, respectively; P < 0.001). These relationships were also observed after adjusting for reduced estimated glomerular filtration rate (estimated GFR < 60 mL/minute/1.73 m2) or Killip classifications. In multivariable analysis, high levels of BUN significantly predicted in-hospital mortality, after adjusting for creatinine and other known predictors (BUN tertile 3 versus 1, adjusted odds ratio [OR]: 2.59, 95% confidence interval [95% CI]: 1.57-4.25, P < 0.001; BUN tertile 2 versus 1, adjusted OR: 1.60, 95% CI: 0.94-2.73, P = 0.081). A high level of BUN could be a useful predictor of in-hospital mortality in AMI patients.

BACKGROUND According to troponin-based criteria of myocardial infarction (MI), patients without elevation of creatine kinase (CK), formerly classified as unstable angina (UA), are now diagnosed as non-ST-elevation MI (NSTEMI), but little is known about their outcomes.Methods and Results:Between July 2012 and March 2014, 3,283 consecutive patients with MI were enrolled. Clinical follow-up data were obtained up to 3 years. The primary endpoint was a composite of all-cause death, non-fatal MI, non-fatal stroke, cardiac failure and urgent revascularization for UA. There were 2,262 patients with ST-elevation MI (STEMI), 563 NSTEMI with CK elevation (NSTEMI+CK) and 458 NSTEMI without CK elevation (NSTEMI-CK). From day 0, Kaplan-Meier curves for the primary endpoint began to diverge in favor of NSTEMI-CK for up to 30 days. The 30-day event rate was significantly lower in patients with NSTEMI-CK (3.3%) than in STEMI (8.6%, P

A 59-year-old woman presented to Okinawa Chubu Hospital with a several-month history of progressive dyspnea. The patient initially noted exertional dyspnea after walking only a half-mile or when lifting heavy objects. Dyspnea worsened progressively, resulting in multiple syncopal episodes. The patient denied chest pain or dyspnea at rest. Her past history was significant for Ebstein anomaly, hypertension, hyperlipidemia, and duodenal ulcer. Her current medication included furosemide 20 mg twice a day, spironolactone 25 mg every day, losartan 25 mg every day, and pravastatin 10 mg every day. On initial examination, her blood pressure was 100/75 mm Hg, her heart rate was 75 bpm, and her respiratory rate was 18 breaths/min. A grade 4 systolic ejection murmur was noted throughout the precordium. Jugular venous pressure was not elevated and peripheral edema was not present. A chest roentgenogram showed cardiomegaly(Figure 1A)without pulmonary vascular congestion. An ECG showed normal sinus rhythm and marked left ventricular hypertrophy as manifested by high voltage and strain-type ST-T changes in I, aVL, V4 through V6(Figure 1B). Laboratory tests showed normal kidney and liver functions and no evidence of anemia, and brain natriuretic peptide was 399 pg/mL (

SummaryPrimary chylopericardium is a rare condition. The etiology and the treatment remain unclear. We report two cases of primary chylopericardium successfully treated by surgery. Both cases were asymptomatic young women and were found to have cardiomegaly on chest X-ray at a routine annual health examination. An echocardiography demonstrated massive pericardial effusion and chylous fluid was obtained with pericardiocentesis. Lymphoscintigraphy demonstrated abnormal communication between the pericardial sac and the thoracic duct. Because of reaccumulation of chylous pericardial effusion after conservative treatment, we performed surgical ligation of thoracic duct and partial pericardectomy by video-assisted thoracic surgery (VATS) in one case and by thoracotomy in another case. After surgery, both patients are doing well without recurrence of pericardial effusion. Surgical treatment including VATS is effective and should be performed in case of primary chylopericardium.

Background Not only symptoms but electrocardiographic (ECG) changes mimicking acute coronary syndrome as well have been known to develop in acute aortic dissection (AAD). However, detailed information is lacking. Objective We sought to evaluate incidence, patterns, and underlying mechanisms for acute ECG changes in type A AAD. Methods Retrospective study in a single tertiary care hospital. A total of 159 cases (mean age 65.1 ± 14.8 years, male/female = 67/92) that presented within 12 h from the onset were included. Shift of the ST segment ≧0.1 mV or changes of the T wave were considered acute ECG changes. Results Acute and chronic ECG changes were observed in 49.7% and 36.5% cases, respectively. ECG was normal only in 27.0% cases. ST elevation was observed in 8.2% cases and was closely related to direct coronary involvement. ST depression and T wave changes were observed in 34.0% and 21.4% cases, respectively. Cases with ST depression or T wave changes had higher incidence of shock (65.2% vs. 28.8%, p

Acute kidney injury (AKI) is associated with poor outcomes after acute myocardial infarction (AMI); however, its prognostic impacts of AKI on short- and long-term mortality in ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI) patients is

Purpose: Several studies have reported gender difference in presentation, management and outcome in patients with acute myocardial infarction (AMI). In this study, we focused the impact of age on gender difference in mortality after AMI. Methods: Between July 2012 and March 2014, 3283 patients were admitted to the 28 hospitals participating to the J-MINUET group within 48 hours after the onset of AMI. AMI was diagnosed by universal definition (type 1 or type 2). Patients were divided into 5 strata according to their age: those with age Results: There were 813 women (24.8%). Women were significantly older than men (74.5±11.8 years vs 66.6±12.3 years, P Conclusions: Women had higher in-hospital mortality than men after AMI even in the contemporary troponin era. However, their high mortality was mostly explained by their advanced age.

A 70-year-old woman with Wolf-Parkinson-White syndrome developed cardiac tamponade while undergoing radiofrequency catheter ablation for left posterolateral accessory pathway from the ventricular side below the mitral valve, requiring emergency surgery. During surgery, the patient was found to have perforation of the left posterior free wall as well as left atrial dissection. The patient died despite emergency measures. This case was remarkable because radiofrequency catheter ablation resulted in two very rare complications occurring at the same time in a patient.

New criteria for diagnosis of acute myocardial infarction (AMI) were proposed in 2000 as a universal definition, in which cardiac troponin (cTn) was the preferred biomarker. A large number of patients formerly classified by creatine kinase (CK) as unstable angina are now ruled-in by cTn as non-ST-elevation myocardial infarction (NSTEMI).The Japanese registry of acute Myocardial INfarction diagnosed by Universal dEfiniTion (J-MINUET) is a prospective and multicenter registry conducted in 28 institutions. We enrolled 3,283 consecutive patients with AMI diagnosed by cTn-based criteria who were admitted to participating institutions within 48 h of symptom onset. There were 2,262 patients (68.9%) with STEMI and 1,021 (31.1%) with NSTEMI. CK was not elevated more than twice the upper limit of normal in 458 patients (44.9%) with NSTEMI (NSTEMI-CK). Although there was no significant difference in the in-hospital mortality of STEMI and NSTEMI with CK elevation (NSTEMI+CK) patients (7.1% vs. 7.8%, P=0.57), it was significantly lower in patients with NSTEMI-CK than in those with STEMI or NSTEMI+CK (1.7%, P0.001 for each).J-MINUET revealed the clinical presentation, management and outcomes of Japanese patients with AMI in the current cTn era. We should be aware of the difference between AMI diagnosed by CK-based criteria and AMI diagnosed by cTn-based criteria when using universal definitions for the diagnosis of AMI.

BackgroundInitial diagnosis of acute aortic dissection (AAD) in the emergency room (ER) is sometimes difficult or delayed. The aim of this study is to define clinical predictors related to inappropriate or delayed diagnosis of Stanford type A AAD.MethodsWe conducted a retrospective analysis of 127 consecutive patients with type A AAD who presented to the ER within 12 h of symptom onset (age: 69.0 ± 15.4 years, male/female = 49/78). An inappropriate initial diagnosis (IID) was considered if AAD was not included in the differential diagnosis or if chest computed tomography or echocardiography was not performed as initial imaging tests. Clinical variables were compared between IID and appropriate diagnosis group. The time to final diagnosis (TFD) was also evaluated. Delayed diagnosis (DD) was defined as TFD > third quartile. Clinical factors predicting DD were evaluated in comparison with early diagnosis (defined as TFD within the third quartile). In addition, TFD was compared with respect to each clinical variable using a rank sum test.ResultsAn IID was determined for 37% of patients. Walk-in (WI) visit to the ER [odds ratio (OR) 2.6, 95% confidence interval (CI) = 1.01-6.72, P = 0.048] and coronary malperfusion (CM, OR = 6.48, 95% CI = 1.14-36.82, P = 0.035) were predictors for IID. Overall, the median TFD was 1.5 h (first/third quartiles = 0.5/4.0 h). DD (>4.5 h) was observed in 27 cases (21.3%). TFD was significantly longer in WI patients (median and first/third quartiles = 1.0 and 0.5/2.85 h for the ambulance group vs. 3.0 and 1.0/8.0 h for the WI group, respectively; P = 0.003). Multivariate analysis revealed that WI visit was the only predictor for DD (OR = 3.72, 95% CI = 1.39-9.9, P = 0.009). TFD was significantly shorter for appropriate diagnoses than for IIDs (1.0 vs. 6.0 h, respectively; P < 0.0001).ConclusionsWI visit to the ER and CM were predictors for IID, and WI was the only predictor for DD in acute type A AAD in the community hospital.

Introduction: Cardiovascular Implantable Electronic Device(CIED) Infections are one of the most serious complication after CIED implantation or replacement. To prevent infection, appropriate skin antisepsis and perioperative antibiotic prophylaxis at CIED implantation/replacement are important. But the most optimal antisepsis for CIED surgery is not well defined. Then we assessed whether additional wiping of the skin with 70% isopropyl alcohol just before routine skin antisepsis with povidone-iodine reduces the incidence of CIED infection. Methods: Consecutive 473 cases of CIED implantation or generator replacement from Jan.2008 to Dec.2013 at one community hospital were divided into two groups according to preoperative skin antisepsis with 70% isopropyl alcohol wipes lasting for at least 1 minute just before povidone-iodine scrub and paint(IPA group, n=183), or povidone-iodine only(No IPA group, n=290). All cases received perioperative antibiotic prophylaxis 30 minute before and 6 hours after procedure. Incidence of CIED infection requiring complete extraction of the leads and the generator within 1-year after implantation/replacement were compared between two groups by Kaplan-Meier analysis. Results: There were no significant difference in background CIED infection risk factors identified by past studies (diabetes, renal insufficiency, anticoagulant use, corticosteroid use, tempolary pacing, and generator replacement) between two groups. During the follow up period, 8 cases of confirmed CIED infection requiring complete extraction were identified, 6 pacemaker and 2 implantable cardioverter-defibrillator(ICD) or biventricular ICD. All infected cases belonged to No IPA group (p = 0.0235). Conclusions: In conclusion, wiping of the skin with 70% isopropyl alcohol just before routine antisepsis with povidone-iodine at CIED implantation/replacement significantly reduces the incidence of infection.