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Since the Great East Japan Earthquake in March 2011, an increase in lifestyle-related diseases due to changes in living environment following the nuclear power plant accident has been reported in Fukushima Prefecture, especially among evacuees. However, no long-term studies covering the entire Fukushima Prefecture have been conducted. The study aim was to investigate the effects of post-disaster evacuation life on the prevalence of dyslipidemia in Fukushima Prefecture using a national database. The data from 3,866,674 people who underwent specific health checkups between fiscal year (FY) 2008 and FY2017 were analyzed. Fukushima Prefecture was divided into four areas, and the prevalence of dyslipidemia and related parameters were compared. The prevalence of dyslipidemia increased overall, with a particularly sharp increase after FY2011 in the evacuation area. The sex- and age-adjusted odds ratio (95% confidence intervals) of having dyslipidemia in the evacuation area compared with that in the control area was 0.951 (0.929–0.973) in FY2008–2010, which increased to 1.130 (1.105–1.155) in FY2012–2014 and 1.117 (1.092–1.143) in FY2015–2017. Since the prevalence of dyslipidemia has increased and remained high after the earthquake in Fukushima Prefecture, especially in the evacuation area, continued measures to prevent cardiovascular diseases among the residents are needed.

Previously, we proposed an ultrasonic measurement method of arterial wall elasticity for the early detection of arteriosclerosis. Since vascular wall elasticity depends on blood pressure, in this study, the elasticity and viscosity were estimated using the hysteresis loop determined between the incremental strain in the wall and internal pressure by altering the internal pressure in the phantom and in vivo experiments. Consequently, both the estimated elasticity and viscosity increased with the internal pressure. Moreover, the slope of each hysteresis loop was larger than that of the approximated curve for the lowest blood pressures of the hysteresis loops with different internal pressures, as the blood pressure changed in the order of several hertz within a single heartbeat. Hence, we conclude that measuring both the blood pressure and the elastic and viscous moduli would be beneficial in comprehensively investigating more vessel wall properties that change with the progression of arteriosclerosis.

Reflected wave increases after endovascular aortic repair (EVAR) in patients with aortic aneurysm. This affects the left ventricular (LV) diastolic function and leads to a poor prognosis. This study aimed to evaluate the relationship between increased reflected wave amplitude and aortic diameter after EVAR. EVAR was performed in seven healthy goats. We assessed wave intensity (WI), aortic diameter, and stiffness parameter β. Moreover, we evaluated the relationship between negative reflected wave (NW, reflected waves toward the heart from the periphery by WI) and other parameters after EVAR. Results showed an increase in stiffness parameter β (3.5 ± 0.3 vs 15.9 ± 4.7, p = 0.018) and a decrease in the change of aortic diameter (6.9 ± 0.7 vs 2.7 ± 0.4%, p = 0.018) after EVAR. The NW was significantly amplified after EVAR from baseline (−589.8 ± 143.4 to − 1192.3 ± 303.7 mmHg-m/sec3, p = 0.043). The NW showed a significant correlation with maximum aortic diameter (R = 0.707, p = 0.038) and minimum aortic diameter (R = 0.724, p = 0.033). The reflected wave was enhanced after EVAR and was correlated to the aortic diameter at the stent-graft site. It is important to consider that patients with smaller aortic diameters in landing zone who undergo EVAR may develop LV dysfunction.

Objectives: To evaluate the early and late outcomes of the modified Bentall procedure with the flanged technique. Methods: We reviewed the medical records of 63 patients who had undergone root replacement by the modified Bentall procedure at our institute between January 2001 and December 2018. In most cases, we adopted a composite graft constructed with a mechanical valve or bioprosthesis and a Dacron graft by the flanged technique. Since 2011, we have used Valsalva grafts. Results: Mean age 57 ± 16 years, range 16-80, male 43 cases. The mean follow-up was 75 ± 56 months (range 0-216). Through April 1, 2020, we could follow up on 61 cases (97%) within a six-month period. Hospital mortality was 7.9% (4.8% in elective cases). In late follow-up, eight deaths were observed. In the bio-Bentall group (n=26), no deaths or major adverse valve-related events (MARVEs) occurred. In the mechanical Bentall group (n=37), seven cases of MARVEs, including two cerebral hemorrhages and one cerebral embolism, were observed. All patients were free from MARVEs at 5 years post procedure in the bio-Bentall group, and 93.8% and 76.8% were event-free at 5 years and 10 years, respectively, in the mechanical Bentall group. Conclusions: The 18-year results of the modified Bentall procedure were acceptable, providing excellent outcomes in the bio-Bentall group. The flanged technique enabled the use of a larger prosthesis, which may have resulted in good durability with the bio-Bentall procedure.

OBJECTIVES The aim of this study was to evaluate the 18-year results of emergency operations for acute type A aortic dissection, especially in octogenarians. METHODS We reviewed 199 patients who underwent surgical aortic repair of an acute type A aortic dissection from January 2001 to December 2018. If the primary entry existed in the ascending aorta, we limited the extent of the replacement to within the ascending aorta. We analysed the early and late outcomes and identified the predictive factors for in-hospital death and difficulty of direct discharge to home. RESULTS The hospital mortality was 16%. The causes of death were postoperative bleeding (n = 8, 4%), intestinal ischaemia (n = 6, 3%), respiratory failure (n = 5, 3%), systemic inflammatory response syndrome (n = 4, 2%), low output syndrome (n = 3, 2%), sudden death (n = 3, 2%), myonephrotic metabolic syndrome (n = 2, 1%) and stroke (n = 1, 1%). Multivariable analysis revealed that an estimated glomerular filtration rate CONCLUSIONS From the perspective of saving lives, the results of emergency surgery for octogenarians were acceptable. Avoiding the postoperative decline in activities of daily living in octogenarians is a consideration going forward.

BACKGROUND Kinking of the internal carotid artery is a cardiovascular (CV) risk factor. However, it remains unclear as to whether kinking of the common carotid artery (CCA) can also predict CV events. We conducted a long-term follow-up study to examine whether CCA kinking as assessed by carotid ultrasonography is a predictor of CV events in asymptomatic patients with CV risk factors. METHODS We enrolled 598 patients (mean age, 66.8 ± 11.8 years) who were divided into two groups according to CCA kinking severity: kinking of 0-29° (Group I); and kinking at ≥30° (Group II). We assessed whether CCA kinking predicts CV events during follow-up. RESULTS A total of 91 CV events were observed during the follow-up period (median, 124 months). Hypertension (P

Medical treatment for heart failure is still limited in patients with symptomatic aortic regurgitation (AR). Here we report the effects of mokuboito used in combination with standard medical therapy for heart failure in an inoperable patient with symptomatic severe AR. We observed acute effects of mokuboito in decreasing systemic vascular resistance and increasing cardiac output, as well as its chronic effects in improving New York Heart Association class, plasma brain natriuretic peptide levels, and left ventricular diastolic function. Given its efficacy, the use of mokuboito might be an additional treatment for patients with heart failure.

This case report presents a patient with Takotsubo cardiomyopathy (TCM) and complete atrioventricular (AV) block who was treated with permanent pacemaker implantation. A 78-year-old woman with a history of hypertension presented with a 6-month history of palpitations. On initial evaluation, her heart rate was 40 beats/minute. Electrocardiography revealed a complete AV block and T-wave inversion in these leads: I, II, aVL, aVF, and V3–6. Echocardiography showed akinesis from the midventricle to the apex and hyperkinesis on the basal segments. The patient was diagnosed with TCM and complete AV block. Because improvement of TCM may subsequently improve the AV node dysfunction associated with TCM, the patient was admitted for treatment of heart failure without pacemaker implantation. The left ventricular (LV) abnormal wall motion improved gradually; however, the AV block persisted intermittently. On hospital day 14, a pause of 5–6 seconds without LV contraction was observed, and permanent pacemaker implantation was performed. On day 92, echocardiography revealed normal LV wall motion. However, electrocardiography revealed that the pacemaker rhythm with atrial sensing and ventricular pacing remained. Although specific degree of damage that may result from AV block associated with TCM is unknown, some of these patients require pacemaker implantation, despite improvement of abnormality in LV wall motion.

The aim of this study was to assess potential predictors of aortic events after an emergency surgery for acute type A aortic dissection, especially paying attention to the findings of computed tomography (CT) performed immediately after the surgery.Between January 2001 and December 2015, 72 patients, who were diagnosed as having Stanford type A acute aortic dissection with a patent false lumen in the descending thoracic aorta, survived the emergency operation, and had postoperative CT scan data, were included in this study (mean follow-up, 8.2 ± 3.8 years; range 0.8-17.4 years). From the CT scan data, the diameter of the false lumen (FL-D) and true lumen (TL-D) were measured, and the FL-D:TL-D ratio was calculated. Long-term outcomes of the FL-D TL-D group (n = 30) and the FL-D TL-D group (n = 42) were compared.In the late follow-up, 17 aortic events in the downstream aorta were observed. The FL-D:TL-D ratio (Our results suggest that the false lumen:true lumen ratio predicts long-term prognosis after surgical repair of acute type A aortic dissection.

Myocardial fibrosis, as detected by late gadolinium enhancement (LGE) magnetic resonance imaging (MRI), is related to mortality after aortic valve replacement (AVR). This study aimed to determine whether LGEMRI predicts improvement in global longitudinal strain (GLS) after AVR in patients with severe aortic stenosis (AS). Twenty-nine patients with severe AS who were scheduled to undergo AVR were enrolled. Two-dimensional echocardiography and contrast-enhanced MRI were performed before AVR. GLS and LGEcore (g: > 5 SD of normal area), LGEgray (g: 2–5 SD), and LGEcore+gray (g) were measured. One year after AVR, GLS were examined by echocardiography to assess improvement in LV function. Preoperatively, GLS correlated with LGEcore (g) (r2 = 0.14, p 2 = 0.32, p 2 = 0.36, p 1year ≥ −19.9%) compared to those with no improvement (1.34 g vs. 4.70 g, p

Tacrolimus (TAC) is used for the prophylaxis and treatment of acute graft-versus-host disease after bone marrow transplantation (BMT). However, few have reported on TAC-induced left ventricular hypertrophy. This study aimed to assess the relationship between blood concentration of TAC and development of TAC-induced left ventricular (TI-LV) dysfunction in adult BMT patients with hematologic malignant diseases, and to evaluate whether TAC concentration can predict TI-LV dysfunction occurrence in these patients. We enrolled 16 consecutive patients (mean age 44.6 ± 13.0 years) who received TAC after BMT. Echocardiography was performed before and after BMT, and blood concentrations of TAC were evaluated in terms of AUC15 (area sum of TAC > 15 ng/ml during follow-up). We assessed the relationship between AUC15 and development of TI-LV dysfunction after TAC. During the follow-up period (mean duration 47.6 ± 13.7 days), interventricular septum thickness (IVST, P = 0.001) and posterior wall thickness (PWT, P

Background This study aimed to assess the deformation of the mitral valve complex during the displacement of the beating heart by using three-dimensional echocardiography in a porcine off-pump coronary artery bypass grafting (OPCAB) model. Methods In nine healthy swine, we positioned the beating heart as an OPCAB model, i.e. control, left anterior descending artery (LAD), right coronary artery (RCA), and left circumflex artery (LCX) positions. In each position, three-dimensional echocardiography was performed to assess the mitral valve complex with hemodynamic parameters. We analyzed the deformation of the mitral valve and the three-dimensional coordinates of the papillary muscles. Results There was a significant increase in maximum tenting length and tenting volume (control 0.70 ± 0.30, LAD 0.65 ± 0.27, RCA 0.79 ± 0.23, LCX 0.95 ± 0.34 cm 3 , p r = −0.643, p p Conclusions The prime cause of the deformation of the mitral leaflets is suggested to be the displacement of the PPM associated with the change in geometry of the left ventricle in a porcine model.

We hypothesized that mast cells may participate in coronary angiogenesis in acute myocardial infarction, contributing to myocardial salvage. The left coronary artery was occluded in control (n = 30) and Ws rats (n = 30), which genetically lacked c-kit, resulting in a mast cell deficiency. Four weeks later, the infarct area, i.e., infarct core and surrounding infarct areas, and the non-infarct area were assessed histopathologically. The mast cell and small vessel densities were assessed using toluidine blue and alkaline phosphatase staining. Myocardial perfusion was assessed by myocardial contrast echocardiography (MCE). In Ws rats, the percentage infarct core area increased (p

The aim of this study was to assess whether mast cells are involved in the recovery of diminished cutaneous blood flow (CBF) by bone marrow cell transplantation (BMCT) in limb arterial occlusion. In a hindlimb ischemia model, CBF was measured by laser Doppler perfusion imaging in White spot (Ws) rats which genetically lack mast cells, and their wild-type with or without BMCT. After 14 days, tissue mast cell density was assessed by toluidine blue staining. To evaluate angiogenesis, we also determined CD 31-positive capillary density in the ischemic limbs.CBF in ischemic limbs decreased to 36 +/- 2% of nonischemic limbs, but 7 to 14 days later it naturally recovered to 65 +/- 2% and reached a plateau in both types of rats. BMCT further (P < 0.05) increased CBF with increases in tissue mast cell and capillary densities in wild-type rats, but not in Ws rats. Treatment with sodium cromoglycate, an inhibitor of mast cell degranulation, diminished the increases in mast cell and capillary densities, and CBF by BMCT in ischemic limbs of wild-type rats. Mast cells may not be involved in ischemia-induced natural angiogenesis and a partial recovery of CBF, however, they appear to be involved in the therapeutic angiogenesis by BMCT.

The aim of this study was to evaluate whether the ratio of early diastolic transmitral velocity to early diastolic mitral annular velocity (E/E') can be applied to identify diastolic heart failure (HF) noninvasively rather than using brain natriuretic peptide (BNP) or enlargement of left atrium (LA) in patients with atrial fibrillation (AF) by comparing the severity of HF symptoms. Moreover, we investigated the relationship between the changes in E/E' and the severity of HF or LA remodeling in the follow-up period.We examined 73 patients with nonvalvular AF disease and preserved left ventricular ejection fraction (50%), ie, patients with diastolic HF accompanied with New York Heart Association (NYHA) functional class I to IV (n = 32, HF group) and those without HF (n = 41, non-HF group). No patients showed dyspnea caused by anemia, renal failure, lung disease, or other disease states except HF. We evaluated E, E', and E/E' by Doppler echocardiography, and the LA area (LAA) by 2-dimensional echocardiography. BNP levels were also examined. A follow-up study was performed in 18 of the 32 patients with HF.E/E', LAA, and BNP were higher in the HF group than in the non-HF group (E/E', 15 +/- 5 vs 9 +/- 2; LAA, 24 +/- 6 vs 20 +/- 6 cm(2); and BNP, 321 +/- 200 vs 140 +/- 76 pg/mL, each P.01). Using the receiver operating characteristic curve for identification of symptomatic diastolic HF with NYHA functional class II to IV, the areas under the curves were: E/E', 0.96 (95% confidence interval 0.91-1.0); LAA, 0.77 (95% confidence interval 0.64-0.89); and BNP, 0.85 (95% confidence interval 0.75-0.95). In the HF group, 18 patients who were re-examined 17 +/- 9 weeks after were divided into two groups, depending on the improvement in NYHA functional class, ie, improved group (n = 10) and unchanged group (n = 8). In the follow-up period, E (112 +/- 20-94 +/- 21 cm/s), E/E' (17.1 +/- 5-13.1 +/- 3), and LAA (28 +/- 5-24 +/- 4) decreased in the improved group (each P.05), but E' and BNP did not.E/E' could be useful in identifying symptomatic diastolic HF and evaluating the functional state in the process of HF in patients with AF. Moreover, E/E' is able to assess the improvement of diastolic HF in AF.

On what occasion does ultrasonography demonstrate its power? When and where can we, as the ones with the knowledge and skills to utilize this diagnostic technique, demonstrate our power? In daily clinical practice, where normal medical services are available, ultrasonography is just another diagnostic imaging technique. However, ultrasonography is able to tell us what is happening to the patient in front of us. Whether we understand it or not is up to our skills as clinicians. In order to understand the pathophysiology of our patients with information obtained by ultrasonography, in addition to a full knowledge of ultrasonography, it will be necessary to obtain profound insight on their condition, physical findings and laboratory data other than ultrasonographic findings. Being a cardiologist who specializes in ultrasonography, I believe that ultrasonography should not just be applied as a means of diagnostic imaging, but that we should also possess the focus, determination and passion to comprehend pathophysiology from echo images. On the other hand, how is ultrasonography used in nonordinary clinical practice? I am currently on a bullet train bound for Hiroshima. Sitting next to me is a cardiac surgeon who is sub-specialized in vascular ultrasonography. We both specialize in ‘‘ultrasonographic diagnosis’’ and are also colleagues who carried out leg vein echo screening on deep venous thrombosis (DVT) at shelters during the unprecedented disaster of the Great East Japan Earthquake in March 2011, of which we were also victims. At the time of the disaster, the Japan Society of Ultrasonics in Medicine sent portable ultrasonic devices to the stricken areas, which we received along with passion and support of the many people who sent them. We could therefore perform DVT screening at shelters and cooperate with central hospitals when necessary. In non-ordinary practice such as a time of disaster, it is our passion and expertise as ultrasonography specialists that make ultrasonography so powerful. In August 2014, another disaster hit Japan in the form of a deadly landslide that inflicted immense damage to a mountainous region of Hiroshima. I would like to offer my deepest condolences for the people who perished in the horrific event. I would also like to express my great gratitude to the many people working in medical teams established to provide shelter-based treatment for victims. Lessons learnt from the Great East Japan Earthquake have been put to good use. I will be joining one of the teams as an outside medical support staff member, and I will be involved in DVT screening at the shelters, using a portable ultrasonic device borrowed from the Japan Society of Ultrasonics in Medicine. This emergency system of lending ultrasonic devices was established during the Great East Japan Earthquake, thus enabling the passion and support of countless numbers of people, in Japan and overseas, to be both given and received. By the time this article is published, we will have already celebrated the beginning of a new year. A year in which I hope to enter a new era, spearheaded by the passion and determination of those who perform ultrasonography, demonstrating its power, leading to a better future.

Introduction: It is considered that morphological changes of mitral valve complex and worsening of mitral regurgitation (MR) cause the hemodynamic deterioration during off-pump coronary artery bypass grafting (OPCAB) in ischemic heart disease. Hypothesis: Mitral valve tethering is caused by dislocation of papillary muscle and leads to exacerbation of ischemic MR and hemodynamics. Methods: In 9 healthy swine with median sternotomy, we positioned the beating heart using Starfish heart positioner ® and Octopus 2 ® (Medtronic) as OPCAB model. In 4 positions for CABG, i.e., control, LAD-, RCA-, and LCX- positions, three-dimensional (3D) full volume images by echocardiography were acquired (iE33 ® and X5-1 ® , Phillips Healthcare) to assess mitral valve complex with hemodynamic parameters. We assessed the morphological changes of the mitral valve complex in 4 positions using by Real-view ® (YD Co.) and Cardio-view ® (TomTec). Results: Systolic arterial pressure was significantly lower in LCX position than in control position (LCX 48.9±2.5 vs control 69.8±2.7 mmHg, P3 , P Conclusions: In the dislocated and rotated position of the heart, especially in LCX position, the tethering of the mitral valve leaflets was increased, and related to the displacement of posterior papillary muscle. This suggests that mitral valve tethering is caused by dislocation of papillary muscle and leads to exacerbation of ischemic MR and hemodynamics during OPCAB.

We hypothesized that assessment of 3D wall motion tracking method is possible to detect small change of systolic function and myocardial risk area by 3D adenosine stress echocardiography inpatients with ischemic heart disease (IHD). We examined 39 vessel areas by 3D adenosine stress

Echocardiography is one of the most important examinations in patients with heart disease. Since high temporal resolution is necessary to assess the function of a "beating heart", there is no alternative modality, such as cardiac-CT or MRI. Patients are assessed for their cardiac functions, i.e., left ventricular systolic and diastolic function, and valvular function with blood flow velocity by echocardiography. Using newly developed equipment, including portability, we also examined cardiac function by 3D echocardiography and the speckle tracking method. Echocardiography plays an important role in the diagnosis and assessment of physiological function in heart disease patients; however, it depends on the sonographer's skill and knowledge whether it is possible to obtain important and valuable information by echocardiography. It is necessary to plan a systematic educational program for residents and sonographers.

A 73-year-old man was hospitalized for unstable angina pectoris with no history of myocardial infarction. After undergoing percutaneous coronary intervention, left ventriculography incidentally revealed a cavity in the anterior wall, and echocardiography found the cavity wall to be dyskinetic. Myocardial contrast echocardiography revealed that the wall of the cavity was surrounded by myocardial tissue with low perfusion. Furthermore, radial strain in the wall of the cavity was low. Myocardial scintigraphy showed a localized defect on the anterior wall. The patient was finally diagnosed as true aneurysm after asymptomatic and localized myocardial infarction, and has since been followed up by echocardiography in the outpatient clinic.

Background: The recently developed real-time 3-dimensional echocardiography (RT3DE) is a promising imaging method to quantify cardiac chamber volumes and their functions in clinical practice. However, normal reference values of RT3DE parameters have not been fully investigated in a large, healthy Japanese population. Methods and Results: This study consisted of 410 healthy subjects aged from 20 to 69 years who had a RT3DE at one of the 23 collaborating institutions. All subjects had no history of cardiac disease and no risk factors. The mean values in men and women were as follows: 50±12ml/m2 and 46±9ml/m2 for left ventricular (LV) end-diastolic volume index, 19±5ml/m2 and 17±4ml/m2 for end-systolic volume index, 61±4% and 63±4% for ejection fraction, 64±12g/m2 and 56±11g/m2 for mass index, 23±6ml/m2 and 24±6ml/m2 for left atrial (LA) maximum volume index, 10±3ml/m2 and 10±3ml/m2 for minimum volume index, and 58±6% and 58±6% for percent volume change. LV sizes decreased with age, whereas LV mass index did not change. LA sizes slightly increased with age. Conclusions: This multicenter investigation determined normal reference values for LV and LA sizes, and their functional parameters on RT3DE in a large, healthy Japanese population. The results of the present study support the use of RT3DE for the diagnosis and management of cardiovascular disease. (Circ J 2012; 76: 1177-1181)

Background The scintigraphic perfusion defect size (DS) at 1 week after acute myocardial infarction (AMI) predicts remote left ventricular (LV) volumes and LV ejection fraction (LVEF). The present study examined whether LV volumes and LVEF 6 months after AMI may be better predicted by the combination of LV volumes and LVEF just after reperfusion, and DS at 1 week, after AMI in patients with Thrombolysis In Myocardial Infarction (TIMI) grade III reperfusion by percutaneous coronary intervention. Methods and Results In 48 patients with AMI and TIMI grade III reperfusion, quantitative gated SPECT (QGS) was performed just after reperfusion, and at 1 week and 6 months after AMI. LV end-diastolic volume index decreased (108±8 to 93±6 ml/m2, p

A patient had multiple myeloma and associated cardiac amyloidosis, which caused diastolic dysfunction and recurrent ventricular fibrillation. After implantation of a cardioverter-defibrillator (ICD), the patient underwent autologous peripheral blood stem cell transplantation (PBSCT). The life-threatening arrhythmias, such as ventricular fibrillation, disappeared, and diastolic dysfunction assessed by quantitative gated single photon emission computed tomography and Doppler echocardiography improved 7 months later. This may be the first report to document improvement of both a lethal rhythm disorder and diastolic dysfunction by PBSCT following ICD implantation in a case of cardiac amyloidosis associated with multiple myeloma. (Circ J 2008; 72: 331 - 334)

BACKGROUND The relationships between flow reserves in coronary and peripheral circulation and their modification by statin therapy have not been assessed in the same patients, especially females. METHODS AND RESULTS To assess the effect of pravastatin on both circulation, in 20 postmenopausal female patients with hypercholesterolemia but a low probability of coronary artery disease, the forearm blood flow reserve (FBFR) using the plethysmographic method and coronary flow velocity reserve (CFVR) by Doppler echocardiography were measured before, 4 and 8 weeks after starting the pravastatin and/or diet therapy. At baseline, CFVR and FBFR had a positive linear correlation (r=0.63, p

An 81-year-old woman was admitted for treatment of diastolic heart failure. Two weeks after admission, she suffered sudden chest pain without somatic and/or psychological stress. Electrocardiography showed ST elevation in leads V2- V5. Coronary angiography did not reveal any significant stenosis in the epicardial coronary artery. Left ventriculography showed apical akinesis with basal and mid hyperkinesis. The diagnosis was ampulla cardiomyopathy. The abnormality on electrocardiography was normalized 2 months later, but apical akinesis persisted for 1 year. Myocardial contrast echocardiography showed microvascular dysfunction consistent with the apical akinesis for 1 year. Microvascular dysfunction may be important in the pathophysiological state of ampulla cardiomyopathy.

A 60-year-old man came to our hospital with dyspnea and was found at the front of our hospital due to syncope. He had cystic lung disease and a 2-month history of progressively worsening dyspnea. He regained consciousness in the emergency room; however, his lips were cyanotic and oxygen saturation was 70 %. He was afebrile, with a blood pressure of 116/79 mmHg and a heart rate of 70 bpm. There was no heart murmur, moist rale, or peripheral edema. Chest radiography showed pulmonary edema with bilateral pleural effusion. Electrocardiogram showed biphasic pulmonary P waves with regular sinus rhythm. Echocardiography demonstrated that the left atrium (LA) was occupied by a giant mass (7.6 9 4.8 cm, Fig. 1a, b). The mass was of low density and homogenous, and the mobility was poor. It was unclear whether the mass had a stalk or was attached on the LA wall. Color Doppler method revealed that the mass disturbed the left ventricular inflow (Fig. 1c, d). The mass was presumed to be a myxoma because he had been asymptomatic with sinus rhythm for a long time. He was referred to another hospital for emergency surgery. Just after the transfer, he was examined by chest enhanced computed tomography (CT) in the emergency room. The findings indicated a right lung cancer (Fig. 2, yellow arrow). The tumor directly infiltrated the wall of the LA. In addition, the mass in the LA, which was of homogenous low density without enhancement, was suspected to be thrombus (Fig. 2, white arrow). By the findings of a blood sampling examination (FDP 6.4 lg/ml, D-dimer 4.0 lg/ml), it was suspected that there was intracardiac thrombus, chronic DIC state, and/or deep vein thrombosis. He was diagnosed as having primary lung cancer with direct invasion into the LA and thrombus of the LA. Emergency surgery was considered; however, he was treated conservatively because the lung cancer was of stage IV. He was kept under sedation due to worsening dyspnea and eventually died of respiratory and circulatory disturbance on the 6th day of hospitalization. The pathological findings were: (1) primary lung adenocarcinoma in the right hilum pulmonis and the lower lobe with direct invasion to the LA and (2) stratified thrombus in the LA (the core of thrombus was the carcinoma cells in the LA). This is a rare case of a giant LA thrombus with direct invasion of lung cancer into the left atrium. The thrombus was first suspected as myxoma because of the patient’s history of illness and the echocardiographic findings (low density, homogenous) without atrial fibrillation. It seems that projecting carcinoma cells to the LA became the core and the LA thrombus stratified as it grows into a chronic DIC state based on malignancy. Few cases of intracardiac extension of lung cancer [1] and LA thrombus caused by direct invasion [2] have been reported. In urgent patients with circulatory disturbance, we have to make a decision M. Iwai-Takano (&) Intensive Care Unit, Fukushima Medical University Hospital, 1 Hikarigaoka, Fukushima 960-1295, Japan e-mail: masumi@fmu.ac.jp

We report a rare case of a giant coronary artery aneurysm with recurrent myocardial infarction (MI) in a 52-year-old man. He was admitted with severe chest pain and was diagnosed with acute MI. Ten days after thrombolysis, a transthoracic echocardiogram demonstrated a spherical mass apposed to the outer wall of the right atrium. Computed tomography with angiography showed this mass to be a huge aneurysm of the right coronary artery with a maximal diameter of 4 cm and filled with mural thrombus. Surgical resection of the aneurysm and coronary arterial bypass grafting were recommended. On day 60, while the patient awaited surgical treatment, recurrent MI caused by thrombotic occlusion occurred in the aneurysm site despite anticoagulant therapy. Two days after thrombolytic therapy, he underwent coronary artery bypass grafting and aneurysmal resection.