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Dissection of the sinus of Valsalva is an extremely rare accident during percutaneous coronary intervention (PCI), but it can lead to serious complications such as dissection of the ascending aorta. We experienced a localized dissection of the right coronary cusp without coronary artery involvement that was induced by a guiding catheter during PCI in a patient with acute myocardial infarction. The localized dissection showed pooling of the contrast medium in the acute phase, but it subsided spontaneously after 12 days without any sequelae. Manipulation of the guiding catheter should be performed with great caution not only in the coronary artery but also in the sinus of Valsalva.

洞機能不全症候群 (SSS) における, 右心房有効不応期 (RA-ERP) のdispersion (ERPD) を検討した.対象はSSS32例 (平均年齢: 71歳, 男性: 12例, 女性20例) で, このうち15例 (47%) は発作性心房細動 (AF) を伴った徐脈頻脈症候群であった.洞機能障害やAFを伴わない房室プロック (AVB) 31例 (平均年齢: 77歳, 男性: 15例, 女性16例) を対照に, 心房期外刺激法を用いRA-ERPを, 高位, 中位, 低位の側壁および中隔の6点にて測定した.ERPD (最長ERP-最短ERP) は, SSS例78±38msec、AVB例45±22msecでSSS例において有意に大きかった (p

We report 2 cases with an isolated single coronary artery who underwent successful primary coronary intervention for acute coronary syndrome. Although coronary angioplasty with stenting may be a feasible therapeutic option for atherosclerotic stenosis in a single coronary artery, the operator should be aware of the potential risk of complications.

A 70-year-old Japanese woman was admitted to our hospital because of transient second degree atrioventricular (AV) block. An electrophysiologic study (EPS) was performed, and Mobitz type II infra-Hisian block during atrial pacing at a rate of 130/min was noted. An AV nodal reentrant tachycardia (AVNRT) was induced by ventricular pacing at a rate of 180/min, and 2:1-3:1 infra-Hisian block during AVNRT was observed. The AV block and AVNRT rarely occurred in the clinical setting, and the patient did not complain of any symptoms related to these arrhythmias. Therefore, the patient refused permanent pacemaker implantation, although she continued to be followed in our outpatient clinic. However, the patient was re-admitted one year later because of palpitations and dyspnea upon exertion related to the AV block. The 12-lead ECG showed high degree AV block with narrow QRS complexes. The patient underwent pacemaker implantation during the subsequent hospitalization, and her symptoms improved postoperation. AV block during AVNRT is sometimes observed, and it has been considered as a functional AV block. In the present case, a pathologic conduction disturbance in the His-Purkinje system caused the high degree AV block during AVNRT. The high degree AV block during AVNRT may indicate the existence of a conduction disturbance in the His-Purkinje system in some of these types of cases.

クラスI群薬無効の心房細動 (AF) 78例・心房粗動 (AFL) 23例, 計101例 (平均年齢61歳, 男性78例) に対するベプリジルの効果, 心電図変化および副作用をretrospectiveに検討した.持続性AFでは37例中17例 (45.9%) で, ベプリジル開始平均2.4カ月後に洞調律に復し, そのうち16例で洞調律が維持された (平均観察期間8, 5カ月) .発作性AFでは38例中32例 (84.2%) で平均観察期間8.2カ月間, 洞調律が維持された, 持続性AFLでは7例全例でベプリジル開始平均2.1ヵ月後, 洞調律へ復帰し, その全例で平均観察期間22.6カ月間, 洞調律が維持された.発作性AFLでは, 15例中12例 (80%) で洞調律が維持された (平均観察期間17.1ヵ月) .また, 電気的除細・粗動で洞調律に復した持続性AF9例中6例 (67.6%) で洞調律が維持された (観察期間平均10.5カ月) .2度以上の房室プロックの出現はなく, P拍数は68.2±10.9から60.0±9.0/分 (p

失神発作時にST上昇を伴った頸動脈洞症候群の2例を経験した.症例1は73歳男性, 頸部伸展時に洞徐脈から接合部調律となり, 血圧低下が出現, その後心電図上II, III, aVFでST上昇を認めた.硫酸アトロピンおよびジソピラミド静注で発作は改善し, DDDペースメーカーとジソピラミドの内服で失神発作は予防されていたが, 胸部大動脈瘤を合併しており, 1カ月後に突然死した.症例2は83歳男性で, DDDペースメーカー植え込み後に失神が再発, 排尿後の失神発作時に心電図モニター上ペーシング調律に伴いー過性のST上昇を認めた.冠動脈造影で軽度の硬化性病変と冠攣縮傾向を認め, ジルチアゼム投与を開始したが血圧低下のため, エフエドリンを併用した.以後, 内服は自己中断したが, 11カ月間失神発作は出現していない, 頸動脈洞症候群では迷走神経反射に伴いST上昇が誘発されることがあり, 冠攣縮による可能性が示唆された.

Positive responses to head-up tilt testing occur in healthy subjects. However, the reproducibility of "false-positive" tilt testing results has not been clarified. To study the reproducibility of "false-positive" responses, we prospectively performed 2 tilt tests separated by 1 to 10 (mean 3.2) weeks in 20 healthy males aged 23 to 40 years (mean 30 years). The baseline tilt test (80 degrees for 30 minutes) ended positive in 4 (20%) subjects on the initial test and 2 (10%) on the second test with only 1 (5%) who had consecutive positive responses. No additional positive responses were noted during the isoproterenol (0.01 microgram/kg/min)-tilt test for 10 minutes. We demonstrated that a false-positive response occurred in 5 (25%) of 20 young males who underwent 2 tilt tests, however, only 1 (5%) subject had consecutive positive responses. Poor reproducibility may be characteristic of false-positive responses in head-up tilt testing.

Paroxysmal AV Block During HUT Testing. Introduction: Prolonged asystole during head-up tilt testing has been reported, but the occurrence of paroxysmal AV block appears to he rare. Methods and Results: A 25-year-old man with no history of syncope underwent head-up tilt testing. After 11 minutes of 80° tilting, he developed syncope with paroxysmal AV block and asystole lasting 10.5 seconds. However, this response was not reproduced during a subsequent tilt test 4 weeks later. Treadmill exercise testing and Holter monitoring showed no abnormalities. Power spectral analysis of heart rate variability revealed a marked increase in sympathetic activity several minutes before the induction of paroxysmal AV block. Conclusion: We report a case of paroxysmal AV block that occurred during head-up tilt testing but did not recur on a subsequent test in an apparently healthy young man.

Circadian Variation of Vasovagal Syncope. Introduction. Circadian patterns have been demonstrated for several cardiovascular catastrophes. Chronobiologic factors play a role in the emergence of vasovagal syncope (VVS); however, diurnal variation of syncopal episodes in VVS has not been reported previously. Methods and Results. We assessed daily distribution of the time of syncopal episodes in VVS. Time of syncope could be determined in 80 episodes in 54 patients (32 men and 22 women; mean age 37 years, range 12 to 67). Patients who were prescribed beta blockers or vasodilators, and who had syncopes related to alcohol intake, were excluded from the study. Head-up tilt testing was performed in 53 patients. The distribution of the episodes of VVS in 3-hour intervals differed significantly from uniform occurrence (P < 0.0001). with a peak frequency between 6 A.M. and noon (67.5% of total episodes). In patients who had experienced the initial syncope in the morning, most (78%) of the next syncopal episodes also occurred in the morning. There was no significant correlation between the time of last syncopes and tilt testing results. Conclusion. We demonstrated a prominent circadian variation in the frequency of VVS, with a peak in the morning. Recognition of the daily distribution of VVS is useful for patient education and therapeutic strategy. (J Cardiovasc Eleciroptiysiol. Vol. 11. pp. 1078-1080, October 2000)

A 16-year-old boy was diagnosed with idiopathic postural orthostatic tachycardia syndrome (POTS) during head-up tilt testing. During a passive tilt, the patient's heart rate (HR) increased by 30 beats/min within 5 min. After 25 min of tilting, his HR further increased to 133 beats/min and he began to complain of lightheadedness and weakness without hypotension. Power spectral analysis of HR variability during the tilt test revealed that the ratio of low and high frequency powers increased with the onset of orthostatic intolerance. Propranolol (10 mg every morning) dramatically alleviated his clinical symptoms, and he has been asymptomatic with gaining weight after discontinuing his crowded train commuting. (Jpn Circ J 1999; 63: 496 - 498)

Background A genetic correlation between Brugada syndrome (BS) and sinus node dysfunction (SND) has been proposed, although the clinical and electrophysiologic characteristics of this concomitant condition are unknown. Methods and Results The study comprised 5 patients with symptomatic BS (4 with spontaneous episodes of ventricular fibrillation (VF) and 1 with syncope) of whom 3 had a documented sinus pause >3 s (a 42- and 62-year-old man, and a 49-year-old woman). Only 1 of them had a family history of sudden death; 2 of them had also had an episode of atrial fibrillation or flutter. Electrophysiologic study demonstrated prolonged sinus node recovery time in 2 patients (2.6 s and >5 s), in whom a cardiac pacemaker had been implanted before the diagnosis of BS was made after episodes of VF. Finally, all 3 patients received an implantable cardioverter defibrillator, including 2 upgrades from pacemaker. Conclusions SND is not a rare concomitant disorder in BS and there is a possible genetic connection. (Circ J 2005; 69: 946 - 950)

A 56 year-old man was referred to hospital for evaluation of syncopal episodes. During head-up tilt testing, his symptom was reproduced, associated with bradycardia and hypotension, by a low dose of isoproterenol (0.02 microg. kg (-1). min(-1)) infusion in the supine position before tilting-up. Isoproterenol infusion can provoke a vasovagal response without tilting. Careful observation of the patient's hemodynamics is mandatory not only during tilting, but also in the supine position before tilting-up.

Isoproterenol is widely used as a provocative medium for vasovagal responses during tilt testing. Dose of isoproterenol infusion is generally titrated empirically by increase in resting heart rate before tilt up. To determine the optimal increase in resting heart rate with isoproterenol for tilt-induced vasovagal responses, we studied 97 consecutive patients with unexplained syncope. After the end of a negative baseline tilt (80 degrees for 30 min), the isoproterenol tilt was performed using one of two protocols: two-stage isoproterenol-tilt protocol, with doses of 0.01 and 0.02 microg/kg per min for 10 min each, or one-stage isoproterenol-tilt protocol, with a dose of 1 or 2 microg/min for 10 min. The resting heart rate increase was defined as a percentage increase in the resting heart rate after isoproterenol infusion, compared to the baseline heart rate before the tilt test. In 117 tilt procedures, 28 (93%) of the 30 positive responses occurred with a resting heart rate increase of > or = 21%. With the resting heart rate increase of 60 and 100%, 18 (60%) and 27 (90%) positive responses were observed, respectively. In conclusion, the minimum resting heart rate increase of > or = 21% was required to provoke a vasovagal response during subsequent isoproterenol-tilt (80 degrees for 10 min). Preferably, heart rate should be increased to 60-100% by isoproterenol titration before tilting.

We report 2 cases with an isolated single coronary artery who underwent successful primary coronary intervention for acute coronary syndrome. Although coronary angioplasty with stenting may be a feasible therapeutic option for atherosclerotic stenosis in a single coronary artery, the operator should be aware of the potential risk of complications.

We present herein a case of superior vena cava (SVC) syndrome caused by localized fibrosing mediastinitis (FM), which had histological features similar to xanthogranulomatous pyelonephritis (XGP). A 63-year-old woman presented with facial swelling 5 months after undergoing right nephrectomy for XGP. Radiologic investigations of the chest confirmed the presence of SVC obstruction due to an intraluminal tumor. The histological features of the tumor were consistent with those of FM and were very similar to those of XGP. Although the pathogenesis of neither FM nor XGP is known, some pathogenic process of FM and XGP may be the same.

Cardiac hemangioma is extremely rare. We encountered two patients with cardiac hemangioma detected by thoracic echocardiography during a medical checkup. In the first case, transthoracic echocardiography revealed a pedunculated tumor in the left ventricle. Selective left coronary angiography demonstrated that the main feeding artery of the tumor arose from the third diagonal branch of the left anterior descending coronary artery. In the second case, thoracic and transesophageal echocardiography showed an oval tumor arising from the right atrium. Both tumors were successfully resected. Histopathological examination revealed that one of the tumors was a capillary hemangioma and the other was a mixed capillary and cavernous hemangioma. After operation, both patients had an uneventful recovery without any complications.

Head-up tilt testing is a useful but time-consuming procedure. If we could accurately predict the tilt testing results; we would be able to substantially shorten the duration of tilt protocol. To clarify the hypothesis that an early increase in heart rate (HR) during tilting can predict the passive tilt results in our protocol (80-degree angle for 30 minutes), we studied 115 consecutive patients (72 men, 43 women, mean age 46 +/- 19 years) who were clinically diagnosed with neurally mediated syncope. Twenty-nine (25%) patients had a positive tilt test (P group), whereas 86 (75%) patients had a negative test (N group). The early HR increase was defined as the maximum HR during the first 5 minutes of tilting minus the resting HR before tilting. The early HR increase was significantly higher in the P group (23.8 +/- 9.5 beats/min) than in the N group (17.5 +/- 8.2 beats/min, P = 0.0008), but it was negatively correlated with the tilt duration to positive response (r = -0.52, P = 0.0032) and the patient age in the entire study population (r = 0.62, P0.0001). Results of multiple regression analysis indicated that age, tilt result, and tilt duration were independently associated with the early HR increase. As a result, an early HR increaseor = 18 beats/min, the best apparent cut-off point obtained in our study, was a sensitive (100%) marker for prediction of a positive response ator = 15 minutes of tilting, but it showed a low specificity (61%). In conclusion, an early HR increase during 80-degree tilting may be only predictive for a positive resultor = 15 minutes because it depends on the tilt duration to a positive response and patient age.

Electrocardiographic changes were evaluated retrospectively in five patients without previous episodes of syncope or ventricular fibrillation who developed abnormal ST segment elevation mimicking the Brugada syndrome in leads V1-V3 after the administration of class Ic antiarrhythmic drugs. Pilsicainide (four patients) or flecainide (one patient) were administered orally for the treatment of symptomatic paroxysmal atrial fibrillation or premature atrial contractions. The QRS duration, QTc, and JT intervals on 12 lead surface ECG before administration of these drugs were all within normal range. After administration of the drugs, coved-type ST segment elevation in the right precordial leads was observed with mild QRS prolongation, but there were no apparent changes in JT intervals. No serious arrhythmias were observed during the follow up periods. Since ST segment elevation with mild QRS prolongation was observed with both pilsicainide and flecainide, strong sodium channel blocking effects in the depolarisation may have been the main factors responsible for the ECG changes. As the relation between ST segment elevation and the incidence of serious arrhythmias has not yet been sufficiently clarified, electrocardiographic changes should be closely monitored whenever class Ic drugs are given. Keywords: class Ic antiarrhythmic drugs; Brugada syndrome; ST segment elevation

The results of head-up tilt testing were compared between 24 patients with situational syncope and 44 age-matched patients with typical vasovagal syncope. Patients with situational syncope showed poor positive responses, especially in the passive tilt results (8.3% vs. 39%, p = 0.0078).

Dislodgment of an atrial screw-in pacing lead is quite rare. This report describes a rare case of an atrial screw-in lead dislodgment 10 years after implantation. Although it is an uncommon complication, very late dislodgment can occur postoperatively, and careful follow-up is necessary.