小林 欣夫

A 23-year-old female was referred for evaluation of syncope associated with standing for a long time at a morning gathering. She had experienced 2 episodes of syncope and frequent episodes of pre-syncope at morning gathering. Head-up tilt test demonstrated decrease in blood pressure from 104/65 to 55/28 mmHg and heart rate from 69 to 40 bpm associated with pre-syncope 15 min after the table was tilted upright to a 70° angle. Furthermore epinephrine stress test was performed because electrocardiogram showed prolongation of corrected QT interval of 546 msec. With epinephrine infusion, QT interval prolongation of 48 msec that was sensitive and specific marker for LQT1 was observed. Genetic testing identified KCNQ1, A525V mutation that is associated with LQT1. Since starting propranolol, QT interval was shortened from 546 to 492 msec and she has had no symptom. This case emphasizes the importance to exclude possibility of long QT syndrome in patients with neurally mediated syncope. © 2011, Japanese Heart Rhythm Society. All rights reserved.

Background: Three-dimensional quantitative coronary angiography (3D-QCA) reportedly allows more accurate delineation of true vessel geometry when compared with standard two-dimensional (2D) QCA and has been validated by intravascular ultrasound (IVUS). This study sought to compare diagnostic efficiency of 2D- and 3D-QCA, and IVUS in identifying hemodynamically significant coronary stenoses as determined by fractional flow reserve (FFR). Methods: Forty-two lesions in 40 patients were assessed by FFR, IVUS, and 2D- and 3D-QCA. Correlations between FFR values and anatomical parameters obtained by 2D- and 3D-QCA and IVUS were analyzed. The receiver operating characteristic (ROC) curves were used to compare the diagnostic accuracy of the parameters for predicting FFR <= 0.80. Results: Mean FFR value was 0.75 +/- 0.13. FFR <= 0.80 was observed in 28 lesions (67%). Of IVUS measurements, minimum lumen area (MLA) well correlated with FFR values (r = 0.71, p < 0.001). Of 3D- and 2D-QCA measurements, minimum lumen diameter (MLD) correlated best with FFR values (r = 0.79, p < 0.01; r = 0.68,p < 0.01, respectively), followed by MLA (r = 0.76, p < 0.01; r = 0.67, p < 0.01, respectively). The area under the ROC curve for 3D-QCA MLD was greater than those for 2D-QCA MLD (p = 0.03) and 2D-QCA MLA (p = 0.03). On the other hand, the AUC for 3D-QCA MLD, 3D-QCA MLA, and IVUS MLA were not significantly different. Conclusions: 3D-QCA is more useful than 2D-QCA and possibly comparable to IVUS in the assessment of functional stenosis severity. When FFR is not available, 3D-QCA MLA and MLD may assist in the assessment of functional severity of intermediate lesions. (C) 2016 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.

The aim of this study was to evaluate neointimal coverage in the very early phase after second-generation drug-eluting stent (DES) implantation using optical coherence tomography (OCT). Patients who underwent staged percutaneous coronary intervention within 30 days after DES implantation were enrolled. OCT was performed to observe DES previously implanted. The median time interval from implantation to OCT examination was 21.5 days. A total of 10,625 struts of 54 stents (52 everolimus-eluting stents and 2 zotarolimus-eluting stents) in 42 lesions were analyzed. Strut tissue coverage was observed in 71.1 +/- 19.2 % of the struts, malapposed struts in 2.56 +/- 3.37 %, strut tissue coverage at the side branch orifice in 10.6 +/- 17.2 %, and struts with protrusion in 0.95 +/- 3.46 %. Mean tissue thickness on the covered struts was 39.8 +/- 14.2 A mu m. The percentage of stent coverage was significantly lower in the overlapping segments than in the non-overlapping segments (48.4 +/- 17.5 % vs. 74.4 +/- 20.2 %, P < 0.05). Most of the stent struts were covered by tissue within 30 days after second-generation DES implantation. However, the percentage of strut coverage was lower in the overlapping segments than in the non-overlapping segments, suggesting that very early interruption of dual antiplatelet therapy might result in increased risk of stent thrombosis, even in second-generation DES.

BACKGROUND Several studies have reported that central systolic blood pressure (SBP) estimation is affected by calibration methods. However, whether central pulsatile indices, namely pulse pressure (PP) and fractional PP (FPP) (defined as PP/mean arterial pressure (MAP)), also depend on calibration methods remains uninvestigated. This study assessed the accuracy and discriminatory ability of these indices for coronary atherosclerosis using 2 calibration methods. METHODS Post-hoc analysis of a previous cross-sectional study (n = 139) that investigated the association between central pulsatile indices and coronary atherosclerosis. A validated-oscillometric device provided PP and FPP at the brachial artery (bPP and bFPP) and central artery using 2 calibration methods: brachial SBP/diastolic BP (DBP) (cPPsd and cFPPsd) and MAP/DBP (cPPmd and cFPPmd). Accuracy was assessed against invasive measurements (cPPinv and cFPPinv). Multivariate logistic and linear regression analyses were performed to assess the association between pulsatile indices and the presence of coronary artery disease (CAD) and SYNTAX score, respectively. RESULTS cPPmd and cFPPmd were closer to invasive values than cPPsd (cPPsd: 39.6 +/- 12.6; cPPmd: 60.2 +/- 20.1; cPPinv: 71.4 +/- 22.9). cFPP exhibited similar results (cFPPsd: 0.35 +/- 0.09; cFPPmd: 0.55 +/- 0.14; cFPPinv: 0.70 +/- 0.19). In patients = 70 years, only cFPPmd was significantly associated with CAD risk (odds ratio: 1.66 (95% confidence interval: 1.05-2.64)). SYNTAX score was significantly correlated with cPPmd, cFPPmd, and bFPP (standardized beta: cPPmd 0.39, cFPPmd 0.50, bFPP 0.42, all P < 0.01). No significant association was observed in patients aged < 70 years. CONCLUSIONS Central pulsatile indices calibrated with brachial MAP/DBP were more accurate and discriminatory for coronary atherosclerosis than SBP/DBP calibration.

Background: Studies have established the prognostic value of central SBP and pulse pressure (PP). The SphygmoCor XCEL (AtCor Medical, Sydney, Australia) device provides practical central blood pressure (BP) measurement for daily clinical use with its easy-to-use, operator-independent procedure. However, this device has not been validated against invasive measurement. Method: Simultaneous oscillometric and high-fidelity invasive measurements of central SBP and PP were compared for 36 patients who underwent coronary arteriography. Invasive measurement of brachial BP was also performed. Oscillometrically measured brachial SBP and DBP were used for calibration. Results: The differences between the invasive and the oscillometric measurements were -4.6 +/- 9.9mmHg for central SBP and -18.5 +/- 10.6mmHg for central PP (mean +/- SD). We found strong correlation between the invasive and oscillometric measurements (central SBP and central PP, respectively: r = 0.91 and 0.89; slope, 1.28 and 1.38; both P<0.001). Although the large slopes of the regression lines indicated a systemic bias toward lower values when measuring in high pressure ranges, the bias was mainly due to calibration error rather than device-specific error because errors of the central measurements correlated well with those of brachial measurements (SBP and PP, respectively: r = 0.80 and 0.77; both P<0.001). Conclusion: The impaired accuracy of central BP measurement was mainly due to calibration-derived, but not device-dependent, bias. Strong correlation between oscillometric and invasive measurements indicates that SphygmoCor XCEL warrants future investigations to determine the clinical validity of this device.

Intravascular ultrasound (IVUS) is a reliable imaging tool to guide percutaneous coronary intervention. There has been increasing evidence supporting the clinical utility of IVUS-guided drug-eluting stent (DES) implantation, including randomized trials, observational studies, and meta-analyses of both. IVUS provides cross-sectional views of the coronary artery wall, and allows us to assess stenosis severity, identify plaque morphology, optimize stent implantation, and understand mechanism of stent failure. IVUS guidance can increase DES efficacy and decrease clinical events. In this review article, we summarize available evidence on IVUS-guided DES implantation.

Dipeptidyl peptidase-4 (DPP-4) inhibitors are a new class of oral hypoglycemic agents for patients with type 2 diabetes mellitus and have potential antiatherosclerotic properties. Meanwhile, it is unclear how DPP-4 inhibitors have protective effects on atherosclerosis. Our aim was to determine the effects and its mechanisms of DPP-4 inhibitors on cultured endothelial cells. Human umbilical vein endothelial cells (HUVECs) were cultured in hypoxic condition. To evaluate the protective effects of DPP-4 inhibitor on HUVECs, DPP-4 inhibitor was added in the cell culture medium and the cell viability was assessed by TUNEL assay. And we examined the intracellular signaling pathways in relation to the effects of DPP-4 inhibitor. DPP-4 inhibition had beneficial effects by inhibiting the apoptosis under hypoxic conditions in HUVECs. The antiapoptotic effects of DPP-4 inhibitor were abolished by the pretreatment with a CXCR4 antagonist or a Stat3 inhibitor. DPP-4 inhibition has beneficial effects on HUVECs by inhibiting the apoptosis under hypoxic conditions. SDF-1 alpha/CXCR4/Stat3 pathways might be involved in the mechanisms of the cytoprotective effects of DPP-4 inhibitor. These results suggested that DPP-4 inhibitor has a potential for protecting vessels. (C) 2017 The Authors. Production and hosting by Elsevier B. V. on behalf of Japanese Pharmacological Society. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

We investigated age-related change in the contribution of stroke volume (SV) to central PP (cPP). Eighty seven adult subjects who were free of vasoactive agents were included. Subjects were divided into three age groups: young (20-39 years, n = 26), middle (40-49 years, n = 29), and old (>= 50 years, n = 32). SV was calculated by Doppler echocardiography. Hemodynamic indices were measured using a brachial cuff-based oscillometric method. The brachial and cPP showed a small decline from the young group to the middle group and a greater rise after 50 years old. SV significantly and positively correlated with brachial (r = 0.53, p < 0.01) and cPP (r = 0.57, p < 0.01) in the young group. In the middle group, the association of SV with brachial pulse pressure was significant (r = 0.38, p = 0.04) and that with cPP was bordering significant (r = 0.34, p = 0.07). No significant association was found between SV and PP in the old group. In conclusion, the contribution of SV to cPP decreases with age. Age-related changes in the determinants of cPP should be considered when investigating the clinical value of cPP.

The aim of this study was to investigate the association of aortic pulsatility assessed by a non-invasive brachial cuff-based method with coronary atherosclerosis. In total, 139 patients undergoing coronary angiography were included in this cross-sectional study. Aortic blood pressure (BP) indices were recorded invasively by a fluid-filled catheter and non-invasively by a brachial cuff-based oscillometric device. Fractional pulse pressure (FPP) was defined as pulse pressure (PP)/mean BP and pulsatility index (PI) as PP/diastolic BP. Aortic FPP and PI in coronary artery disease (CAD) patients were significantly higher than in non-CAD patients in both invasive and non-invasive methods. Multivariate logistic regression analysis demonstrated that non-invasively measured aortic FPP and PI were associated with CAD risk in patients aged 70 years [aortic FPP per 0.1 odds ratio (OR)=1.66, 95% confidence interval (CI) 1.05-2.64; aortic PI per 0.1 OR =1.39, 95% CI 1.02-1.88; all p<0.05], but were not associated with CAD risk in patients aged <70 years. In linear regression analysis, non-invasively measured aortic FPP and PI correlated with SYNTAX and Gensini scores only in patients aged 70 years. Aortic FPP and PI measured non-invasively by a brachial cuff-based oscillometric device were associated with coronary atherosclerosis in elderly patients.

Background: Inducing maximal coronary hyperemia is important to measure fractional flow reserve (FFR) accurately. Intravenous adenosine and adenosine 5'-triphosphate (ATP) have been used to achieve maximal hyperemia. However, they may not induce maximal hyperemia in all patients. The present study evaluated the combined effect of intracoronary papaverine and intravenous ATP on FFR measurements. Methods: FFR measurements with administration of intracoronary papaverine (12 mg in the left coronary artery and 8 mg in the right coronary artery), intravenous ATP (140 mu g/kg/min), and combined administration of intracoronary papaverine and intravenous ATP were performed in 51 patients with 57 intermediate lesions. Results: The mean FFR after intravenous ATP was higher compared to intracoronary papaverine and intravenous ATP plus intracoronary papaverine (0.76 +/- 0.13 vs. 0.75 +/- 0.13 vs. 0.75 +/- 0.13, p = 0.01). FFR-positive lesions (FFR <= 0.80) were observed more frequently with intravenous ATP plus intracoronary papaverine compared to intravenous ATP (64.9% vs. 47.4%, p = 0.02). Of 32 and 25 FFR-negative lesions with intravenous ATP and intracoronary papaverine, 11 (34%) and 7 (28%) had positive FFR after administration of intravenous ATP plus intracoronary papaverine. No ventricular tachycardia or ventricular fibrillation was observed after administration of intracoronary papaverine. Conclusions: Maximal hyperemia may not be induced with intravenous ATP in all lesions. When sufficient hyperemia is doubtful during intravenous infusion of ATP, additional intracoronary administration of papaverine may be a possible option. (C) 2016 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.

BackgroundBaseline coronary artery diameter and coronary artery dilation response to nitrate are associated with coronary vasoreactivity.ObjectivesThe present study investigated the predictive value of coronary artery tone for a positive intracoronary acetylcholine (ACh) provocation test.MethodsA total of 197 patients who underwent an ACh provocation test in the right coronary artery were included. A positive ACh provocation test was defined as transient total or subtotal occlusion of a coronary artery with signs/symptoms of myocardial ischemia. The segment, from the ostium to the bifurcation, of the right coronary artery was analyzed quantitatively. Coronary artery dilation response to isosorbide dinitrate (ISDN) was defined as the mean lumen diameter after an intracoronary injection of ISDN divided by the diameter before administration of ACh (i.e. baseline coronary artery diameter).ResultsAfter the administration of ACh, 49 patients (24.9%) had a positive ACh provocation test. Smaller baseline right coronary artery diameter (2.350.45 vs. 2.73 +/- 0.48mm, P<0.001) and greater right coronary artery dilation response to ISDN (1.34 +/- 0.12 vs. 1.15 +/- 0.11, P<0.001) were observed in patients with a positive ACh provocation test. The receiver operating characteristic curve for baseline coronary artery diameter poorly predicted the occurrence of a positive ACh provocation test (area under the curve 0.71). The predictive values of dilation response of the right coronary artery to ISDN for the occurrence of a positive ACh provocation test (area under the curve 0.87) was significantly better compared with that of baseline right coronary artery diameter (P<0.001).ConclusionCoronary artery dilation response to nitrate is a more accurate predictor of a positive intracoronary ACh provocation test compared with baseline coronary artery diameter.

Background: In this study, differences in older patients between drug use as reported in clinical practice and in clinical trials for regulatory approval were examined. Methods: Electronic medical record (EMR) data such as patient background (age, sex), concomitant drugs, data on laboratory tests, and prescribed doses of drugs from outpatients with rheumatoid arthritis, diabetes, high blood pressure, or depression at Chiba University Hospital were obtained for the period from January 2003 to December 2012. These data were compared with data from relevant clinical trials for regulatory approval in order to examine differences in drug use. Results: There were 5134 eligible patients. The prescribed doses of drugs were lower than the standard approved doses for depression and rheumatoid arthritis but were generally within the approved dose range for type 2 diabetes mellitus and hypertension. When comparing the characteristics of older patients taking tacrolimus, 5.6% to 17.0% of those would not be able to participate in clinical trials because of liver or renal abnormality, and the incidence rates of some adverse drug events (ADEs) differed significantly between clinical practice and clinical trials. Conclusions: Appropriate doses of drugs for older patients may differ from approved doses in certain diseases. Complex situations such as a lot of polypharmacy, comorbidity, and functional impairment in older patients in clinical practice make it difficult to evaluate safety based on data from clinical trials. In the future, utilization of a database created from the EMR of older patients should be considered for assessment of drug safety in older patients in clinical practice.

Purpose: We investigated the relationship of left ventricular (LV) diastolic dysfunction and LV mass index (LVMI) against pulmonary hypertension (PH) in systemic autoimmune disease (SAD). Methods: A total of 84 SAD patients (68 females; 53 +/- 17 years; systemic lupus erythematosus, 27%; scleroderma, 17%; vasculitis, 16%; mixed connective tissue disease, 13% and polymyositis/dermatomyositis complex, 10%) without significant pericardial effusion (PE) on TTE (Vivid E9, GE) were analyzed. On TTE, PH was defined as peak tricuspid regurgitation velocity (TRV) of >= 2.9 m/s based upon 2015 ESC guideline. Left atrial volume index (LAVI) and E/E' were measured as indicators of LV diastolic dysfunction. LVMI was also measured. Results: Seven patients (8%) had PH. PH patients had greater LAVI (p < 0.001), E/E' (p = 0.004), LVMI (p= 0.009) than non-PH patients. LAVI (R = 0.458), E/E' (R = 0.337), and LVMI (R = 0.313) significantly and positively correlated with TRV (all p < 0.05). Multiple regression analysis was performed to explore determinants of TRV. Age, female sex, and brain natriuretic peptide (BNP) were included in all the models. Three multiple regression models were generated using 1) LAVI, 2) E/E', and 3) LVMI and included LAVI, E/E', LVMI, and BNP as significant variables influencing TRV. Multi logistic regression analysis for predicting TRV of >= 2.9m/s showed that LAVI, and E/E' were significant predictors (Odds ratio, 1.296, and 1.370, respectively). Conclusion: In SAD patients without PE, LV diastolic dysfunction and increment of LVMI was closely associated with PH based upon TRV. LAVI and E/E' were independent predictors for PH. Measuring LAVI and E/E' may be a key to determine the mechanism of PH in these patients. (C) 2016 Elsevier Ireland Ltd. All rights reserved.

Anaphylactic shock is the most critical iodine contrast media-mediated adverse reaction. Although nonionic iodine contrast media is widely used and is less likely to induce adverse reactions compared with ionic contrast media, patients with a history of contrast-induced allergic reactions provide a dilemma to interventional cardiologists because of the greater risk of nonionic or ionic contrast media-induced allergic reactions [1]. Most episodes of anaphylaxis develop early and resolve completely with appropriate treatment; however, approximately 10%-20% of these cases present with delayed onset of symptoms, follow a biphasic or protracted course, and create a very critical situation that requires immediate intervention [2,3]. We herein report a critical case of iodine contrast media-induced biphasic anaphylactic shock that required extracorporeal membrane oxygenation (ECMO) for hemodynamic stabilization with hemodialysis to retrieve contrast media.

Purpose: To detect stable ischemic left ventricular (LV)-segments confirmed via invasive fractional flow reserve (FFR) by quantitative longitudinal-strain (LS) determined using resting multilayer TTE. Methods: A retrospective analysis of 39 stable patients (32 males; 65.8 +/- 11.9 years) with 46 coronary arteries with >= 50% stenosis confirmed by invasive coronary angiography who underwent invasive FFR measurement and TTE (Vivid E9, GE). On TTE, regional LS (absolute values) were calculated in whole, endocardial, and epicardial layers perfused by stenotic coronary arteries. Results: Of the 46 vessels, FFR values of <0.75, >= 0.75, <= 0.80 and >0.80 were observed in 17, 29, 27 and 19 vessels, respectively. In a vessel-by-vessel analysis, the whole-layer and endocardial LS were significantly smaller in LV-segments perfused by vessels with an FFR < 0.75 than in those with an FFR >= 0.75, but epicardial LS was not. In ROC curves, the best cutoff values of whole-layer, endocardial and epicardial LS were, respectively, 14.0% (sensitivity, 94%; specificity 38%; area under the curve, 0.685), 10.0% (47%; 86%; 0.664) and 14.0% (100%; 24%; 0.640) to detect LV-segments with an FFR < 0.75; and 14.0% (82%; 37%; 0.561), 10.0% (33%; 84%; 0.573), and 14.0% (89%; 21%; 0.538) to detect LV-segments with an FFR <= 0.80. Conclusion: For stable subjects with coronary arteries with >= 50% stenosis, the regional whole-layer and endocardial LS were significantly smaller in LV-segments perfused by vessels with an FFR < 0.75 than in those with an FFR = 0.75, but epicardial LS was not; and that the whole-layer and endocardial LS had a modest diagnostic efficiency in identifying LV-segments perfused by vessels with an FFR < 0.75. (C) 2016 Elsevier Ireland Ltd. All rights reserved.

Background/objectives: Several studies have already shown the correlation between the right ventricle (RV) hemodynamic values and either glucose uptake or fatty acid uptake in the RV, respectively. However, there are few studies to compare the RV metabolic alteration before and after treatment for pulmonary hypertension. The aims of this study are to assess right ventricular glucose and fatty acid in chronic thromboembolic pulmonary hypertension (CTEPH) patients before and after pulmonary thromboendarterectomy and to examine whether there is a correlation between right ventricular glucose and fatty acid uptake. Methods: To assess glucose and fatty acid accumulation in the RV, [F-18] fluoro-2-deoxyglucose (FDG)-positron emission tomography (PET) and I-123-beta-methyl iodophenyl pentadecanoic acid (BMIPP) imaging were performed in CTEPH patients before (FDG: n = 20, BMIPP: n = 13) and after (FDG: n = 12, BMIPP: n = 8) thromboendarterectomy. Results: Both [F-18] FDG uptake and I-123-BMIPP uptake in RV of post-PEA patients obviously decreased after this operation procedure (p < 0.01). The right ventricle [F-18] FDG uptake was also significantly correlated with I-123-BMIPP uptake (r = 0.45, p = 0.04). Conclusions: In this study, we observed that both glucose and fatty acid accumulated in the RV of patients with CTEPH. Although the exact details of the altered energy metabolism in the stressed RV remain unknown, this is the first study to evaluate both glucose and fatty acid uptake before and after thromboendarterectomy in patients with CTEPH, even though the number of the patient is limited. (C) 2016 Elsevier Ireland Ltd. All rights reserved.

Background: Inflammatory responses, especially by CD4(+) T cells activated by dendritic cells, are known to be important in the pathophysiology of cardiac repair after myocardial infarction (MI). Although co-stimulatory signals through B7 (CD80/86) and CD28 are necessary for CD4(+) T cell activation and survival, the roles of these signals in cardiac repair after MI are still unclear. Methods and Results: C57BL/6 (Control) mice and CD28 knockout (CD28KO) mice were subjected to left coronary artery permanent ligation. The ratio of death by cardiac rupture within 5 days after MI was significantly higher in CD28KO mice compared with Control mice. Although there were no significant differences in the infarct size between the 2 groups, left ventricular end-diastolic and end-systolic diameters were significantly increased, and fractional shortening was significantly decreased in CD28KO mice compared with Control mice. Electron microscopic observation revealed that the extent of extracellular collagen fiber was significantly decreased in CD28KO mice compared with Control mice. The number of a-smooth muscle actin-positive myofibroblasts was significantly decreased, and matrix metalloproteinase-9 activity and the mRNA expression of interleukin-1 beta were significantly increased in CD28KO mice compared with Control mice. Conclusions: Deletion of CD28 co-stimulatory signals exacerbates left ventricular remodeling and increases cardiac rupture after MI through prolongation of the inflammatory period and reduction of collagen fiber in the infarct scars.

Purpose: This study evaluated the post-systolic strain index (PSI), and the time interval between aortic valve closure (AVC) and regional peak longitudinal strain (PLS), measured by transthoracic echocardiography (TTE), for detection of left ventricular (LV) myocardial ischemic segments confirmed by invasive fractional flow reserve (FFR). Materials and methods: 39 stable patients (32 males; 65.8 +/- 11.9 years) with 46 coronary arteries at >= 50% stenosis on invasive coronary angiography underwent 2D speckle tracking TTE (Vivid E9, GE Healthcare) and invasive FFR measurements. PSI, AVC and regional PLS in each LV segment were calculated. Results: FFR <= 0.80 was detected in 27 LV segments. There were no significant differences between segments supplied by FFR <= 0.80 and FFR >0.80 vessels in either PSI or the time interval between AVC and regional PLS. To identify LV segments +/- FFR <= 0.80, the receiver operator characteristic (ROC) curves for PSI, and the time interval between AVC and regional PLS had areas under the curve (AUC) values of 0.58 and 0.57, respectively, with best cut-off points of 12% (sensitivity 70.4%, specificity 57.9%) and 88 ms (sensitivity 70.4%, specificity 52.6%), respectively, but the AUCs were not statistically significant. Conclusion: In stable coronary artery disease patients with >= 50% coronary artery stenosis, measurement of PSI, and the time interval between AVC and regional PLS, on resting TTE, enabled the identification of LV segments with FFR <= 0.80 using each appropriate threshold for PSI, and the time interval between AVC and regional PLS, with reasonable diagnostic accuracy. However, the AUC values were not statistically significant. (C) 2016 Elsevier Ireland Ltd. All rights reserved.

Background: Because it is difficult to distinguish between focal takotsubo cardiomyopathy and aborted myocardial infarction, there is little information about the prevalence and clinical features of focal takotsubo cardiomyopathy. Methods and Results: Our cardiac catheterization databases were queried to identify patients with focal takotsubo cardiomyopathy and other types of takotsubo cardiomyopathy. We defined focal takotsubo cardiomyopathy as hypo-, a-or dyskinesis in both anterolateral and septal segments without obstructive coronary artery disease explaining the wall motion abnormality. A total of 10 patients were diagnosed with focal takotsubo cardiomyopathy. The control group comprised patients with takotsubo cardiomyopathy with apical, mid-ventricular, or basal ballooning. Clinical features and in-hospital outcomes were compared between patients with focal takotsubo cardiomyopathy and those with other types of takotsubo cardiomyopathy. Among the 144 patients with takotsubo cardiomyopathy, the apical, mid-ventricular, basal, and focal types occurred in 85 (59.0%), 49 (34.0%), 0 (0%), and 10 patients (6.9%), respectively. The left ventricular ejection fraction was significantly higher in the focal group compared with the apical and mid-ventricular group (56 +/- 13 vs. 45 +/- 13 vs. 46 +/- 12%, P=0.03). In-hospital outcome was not significantly different among the 3 groups. Conclusions: Focal takotsubo cardiomyopathy is not rare. Biplane left ventriculography is useful for its diagnosis.

There has been a significant increase in the number of patients receiving cardiovascular implantable electronic devices (CIED) over the last two decades. CIED infection represents a serious complication after CIED implantation and is associated with significant morbidity and mortality. Recently, newly advanced technologies have offered attractive and suitable therapeutic alternatives. Notably, the leadless pacemaker and anti-bacterial envelope decrease the potential risk of CIED infection and the resulting mortality, when it does occur. A completely subcutaneous implantable cardioverter defibrillator is also an alternative to the transvenous implantable cardioverter defibrillator (ICD), as it does not require implantation of any transvenous or epicardial leads. Among the patients who require ICD removal and subsequent antibiotics secondary to infection, the wearable cardioverter defibrillator represents an alternative approach to inpatient monitoring for the prevention of sudden cardiac death. In this review paper, we aimed to introduce the advanced technologies and devices for prevention of CIED infection.

Although apical ballooning is the most common morphological type of takotsubo cardiomyopathy, variants have been reported. Several case reports have demonstrated focal takotsubo cardiomyopathy. Most cases had left ventricular wall motion abnormality in the anterolateral segment. We present a case of focal ventricular ballooning localized especially in the inferior mid-ventricular segment. &lt Learning objective: Focal takotsubo cardiomyopathy localized especially in the inferior mid-ventricular segment is rare. However, it is important to distinguish focal takotsubo cardiomyopathy from acute coronary syndrome because patient follow-up and medical management are different. Cardiac magnetic resonance imaging is useful to make a definitive diagnosis for focal takotsubo cardiomyopathy.&gt

Purpose: Systemic autoimmune disease (SAD) frequently affects the pericardium, and pathology is characterized by both immunological and inflammatory processes. We hypothesized that these processes simultaneously influence mitral-valve (MV) deterioration and left-ventricular (LV) wall thickening in SAD subjects. Methods: 101 SAD subjects were selected (76 female; 53 +/- 17 years; systemic-lupus-erythematosus, 26%; vasculitis, 20%; scleroderma, 14%; polymyositis/dermatomyositis complex, 10%; mixed connective tissue disease, 11% and rheumatoid-arthritis, 2%). MV anterior-mitral-leaflet (AML) length, AML thickness index, AML doming height and LV mass index (LVMI) were measured using transthoracic-echocardiography (TTE) and the presence of MV calcification, MV sub-valvular thickening and pericardial effusion (PE) were estimated. AML thickness index was calculated as the ratio of AML thickness to aortic posterior wall thickness. The correlation between LVMI and ECG V1S + V5R voltage was used to assess the etiology of LV wall thickening. Results: 19 subjects (19%) had significant PE. PE subjects had a significantly greater AML thickness index (1.55 +/- 0.48 vs. 1.14 +/- 0.32, P < 0.001), AML doming height (1.26 +/- 1.54 mm vs. 0.03 +/- 0.91 mm, P < 0.001), more frequent MV sub-valvular thickening (26% vs. 5%, P - 0.003) and greater LVMI (104.7 +/- 34.6 g/m2 vs. 80.6 +/- 21.0 g/m2, P = 0.002). Significant correlation was observed between LVMI and ECG V1S + V5R voltage in 79 subjects without PE (R = 0.39, P < 0.001). However, in 18 subjects with PE, no such correlation was observed (R = 0.30, P = 0.23). Conclusions: MV, MV sub-valvular deterioration and increased LVMI, unrelated to high voltage ECG criteria, were frequently detected in SAD subjects with PE. Immunological and inflammatory processes in SAD may not only cause pericardium inflammation, but may also cause MV deterioration and LV wall thickening. (C) 2016 Elsevier Ireland Ltd. All rights reserved.

Clopidogrel resistance is associated with stent thrombosis. Prasugrel achieves greater platelet inhibition with less variability among patients than does clopidogrel. Thus, a patient who had stent thrombosis due to clopidogrel resistance may receive prasugrel to prevent repeated episodes of stent thrombosis. This case report describes a case of repetitive stent thrombosis in which resistance not only to clopidogrel, but also to prasugrel, was observed. Learning objective: In the face of clopidogrel resistance, prescribing prasugrel may be an acceptable treatment option. However, cross-unresponsiveness may be observed between clopidogrel and prasugrel. Thus, platelet function assay should be performed in patients with stent thrombosis, even when clopidogrel is replaced with prasugrel.

Cardiac stem cells or precursor cells regenerate cardiomyocytes; however, the mechanism underlying this effect remains unclear. We generated CreLacZ mice in which more than 99.9% of the cardiomyocytes in the left ventricular field were positive for 5-bromo-4-chloro-3-indolyl-beta-D-galactoside (X-gal) staining immediately after tamoxifen injection. Three months after myocardial infarction (MI), the MI mice had more X-gal-negative (newly generated) cells than the control mice (3.04 +/- 0.38/mm(2), MI; 0.47 +/- 0.16/mm(2), sham; p < 0.05). The cardiac side population (CSP) cell fraction contained label-retaining cells, which differentiated into X-gal-negative cardiomyocytes after MI. We injected a leukemia inhibitory factor (LIF)-expression construct at the time of MI and identified a significant functional improvement in the LIF-treated group. At 1 month after MI, in the MI border and scar area, the LIF-injected mice had 31.41 +/- 5.83 X-gal-negative cardiomyocytes/mm(2), whereas the control mice had 12.34 +/- 2.56 X-gal-negative cardiomyocytes/mm(2) (p < 0.05). Using 5-ethy-nyl-2'-deoxyurinide (EdU) administration after MI, the percentages of EdU-positive CSP cells in the LIF-treated and control mice were 29.4 +/- 2.7% and 10.6 +/- 3.7%, respectively, which suggests that LIF influenced CSP proliferation. Moreover, LIF activated the Janus kinase (JAK) signal transducer and activator of transcription (STAT), mitogen-activated protein kinase/extracellular signal-regulated (MEK) extracellular signal-regulated kinase (ERK), and phosphatidylinositol 3-kinase (PI3K)-AKT pathways in CSPs in vivo and in vitro. The enhanced green fluorescent protein (EGFP)-bone marrow-chimeric CreLacZ mouse results indicated that LIF did not stimulate cardiogenesis via circulating bone marrow-derived cells during the 4 weeks following MI. Thus, LIF stimulates, in part, stem cell-derived cardiomyocyte regeneration by activating cardiac stem or precursor cells. This approach may represent a novel therapeutic strategy for cardiogenesis.

The radial artery is increasingly used as a second arterial conduit for myocardial revascularization. However, the radial artery is susceptible to vasospasm, which is thought to be the principal cause of graft failure. The radial artery is harvested as a skeletonized or a non-skeletonized graft, but the effect of different harvesting technique remains unknown. In this study, we compared the early- and mid-term angiographic findings to elucidate its influence on the graft luminal diameter. We harvested 39 radial arteries either as a skeletonized (n = 18) or a non-skeletonized graft (n = 21) using an ultrasonic scalpel. We constructed a composite straight graft by combining a right internal thoracic artery and a radial artery. All the radial artery grafts were sequentially anastomosed to coronary arteries. We measured the diameters of the radial arteries before the operation, within 1 month and 1 year after the operation. At early postoperative period, graft diameter was significantly larger in skeletonized grafts. Graft diameter at the point before the first and the second anastomosis was similar in skeletonized grafts, although that was significantly smaller before the second anastomosis in non-skeletonized grafts. However, 1 year after the operation, the graft diameter was comparable and equally reduced after the first anastomosis in both groups. Skeletonization with an ultrasonic scalpel increases the luminal diameter of the radial artery graft at early postoperative period, which, however, reduces possibly as adaptation to graft flow 1 year after the operation.

Sodium-ion batteries are attractive energy storage media owing to the abundance of sodium, but the low capacities of available cathode materials make them impractical. Sodium-excess metal oxides Na2MO3 (M: transition metal) are appealing cathode materials that may realize large capacities through additional oxygen redox reaction. However, the general strategies for enhancing the capacity of Na2MO3 are poorly established. Here using two polymorphs of Na2RuO3, we demonstrate the critical role of honeycomb-type cation ordering in Na2MO3. Ordered Na2RuO3 with honeycomb-ordered [Na1/3Ru2/3]O-2 slabs delivers a capacity of 180 mAhg(-1) (1.3-electron reaction), whereas disordered Na2RuO3 only delivers 135 mAhg(-1) (1.0-electron reaction). We clarify that the large extra capacity of ordered Na2RuO3 is enabled by a spontaneously ordered intermediate Na1RuO3 phase with ilmenite O1 structure, which induces frontier orbital reorganization to trigger the oxygen redox reaction, unveiling a general requisite for the stable oxygen redox reaction in high-capacity Na2MO3 cathodes.