Summary A 40-year-old man was referred to our hospital because of an abnormal shadow on the left cardiac border on the chest roentgenogram at the regular medical health examination without any ...symptoms. A giant coronary artery aneurysm of left anterior descending artery with a maximum diameter of approximately 50 mm was detected with computed tomography and coronary angiography. The patient was treated and followed up medically. Four years later, the size of the coronary artery aneurysm became larger. Then resection of the coronary artery aneurysm and coronary artery bypass grafting were successfully performed. Coronary artery aneurysms are rare in adults and are usually found in association with Kawasaki disease, coronary atherosclerosis, and so on. We also review the literature of giant coronary artery aneurysms exceeding 50 mm in diameter.
Abstract Background Renal insufficiency is recognized as a predictor of mortality and adverse outcome in heart failure (HF) patients. However, the long-term clinical outcome of cardiac ...resynchronization therapy (CRT) in Japanese HF patients with renal insufficiency remains uncertain. Methods We evaluated 67 consecutive patients who underwent CRT at our hospital. The patients were divided into two groups according to a baseline estimated glomerular filtration rate (e-GFR) cut-off value of 50 ml/min, which is defined as the time at which patients should be referred to a nephrologist, by the Japanese Society of Nephrology. Follow-up echocardiographic findings and renal function were examined at 3–6 months after CRT. Then, we compared long-term clinical outcomes between the two groups, and analyzed the effect of CRT on renal function, echocardiographic parameters and cardiac survival. Results During a mean follow-up period of 30.3 months, patients with advanced renal insufficiency (e-GFR < 50 ml/min) had significant higher all-cause mortality (log-rank p = 0.033) and higher cardiac mortality combined with HF hospitalization (log-rank p = 0.017) than patients with e-GFR ≥ 50 ml/min. Multivariate analysis revealed that advanced renal insufficiency was an independent predictor of cardiac mortality combined with HF hospitalization (odds ratio = 3.01, p = 0.008). Subgroup analysis in the baseline advanced renal insufficiency group revealed that patients with preserved renal function by CRT (<10% reduction in e-GFR) had a higher rate of decrease of left ventricular end-systolic diameter (−14.0% vs. −0.8%, p = 0.023) and lower cardiac mortality combined with HF hospitalization (log-rank p = 0.029) compared with patients with deterioration of renal function (≥10% reduction in e-GFR). Conclusions The present study suggests that advanced renal insufficiency is quite useful for the prediction of worsening clinical outcomes in HF patients treated by CRT. Preservation of renal function by CRT brings about better cardiac survival through prevention of adverse cardiac events, even in HF patients with advanced renal insufficiency.
Abstract Background Research on the correlation of serum bilirubin level with cardiac function as well as outcomes in heart failure patients with cardiac resynchronization therapy (CRT) has not yet ...been reported. The aim of this study was to analyze the relationship between change in serum bilirubin level and left ventricular reverse remodeling, and also to clarify the impact of bilirubin change on clinical outcomes in CRT patients. Methods We evaluated 105 consecutive patients who underwent CRT. Patients who had no serum total-bilirubin data at both baseline and 3–9 months’ follow-up or had died less than 3 months after CRT implantation were excluded. Accordingly, a total of 69 patients were included in the present analysis. The patients were divided into two groups: decreased bilirubin group (serum total-bilirubin level at follow-up ≤ that at baseline; n = 48) and increased bilirubin group (serum total-bilirubin level at follow-up > that at baseline; n = 21). Results Mean follow-up period was 39.3 months. In the decreased bilirubin group, mean left ventricular end-systolic diameter decreased from 54.5 mm to 50.2 mm ( p = 0.001) and mean left ventricular ejection fraction increased significantly from 29.8% to 37.0% ( p = 0.001). In the increased bilirubin group, there was no significant change in echocardiographic parameters from baseline to follow-up. In Kaplan–Meyer analysis, cardiac mortality combined with heart failure hospitalization in the increased bilirubin group was significantly higher than that in the decreased bilirubin group (log-rank p = 0.018). Multivariate Cox regression analysis revealed that increased bilirubin was an independent predictor of cardiac mortality combined with heart failure hospitalization (OR = 2.66, p = 0.023). Conclusions The change in serum bilirubin is useful for assessment of left ventricular reverse remodeling and prediction of outcomes in heart failure patients with CRT.
Summary Background Studies of the characteristics, risk factors, prognostic factors, and outcomes of diastolic heart failure (DHF) have yielded inconsistent findings. Moreover, few epidemiological ...studies of DHF have been performed in Japan. Methods and results We studied patients with heart failure who were admitted consecutively to Yokohama City University Hospital from 2000 through 2003. Heart failure with a left ventricular ejection fraction (LVEF) of ≥50% was classified as DHF ( n = 67), and that with an LVEF of ≤35% was classified as systolic heart failure (SHF; n = 72). Relative wall thickness (RWT) (0.61 vs. 0.34, p < 0.0001) and left ventricular mass index (210.3 vs. 152.1, p < 0.0001) were greater in DHF than in SHF. Age (odds ratio OR = 1.068, 95% CI = 1.020–1.119; p = 0.006) and RWT (OR = 17.945, CI = 5.883–54.745; p < 0.0001) were positive risk factors for DHF. A history of myocardial infarction was a negative risk factor for DHF (OR = 0.053, CI = 0.008–0.342; p = 0.002). Left ventricular mass index was slightly but not significantly related to DHF (OR = 1.010, CI = 1.000–1.019; p = 0.053). Survival did not differ significantly between patients with DHF and those with SHF. Advancing age and a greater RWT were positive risk factors for DHF. Conclusion LV geometry of DHF and SHF are quite different. DHF is characterized by concentric hypertrophy of the left ventricle, whereas SHF is characterized by eccentric hypertrophy. Age and RWT were positive risk factors for DHF. Survival is similar in DHF and SHF.
Summary Background ST-segment elevation of ≥1.0 mm in the right precordial chest lead V4R (ST↑V4R) has been shown to be a reliable marker of right ventricular involvement (RVI) in inferior acute ...myocardial infarction (IMI). However, the impact of left ventricular posterior wall involvement (PWI) on the relation between ST↑V4R and RVI is unknown. Methods We studied 267 patients with recanalized IMI due to the right coronary artery (RCA) occlusion within 6 h after symptom onset. A 12-lead electrocardiogram, lead V4R, and leads V7–9 were recorded on admission. RVI was defined as occlusion proximal to the first major right ventricular branch of the RCA. The perfusion territory of the RCA was assessed by angiographic distribution score, and PWI was defined as a score of ≥0.7. Patients were stratified according to the presence or absence of PWI and RVI. Results RVI was associated with higher peak creatine kinase and a higher rate of impaired myocardial reperfusion, defined as a myocardial blush grade of 0 or 1 after recanalization, in the presence or absence of PWI, especially the former. RVI was associated with a higher rate of ST↑V4R in the absence, but not in the presence, of PWI. ST↑V4R identified RVI with sensitivities of 34% and 96% ( p < 0.001), and specificities of 83% and 82% (NS) in the presence and absence of PWI, respectively. Conclusions In patients with recanalized IMI, RVI is associated with larger infarction and impaired myocardial reperfusion in the presence or absence of PWI, especially the former. However, the presence of PWI attenuates the predictive value of ST↑V4R for RVI.
Another case study by Dr. Jayaprakash Shentha and colleagues describes a Riata lead failure presenting as a life-threatening electrical storm. Dr. Ritsuko Kono and colleagues review the incidence of ...arrhythmias, their electrophysiological mechanisms, and the clinical diagnosis of RNRVAS by using dual-chamber implantable cardiac devices, whereas a case study by Dr. Takeshi Kitamura demonstrates that automatic switching between AAI and DDD modes can prevent RNRVAS. ...a number of challenges have complicated the development and improvement of the cardiac pacemaker.
「Introduction」Anti-arrhythmic drugs are often prescribed for pacemaker and implantable cardioverter-defibrillator (ICD) patients for a number of reasons. However, we must be aware that ...anti-arrhythmic drugs may influence pacing threshold and defibrillation threshold. Sometimes awareness on the part of the physician is critical for patients with an implanted pacemaker or an ICD. 「I. Effects of anti-arrhythmic drugs on pacing threshold」Patients with implanted pacemakers often have tachyarrhythmias, such as atrial fibrillation. Anti-arrhythmic drugs usually have bradycardiac effects. 1-8) Pacemaker implantation allows the use of anti-arrhythmic drugs for patients with bradycardia. However, pacing threshold is sometimes increased by the anti-arrhythmic drugs. Factors affecting pacing threshold are posture, exercise, diet, sleep, minerals, pH, hormones, autonomic tones, and underlying diseases. 2) Type of pacing leads9) and anti-arrhythmic drugs1-8) also have great impacts on the pacing threshold.
Abstract Patients with corrected transposition of great arteries (c-TGA) are generally known to develop atrioventricular block, systemic right ventricular dysfunction, and tricuspid regurgitation ...over time, which are associated with tachyarrhythmia and progressive heart failure. A 76-year-old man had been diagnosed with c-TGA. He developed a cardiopulmonary arrest while playing tennis, and an automated external defibrillator detected ventricular fibrillation (VF). Immediate cardiopulmonary resuscitation and intensive treatment were performed. He fully recovered without neurological sequelae. QRS duration was 172 ms. Echocardiography showed marked dysfunction and dyssynchrony of the systemic right ventricle (systemic right ventricular end-diastolic diameter/end-systolic diameter = 73/60 mm, systemic right ventricular ejection fraction = 34%). For secondary prevention and treatment of progressive heart failure, cardiac resynchronization therapy with defibrillator (CRT-D) implantation was recommended. Venography via the left cubital superficial vein revealed a persistent left superior vena cava (PLSVC) and giant coronary sinus that did not connect with the right superior vena cava (SVC). Because of the acute angle between the PLSVC and great cardiac vein, we selected a right-sided approach via the right SVC. We were finally able to deliver a coronary sinus lead to the lateral vein. CRT-D implantation can be achieved even in patients with c-TGA and PLSVC. < Learning objective: CRT-D implantation can be achieved even in a patient with c-TGA and PLSVC.>
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