Negative remodeling at the ostium of the left anterior descending artery induced myocardial ischemia

We report a case of a patient with exertional angina whose coronary angiography showed a severe stenosis at the ostium of the left coronary anterior descending artery. However, intravascular ultrasound imaging demonstrated only mild plaque burden and negative remodeling, with a 0.66 ratio of external elastic membrane area of the lesion to the distal site. The lesion was successfully treated with stenting. Therefore, our case suggests that negative remodeling at an ostial lesion could be the primary cause of myocardial ischemia.

Primary stenting to a 100-year-old female with acute myocardial infarction

Because of the high complication rates of coronary intervention and intra aortic balloon counterpulsation, we seldom perform invasive strategies for very elderly patients with acute coronary syndrome and heart failure. We herein report a rare case of a 100-year-old female with non-ST elevation acute coronary syndrome complicated by heart failure, who was successfully treated by stenting to the proximal left circumflex artery in the left main bifurcation lesion and intra aortic balloon pumping.

Coronary slow flow phenomenon caused by contrast-induced microvascular spasm

Coronary slow flow phenomenon is not an infrequent finding and is often associated with chest pain, but the mechanism has not been fully elucidated. We report a case of coronary slow flow phenomenon induced after contrast injection which was resolved by nicorandil administration. Therefore, the microvascular spasm might be an important factor in coronary slow flow phenomenon and contrast medium can be a trigger.

Different effects of simvastatin and losartan on cytokine levels in coronary artery disease

BACKGROUND AND OBJECTIVE

Use of HMG-CoA reductase inhibitors (statins) and angiotensin II type 1 (AT(1)) receptor antagonists reduces the incidence of cardiovascular events. The cytokines macrophage colony-stimulating factor (M-CSF) and transforming growth factor (TGF)-beta may exert proatherogenic and antiatherogenic effects, respectively. In this study, we examined whether treatment with a statin or an AT(1) receptor antagonist alters M-CSF and TGF-beta levels in patients with coronary artery disease.

METHODS

Twenty-seven consecutive patients with coronary artery disease were randomly assigned to the following three treatment groups for 8 weeks: simvastatin 5 mg/day (n = 10); losartan 50 mg/day (n = 9); or control (usual treatment; n = 8). Blood samples were collected before and after treatment.

RESULTS

Clinical characteristics and baseline cytokine levels were comparable among the three groups. Serum levels of M-CSF were significantly decreased only in the simvastatin group (from 403 +/- 71 to 303 +/- 116 pg/mL; p = 0.009). Plasma levels of TGF-beta were significantly increased only in the losartan group (from 5.01 +/- 1.13 to 7.50 +/- 3.83 ng/mL; p = 0.021). Simvastatin decreased serum M-CSF levels independently of changes in total cholesterol or low-density lipoprotein-cholesterol.

CONCLUSIONS

The results of this study indicate that simvastatin decreases serum levels of M-CSF while losartan increases plasma levels of TGF-beta, suggesting that the two drugs may have different anti-atherosclerotic properties.

Clinical and angiographic predictors of luminal changes beyond 6 months after implantation of thicker strut coronary stents

BACKGROUND

Late luminal changes beyond 6 months after thicker strut stent implantation have not been fully elucidated. The purpose of this study was to clarify the clinical and angiographic predictors of late changes in minimal lumen diameter (MLD) after 6-month follow-up of stenting.

METHODS AND RESULTS

Fifty-one lesions from 44 patients who underwent successfully S670/660 stent (Medtronic Vascular, Santa Rosa, CA, USA) implantations without target lesion revascularization were studied at 6-month follow-up and coronary angiography was repeated after the follow-up. Late luminal loss beyond 6 months after stenting significantly correlated with late loss (r=-0.42, p=0.0025) and MLD (r=0.28, p=0.047) at 6-month follow-up. On multivariate analysis, age (p=0.005), diabetes mellitus (p=0.002), hyperlipidemia (p=0.023), smoking (p=0.015), bifurcation lesion (p=0.018), small stent diameter (p=0.001) and MLD at 6-month follow-up (p<0.001) were identified as independent predictors of late luminal loss.

CONCLUSIONS

This study demonstrated that older age, diabetes mellitus, hyperlipidemia, smoking and small stent diameter (<3.0 mm) were associated with late luminal loss beyond 6 months after stenting, and that a bifurcation lesion and small lumen diameter at 6 months were associated with late luminal recovery.

Personal experience of laparoscopic cholecystectomy

BACKGROUND/AIMS

We performed laparoscopic cholecystectomy with a surgical team consisting of the same operator and the same first assistant to evaluate a personal learning curve of laparoscopic cholecystectomy.

METHODOLOGY

In the 135 patients who underwent the laparoscopic cholecystectomy, operative complications, postoperative complications and operative time were evaluated on the basis of using different camera assistants and the chronological advancement of the same operator and the same first assistant.

RESULTS

The average operative time was 120 +/- 54 minutes. The operative time was statistically longer in the first ten cases. The major complication during operation, which was ligation of the common bile duct, occurred in the 7th case. The other operative complications, such as minor bile duct injury or mild bleeding, occurred occasionally in spite of experience or inexperience; the operative complications, however, tended to occur under the same camera assistant. On the other hand, the operative time was not related to the use of different camera assistants.

CONCLUSIONS

From the personal learning curve of laparoscopic cholecystectomy, operative time is relatively longer in the early 10 cases. Complications tend to occur under the same camera assistant.

Role of cytokines in the pathogenesis of restenosis after percutaneous transluminal coronary angioplasty

BACKGROUND

Inflammatory cytokines play an important role in mediating inflammatory/proliferative responses including atherosclerosis. However, their role in the pathogenesis of restenosis after percutaneous transluminal coronary angioplasty (PTCA) remains to be clarified.

OBJECTIVE

To determine plasma levels of inflammatory cytokines as well as cytokine-generation capacities of monocytes before PTCA and after the follow-up period.

METHODS

Plasma levels of cytokines in 34 consecutive patients before and 3-6 months after PTCA were measured by enzyme-linked immunosorbent assay. We measured the plasma levels of macrophage-colony-stimulating factor (MCSF) and transforming growth factor-beta. Cytokine-generation capacities of monocytes were also measured by a whole-blood induction method with lipopolysaccharide. The levels of cytokines measured for assessment of the capacities included those of interleukin-1alpha, interleukin-1beta, interleukin-6, granulocyte-colony-stimulating factor, tumor necrosis factor-alpha and interferon-gamma.

RESULTS

Plasma levels of MCSF in patients without restenosis (n = 20) decreased significantly (from 1460+/-138 microg/ml before PTCA to 1039+/-125 microg/ml after the follow-up period, P < 0.01), whereas those in patients with restenosis (n = 14) increased significantly (from 1107+/-105 microg/ml before PTCA to 1039+/-125 microg/ml after the follow-up period, P < 0.05). We noted a positive correlation between the increase in plasma levels of MCSF and the extent of loss of lumen by restenosis. Cytokine-generation capacities of monocytes for interleukin-1alpha and interleukin-1beta of patients with restenosis significantly increased but those of patients without restenosis did not. Furthermore, plasma levels of C-reactive protein decreased significantly only in patients without restenosis after the follow-up period.

CONCLUSIONS

These results suggest that inflammatory changes mediated by cytokines may be involved in the pathogenesis of restenosis after PTCA.

Coronary microvascular abnormality in the reversible systolic dysfunction observed after noncardiac disease

Acute reversible left ventricular wall motion abnormalities mimicking myocardial stunning have been reported with noncardiac disease and their coronary angiograms did not demonstrate organic stenosis or vasospasm in the epicardial coronary arteries. Thus, this mechanism has not yet been fully clarified. Two patients are reported as demonstrating acute reversible wall motion abnormalities after noncardiac disease. The electrocardiographic and echocardiographic findings mimicked myocardial stunning and confirmed the previous reports. The coronary angiograms did not show any corresponding coronary stenosis or vasospasm, but did show a reduced coronary flow reserve. Cardiac metaiodobenzylguanidine scintigraphy demonstrated regional defects involving the apex, a decreased heart/mediastinum ratio and an enhanced washout rate, which partially returned to normal after 3 months. Microvascular dysfunction and sympathetic nervous abnormalities might be responsible for the reversible contractile impairment.

Sarcoplasmic reticulum Ca2+ regulatory protein gene expression in human right atrium under hemodynamic overload

Sarcoplasmic reticulum (SR) Ca2+-adenosine triphosphatase (ATPase) mRNA expression is reduced in the failing human myocardium. However, it is not known whether SR Ca2+-regulatory protein gene expression is altered in human myocardial tissue subjected to pressure overload or volume overload. We sought to determine whether SR Ca2+-regulatory protein gene expression is altered in human atrial tissue subjected to mechanical overload. We obtained right atrial myocardial tissue (about 250mg) at open-heart surgery from three groups of patients: no hemodynamic overload to the right atrium (control group; 12 patients), atrial septal defect (ASD group; 8 patients), and tricuspid regurgitation (TR group; 7 patients). We measured the myocyte size, the area of interstitial fibrosis, SR Ca2+,-ATPase, and ryanodine receptor mRNA abundance. The isolated cardiocyte area and the percent area of interstitial fibrosis were in the order TR > ASD > control (P < 0.05). The SR Ca2+-ATPase mRNA level in TR was significantly decreased (P = 0.004) compared with the control, whereas in the ASD group it did not differ significantly from control. There were no significant differences in ryanodine receptor mRNA levels among the three groups. SR Ca2+-ATPase gene expression was downregulated in human atrial tissue with TR but not in ASD, which might have resulted from the differences in the degree and/or the type of hemodynamic overload to the myocardium.

Three siblings of familial amyloid cardiomyopathy with isoleucine-50 transthyretin mutation

We herein describe three siblings with familial amyloid cardiomyopathy in a Japanese family, who demonstrated an Ile-50 mutation in the transthyretin gene. In their clinical course, the symptoms started at from 50 to 55 years of age, and two cases died within 5 years. However, one case is still alive seven years after onset probably due to either the implantation of a pacemaker for a complete atrio-ventricular block or the administration of dimethylsulphoxide. Based on our findings, some differences were observed not only in the mutation of the transthyretin gene but also in the clinical course between our cases and the previously reported cases.

A rare case of large ventricular septal defect with minimal pulmonary vascular obstructive changes in a 41-year-old woman

We describe a case of large ventricular septal defect (VSD) with minimal obstructive changes in the small pulmonary arteries of a 41-year-old woman. Before cardiac catheterization, some laboratory findings led us to consider that surgical closure of the defect would not be possible. However, because hemodynamic examinations showed only mildly elevated pulmonary vascular resistance, we patch-closed the VSD successfully. The histology of lung specimens showed only minimal obstructive changes in the small pulmonary arteries. Considering the size of the VSD and the age at which we hemodynamically evaluated the patient, the mildness of the pulmonary vascular obstructive changes appeared to be atypical in the natural course of a VSD of this size.