Efficacy of Computed Tomography-Based Evaluation of Myocardial Extracellular Volume Combined With Red Flags for Early Screening of Concealed Cardiac Amyloidosis in Patients With Atrial Fibrillation

BACKGROUND

The prevalence of transthyretin amyloid cardiomyopathy (ATTR-CM) in atrial fibrillation (AF) patients remains unclear. We explored the efficacy of computed tomography-based myocardial extracellular volume (CT-ECV) combined with red flags for the early screening of concealed ATTR-CM in AF patients undergoing catheter ablation.Methods and Results: Patients referred for AF ablation at Oita University Hospital were prescreened using the red-flag signs defined by echocardiographic or electrocardiographic findings, medical history, symptoms, and blood biochemical findings. Myocardial CT-ECV was quantified in red flag-positive patients using routine pre-AF ablation planning cardiac CT with the addition of delayed-phase cardiac CT scans. Patients with high (>35%) ECV were evaluated using technetium pyrophosphate (99 mTc-PYP) scintigraphy. A cardiac biopsy was performed during the planned AF ablation procedure if 99 mTc-PYP scintigraphy was positive. Between June 2022 and June 2023, 342 patients were referred for AF ablation. Sixty-seven (19.6%) patients had at least one of the red-flag signs. Myocardial CT-ECV was evaluated in 57 patients because of contraindications to contrast media, revealing that 16 patients had high CT-ECV. Of these, 6 patients showed a positive 99 mTc-PYP study, and 6 patients were subsequently diagnosed with wild-type ATTR-CM via cardiac biopsy and genetic testing.

CONCLUSIONS

CT-ECV combined with red flags could contribute to the systematic early screening of concealed ATTR-CM in AF patients undergoing catheter ablation.

Cardiomyopathy with an LMNA Genetic Variant Affecting Three Consecutive Generations: A Case Series

We report the case of a family afflicted with cardiac laminopathy who showed atrial fibrillation (AF) and complete atrioventricular block across three generations. Implantable cardioverter defibrillators (ICDs) implantation, or cardiac resynchronization therapy (CRT) were delivered to the three patients (proband; 61 years old, proband's mother: 84 years old, and proband's daughter; 38 years old) to prevent sudden cardiac death or suppress heart failure progression. A novel frameshift mutation (LMNA Exon 9: c.1550dupA;p. N518Efs*34) was found in all three cases through genetic testing, and this mutation may potentially result in the relatively late appearance of a phenotype of left ventricular systolic dysfunction.

Remission of Cardiac Sarcoidosis after the Administration of Methotrexate as First-line Drug Therapy

A 54-year-old woman developed new-onset heart failure and was diagnosed with cardiac sarcoidosis. An implantable cardioverter-defibrillator with biventricular pacing was implanted before immunosuppressive therapy to prevent sudden death. The patient refused oral steroids because she disliked their specific side effects and potential adverse events with long-term use; therefore, methotrexate was chosen as an alternative first-line drug. Nine months after starting oral therapy, 18F-fluorodeoxyglucose-positron emission tomography revealed remission of sarcoidosis, disappearance of heart failure symptoms, marked improvement in cardiac contractility, and a reduced frequency of ventricular arrhythmias.

Role of polyunsaturated fatty acids in Japanese patients with coronary spastic angina

BACKGROUND

n-3 polyunsaturated fatty acids (PUFAs) reduce the risk of ischemic heart disease. However, there are few reports of a relationship between n-3 PUFAs and coronary spastic angina (CSA). This study aimed to assess the age-dependent role of serum levels of fatty acid in patients with CSA.

METHODS AND RESULTS

We enrolled 406 patients who underwent ergonovine tolerance test (ETT) during coronary angiography for evaluation of CSA. All ETT-positive subjects were diagnosed as having CSA. We categorized the patients by age and results of ETT as follows: (1) young (age ≤ 65 years) CSA-positive (n = 32), (2) young CSA-negative (n = 134), (3) elderly (age > 66 years) CSA-positive (n = 36), and (4) elderly CSA-negative (n = 204) groups. We evaluated the serum levels of eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA), arachidonic acid, and dihomo-gamma-linolenic acid. In the young groups, the serum levels of EPA (64.3 ± 37.7 μg/mL vs. 49.4 ± 28.8 μg/mL, p = 0.015) and DHA (135.7 ± 47.6 μg/mL vs. 117.4 ± 37.6 μg/mL, p = 0.020) were significantly higher in the CSA-positive group than in the CSA-negative group, respectively. However, this was not the case with elderly groups. In the multivariate analysis in young groups, the serum levels of EPA (p = 0.028) and DHA (p = 0.049) were independently associated with the presence of CSA, respectively.

CONCLUSION

Our results suggested that the higher serum levels of EPA and/or DHA might be involved in the pathophysiology of CSA in the young population but not in the elderly population.

Vagal response is involved in the occurrence of ventricular fibrillation in patients with early repolarization syndrome

BACKGROUND

Patients with early repolarization syndrome (ERS) and Brugada syndrome (BruS) have comparable clinical symptoms. In both conditions, ventricular fibrillation (VF) is experienced often near midnight or in the early morning hours when the parasympathetic tone is augmented. However, differences between ERS and BruS regarding the risk of VF occurrence have recently been reported. The role of vagal activity remains especially unclear.

OBJECTIVE

The goal of this study was to determine the relationship between VF occurrence and autonomic nervous activity in patients with ERS and BruS.

METHODS

We enrolled 50 patients with ERS (n = 16) and BruS (n = 34) who received an implantable cardioverter-defibrillator. Of these, 20 patients (5 ERS and 15 BruS) experienced VF recurrence (recurrent VF group). We investigated baroreflex sensitivity (BaReS) with the phenylephrine method and heart rate variability using Holter electrocardiography in all patients to estimate autonomic nervous function.

RESULTS

In both patients with ERS and BruS, there was no significant difference in heart rate variability between the recurrent VF and nonrecurrent VF groups. However, in patients with ERS, BaReS was significantly higher in the recurrent VF group than in the nonrecurrent VF group (P = .03); this difference was not evident in patients with BruS. High BaReS was independently associated with VF recurrence in patients with ERS according to Cox proportional hazards regression analyses (hazard ratio 1.52; 95% confidence interval 1.031-3.061; P = .032).

CONCLUSION

Our findings suggest that in patients with ERS, an exaggerated vagal response, as represented by increased BaReS indices, may be involved in the risk of VF occurrence.

Predictors of outcome after catheter ablation for atrial fibrillation: Group analysis categorized by age and type of atrial fibrillation

BACKGROUND

The outcome of catheter ablation could probably differ among patients with atrial fibrillation (AF), depending on age and AF type. We aimed to investigate the difference in predictors of outcome after catheter ablation for AF among the patient categories divided by age and AF type.

METHODS AND RESULTS

A total of 396 patients with AF (mean age 65.69 ± 11.05 years, 111 women [28.0%]) who underwent catheter ablation from January 2018 to December 2019 were retrospectively analyzed. We divided the patients into four categories: patients with paroxysmal AF (PAF) or persistent AF (PeAF) who were 75 years or younger (≤75 years) or older than 75 years (>75 years). Kaplan-Meier survival analysis demonstrated that patients with PAF aged ≤75 years had the lowest AF recurrence among the four groups (log-rank test, p = .0103). In the patients with PAF aged ≤75 years (N = 186, 46.7%), significant factors associated with recurrence were female sex (p = .008) and diabetes (p = .042). In the patients with PeAF aged ≤75 years (N = 142, 35.9%), the only significant factor associated with no recurrence was medication with a renin-angiotensin system inhibitor (p = .044). In the patients with PAF aged >75 years (N = 53, 14.4%), diabetes was significantly associated with AF recurrence (p = .021). No significant parameters were found in the patients with PeAF aged >75 years (N = 15, 4.1%).

CONCLUSIONS

Our findings indicate that the risk factors for AF recurrence after catheter ablation differed by age and AF type.

Risk stratification of ventricular fibrillation in patients with symptomatic Brugada syndrome using pharmacological tests

BACKGROUND

Brugada syndrome (BrS), which is characterized by J-point elevation in right precordial leads of a 12-lead electrocardiogram, is associated with the occurrence of ventricular fibrillation (VF). However, risk stratification of VF in patients with BrS remains challenging.

OBJECTIVE

The aim of this study was to identify a risk predictor of VF in patients with BrS using pharmacological tests.

METHODS

Twenty-one consecutive patients with BrS and a history of documented spontaneous VF (n = 16) or syncope presumed to be caused by lethal ventricular arrhythmia (n = 5) were enrolled. J-wave changes in response to intravenous verapamil, propranolol, and pilsicainide were separately assessed.

RESULTS

During the median follow-up period of 86.0 months, 8 patients had VF recurrence (recurrence group) and 13 patients did not have VF recurrence (non-recurrence group). Intravenous propranolol injection induced significant J-wave augmentation (i.e., increase in amplitude >0.1 mV) in the inferior and/or lateral leads in the recurrence group compared to the non-recurrence group (p = .048 and p = .015, respectively). Kaplan-Meier analysis revealed that VF recurrence is significantly higher in patients with BrS and J-wave augmentation due to intravenous propranolol than in patients without J-wave augmentation (p = .014).

CONCLUSION

The study results show that propranolol-induced J-wave augmentation is involved in the risk of VF in patients with BrS. The results suggest that early repolarization patterns in response to pharmacological tests may be useful for risk stratification of VF in patients with symptomatic BrS.

Adolescent Persistent Atrial Fibrillation Concomitant with Pectus Excavatum

A 19-year-old man with pectus excavatum developed symptomatic persistent atrial fibrillation (AF). He had no remarkable medical history or comorbidities and had not exercised intensely during childhood. Electrical cardioversion and pre-treatment with amiodarone for two months failed to maintain sinus rhythm. Computed tomography before ablation revealed compression of the right and left atria between the sternal bone and vertebral bodies. Voltage mapping revealed that the right and left atrial voltages were preserved within the normal limit. However, radiofrequency catheter ablation successfully eliminated recurrent persistent AF. No recurrence was observed during eight months of follow-up.

Accuracy of pre- and postcontrast 3D time-of-flight MR angiography in patients with acute ischemic stroke: correlation with catheter angiography

BACKGROUND AND PURPOSE

3D time-of-flight (TOF) MR angiography (MRA) is insensitive to slow flow; however, the use of MR imaging contrast agents helps to visualize slow-flow vessels and avoids overestimation of vascular occlusion. The purpose of this study was to correlate pre- and postcontrast 3D TOF MRA with the results of conventional angiography during endovascular reperfusion therapy and to determine the accuracy of postcontrast 3D TOF MRA.

MATERIALS AND METHODS

Thirteen patients who underwent endovascular reperfusion therapy for acute ischemic stroke were retrospectively analyzed. MR imaging techniques included single-slab 3D TOF MRA with and without contrast, as well as perfusion-weighted imaging. Angiography during reperfusion therapy was used as a standard of reference. Affected arteries were divided into segments either proximal or distal to the lesion, and pre- and postcontrast MRA signals were graded as absent, diminished or narrowed, or normal.

RESULTS

In 2 of 5 patients with arterial stenosis and 6 of 8 patients with complete occlusion, MRA signal intensity proximal to each lesion was absent, indicating a proximal pseudo-occlusion on precontrast MRA. Postcontrast MRA demonstrated an arterial signal intensity proximal to the stenotic or occlusive lesions in all 13 patients. Arterial signal intensity distal to the occlusion was identified on postcontrast MRA in 7 of 8 patients having complete occlusion, and the extent of occlusion on postcontrast MRA was similar to results of conventional angiography.

CONCLUSION

In this small series, postcontrast 3D TOF MRA more accurately delineated the extent of stenotic or occlusive arterial lesions than precontrast MRA.

Treatment of A-pattern esotropia with marked mongoloid slanting palpebral fissures

BACKGROUND

The association of oblique palpebral fissures and A- or V-pattern has not been clarified. We report two cases of A-pattern esotropia with marked mongoloid slanting palpebral fissures associated with vertical displacement of the horizontal rectus muscle.

CASES

Case 1 was a boy with Prader-Willi syndrome. He showed A-pattern esotropia with upward slanting palpebral fissures. Severe superior oblique muscle overaction was observed. Case 2 was a girl with meningocele. She also showed A-pattern esotropia with upward slanting palpebral fissures.

OBSERVATIONS

In case 1, weakening surgery of the superior oblique muscles did not improve the A-pattern. Coronal images of computed tomography showed one-half-muscle-width upward displacement of both lateral rectus muscles. After downward transposition surgery of the lateral rectus muscles, the preoperative A-pattern of 25 prism diopters (PD) was successfully corrected to 10 PD. In case 2 also, upward displacement of both lateral rectus muscles was shown by computed tomography. The preoperative A-pattern of 26 PD was corrected to 4 PD postoperatively after upward transposition surgery of the medial rectus muscles.

CONCLUSIONS

The vertical displacement of horizontal rectus muscles was considered the principal cause of A-pattern in these cases associated with marked mongoloid slanting palpebral fissures.

Measurement of the car steering wheel turning force of persons with cervical cord injuries

Steering wheel turning force was measured in persons with cervical cord injuries for evaluation of their ability to drive a car. Seventeen subjects were divided into two groups according to their functional level: Group I (comprising 11 subjects of functional level C6) and Group II (comprising 6 subjects of functional level C7-C8). A device for hand fastening was attached to a steering wheel, which was mounted onto the rotation shaft of a Cybex machine, and the torque for turning the wheel with the right hand at a constant speed was measured. Persons with cervical cord injuries showed characteristically higher left-turning torque than right-turning torque. Mean values and standard deviation of the two groups were: 0.52 +/- 0.16 kgf-m (left-turning) and 0.40 +/- 0.12 kgf-m (right-turning) for Group I; and 0.81 +/- 0.16 kgf-m (left-turning) and 0.76 +/- 0.15 kgf-m (right-turning) for Group II. Subjects in Group I had a turning torque lower than 0.30 kgf-m (the lowest wheel turning torque shown by Japanese cars equipped with a power-steering system) at a turning angle range of between 0-135 degrees in left-turning and 45-200 degrees in right-turning.

[The alternation of peripheral lymphocyte subsets in head and neck carcinoma]

Peripheral lymphocyte subsets of 115 patients with head and neck carcinomas were examined by the monoclonal antibody technique. In fresh tumor-bearing, the OKT 4 rate was decreased (P less than 0.01) and the OKT 8 rate was increased (P less than 0.05). Consequently the OKT4/OKT8 ratio was decreased (P less than 0.01) compared with normal healthy individuals. This result shows the abnormality of cellular immunity in carcinoma cases. The OKT4/OKT8 ratio reflected the clinical stages and courses sufficiently and correlated with other immunological parameters. The OKT4/OKT8 ratio is considered to be one of the parameters for elucidating the clinical conditions and immunities of carcinoma patients.

[The clinical value of long-term administration of OK-432 in head and neck cancer]

In order to evaluate the clinical effect of longer-term administration of OK-432, 72 cases of head and neck squamous cell carcinoma with stage III and IV were divided into two groups: a shorter-term group (25 cases), given OK-432 for less than 6 months mainly during the period of admission, a longer-term group (47 cases), given OK-432 for more than 6 months not only for the period of admission but also during ambulation. The immunological parameters and the cumulative survival rates were compared between the two groups. In the longer-term group, the absolute number of peripheral lymphocytes was significantly higher and the positive rate of skin reaction with PPD was higher than in the shorter-term group. However there was no difference in the positive rate of skin reaction with Su-PS between the two groups. OKT4/OKT 8 ratio and PHA blastogenic rate were higher, although not to a statistically significant extent, in the longer-term group. The cumulative survival rate was significantly higher up to 12 months (p less than 0.01) and 18 months (p less than 0.05) in the longer-term group than the shorter-term group. These results of the immunological parameters and the cumulative survival rates suggest the clinical efficacy of longer-term administration of OK-432.

[Combination chemotherapy of cisplatin, vincristine and peplomycin for patients with head and neck carcinoma]

The effectiveness of combined CDDP chemotherapy with other anticancer drugs in patients with head and neck carcinoma was investigated. The response rate for COP therapy (CDDP, Vincristine, Peplomycin) was better than those for CDDP administration only or CP (CDDP Peplomycin) therapy for carcinomas of the head and neck. Forty-seven cases treated with COP therapy, were analyzed in detail. (1) Non-treated fresh cases showed a better response than recurrent cases. In other words, the induction chemotherapy is useful. (2) The grade of differentiation of squamous cell carcinoma had no correlation with the response. (3) No relationship between the primary site and the respose rate was detected. (4) Nephrotoxicity was considered to be the dose-limiting factor of CDDP therapy. COP therapy did not show any remarkable side effects. COP chemotherapy is therefore concluded to be effective for the treatment of squamous cell carcinomas of the head and neck.

[Immunotherapy, with OK-432 for cases of nasopharyngeal carcinoma]

The prognosis of nasopharyngeal carcinoma (NPC) is very poor, due to the extreme failure of the immuno-surveillance mechanism in such cases. As an immunotherapeutic agent, OK-432 was administered to NPC patients. Cases were divided into two groups. One was given OK-432 for less than 6 months (short-term group), while a long-term group, was treated with OK-432 for over 6 months. These two groups were evaluated for immunological activity and prognosis. As immunological parameters, the numbers of white blood cells and lymphocytes were counted, and delayed skin reactivities with Su-PS and PPD were determined. No influence on the number of white blood cells and lymphocytes could be observed in either of the two groups. However, the skin tests showed better improvement of immunity in the long-term group than in the short-term cases. Furthermore, these reactivities correlated well with the clinical status of NPC patients. As to the absolute number of lymphocytes, improvement in the long-term NPC group was delayed in comparison to that of another head and neck carcinoma group given long-term OK-432 treatment. The prognosis of the long-term administered group was apparently better than that of the short-term group. Long-term administration of OK-432 is therefore indispensable for the treatment of NPC cases, because of the extreme decline of their immunity.