Triggers of Ventricular Fibrillation in Patients With Inferolateral J-Wave Syndrome

BACKGROUND

There are few data on ventricular fibrillation (VF) initiation in patients with inferolateral J waves.

OBJECTIVES

This multicenter study investigated the characteristics of triggers initiating spontaneous VF in inferolateral J-wave syndrome.

METHODS

A total of 31 patients (age 37 ± 14 years, 24 male) with spontaneous VF episodes associated with inferolateral J waves were evaluated to determine the origin and characteristics of triggers. The J-wave pattern was recorded in inferior leads in 11 patients, lateral leads in 3, and inferolateral leads in 17.

RESULTS

The VF triggers (n = 37) exhibited varying QRS durations (176 ± 21 milliseconds, range 119-219 milliseconds) and coupling intervals (339 ± 46 milliseconds, range 250-508 milliseconds) with a right (70%) or left (30%) bundle branch block (BBB) pattern. Trigger patterns were associated with J-wave location: left BBB triggers with inferior J waves and right BBB triggers with lateral J waves. Electrophysiologic study was performed for 22 VF triggers in 19 patients. They originated from the left or right Purkinje system in 6 and from the ventricular myocardium in 10 and were undetermined in 6. Purkinje vs myocardial triggers showed distinct electrocardiographic characteristics in coupling interval and QRS-complex duration and morphology. Abnormal epicardial substrate associated with fragmented electrograms was identified in 9 patients, with triggers originating from the same region in 7 patients. Catheter ablation resulted in VF suppression in 15 patients (79%).

CONCLUSIONS

VF initiation in inferolateral J-wave syndrome is associated with significant individual heterogeneity in trigger characteristics. Myocardial triggers have electrocardiographic features distinct from Purkinje triggers, and their origin often colocalizes with an abnormal epicardial substrate.

Acute coronary syndrome with simultaneous two-vessel occlusion De Winter ST-segment depression or reciprocal change?

We discuss a case of acute coronary syndrome (ACS) with simultaneous two-vessel occlusions in a man in his 20s. The serial electrocardiograms (ECG) showed very early dynamic changes of ST-T configuration resulting from ischemic zone depth or area between anterior wall versus inferior wall. The upsloping ST depression along with tall tentorial T waves in the precordial leads, as shown in the index ECG, raises the possibilities of a de Winter pattern. The retrospective assessment of the index ECG identified prominent T waves and a mild degree of ST-segment elevations in the inferior leads, given the electrocardiographic findings previously recorded at his workplace medical examination obtained at a later date. If the subtle ST-segment elevations in leads II, III, and aVF and the tall T waves were not overlooked in the index ECG, the probability of reciprocal ST-segment depressions in the precordial leads should also be taken into account. We recognize our ECG findings as intriguing ST-T deviation patterns that can change depending on the time sequence and anatomical dominancy of two infarct-related arteries. We finally suggest physicians should bear in mind the possibility of simultaneous multiple vessel occlusions when they encounter ACS patients with hemodynamic instability as in this present case.

Possible Coronary Sequelae of Kawasaki Disease in an Elderly Man

Kawasaki disease (KD) is an acute self-limited syndrome that predominantly affects children. Coronary sequelae have been identified to be responsible for a small, but significant percentage of young adults who present with myocardial ischemia. In this study, we present a case of an elderly patient with possible coronary sequelae of KD. A 76-year-old man was referred to our outpatient department for silent myocardial ischemia. Axial images of coronary computed tomography showed multiple lumens in the proximal left anterior descending (LAD) artery. Coronary angiography demonstrated braid-like appearance in the proximal and distal segment of the LAD. Coronary intervention was successfully performed for the proximal LAD lesion using directional atherectomy (DCA) catheter. Microscopic examination of the DCA specimens showed the following histological features: tissues in densely hyalinized fibrosis with occasional microcalcification, or those containing a number of smooth muscle cells (SMCs) with myxoid extracellular matrix. There was paucity of cholesterin crystals and aggregation of foamy cells. In addition, scarcely any inflammatory cell filtration was identified. In the section of SMC-containing samples, formation of multiple re-canalized vessels embracing endothelial cells was confirmed. These histopathologic findings indicated that the present coronary artery lesion has a high possibility of very late cardiovascular sequelae caused by arteritis due to KD, rather than arteriosclerosis. This is the oldest adult case with coronary artery disease possibly resulting from KD sequelae. This case highlights that KD sequelae must be considered as a cause of coronary artery lesion even in older patients.

Pueraria mirifica, an estrogenic tropical herb, unveiled the severity of Type 1 LQTS caused by KCNQ1-T587M

After taking an estrogen-containing supplement derived from a tropical plant Pueraria mirifica, a 24-year-old woman presented marked QT prolongation and repetitive torsade de pointes. The patient was found to carry a heterozygous KCNQ1-T587M mutation. This is the first report on Pueraria mirifica-related acquired long QT syndrome.

Impaired glucose tolerance and future cardiovascular risk after coronary revascularization: a 10-year follow-up report

AIMS

Practical management guidelines for impaired glucose tolerance (IGT) have not been established. Although IGT is a potent marker of cardiovascular disease (CVD), it is still controversial whether its magnitude of CVD risk is comparable to that of frank diabetes. Moreover, information on long-term clinical outcomes of IGT patients undergoing coronary revascularization is limited. The aim of the present work was to investigate the 10-year prognostic impact of IGT in comparison with diabetes in patients with CAD undergoing coronary revascularization.

METHODS

This cohort recruited from two Japanese clinical sites included patients with coronary artery disease (CAD) undergoing percutaneous coronary intervention (PCI) between 2004 and 2008. Patients were categorized into previously known diabetes (PKD, n = 197), newly diagnosed diabetes (NDD, n = 51), and IGT (n = 50) groups according to oral glucose tolerance test results except for PKD. The primary end point was defined as a composite of cardiovascular death, myocardial infarction, stroke, repeat revascularization, and heart failure hospitalization.

RESULTS

The cumulative risk of the primary outcome was significantly higher in the PKD and IGT than in the NDD (log-rank test p = 0.017). A Cox proportional hazards model demonstrated that IGT (hazard ratio [HR], 7.91; 95% confidence interval [CI], 1.84-27.58) and creatinine clearance (HR, 7.89, 95% CI, 2.73-19.10) were predictors of long-term CVD risk, while NDD and PKD were not.

CONCLUSIONS

IGT significantly increased the long-term risk of developing CVD in patients with CAD after PCI compared with diabetes.

P10 A possible link between sarcopenia and major bleeding risk among patients with atrial fibrillation treated with oral anticoagulation undergoing coronary stenting

Background/Introduction

In patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) with stent implantation, oral anticoagulation (OAC) plus dual antiplatelet therapy (DAPT) increases the risk of bleeding. The PRECISE-DAPT (P-DAPT) and DAPT scores were created to predict increased bleeding versus ischemic risk in patients undergoing DAPT. However, not much information is available on predicting bleeding risk associated with OAC concomitant with DAPT in patients with AF treated with coronary stents. Physical frailty or sarcopenia is considered an emerging predictor for bleeding in AF patients.

Purpose

To investigate the relationship between skeletal muscle mass and major bleeding risk in AF patients undergoing PCI and subsequent OAC and DAPT.

Methods

A total of 1,234 consecutive patients after PCI using newer-generation drug eluting stents were evaluated. An anti-thrombotic regimen without OAC was given to 1,077 patients, whereas OAC was required in 157 patients (12.7%) including AF (n = 96). The P-DAPT, DAPT, and HAS-BLED scores were calculated for each of the patients. Any out-of-hospital major bleeding events were identified based on BARC criteria during a median follow-up of 2.9 years. The fat-free mass index (FFMI; kg/m2) was calculated to evaluate skeletal muscle mass as follows: (7.38 + 0.02908 × urinary creatinine (mg/day)) / (height squared (m2)). A Cox proportional hazards model was used to test the significance of the FFMI and these risk scores as predictors of major bleeding, defined as BARC 3 or 5 events in AF patients. The receiver operating characteristic curve (ROC) analyses were used to examine the predictive ability of the FFMI and these scores to identify patients with major bleeding events.

Results

Major bleeding events were observed in 9 (9.3%) patients. Major bleeding was associated with a lower FFMI (hazard ratio [HR] 0.53; 95% confidence interval [CI] 0.36-0.79; p = 0.002), and higher P-DAPT score (HR, 1.07; 95% CI, 1.02-1.11; p = 0.003), but not with the DAPT (HR, 0.71; 95% CI, 0.45-1.12; p = 0.147) and the HAS-BLED score (HR, 1.00; 95% CI, 0.48-2.09; p = 0.990). In the non-OAC cohort, major bleeding was related to a higher P-DAPT score (HR, 1.05; 95% CI, 1.02-1.07; p < 0.0001), but the FFMI (HR, 0.89; 95% CI, 0.73-1.09; p = 0.265) and the DAPT score were not correlated. C-statistics for major bleeding events were 0.82 (95% CI, 0.71-0.93, p = 0.001) for the FFMI and 0.79 (95% CI, 0.68-0.90, p = 0.004) for the P-DAPT score.

Conclusions

Assessment of the FFMI for screening sarcopenia is useful to predict major bleedings specifically in patients with AF undergoing coronary stenting. Both the FFMI and P-DAPT could successfully predict major bleedings in AF patients after PCI. Whether novel bleeding risk scores combined with measuring body composition adequately identify high risk patients needs to be validated.

Dynamicity of hypothermia-induced J waves and the mechanism involved

BACKGROUND

J waves develop during hypothermia, but the dynamicity of hypothermia-induced J waves is poorly understood.

OBJECTIVE

The purpose of this study was to investigate the mechanism of the rate-dependent change in the amplitude of hypothermia-induced J waves.

METHODS

Nineteen patients with severe hypothermia were included (mean age 70 ± 12 years; 16 men [84.2%]). The rectal temperature at the time of admission was 27.8° ± 2.5°C. In addition to prolonged PR, QRS complex, and corrected QT intervals, the distribution of prominent J waves was widespread in all 19 patients.

RESULTS

Nine patients showed changes in RR intervals. When the RR interval shortened from 1353 ± 472 to 740 ± 391 ms (P = .0002), the J-wave amplitude increased from 0.50 ± 0.29 to 0.61 ±0.27 mV (P = .0075). The J-wave amplitude increased in 7 patients (77.8%) and decreased in 2 patients (22.2%) after short RR intervals. The augmentation of J waves at short RR intervals was associated with a significant prolongation of ventricular activation time (35 ± 5 ms vs 46 ± 5 ms; P = .0020), suggesting accentuated conduction delay. Increased conduction delay at short RR intervals was suggested to accentuate the phase 1 notch of the action potential and J waves in hypothermia. None developed ventricular fibrillation, and in 2 of 9 patients with atrial fibrillation, atrial fibrillation persisted after rewarming to normothermia.

CONCLUSION

J waves in severe hypothermia were augmented after short RR intervals in 7 patients as expected for depolarization abnormality, whereas 2 patients showed a bradycardia-dependent augmentation as expected for transient outward current-mediated J waves. Increased conduction delay at short RR intervals can be responsible for the accentuation of the transient outward current and J waves during severe hypothermia.

Impact of glycemic variability on myocardial infarct size in patients with ST-segment elevation myocardial infarction: quantitative assessment of left ventricular wall motion severity

Glycemic variability (GV) is relevant to impaired myocardial salvage in acute ST-elevation myocardial infarction (STEMI). Severity of hypokinesis at the infarct site as assessed from contrast left ventriculography can reportedly predict infarct size in STEMI. We prospectively studied 58 consecutive patients (mean age, 63 ± 11 years) with anterior or inferior STEMI who underwent successful reperfusion therapy. Mean amplitude of glucose excursion (MAGE) was obtained from continuous glucose monitoring system. Patients were divided into the upper tertile of MAGE as Group H, and the other two-thirds as Group L. Serial regional wall motion severity at the infarct site was computed postprocedure and at follow-up using a quantitative left ventricular analysis system. Impaired myocardial salvage was defined as severity recovery ratio < 20%. Significantly shorter onset-to-balloon time (196.9 vs. 279.0 min, p = 0.033) and relatively lower postprocedural wall motion severity (2.4 vs. 2.9, p = 0.096) were observed in Group H, but absolute severity recovery was significantly smaller in Group H (0.5 vs. 1.3, p = 0.017). Multivariate analysis showed higher MAGE as predictive of impaired myocardial salvage (OR, 406.10; 95% CI, 4.41-37,366.60; p = 0.009). Recovery of reginal wall motion severity at the infarct site was compromised in STEMI patients with higher MAGE. Our results suggest that final infarct size is potentially larger than expected in STEMI patients with higher GV.

Significance of Sarcopenia Evaluation in Acute Decompensated Heart Failure

In patients with chronic heart failure (HF), the clinical importance of sarcopenia has been recognized in relation to disease severity, reduced exercise capacity, and adverse clinical outcome. Nevertheless, its impact on acute decompensated heart failure (ADHF) is still poorly understood. Dual-energy X-ray absorptiometry (DXA) is a technique for quantitatively analyzing muscle mass and the degree of sarcopenia. Fat-free mass index (FFMI) is a noninvasive and easily applicable marker of muscle mass.This was a prospective observational cohort study comprising 38 consecutive patients hospitalized for ADHF. Sarcopenia, derived from DXA, was defined as a skeletal muscle mass index (SMI) two standard deviations below the mean for healthy young subjects. FFMI (kg/m²) was calculated as 7.38 + 0.02908 × urinary creatinine (mg/day) divided by the square of height (m²).Sarcopenia was present in 52.6% of study patients. B-type natriuretic peptide (BNP) levels were significantly higher in ADHF patients with sarcopenia than in those without sarcopenia (1666 versus 429 pg/mL, P < 0.0001). Receiver operator curves were used to compare the predictive accuracy of SMI and FFMI for higher BNP levels. Areas under the curve for SMI and FFMI were 0.743 and 0.717, respectively. Multiple logistic regression analysis showed sarcopenia as a predictor of higher BNP level (OR = 18.4; 95% CI, 1.86-181.27; P = 0.013).Sarcopenia is associated with increased disease severity in ADHF. SMI based on DXA is potentially superior to FFMI in terms of predicting the degree of severity, but FFMI is also associated with ADHF severity.

Relationship Between Glucose Fluctuations and ST-Segment Resolution in Patients With ST-Elevation Acute Myocardial Infarction

This study was conducted to assess whether any relationships exist between glucose fluctuations and electrocardiographic surrogate markers of reperfusion injury in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI).We prospectively studied 63 consecutive patients with STEMI undergoing primary PCI. Patients had either diabetes (n = 30), impaired glucose tolerance (n = 26), impaired fasting glucose (n = 1), or normal glucose tolerance (n = 6). STsegment resolution (STR, %) was measured using electrocardiograms recorded 60 minutes after PCI. STR was categorized as ≥ 30% and < 30%. Glucose fluctuations were assessed by the following parameters obtained from a continuous glucose monitoring system: mean amplitude of glucose excursion (MAGE, mg/dL); and area under curve with reference to mean blood glucose (AUC_MBG, mg/ dL/day).Both MAGE and AUC_MBG were significantly higher in STR < 30%. In univariate analysis, MAGE ≥ 70 mg/dL (OR = 17.0; 95%CI, 1.93-150.12; P < 0.01), AUC_MBG ≥ 20 mg/dL/day (OR = 10.9; 95%CI, 1.92-61.77; P < 0.01), and reperfusion arrhythmias (OR = 7.6; 95%CI, 1.32-44.29; P < 0.05) were significantly associated with suboptimal STR. Multiple logistic regression analysis showed only MAGE ≥ 70 mg/dL was predictive of suboptimal STR (OR = 22.5; 95%CI, 2.43-208.66, P < 0.01).Parameters of glucose fluctuations correlated with electrocardiographic surrogate markers of impaired myocardial salvage in STEMI after reperfusion therapy. Our results suggest that glucose fluctuations may represent a potential therapeutic target to reduce myocardial reperfusion injury in STEMI.

Electrode Contact Force-Controlled Bipolar Radiofrequency Ablation: Different Effects on Lesion Size between Dual- and Single-Bath Preparations

BACKGROUND

During bipolar (BIP) radiofrequency (RF) ablation using two catheters in humans, each catheter is placed in separate cardiac chambers or spaces. We developed a contact force-controlled experimental preparation, and compared measurements made with two catheters placed in a single bath (SB), versus each catheter placed in separate baths, in order to assess the preparation-dependent differences in the results of BIP-RF ablation.

METHODS

In the SB experiments, a porcine heart was placed in the center of the bath, while in the dual-bath (DB) experiments, it was placed between two half baths communicating through windows.

RESULTS

The initial impedance was greatest (110.5 ± 7.2 Ω) with the BIP-DB, followed by the BIP-SB (92.0 ± 5.6 Ω) and the unipolar (UNIP) DB (84.9 ± 4.7 Ω) configurations. During 50-W ablation for 60 seconds at a 20-g contact force, the root mean square voltage was 75.7 ± 2.5 V in the BIP-DB, 68.0 ± 2.1 V in the BIP-SB, and 66.8 ± 2.0 V in the UNIP-DB. The mean surface lesion diameters were similar among the three configurations. However, the endocardial lesion depth was 5.60 ± 0.56 mm with the BIP-DB, 4.71 ± 0.64 mm with the BIP-SB, and 4.24 ± 0.58 mm with the UNIP-DB configuration. On average, the endocardial lesions were significantly deeper than the epicardial ones.

CONCLUSIONS

BIP ablation created much deeper lesions as compared to UNIP ablation. Lesion depth could be different depending on experimental preparation, and contact force-controlled DB preparation may be a much more appropriate model for studying the effects of BIP ablation.

Efficacy of multidetector computed tomography for diagnosis of unroofed coronary sinus

The patient was a 62-year-old woman with a chest X-ray abnormality. Transthoracic echocardiography (TTE) showed a dilated right ventricle and right atrium and an enlarged coronary sinus (CS), but definite diagnosis was not possible. Using contrast-enhanced 64-slice multidetector computed tomography (MDCT), curved planar reconstruction along the CS showed a direct connection of the left atrium and CS, in addition to the CS to right atrium connection. Unroofed CS is a rare congenital cardiac anomaly that is difficult to diagnose with TTE alone. Our case indicates that MDCT is useful for determining structural information that cannot be obtained from TTE. <Learning objective: The diagnosis of unroofed coronary sinus (CS) is often difficult because the ability of transthoracic echocardiography to visualize the posterior cardiac structure is limited. In our case, images from 64-slice multidetector computed tomography provided clear visualization of the morphology of the CS and permitted a definite diagnosis of unroofed CS.>.

Comparison of mouse and human ankles and establishment of mouse ankle osteoarthritis models by surgically-induced instability

OBJECTIVE

Prevalence of ankle osteoarthritis (OA) is lower than that of knee OA, however, the molecular mechanisms underlying the difference remain unrevealed. In the present study, we developed mouse ankle OA models for use as tools to investigate pathophysiology of ankle OA and molecular characteristics of ankle cartilage.

DESIGN

We anatomically and histologically examined ankle and knee joints of C57BL/6 mice, and compared them with human samples. We examined joints of 8-week-old and 25-month-old mice. For experimental models, we developed three different ankle OA models: a medial model, a lateral model, and a bilateral model, by resection of respective structures. OA severity was evaluated 8 weeks after the surgery by safranin O staining, and cartilage degradation in the medial model was sequentially examined.

RESULTS

Anatomical and histological features of human and mouse ankle joints were comparable. Additionally, the mouse ankle joint was more resistant to cartilage degeneration with aging than the mouse knee joint. In the medial model, the tibiotalar joint was markedly affected while the subtalar joint was less degenerated. In the lateral model, the subtalar joint was mainly affected while the tibiotalar joint was less altered. In the bilateral model, both joints were markedly degenerated. In the time course of the medial model, TdT-mediated dUTP nick end labeling (TUNEL) staining and Adamts5 expression were enhanced at early and middle stages, while Mmp13 expression was gradually increased during the OA development.

CONCLUSION

Since human and mouse ankles are comparable, the present models will contribute to ankle OA pathophysiology and general cartilage research in future.

Manifestation of Latent Left Ventricular Outflow Tract Obstruction in the Acute Phase of Takotsubo Cardiomyopathy

Objective Left ventricular outflow tract (LVOT) obstruction is a complication in 15-25% of patients with Takotsubo cardiomyopathy and sometimes leads to catastrophic outcomes, such as cardiogenic shock or cardiac rupture. However, the underlying mechanisms have not been clarified. Methods and Results We experienced 22 cases of Takotsubo cardiomyopathy during 3 years, and 4 of these 22 cases were complicated with LVOT obstruction in the acute phase (mean age 79±5 years, 1 man, 21 women). The LVOT pressure gradient in the acute phase was 100±17 mmHg. Transthoracic echocardiogram (TTE) revealed left ventricular hypertrophy (LVH) in one case and sigmoid-shaped septum without LVH in three cases. The complete resolution of the LVOT obstruction was achieved in a few days with normalization of the left ventricular wall motion following administration of beta-blockers. A dobutamine provocation test after normalization of the left ventricular wall motion reproduced the LVOT obstruction in all cases and revealed the presence of latent LVOT obstruction. Conclusion The manifestation of latent LVOT obstruction in the acute phase of Takotsubo cardiomyopathy is one potential reason for the complication of LVOT obstruction with Takotsubo cardiomyopathy.

Primary percutaneous coronary intervention and bleeding risk in the era of drug-eluting stent: a long-term cohort study

Data of long-term efficacy and safety including bleeding risk associated with antithrombotic regimens after primary percutaneous coronary intervention (PCI) using first-generation drug-eluting stent (1st DES) are scarce. Consecutive 422 patients with ST-elevation myocardial infarction (STEMI) underwent primary PCI with DES (285 patients), bare metal stent (BMS, 58 patients) or balloon angioplasty (BA 79 patients). At a median follow-up of 44 months, major cardiovascular events were significantly lower for 1st DES compared with BMS and BA (11.9 vs. 25.9 vs. 16.5 %, p = 0.027). Cardiac death, recurrent myocardial infarction and target lesion revascularization (TLR), differed among the groups (DES 8.8 %; BMS 13.8 %; BA 17.7 %; p = 0.019), although the superiority of DES subsided beyond 1 year by increased late TLRs. Major bleedings were not higher in DES than in BMS and BA (4.6 vs. 6.9 vs. 1.5 %, p = 0.252). Multivariate logistic regression analysis revealed that both dual antiplatelet therapy (DAPT) >24 months and indefinite oral anticoagulation (OAC) were associated with a major bleeding. The risk was even greater with triple antithrombotic therapy (odds ratio 19.5; 95 % confidence interval 3.73-102.07; p < 0.0001). 1st DES showed favorable overall long-term clinical outcome in STEMI, with an inherent limitation of an increased risk of late TLR. Prolonged DAPT and OAC synergistically increase the risk of major bleeding after primary PCI.

Manifestation of latent left ventricular outflow tract obstruction caused by acute myocardial infarction: An important complication of acute myocardial infarction

BACKGROUND

Although transient left ventricular outflow tract (LVOT) obstruction is reported as a complication with acute myocardial infarction (AMI), the mechanisms and features of LVOT obstruction in AMI are unclear.

METHODS AND RESULTS

Herein, we present two cases of transient LVOT obstruction with anteroseptal AMI. The features of these two cases were one-vessel disease (1-VD) of the left anterior descending artery (LAD) and maintenance of blood flow to the major septal branch (SB). Moreover, LVOT obstruction was revealed after dobutamine infusion in the chronic phase and the aorto-septal angle was low in these two cases, meaning that latent LVOT obstruction was due to sigmoid-shaped septum.

CONCLUSIONS

Latent LVOT obstruction would be manifested in the acute phase of AMI. 1-VD of LAD and the maintenance of major SB blood flow are important factors with respect to the manifestation of latent LVOT obstruction.

Electrical storm in idiopathic ventricular fibrillation is associated with early repolarization

OBJECTIVES

This study sought to characterize patients with idiopathic ventricular fibrillation (IVF) who develop electrical storms.

BACKGROUND

Some IVF patients develop ventricular fibrillation (VF) storms, but the characteristics of these patients are poorly known.

METHODS

Ninety-one IVF patients (86% male) were selected after the exclusion of structural heart diseases, primary electrical diseases, and coronary spasm. Electrocardiogram features were compared between the patients with and without electrical storms. A VF storm was defined as VF occurring ≥3 times in 24 h and J waves >0.1 mV above the isoelectric line in contiguous leads.

RESULTS

Fourteen (15.4%) patients had VF storms occurring out-of-hospital at night or in the early morning. J waves were more closely associated with VF storms compared to patients without VF storms: 92.9% versus 36.4% (p < 0.0001). VF storms were controlled by intravenous isoproterenol, which attenuated the J-wave amplitude. After the subsidence of VF storms, the J waves decreased to the nondiagnostic level during the entire follow-up period. Implantable cardioverter-defibrillator therapy was administered to all patients during follow-up. Quinidine therapy was limited, but the patients on disopyramide (n = 3), bepridil (n = 1), or isoprenaline (n = 1) were free from VF recurrence, while VF recurred in 5 of the 9 patients who were not given antiarrhythmic drugs.

CONCLUSIONS

The VF storms in the IVF patients were highly associated with J waves that showed augmentation prior to the VF onset. Isoproterenol was effective in controlling VF and attenuated the J waves, which diminished to below the diagnostic level during follow-up. VF recurred in patients followed up without antiarrhythmic agents.

[Cardiogenic shock due to takotsubo cardiomyopathy during induction therapy for acute myeloid leukemia]

A 61-year-old man admitted for pancytopenia was diagnosed with acute myeloid leukemia. On day 26 of induction therapy, the patient suddenly developed cardiogenic shock. The ultrasound cardiogram showed imaging features typical of takotsubo cardiomyopathy. Cardiogenic shock caused by takotsubo cardiomyopathy is rare in patients with hematological malignancies but is a severe complication during chemotherapy.

Electrocardiographic characteristics and SCN5A mutations in idiopathic ventricular fibrillation associated with early repolarization

BACKGROUND

Recently, we and others reported that early repolarization (J wave) is associated with idiopathic ventricular fibrillation. However, its clinical and genetic characteristics are unclear.

METHODS AND RESULTS

This study included 50 patients (44 men; age, 45 ± 17 years) with idiopathic ventricular fibrillation associated with early repolarization, and 250 age- and sex-matched healthy controls. All of the patients had experienced arrhythmia events, and 8 (16%) had a family history of sudden death. Ventricular fibrillation was inducible by programmed electric stimulation in 15 of 29 patients (52%). The heart rate was slower and the PR interval and QRS duration were longer in patients with idiopathic ventricular fibrillation than in controls. We identified nonsynonymous variants in SCN5A (resulting in A226D, L846R, and R367H) in 3 unrelated patients. These variants occur at residues that are highly conserved across mammals. His-ventricular interval was prolonged in all of the patients carrying an SCN5A mutation. Sodium channel blocker challenge resulted in an augmentation of early repolarization or development of ventricular fibrillation in all of 3 patients, but none was diagnosed with Brugada syndrome. In heterologous expression studies, all of the mutant channels failed to generate any currents. Immunostaining revealed a trafficking defect in A226D channels and normal trafficking in R367H and L846R channels.

CONCLUSIONS

We found reductions in heart rate and cardiac conduction and loss-of-function mutations in SCN5A in patients with idiopathic ventricular fibrillation associated with early repolarization. These findings support the hypothesis that decreased sodium current enhances ventricular fibrillation susceptibility.

[Neonatal molding for minor deformities of auricular cartilage: a simple method]

Non-surgical correction of minor ear deformities by external splinting during neonatal age is a well-known, effective technique, but not frequently used in France. We would like to popularize an established, simple method that uses cheap, available means (a wire, adhesive strips and a silicone probe). It can be performed by parents, paediatricians and nurses. Spreading this method would allow early onset of treatment and better clinical results. On the long run, it would have a certain economic aftermath on national health insurance by reducing the number of surgical procedures for deformed ears.

Inappropriate pacing inhibition triggered by QT prolongation due to T wave oversensing in an ICD recipient presenting with long QT syndrome

Inappropriate inhibition of atrial pacing due to T-wave oversensing (TWOS) was observed in a patient presenting with congenital long QT syndrome, treated with an implantable cardioverter defibrillator (ICD) and beta-adrenergic blocker. Development of TWOS was associated with further QT interval prolongation in the absence of amplitude changes in the intracardiac T and R waves. Replacement of the ICD generator with a sensing filter designed to attenuate the intracardiac T wave suppressed TWOS and normalized the pacing functions.

Endocardial arrhythmogenic mechanisms of torsades de pointes in patients with the congenital long QT syndrome

We injected acetylcholine (Ach) into the coronary artery to ascertain whether coronary vasospasm contributed to the syncopal events or chest oppression suffered by 3 patients with long QT syndrome (LQTS). During the test, a quadripolar electrode catheter was placed in the right ventricle and the activation-recovery interval was reanalyzed from the stored data. Intracoronary Ach transiently prolonged the QT intervals in all 3 patients without inducing coronary vasospasm. The Ach-induced QT prolongation was associated with enhanced spatial and temporal dispersion of intra-ventricular repolarization. The electrophysiological abnormalities were consistent with the putative arrhythmogenic mechanisms identified in experimental studies of LQTS.

[Cleft lip and palate management by Pr Hosaka's team at the Showa University, Tokyo (Japan)]

We describe the particularities of cleft lip and palate treatment in the department of plastic surgery managed by Pr Hosaka at the Showa University in Tokyo. Their surgical technic inherited from Pr Onizuka, their multidisciplinary approach, and their experience with over 300 cases a year were not reported in a non-Japanese journal. Therefore, we found interesting to describe their whole management.

Effects of bepridil versus E-4031 on transmural ventricular repolarization and inducibility of ventricular tachyarrhythmias in the dog

BACKGROUND

Bepridil (a multiple channel blocker) may markedly prolong the QT interval and induce polymorphic ventricular tachyarrhythmias (VTA). We compared the transmural ventricular repolarization characteristics and inducibility of polymorphic VTA after administration of bepridil versus the pure I(Kr) blocker, E-4031, each administered to five open-chest dogs.

METHODS

We used plunge needle electrode to record transmural left ventricular (LV) repolarization and activation-recovery interval (ARI) to estimate local repolarization. The correlation between paced cycle length and ARI was separately examined in the LV endocardium, mid-myocardium (Mid), and epicardium. Attempts to induce VTA were made during bradycardia and sympathetic stimulation.

RESULTS

Bepridil and E-4031 prolonged QT interval and ARI in all LV layers, though the magnitude of prolongation was greatest in Mid, increasing the transmural ARI dispersion, particularly during bradycardia. Compared with E-4031, bepridil caused mild, reverse use-dependent changes in ventricular repolarization, and less ARI dispersion than E-4031 during slow ventricular pacing. Both drugs increased ARI(max) and cycle length at 50% of ARI(max), though the changes were smaller after bepridil than after E-4031 administration. Bradycardia after the administration of each drug induced no VTA; however, sympathetic stimulation induced sustained polymorphic VTA in two of five dogs treated with E-4031 versus no dog treated with bepridil.

CONCLUSIONS

Unlike the pure I(kr) blocker, E-4031, bepridil exhibited weak properties of reverse use-dependency and protected against sympathetic stimulation-induced VTA. It may be an effective supplemental treatment for recipients of implantable cardioverter defibrillator.

[Pure red cell aplasia after resection for thymoma with myasthenia gravis]

A 73 year-old woman was diagnosed as thymoma with myasthenia gravis (MG) [ocular type] 18 years ago, but she rejected surgical treatment. The remission of myasthenia gravis has been obtained by treatment of medication. This time, to avoid myasthenic crisis at the time of orthopedic surgery, she underwent surgical treatment for thymoma: extended-thymectomy, resection of the left brachiocephalic vein and reconstraction using ringed polytetrafluoroethylene (ePTFE) graft. Pathologic diagnosis was Masaoka stage III thymoma and World Health Organization (WHO) type B2 + B3. After orthopedic surgery, irradiation was performed for mediastinum. During this period from the resection of thymoma to irradiation, she developed gradually progressive anemia, and as a result of bone marrow examination, she was diagnosed as pure red cell aplasia (PRCA). PRCA has improved with immunosuppressive treatment. One year have passed with no recurrence of thymoma and PRCA.

Efficacy of procainamide and lidocaine in terminating sustained monomorphic ventricular tachycardia

BACKGROUND

The efficacy of antiarrhythmic drugs in terminating sustained monomorphic ventricular tachycardia (SMVT) was assessed in a retrospective manner to provide a basis for recommending their use.

METHODS AND RESULTS

The 90 patients were included in this study to evaluate the efficacy to terminate SMVT using procainamide or lidocaine. All patients were alert and responsive. The mean systolic blood pressure was 91+/-25 mmHg (range, 40-150 mmHg). SMVT was diagnosed from ECG recordings and later in an electrophysiologic study. VTs with a cycle length of 329+/-55 and 324+/-61 ms were treated with the mean doses of 358+/-50 mg and 81+/-30 mg of procainamide and lidocaine and were terminated in 53/70 (75.7%) and in 7/20 (35.0%) respectively. The drugs were discontinued if there was no rise in blood pressure after slowing of the tachycardia rate or if there were signs of impending deterioration in consciousness. Though procainamide was effective, blood pressure was often low and DC shock should be available at all times during administration of the drug.

CONCLUSIONS

Procainamide, the relatively older drug, was more effective than lidocaine in terminating SMVT associated with structural heart diseases. This is a retrospective analysis but can form the basis for formulating guidelines for initial management of SMVT.

[Induction chemoradiation followed by resection through anterior approach for superior sulcus tumor]

Two cases of induction chemoradiation followed by surgical resection were reported. A 53-year-old man and a 68-year-old man who had been suffering form alleviate pain in their left shoulder and arms were referred to our hospital. Physical examination revealed Horner's syndrome on the left side in both patients. A transcutaneous needle biopsy confirmed non-small-cell lung cancer. Under the diagnosis of superior sulcus tumor in stage IIIB (T4N0M0), induction chemotherapy and radiation were given. After tumor reduction, they underwent resection through cervical anterior approach because subclavian vessel invasion was suspected. The clavicle was divided for the resection and reconstruction of subclavian artery in case 2. For the treatment of anterior superior sulcus tumors, anterior approach provides a safe and effective exposure.

Delayed pericardial effusion due to perforation of the right ventricular outflow tract by an ICD lead

A delayed pericardial effusion developed in a recipient of a cardioverter defibrillator (ICD). After an uneventful implant procedure and postoperative recovery, the patient suffered loss of appetite and fatigue, and was re-admitted to the hospital 48 days later. Her vital signs were stable and cardiac silhouette on chest roentgenogram was normal. However, blood cell counts and chemistry revealed the presence of anemia and liver dysfunction, an echocardiogram showed a diffuse pericardial effusion, and computed tomography suggested that the ICD lead, screwed in the right ventricular outflow tract, had perforated the wall. In order to make a prompt diagnosis and initiate timely corrective treatment, the physician in charge of long-term follow-up should remember that a pericardial effusion can be delayed and accumulate in the absence of typical signs of cardiac tamponade after ICD lead implantation.

[Single-stage operation for synchronous bilateral multiple lung cancer through median sternotomy]

An asymptomatic 65-year-old woman was incidentally found to have abnormal shadows on a chest X-ray during a medical examination. A chest computed tomography (CT) scan showed a pulmonary nodule in both right and left lung. Those were diagnosed as synchronous cStage IA bilateral lung cancer, and right upper lobectomy and segmentectomy of the left lung with lymphoadenectomy were sequentially performed through median sternotomy. The patient showed a favorable course after surgery, and was discharged on postoperative day 12. The pathological diagnosis was synchronous lung cancer and both were adenocarcinoma. The pathological stage was IA on the right side and IB on the left. A single-stage operation through median sternotomy was a useful surgical procedure for treating this case of synchronous bilateral lung cancer.

Improved cardiac function after sirolimus-eluting stent placement in diabetic patients by pioglitazone: combination therapy with statin

BACKGROUND

Peroxisome proliferator-activated receptor-gamma (PPAR-gamma) agonists are used as anti-diabetic drugs, and their pleiotrophic action has been reported to improve endothelial function leading to cardioprotective effects. In this study we evaluated the long-term effect of pioglitazone on cardiac function in diabetic patients after percutaneous coronary intervention (PCI) by drug-eluting stent (DES).

METHODS AND RESULTS

We investigated 54 diabetic patients who received PCI using a sirolimus-eluting stent. We excluded cases of acute myocardial infarction. They were divided into two groups: Group C received only conventional therapy (n=26) and Group P received additionally pioglitazone 15 mg/day (n=28). The left ventricular ejection fraction (LVEF) was measured by left ventriculography and analyzed before and 8 months after PCI. In Group C, LVEF did not change significantly: 55.6% vs. 56.7%, before and after PCI respectively (p=0.58). However, pioglitazone significantly improved LVEF: 54.4% vs. 60.0% (p=0.014). Multiple linear regression analysis showed that DeltaLVEF was significantly related to pioglitazone therapy (p=0.037). In particular, the combination of pioglitazone and statin improved LVEF (DeltaLVEF 9.6% with vs. 2.2% without statin).

CONCLUSIONS

Pioglitazone improved cardiac function after PCI using SES in diabetic patients, especially in combination with a statin.

Focal atrial tachycardia refractory to radiofrequency catheter ablation originating from right atrial appendage

A 44-year-old female presented with incessant, drug-refractory atrial tachycardia (AT). An electrophysiological study suggested focal abnormal automaticity, and localized the AT origin to the apex of the right atrial appendage (RAA). Repeated radiofrequency catheter ablation to the site of the earliest endocardial activation during AT failed. At surgery, right atrial appendectomy terminated the AT. On macroscopic findings, the cavity of the RAA became a dead-end before the apex. In patients with drug and radiofrequency catheter ablation, refractory focal AT arising from the RAA, especially the apex of the RAA, in our opinion surgical treatment could be considered in the lack of efficacy of ablation.