RZZ-Spindly and CENP-E form an integrated platform to recruit dynein to the kinetochore corona

Chromosome biorientation on the mitotic spindle is prerequisite to errorless genome inheritance. CENP-E (kinesin-7) and dynein-dynactin (DD), microtubule motors with opposite polarity, promote biorientation from the kinetochore corona, a polymeric structure whose assembly requires MPS1 kinase. The corona's building block consists of ROD, Zwilch, ZW10, and the DD adaptor Spindly (RZZS). How CENP-E and DD are scaffolded and mutually coordinated in the corona remains unclear. Here, we show that when corona assembly is prevented through MPS1 inhibition, CENP-E is absolutely required to retain RZZS at kinetochores. An RZZS phosphomimetic mutant bypasses this requirement, demonstrating the existence of a second receptor for polymeric RZZS. With active MPS1, CENP-E is dispensable for corona expansion, but strictly required for physiological kinetochore accumulation of DD. Thus, we identify the corona as an integrated scaffold where CENP-E kinesin controls DD kinetochore loading for coordinated bidirectional transport of chromosome cargo.

A mechanism that integrates microtubule motors of opposite polarity at the kinetochore corona

Chromosome biorientation on the mitotic spindle is prerequisite to errorless genome inheritance. CENP-E (kinesin 7) and Dynein-Dynactin (DD), microtubule motors with opposite polarity, promote biorientation from the kinetochore corona, a polymeric structure whose assembly requires MPS1 kinase. The corona's building block consists of ROD, Zwilch, ZW10, and the DD adaptor Spindly (RZZS). How CENP-E and DD are scaffolded and mutually coordinated in the corona remains unclear. Here, we report near-complete depletion of RZZS and DD from kinetochores after depletion of CENP-E and the outer kinetochore protein KNL1. With inhibited MPS1, CENP-E, which we show binds directly to RZZS, is required to retain kinetochore RZZS. An RZZS phosphomimetic mutant bypasses this requirement. With active MPS1, CENP-E is dispensable for corona expansion, but strictly required for physiological kinetochore accumulation of DD. Thus, we identify the corona as an integrated scaffold where CENP-E kinesin controls DD kinetochore loading for coordinated bidirectional transport of chromosome cargo.

Regulators of tubulin polyglutamylation control nuclear shape and cilium disassembly by balancing microtubule and actin assembly

Cytoskeletal networks play an important role in regulating nuclear morphology and ciliogenesis. However, the role of microtubule (MT) post-translational modifications in nuclear shape regulation and cilium disassembly has not been explored. Here we identified a novel regulator of the tubulin polyglutamylase complex (TPGC), C11ORF49/CSTPP1, that regulates cytoskeletal organization, nuclear shape, and cilium disassembly. Mechanistically, loss of C11ORF49/CSTPP1 impacts the assembly and stability of the TPGC, which modulates long-chain polyglutamylation levels on microtubules (MTs) and thereby balances the binding of MT-associated proteins and actin nucleators. As a result, loss of TPGC leads to aberrant, enhanced assembly of MTs that penetrate the nucleus, which in turn leads to defects in nuclear shape, and disorganization of cytoplasmic actin that disrupts the YAP/TAZ pathway and cilium disassembly. Further, we showed that C11ORF49/CSTPP1-TPGC plays mechanistically distinct roles in the regulation of nuclear shape and cilium disassembly. Remarkably, disruption of C11ORF49/CSTPP1-TPGC also leads to developmental defects in vivo. Our findings point to an unanticipated nexus that links tubulin polyglutamylation with nuclear shape and ciliogenesis.

A non-canonical function for Centromere-associated protein-E controls centrosome integrity and orientation of cell division

Centromere-associated protein-E (CENP-E) is a kinesin motor localizing at kinetochores. Although its mitotic functions have been well studied, it has been challenging to investigate direct consequences of CENP-E removal using conventional methods because CENP-E depletion resulted in mitotic arrest. In this study, we harnessed an auxin-inducible degron system to achieve acute degradation of CENP-E. We revealed a kinetochore-independent role for CENP-E that removes pericentriolar material 1 (PCM1) from centrosomes in late S/early G2 phase. After acute loss of CENP-E, centrosomal Polo-like kinase 1 (Plk1) localization is abrogated through accumulation of PCM1, resulting in aberrant phosphorylation and destabilization of centrosomes, which triggers shortened astral microtubules and oblique cell divisions. Furthermore, we also observed centrosome and cell division defects in cells from a microcephaly patient with mutations in CENPE. Orientation of cell division is deregulated in some microcephalic patients, and our unanticipated findings provide additional insights into how microcephaly can result from centrosomal defects.

Whole-genome screen identifies diverse pathways that negatively regulate ciliogenesis

We performed a high-throughput whole-genome RNAi screen to identify novel inhibitors of ciliogenesis in normal and basal breast cancer cells. Our screen uncovered a previously undisclosed, extensive network of genes linking integrin signaling and cellular adhesion to the extracellular matrix (ECM) with inhibition of ciliation in both normal and cancer cells. Surprisingly, a cohort of genes encoding ECM proteins was also identified. We characterized several ciliation inhibitory genes and showed that their silencing was accompanied by altered cytoskeletal organization and induction of ciliation, which restricts cell growth and migration in normal and breast cancer cells. Conversely, supplying an integrin ligand, vitronectin, to the ECM rescued the enhanced ciliation observed on silencing this gene. Aberrant ciliation could also be suppressed through hyperactivation of the YAP/TAZ pathway, indicating a potential mechanistic basis for our findings. Our findings suggest an unanticipated reciprocal relationship between ciliation and cellular adhesion to the ECM and provide a resource that could vastly expand our understanding of controls involving “outside-in” and “inside-out” signaling that restrain cilium assembly.

Chlamydomonas DYX1C1/PF23 is essential for axonemal assembly and proper morphology of inner dynein arms

Cytoplasmic assembly of ciliary dyneins, a process known as preassembly, requires numerous non-dynein proteins, but the identities and functions of these proteins are not fully elucidated. Here, we show that the classical Chlamydomonas motility mutant pf23 is defective in the Chlamydomonas homolog of DYX1C1. The pf23 mutant has a 494 bp deletion in the DYX1C1 gene and expresses a shorter DYX1C1 protein in the cytoplasm. Structural analyses, using cryo-ET, reveal that pf23 axonemes lack most of the inner dynein arms. Spectral counting confirms that DYX1C1 is essential for the assembly of the majority of ciliary inner dynein arms (IDA) as well as a fraction of the outer dynein arms (ODA). A C-terminal truncation of DYX1C1 shows a reduction in a subset of these ciliary IDAs. Sucrose gradients of cytoplasmic extracts show that preassembled ciliary dyneins are reduced compared to wild-type, which suggests an important role in dynein complex stability. The role of PF23/DYX1C1 remains unknown, but we suggest that DYX1C1 could provide a scaffold for macromolecular assembly.

Most animal cells have antenna-like organelles called “cilia”. These organelles have various important functions both in motility and sensing the environment. Motile cilia are essential for moving cells as well as moving fluids across a surface. The waveform of motile cilia requires large macromolecular motors; these are the ciliary dyneins. These dynein complexes are assembled in the cytoplasm in a pathway called preassembly, and then transported into cilia. Defects in this process cause a heterogeneous human disease called primary ciliary dyskinesia that results, for example, in the disruption of the motility of respiratory tract cilia, sperm and nodal cilia during development. The mechanisms of the preassembly pathway are not fully understood. In this study, we use a mutation in the well-conserved DYX1C1/PF23 gene of the green alga, Chlamydomonas reinhardtii. Loss of a conserved domain (DYX) reveals a failure to assemble most ciliary dyneins. Preassembly of inner arm dyneins is particularly affected. We find that if dynein arms are not assembled, dynein subunits in the cytoplasm are unstable. We suggest that DYX1C1 may play a role as a scaffold for other preassembly factors and the dynein subunits.

Can sedation reduce the cardiac stress during gastrointestinal endoscopy? A study with non-invasive automated cardiac flow measurement by color Doppler echocardiography

BACKGROUND

Upper gastrointestinal endoscopy (UGIE) may cause some cardiac stress. The effect of sedation on hemodynamics during UGIE has not been fully studied, and therefore the aim of this study was to clarify whether or not sedation can reduce cardiac stress dufing UGIE.

METHODS

Eight normal male volunteers undergoing UGIE with sedation (0.1 mg/kg of midazolam) and without it (two endoscopies per volunteer in random order) were monitored throughout the procedure by means of electrocardiogram, blood pressure and peripheral oxygen saturation (SpO2). Cardiac output was measured at six points before, during and after endoscopy from automated cardiac flow measurement by color Doppler echocardiography. Serum norepinephrine, epinephrine, dopamine and ACTH concentrations were measured before and after the examination.

RESULTS

No significant differences in heart rate, systolic blood pressure, rate-pressure product, cardiac output and left ventricular work index were observed between the sedated and non-sedated groups. SpO2 hardly changed during endoscopy in the non-sedated group, but decreased slightly in the sedated group (P = 0.075). Although all serum catecholamine concentration changes were within normal limits in both groups, after endoscopy only epinephrine concentration was significantly lower in the sedated group than in the non-sedated group (P = 0.0027).

CONCLUSIONS

Conscious sedation with midazolam does not reduce the cardiac stress during UGIE.

Effects of growth hormone following chronic angiotensin-converting enzyme inhibition in chronic heart failure: their relation to infarct size

Growth hormone (GH) has been attracted as a possible adjunctive treatment for severe heart failure. However, its treatment effects have been still controversial. To assess severity of basal cardiac disease states in which GH might be effective, we analyzed the relation of treatment effects of GH following chronic angiotensin-converting enzyme (ACE) inhibition on cardiac function and structures to infarct size in rat model of chronic heart failure after myocardial infarction. One day after coronary occlusion, rats were randomized to either an ACE inhibitor, temocapril (T) (80 mg/L in drinking water) or placebo for 12 weeks. The animals received concomitant recombinant human (rh) GH (2 mg/kg/day, SC) (T + GH) or vehicle during the final 2 weeks. Compared with the T group, the T + GH group with large MI had smaller increments of left ventricular (LV) dP/dt(max) (0 vs 17%) and cardiac output (9 vs 49%), less improvement of LV relaxation (tau) (-3 vs 29%) and systemic vascular resistance (8 vs 29%), and a greater increase in LV end-diastolic pressure (123 vs -5%) than did the T+GH group with moderate MI. In the T + GH group when compared with the T group, these functional alterations were associated with a 12% reduction in the LV capillary density and a 21% increase in hydroxyproline contents in rats with large MI, whereas a 12% increase in the density and similar collagen contents were found in rats with moderate MI. Thus, prominent beneficial cardiovascular effects of the additive short-term, high-dose GH to chronic high-dose ACE inhibition were obtained in rats with moderate MI, whereas little additional benefit or even detrimental effects of GH were found in rats with large MI. The present study may provide an insight into the therapeutic strategy of GH given late after MI in the presence of chronic ACE inhibition in congestive heart failure.

Vagal stimulation prior to atrial rapid pacing protects the atrium from electrical remodeling in anesthetized dogs

Atrial electrical remodeling is thought to be the cause of the maintenance of atrial fibrillation (AF). Although the initiation and maintenance of AF is partially associated with autonomic nervous tone, vagally mediated AF does not tend to become permanent. Therefore, the effects of preceding vagal stimulation (VS) on the atrial effective refractory period (ERP) under electrical remodeling conditions were investigated in anesthetized dogs. Atrial ERPs were measured at 5 sites before and after a 7-h period of atrial rapid pacing in the control group. In the VS group, the vagus nerve was stimulated for 20 min before a period of atrial rapid pacing. Atrial rapid pacing shortened the ERP at each site in the control group (electrical remodeling). On the other hand, atrial rapid pacing after VS did not shorten the ERP at any site in the VS group. Tetrodotoxin, which was administered into the fatty tissue overlying the right atrial side of the right pulmonary vein junctions, blocked the protective effect of VS against the shortening of the ERP induced by atrial rapid pacing. In contrast, atropine did not interfere with such protective effects. These results suggest that VS prior to atrial rapid pacing protects the atrium from atrial electrical remodeling.

Transient left ventricular apical ballooning without coronary artery stenosis: a novel heart syndrome mimicking acute myocardial infarction. Angina Pectoris-Myocardial Infarction Investigations in Japan

OBJECTIVES

To determine the clinical features of a novel heart syndrome with transient left ventricular (LV) apical ballooning, but without coronary artery stenosis, that mimics acute myocardial infarction, we performed a multicenter retrospective enrollment study.

BACKGROUND

Only several case presentations have been reported with regard to this syndrome.

METHODS

We analyzed 88 patients (12 men and 76 women), aged 67 +/- 13 years, who fulfilled the following criteria: 1) transient LV apical ballooning, 2) no significant angiographic stenosis, and 3) no known cardiomyopathies.

RESULTS

Thirt-eight (43%) patients had preceding aggravation of underlying disorders (cerebrovascular accident [n = 3], epilepsy [n = 3], exacerbated bronchial asthma [n = 3], acute abdomen [n = 7]) and noncardiac surgery or medical procedure (n = 11) at the onset. Twenty-four (27%) patients had emotional and physical problems (sudden accident [n = 2], death/funeral of a family member [n = 7], inexperience with exercise [n = 6], quarreling or excessive alcohol consumption [n = 5] and vigorous excitation [n = 4]). Chest symptoms (67%), electrocardiographic changes (ST elevation [90%], Q-wave formation [27%] and T-wave inversion [97%]) and elevated creatine kinase (56%) were found. After treatment of pulmonary edema (22%), cardiogenic shock (15%) and ventricular tachycardia/fibrillation (9%), 85 patients had class I New York Heart Association function on discharge. The LV ejection fraction improved from 41 +/- 11% to 64 +/- 10%. Transient intraventricular pressure gradient and provocative vasospasm were documented in 13/72 (18%) and 10/48 (21%) of the patients, respectively. During follow-up for 13 +/- 14 months, two patients showed recurrence, and one died suddenly.

CONCLUSIONS

A novel cardiomyopathy with transient apical ballooning was reported. Emotional or physical stress might play a key role in this cardiomyopathy, but the precise etiologic basis still remains unclear.

An 80-year-old mitochondrial disease patient with A3243G tRNA(Leu(UUR)) gene presenting cardiac dysfunction as the main symptom

MELAS is characterized by mitochondrial myopathy, encephalopathy, lactic acidosis and stroke-like episodes, but cardiac involvement also frequently occurs. An 80-year-old female patient had been suffering from insulin-dependent diabetes mellitus and neurosensory hearing loss. At the age of 79 she suffered metabolic acidosis with persistent drowsiness and was subsequently found to have severe cardiac dysfunction. Muscle biopsy disclosed the presence of abnormal mitochondria, and the MELAS gene mutation (A3243G of the tRNA(Leu(UUR))) was demonstrated. It is noteworthy that this mitochondrial disease patient has survived until a great age, which shows the wide clinical spectrum of MELAS, especially in the age of onset.

Emotional stress-induced 'ampulla cardiomyopathy': discrepancy between the metabolic and sympathetic innervation imaging performed during the recovery course

Four patients had the clinical features of 'ampulla cardiomyopathy', consisting of acute-onset transient left ventricular apical akinesis with basal normokinesis, normal coronary angiogram, ST-segment elevation and subsequent giant T wave inversion, which mimicked acute coronary syndrome, the onset of which occurred shortly after extreme mental stress. Myocardial necrosis was minimal, although 2 patients showed elevated serum catecholamine levels in the acute phase. Each patient underwent serial cardiac radionuclide single-photon emission computed tomography of myocardial functional sympathetic innervation, fatty acid metabolism and perfusion using I-123-metaiodobenzyl-guanidine (MIBG), I-123-beta-metyl-iodophenyl pentadecanoic acid (BMIPP) and thallium-201 (201Tl), respectively. In the acute phase, MIBG and BMIPP imaging showed an uptake defect in the apical region, whereas 201Tl uptake was mildly decreased. When assessed semi-quantitatively, the MIBG images had higher defect scores from the acute phase throughout the year of observation compared with BMIPP, and 201Tl. These observations suggest that the primary cause of ampulla cardiomyopathy is related to a disturbance of the cardiac sympathetic innervation.

Recurrent cerebral embolism in a familial amyloid polyneuropathy patient who received partial liver transplantation from a living donor

Cerebral embolism in relation to cardiac amyloidosis has not been widely noted. A 47-year-old woman who had been suffering from familial amyloid polyneuropathy (FAP) for 7 years was treated with partial liver transplantation from a living donor and her early postoperative course was uneventful. During the 391st to 613th postoperative day she experienced recurrent cerebral infarctions, but clinical examinations revealed no disorders capable of producing cerebral embolism. At autopsy splenic infarction and intracardiac thrombi adhering to the mitral valve and left atrium were found, and these areas showed severe amyloid deposition. Amyloid heart is considered to be one possible cause of systemic embolism.

Primary cardiac malignant fibrous histiocytoma in the right ventricular infundibulum treated with a cavo-pulmonary shunt and coronary embolization

A 51-year-old woman presented with progressive right ventricular infundibular wall thickening and outflow obstruction. She had had an aorto-coronary bypass for left main coronary artery disease 1 year after radiation therapy for left mammary cancer. Enhanced computed tomography showed a mass in the right ventricular free wall with no connection to the mediastinum; the tumor extended into the main pulmonary artery, but there was no other evidence of a primary or metastatic tumor. A biopsy specimen was obtained and based on the microscopic and immuno-histochemical findings (vimentin and Kp-1 positive) the diagnosis was primary cardiac malignant fibrous histiocytoma, which is very rare. A cavo-pulmonary artery connection lessened her symptoms, but embolization of the coronary artery to try and to reduce the mass had minimal effect. Four months after the tumor was diagnosed she died of extended pulmonary artery obstruction.

Relation between vascular morphologic changes during stent implantation and the magnitude of in-stent neointimal hyperplasia

Intimal hyperplasia usually occurs after balloon overstretch injury or wire coil stimuli to coronary arteries. We examined whether the degree of vessel wall stretch during coronary stent placement could predict the amount of in-stent neointimal hyperplasia after a 6-month follow-up. Serial (preintervention, postballooning, poststent implantation, and a follow-up after 6 months) intravascular ultrasound (IVUS) was used to study 457 consecutive cross-sectional areas in 28 patients. IVUS imaging, using a motorized pullback system at 0.5 mm/s, allowed 1-mm axial increment measurements of the total vascular, stent, and lumen cross-sectional areas. The mean total vascular area changed from 10.89 +/- 2.50 mm2 before to 11.27 +/- 2.49 mm2 after ballooning, to 12.80 +/- 2.59 mm2 after stenting, and to 12.58 +/- 2.41 mm2 at follow-up (p < 0.0001). The mean lumen area changed from 3.36 +/- 1.95 mm2 before to 4.21 +/- 1.65 mm2 after ballooning, to 5.16 +/- 1.09 mm2 after stenting, and to 3.57 +/- 1.23 mm2 at follow-up (p < 0.0001). The mean stent area decreased from 5.25 +/- 1.17 mm2 after stenting to 5.09 +/- 0.90 mm2 at follow-up (p < 0.0001). Stepwise logistic regression analysis showed that delta total vascular area (after stent implantation - before intervention) was a strong predictor of the amount of intimal hyperplasia (r = 0.57, p < 0.0001). Vascular overstretch caused by the stenting procedure promotes intimal hyperplasia in proportion to the degree of sectional vascular stretch.

Connective tissue grafting for root coverage in multiple Class III gingival recessions with enamel matrix derivative: a case report

This case presentation demonstrates an innovative approach to root coverage that uses an enamel matrix derivative in conjunction with periosteal connective tissue grafting in a patient with multiple gingival facial recessions. A 22-year-old female patient presented for the resolution of aesthetic concerns associated with multiple gingival recessions for teeth #23(32) through #25(41). This technique achieved soft tissue coverage of the root surfaces and effectively improved the patient's aesthetic appearance. These satisfactory clinical results have been maintained for 12 months.

[Acute myocardial infarction in elderly patients: medical and social problems]

The number of elderly patients with acute myocardial infarction has been increasing. However, the choice of treatment remains controversial. Medical records of 310 consecutive patients with acute myocardial infarction were reviewed. Two retrospective analyses were performed. 1) Patients were divided into the elderly group(70 years or more) and the younger group(under 70 years). In-hospital course and outcome were compared. 2) Pre-hospital performance status and living status were reviewed in the elderly group. Acute phase reperfusion therapy was performed in fewer patients in the elderly group(60.8% vs 71.9%, p < 0.01). The difference was most pronounced in cases of direct coronary angioplasty(28.6% vs 54.7%, p < 0.05). As a result, the rate of reperfusion success(74.8% vs 86.8%, p < 0.01) was lower in the elderly group. Moreover, the rates of in-hospital death(23.6% vs 6.8%, p < 0.005), pulmonary edema(20.3% vs 10.8%, p < 0.05), cardiogenic shock(11.9% vs 6.0%, p < 0.005), pneumonia(17.3% vs 3.0%, p < 0.005), and delirium(29.4% vs 12.0%, p < 0.001) were higher in the elderly group. Five patients in the elderly group and 3 patients in the younger group required rehabilitation because of worsened performance status. Six of them were non-reperfused patients. Elderly patients considered likely to become bed-ridden because of pre-existing physical disability at admission accounted for 28.9% of the total. Moreover, many elderly patients had poor support systems (8.4% were living alone, 21.0% were living only with their spouse or a child, 30.1% were widows or widowers). These results show that a lower acute phase reperfusion rate(especially angioplasty) resulted in a poor prognosis and worse performance status in elderly patients. Also 30% of patients were not good candidates for conventional treatment because of delirium, and that self-help in daily life is a fundamental goal for most elderly patients. Rapid and simple acute phase reperfusion, subsequent immediate mobilization, and early discharge are recommended for elderly patients with acute myocardial infarction.

Percutaneous cephalic vein approach for permanent pacemaker implantation

Implantation of permanent pacemaker leads into the cephalic vein within the deltopectoral groove is enhanced by introduction of a flexible guidewire into the brachial vein at the antecubital fossa, which is then advanced to the subclavian vein. The cephalic vein within the deltopectoral groove is easily found by incision with the guidewire as a marker. A pacing lead or leads can be inserted along the guidewire or by using a sheath advanced over the guidewire. The procedure was performed on 32 patients and the pacing leads of 28 procedures (DDD 15, VDD 9 and WI 4) were inserted using the cephalic vein without complications.

Effect of distal stenosis of internal thoracic artery bypass grafts on longitudinal phasic blood flow velocity characteristics

BACKGROUND

Left internal thoracic artery (LITA) bypass conduits show gradual longitudinal transition in their phasic flow velocity patterns from the proximal to distal segments, but little is known about the influence of distal stenosis, particularly early after surgery, on that characteristic. The purpose of this study was to evaluate the influence of distal stenosis on these flow velocity patterns.

METHODS

We examined 24 LITAs within 1 month (7 to 30 days) after surgery with a Doppler-tipped guide wire at the proximal, mid, and distal segments. Maximum peak velocities (MPV), time averaged peak velocities (APV), and velocity-time integrals (VTI) were measured.

RESULTS

In LITAs without stenosis (n = 14, group A), the APV, MPV, and VTI values at the diastole were significantly greater than those for distal stenosis (minimal lumen diameter >75%, n = 10, group B). The values of the 3 indexes at the systole in each segment did not differ significantly between the 2 groups. Both groups showed gradual increases in the diastolic/systolic ratios of the 3 indexes from the proximal to distal portions, the ratios in group A being significantly larger than that in group B (APV, P <. 001; MPV, P <.01; TVI, P <.01, respectively). For these indexes, sensitivity and specificity for predicting stenosis of LITA was higher in the proximal and mid portion than in the distal.

CONCLUSIONS

Anastomotic stenosis decreases the diastolic flow component but not the systolic one. By using diastolic/systolic ratios of the 3 indexes, it is possible to predict distal stenosis of LITA from the resting phasic flow velocity pattern.

Soluble form of selectins in blood of patients with acute myocardial infarction and coronary intervention

Soluble (s) P-selectin, sE-selectin, sL-selectin and soluble intercellular adhesion molecule-1 (sICAM-1) levels were examined by monoclonal antibody-based enzyme immunoassay on serum samples taken from nine patients with acute myocardial infarction (AMI) and eight patients with stable angina pectoris (SAP) before and after the successful percutaneous transluminal coronary angioplasty (PTCA). In patients with acute phase of AMI, the levels (mean +/- SEM) of sP-selectin (110 +/- 18 ng/ml) and sE-selectin (54 +/- 15 ng/ml) before PTCA, were significantly higher than those in the SAP group, the values being 44 +/ 27 and 21 +/- 4 ng/ml (p < 0.05), respectively. After recanalization, the levels of sE-selectin and sL-selectin were significantly decreased (sE-selectin 54 +/- 15 to 42 +/- 11 ng/ml, sL-selectin 1104 +/- 106 to 891 +/- 59 ng/ml, P < 0.05, respectively). These findings suggest that the presence of activated and/or injured endothelial cells, which may be involved in the plaque disruption or intraluminal thrombosis in AMI region and that the inflammatory process may be altered after reperfusion therapy.

Intravascular ultrasound findings after successful primary angioplasty for acute myocardial infarction: predictors of abrupt occlusion

OBJECTIVES

This study sought to evaluate the intravascular structure as depicted by intravascular ultrasound after successful primary angioplasty (i.e., without thrombolytic therapy) for acute myocardial infarction and to investigate the related predictors of acute coronary occlusion.

BACKGROUND

The usefulness of primary angioplasty for acute myocardial infarction is still limited by early reocclusion. There are few data regarding the intravascular ultrasound findings after primary angioplasty.

METHODS

Intravascular ultrasound was performed in 27 patients after successful primary angioplasty. Repeat coronary angiography was performed 15 min later, on the following day and 1 month after angioplasty.

RESULTS

Abrupt occlusion occurred in 8 of 27 patients. Angiographic variables in patients with versus those without abrupt occlusion were not significantly different. Intravascular ultrasound disclosed a significantly smaller lumen area ([mean +/- SD] 2.49 +/- 0.72 vs. 5.06 +/- 1.52 mm2, p < 0.001) and a significantly greater percent plaque area (80.5 +/- 9.1% vs. 63.7 +/- 7.8%, p < 0.001) in patients with abrupt occlusion. There was no significant difference in external elastic membrane cross-sectional area. We classified the ultrasound appearance of the intravascular structure as smooth, irregular or filled. Abrupt occlusion occurred in none of 6 patients with a smooth intravascular structure, 24% of 17 patients with an irregular structure and in all 4 with a filled structure (p < 0.05). In the latter group, the lumen was filled with bright speckled or low echogenic material, although angiography revealed excellent coronary dilation in all these arteries.

CONCLUSIONS

Intravascular ultrasound revealed a narrow lumen in coronary arteries showing abrupt occlusion after successful primary angioplasty, even though angiography disclosed successful dilation. Arteries with a lumen filled with bright speckled or low echogenic material frequently develop abrupt occlusion.

Predictive validity of the Braunwald classification of unstable angina for angiographic findings, short-term prognoses, and treatment selection

The authors tested the Braunwald classification for its predictive validity for underlying coronary conditions, clinical courses, and responses to treatment. A reliable definition and classification of unstable angina is needed to help physicians make correct diagnoses of patients' conditions and to appraise findings from clinical trials critically. Many clinical trials have been conducted, but it is difficult to compare the results because of different entry criteria. Of 113 consecutive patients admitted with unstable angina, 89 who had primary angina were studied. Braunwald's classification was applied at admission. The outcomes of interest during hospitalization were coronary angiographic findings, short-term prognoses, and the treatment selected. Multivariate analysis showed that the severity class expressed significant positive predictivity for coronary thrombi (adjusted odds ratio [OR], 6.53; 95% confidence interval [CI], 2.82 to 15.1) and progress to impending infarction (OR, 10.43; CI, 3.35 to 32.49). The treatment (OR, 0.02; CI, 0.004 to 0.08) and electrocardiographic (OR, 0.22; CI 0.10 to 0.49) classes showed independent negative predictivity for coronary vasospasm. The treatment (OR, 3.50; CI, 1.94 to 6.33) and electrocardiographic (odds ratio, 3.27; CI, 1.87 to 5.71) classes showed positive predictivity for the necessity for recanalization treatment with coronary angioplasty or bypass grafting. The Braunwald classification used at admission is highly predictive of underlying coronary conditions, progression to impending infarction, and the final selection of treatment. This classification should be considered in determining patient eligibility in clinical trials and studies.

Delayed improvement in skeletal muscle metabolism and exercise capacity in patients with mitral stenosis following immediate hemodynamic amelioration by percutaneous transvenous mitral commissurotomy

The abrupt improvement in hemodynamics after successful percutaneous transvenous mitral commissurotomy (PTMC) does not immediately enhance exercise capacity. Improved exercise capacity several months after PTMC has been reported. We hypothesized that the delayed improvement in exercise capacity is due partly to the slow improvement in the metabolism of skeletal muscle. This study examined the short- and long-term effects of PTMC on exercise capacity and skeletal muscle metabolism in patients with mitral stenosis. Treadmill exercise testing with respiratory gas analysis was performed in 11 patients with symptomatic mitral stenosis before and 3, 30, and 90 days after successful PTMC. On the same schedule, forearm metabolism of high-energy phosphates was measured by magnetic resonance spectroscopy during and after handgrip exercise. Ten healthy volunteers were examined. PTMC resulted in an immediate symptomatic improvement. However, exercise capacity and skeletal muscle metabolism remained unchanged 3 days after PTMC. At 30 days after PTMC, there were significant improvements in peak oxygen consumption (p <0.05), intracellular pH at end-exercise (p <0.05), and time constant for phosphocreatine recovery (mean +/- SD 88.9 +/- 11.3 vs 106.3 +/- 11.7 seconds, p <0.01) compared with these baseline values. These improvements remained even at 90 days after PTMC. Exercise capacity improved with some time delay after immediate hemodynamic amelioration by PTMC. Long-term improvement in exercise capacity depends partly on the slowly progressing improvement in skeletal muscle metabolism after long-standing mitral stenosis.

Cytoplasmic body myopathy with hypertrophic cardiomyopathy

A patient with cytoplasmic body myopathy presented muscle hypotonia from birth and developed progressive muscular atrophy and weakness, scoliosis, contracture of joints and cardiorespiratory failure. At the age of 17, he died of heart failure. Post mortem examination revealed severe hypertrophy of cardiac walls and generalized muscular atrophy. Microscopic examination showed many cytoplasmic bodies in skeletal muscle fibers and myofiber disarray in myocardium. No cases of cytoplasmic body myopathy with hypertrophic cardiomyopathy have been reported previously. It is suggested that the Z-line component is related to the formation of the cytoplasmic body in skeletal muscle and disarray in the cardiac muscle.

Transient ST elevation and left ventricular asynergy associated with normal coronary artery in aneurysmal subarachnoid hemorrhage

A 62-year-old woman presented with transient ST segment elevation and left ventricular asynergy in an acute phase of subarachnoid hemorrhage (SAH). A coronary arteriogram during ongoing ST elevation showed no fixed stenoses or spasm. These findings refute epicardial coronary vasospasm as a cause of transient ST elevation and left ventricular asynergy in patients with SAH.

[A case of adult pulmonary supravalvular membranous stenosis which was successfully treated by percutaneous transluminal balloon dilatation]

We report a case of adult pulmonary supravalvular stenosis which was successfully treated with percutaneous transluminal balloon dilatation (PTBD). A 42-year-old man was admitted for a heart murmur and abnormal findings in the screening chest roentgenogram. Having no symptoms on admission, his physical activity was evaluated as Class I according to the classification of the New York Heart Association. A systolic murmur (Levine III/VI) with split second sound was audible at the left sternal border in the 3rd intercostal space. Chest roentgenogram revealed 57% of the cardio-thoracic ratio and no signs of increased pulmonary vascular markings. ECG showed incomplete right bundle branch block. Echocardiography and right ventriculography visualized the supravalvular membranous structured stenosed pulmonary artery 1cm above the pulmonic valve. Systolic pressure gradient between the right ventricle and the distal main pulmonary trunk was 54mmHg. The patient was diagnosed as having pulmonary supravalvular membranous stenosis. PTBD was applied using Inoue balloon catheter, where inflation was initiated from approximately 120% of pulmonary arterial diameter and terminated at 150%. This procedure decreased systolic pressure gradient from 54mmHg to 36mmHg without complication. After PTBD right ventriculography demonstrated that a part of the membranous structure had become floppy and movable. Pulmonary arterial diameter was unchanged. We considered that PTBD tore the membranous structure, which consequently resulted in the decrease of systolic pressure gradient. Systolic murmur diminished to Levine II/VI. Six months later, cardiac catheterization showed no change in systolic pressure gradient compared with that immediately after PTBD. This is the first report on pulmonary supravalvular membranous stenosis successfully treated with PTBD.(ABSTRACT TRUNCATED AT 250 WORDS)

A family of Becker's progressive muscular dystrophy with severe cardiomyopathy

A family of Becker's muscular dystrophy with marked cardiomyopathy was studied. The propositus, a 16-year-old boy with marked pseudohypertrophy in calves, showed electrocardiographic abnormalities resembling those in the Duchenne's type. Radionuclide study and endomyocardial biopsy revealed remarkable degeneration of myocardium. His uncle, who also had slight proximal muscular atrophy and weakness, and calves' pseudohypertrophy, died of heart failure at the age of 47, and autopsy showed dystrophic changes in skeletal muscles and extensive myocardial damage. Severe cardiac involvement can occur in Becker's muscular dystrophy which has been known to have an essentially benign clinical course, and radionuclide investigation is useful for the detection of preclinical cardiac lesions in patients with muscular dystrophy.

Clinical applications of a new type of real-time two-dimensional Doppler flow imaging system

The clinical significance of a newly developed real-time 2-dimensional (2-D) Doppler flow imaging technique was assessed. In the instrumentation of the echocardiograph, the pulsed Doppler mechanism was incorporated in a wide-angle, phased-array system. The Doppler flow signals obtained from the cardiac chamber were processed on the basis of the autocorrelation principle. The direction, velocity and variance of the intracardiac blood flow were calculated in real time and displayed in the color-coded mode on the television screen, and were superimposed on the 2-D echocardiographic image of the heart. The technique was used in 20 healthy subjects and 100 cardiac patients. The new technique clearly visualized the whole aspect of intracardiac blood flow by the cine mode in real time; thus, the technique may be called Doppler cineangiocardiography. The mitral inflow and the aortic ejection flow were clearly demonstrated. A regurgitant jet from the valve orifices was dynamically visualized as seen in the cineangiogram. The spatial orientation and extent of the regurgitant jet were easily assessed. The jet stream through the stenotic mitral orifice was well imaged in the left ventricular cavity, showing a variety of stream directions. Intracardiac shunts in ventricular septal defect and atrial septal defect were clearly visualized. The defect could be localized on the interventricular septum on the basis of the site where the shunt flow spurted, although the echocardiographic interruption was not demonstrated in the 2-D echocardiographic image of the cardiac structure. Although some technical problems remain, our new technique greatly improves the diagnostic efficacy of ultrasound.

Augmentation of atrial contribution to left ventricular inflow with aging as assessed by intracardiac Doppler flowmetry

The influence of aging on the left ventricular (LV) function in diastole was investigated from the aspect of the mitral inflow pattern using 2-dimensional Doppler echocardiography. The subjects for the investigation were 69 persons who were diagnosed as healthy by a checkup examination. The peak velocity in the rapid filling phase and that in the atrial contraction phase tended to decrease and to increase with aging, respectively. However, these tendencies were not statistically significant. However, the ratio of the atrial contraction phase to the rapid filling phase showed a significant increase with aging (r = 0.82, p less than 0.001). Therefore, it is considered that the mitral flow conditions are influenced by aging. The result obtained is also interpreted to mean that the LV distensibility in early diastole is impaired with aging and that the contribution of the atrial contraction to LV filling is compensatorily augmented.

Chronic neuropathy associated with immune complexes of hepatitis B virus

In 7 patients, including one autopsied case, with neuropathy associated with hepatitis B virus infection, histologic examination of sural nerve biopsies revealed small vessel vasculitis in the vasa nervorum. In all cases, immunofluorescent deposits of hepatitis B surface antigen, immunoglobulin and C3 complement were detected in the vasa nervorum. That these deposits could represent immune complexes composed of hepatitis B virus was supported by the serologic demonstration of high serum-level of immune complexes and by the ultrastructural demonstration of electron-dense deposits around the endoneural capillary and in the endoneurium. The densities of large myelinated fibers were significantly lower than controls (P less than 0.01) in 6 of 7 cases. These results suggest that immune complexes composed of hepatitis B virus might play a significant role in the pathogenesis of endoneural and epineural vascular lesions, through which neuropathy may be induced in patients with hepatitis B virus infection.