坂倉 建一

Background: Temporary vena cava filters have been used for protection from potentially fatal pulmonary embolism. However, recent reports suggested that they may be associated with serious adverse complications including filter-related thrombosis. The purpose of this study was to examine the clinical complications of temporary vena cava filter placement. Methods: We enrolled 40 consecutive patients from January 2006 to December 2010 who underwent percutaneous temporary vena cava filter insertion in Saitama Medical Center, Jichi Medical University. Results: Major filter complications related to temporary vena cava filters were filter thrombosis in 4 patients (10.2%), filter dislocation in 4 (10.2%), and catheter-related infection in 3 (7.7%). Massive pulmonary embolism and cardiogenic shock was observed in one case (2.5%) at the time of retraction. Conclusion: Temporary filter placement was associated with a high incidence of device-related complications. The benefit of temporary filter placement should be judiciously weighed against the risk of complications. (C) 2012 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.

Although rotational atherectomy (RA) is used for complex lesions in percutaneous coronary intervention, there are several contraindications and precautions. The purpose of our study was to compare complications between off-label and on-label use of RA. We identified 250 consecutive patients who underwent RA. Off-label characteristics included saphenous vein graft lesions, presence of thrombus, unprotected left main stenosis, coronary artery dissection, acute myocardial infarction (MI), left ventricular dysfunction, 3-vessel disease, long lesion (>= 25 mm), or angulated lesion (>= 45 degrees). Patients who had >= 1 off-label characteristic were assigned to the off-label group (156 patients), and patients who had no off-label characteristics were assigned to the on-label group (94 patients). Occurrence of slow flow or periprocedural MI in the off-label group was higher than that in the on-label group (slow flow 30% vs 18%, p = 0.06; MI 8.8% vs 2.1%, p = 0.04), whereas severe complications such as burr entrapment, transection of the guidewire, or perforation were rare in the 2 groups. In conclusion, compared to the on-label group, the off-label group had a higher incidence of slow flow and periprocedural MI. Severe complications such as burr entrapment, transection of the guidewire, or perforation were rare in the 2 groups. 2012 Elsevier Inc. (C) All rights reserved. (Am J Cardiol 2012;110:498 501)

Objectives. The purpose of this study was to investigate the association between beta-blocker use and slow flow during rotational atherectomy (RA). Background. RA is often performed as part of percutaneous coronary interventions for the treatment of calcified lesions; however, the procedure can be complicated by slow flow. Previous reports suggested that the use of beta-blockers was associated with slow flow during RA. Methods. A total of 186 patients who received RA were included, and 87 patients were on beta-blockers. The occurrence of slow flow was compared between the beta-blocker group (n = 87) and the non-beta-blocker group (n = 99). Multivariate logistic regression analysis was performed to investigate whether the use of beta-blockers was associated with slow flow. Results. The occurrence of slow flow was not different between the beta-blocker group (29.9%) and the non-beta-blocker group (24.2%; P=.39). The use of beta-blockers was not significantly associated with slow flow (odds ratio, 0.75; 95% confidence interval, 0.34-1.68; P=.49) after controlling for all potential confounding factors. Conclusions. There was no definitive association between slow flow and the use of beta-blockers during RA. There is no need to discontinue beta-blockers in patients receiving RA.

Drug-eluting stents (DES) have proven to be effective for reducing the rate of restenosis, whereas stem thrombosis (ST) after DES implantation has raised safety concerns. Everolimus-eluting stents (EES) are a new generation of DES that have demonstrated safety and efficacy compared with first-generation DES. However, the use of EES in patients presenting with acute coronary syndrome (ACS) has not been adequately investigated. We compared the clinical outcomes between the ACS and non-ACS groups treated with EES. A total of 335 consecutive patients who received EES implantation between January 2010 and January 2011 were investigated (ACS; n = 172, non-ACS; n = 163). Clinical outcome data were obtained for 94.3% of the patients. Follow-up angiography was performed in 58.5% of all patients. The median follow-up period was 8 months in both groups. Clinical outcomes were not statistically different between the groups. The rate of target lesion revascularization (TLR) was 2.5% in the ACS group and 3.8% in the non-ACS group (P = 0.37). MACE occurred in 8.2% of the ACS group and 10.2% of the non-ACS group (P = 0.54). A definite ST was identified in one patient in each group (P = 0.75). The unadjusted cumulative event rates estimated by the Kaplan-Meier method and the log-rank test showed no significant difference between the groups for TLR, target vessel revascularization (TVR), all-cause death, or MACE. In conclusion, EES was safe and efficacious for patients presenting with ACS, as well as for those with non-ACS during a mid-term follow-up period. (Int Heart J 2012; 53: 215-220)

Aortic dissection is a life-threatening cardiovascular disease with high in-hospital mortality. However, the risk factors of aortic dissection have not been fully elucidated. Obstructive sleep apnea (OSA) has been increasingly recognized as an independent cardiovascular risk factor. Among the underlying mechanisms to explain the association between OSA and cardiovascular morbidity, previous studies reported that intermittent hypoxia and re-oxygenation (IHR) might induce cardiovascular diseases via atherosclerosis. However, little is known about an association between aortic dissection and IHR. The aims of the study were to investigate the prevalence of nocturnal IHR among patients with aortic dissection and compared with that in subjects without aortic dissection, and to investigate whether there is an independent association between aortic dissection and IHR. We enrolled 29 patients with aortic dissection and 59 control subjects. We performed sleep studies and compared the results between the groups. Frequency of IHR is expressed as 3% oxygen desaturation index (ODI). Multivariate analysis was performed to identify determinants of aortic dissection. The percentage of either moderate-to-severe IHR or severe IHR was significantly higher in the aortic dissection group ( = 0.04 and < 0.001, respectively) than in the control group. The mean 3% ODI of patients with aortic dissection was significantly higher than that of control subjects (34.8 +/- A 23.1 and 19.0 +/- A 14.1, = 0.003). In multivariate analysis, 3% ODI was significantly associated with aortic dissection (odds ratio 1.44; 95% confidence interval 1.08-1.91; = 0.01). The present study showed the close association between aortic dissection and, IHR, a major component of OSA.

Rotational atherectomy (RA) can facilitate smooth stent delivery and stein expansion through lesion modification for a calcified coronary lesion. Several studies reported that sirolimus-eluting stent (SES) implantation following RA showed a lower rate of revascularization compared with bare-metal stents (BMS). However, there are limited data that compared the clinical outcomes between SES and paclitaxel-eluting stents (PES) after RA. We compared the long-term clinical outcomes of SES and PES following RA. Two hundred and thirty-three consecutive patients (SES n = 179, PES is = 54) who were treated with SES or PES following RA between 10th September 2004 and 13th April 2010 were investigated. Follow-up data for clinical outcomes were obtained in 91.4% of all subjects. The median follow-up period was 630 days (interquartile range, 300 to 1170 days) in the SES group, and 625 days (interquartile range, 285 to 900 days) in the PES group. Clinical outcomes including target lesion revascularization (TLR) (SES 4.9% versus PES 9.8%, P = 0.31), target vessel revascularization (TVR) (SES 6.8% versus PES 11.8%, P = 0.25), and major adverse cardiac events (MACE) (SES 14.8% versus PES 13.7%, P = 0.8) were not statistically different between the groups. The unadjusted cumulative event rates estimated by the Kaplan-Meier method and the log-rank test showed no significant differences between the two groups for time to event for TLR, cardiovascular death, all-cause death, or MACE. In conclusion, there was no significant difference in the long-term clinical outcomes between SES and PES following RA. (Int Heart J 2012; 53: 149-153)

Peri-stent contrast staining (PSS) is an abnormal angiographic finding following drug-eluting stem implantation which suggests the presence of a space outside the stent struts. PSS has been reported to be associated with very late stent thrombosis (VLST). The aims of this study were to compare the occurrence rate of late acquired PSS between sirolimus-eluting stent (SES) and everolimus-eluting stent (EES) implantation, and to identify clinical characteristics associated with PSS. The percutaneous coronary intervention (PCI) database of our hospital was queried to identify patients meeting the following criteria: (i) patients who received SES or EES in de nova coronary artery lesions; and (ii) patients who had angiographic follow-up between 3 and 15 months after stent implantation. There were 221 patients with 249 lesions treated with SES, and 173 patients with 212 lesions treated with EES. The occurrence of PSS was evaluated and compared between SES and EES implantation on a patient and lesion basis. The occurrence rate of late acquired PSS with EES was lower than that with SES. (On a patient basis; 1.2% versus 4.5%, P = 0.045, on a lesion basis; 0.9% versus 4.0%, P = 0.043). Among the clinical characteristics, chronic total occlusion (CTO) lesions were associated with PSS. The occurrence of late acquired PSS in EES was lower than that in SES. In conclusion, the occurrence rate of late acquired PSS with EES was lower than that with SES, however, it remains to be determined whether this difference translates to the difference in the rate of VLST. (Int Heart J 2012; 53: 165-169)

Background: Little has been known about clinical features and prognosis of very old patients with heart failure with preserved ejection fraction (HFPEF). The aim of this study was to compare clinical features and clinical outcomes between HFPEF and heart failure with reduced ejection fraction (HFREF) in patients older than 80 years. Methods: We enrolled a total of 113 patients over 80 years old, who were admitted for heart failure between 2006 and 2009. We retrospectively analyzed the clinical features including laboratory data and echocardiography parameters. Results: In 53 patients (49%) left ventricular ejection fraction was preserved. The clinical characteristics and treatment between HFPEF and HFREF showed that anemia was one of the risk factors for HFPEF, and the long-term outcomes of HFPEF in this population were not different from that of HFREF. Conclusion: These results suggest that anemia is one of the important risk factors for HFPEF in the very elderly. (C) 2011 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.

Transradial percutaneous coronary intervention (PCI), which is less invasive than transfemoral PCI, may facilitate early rehabilitation of patients with acute myocardial infarction (AMI). The aim of our study was to investigate whether transradial PCI is associated with a shorter coronary care unit (CCU) stay in very elderly AMI patients (>= 80 years old). We enrolled 116 AMI patients aged >= 80 years. There were 39 patients in the transradial group and 77 patients in the non-transradial group. The length of CCU stay, the length of hospital stay, in-hospital mortality, the day of the monitored sitting and standing test, and the occurrence of delirium were compared between the two groups. The duration of CCU stay in the transradial and non-transradial groups was 3.6 +/- 1.5 days and 5.0 +/- 3.2 days, respectively (P = 0.001). The duration of hospital stay in the transradial and non-transradial groups was 13.3 +/- 7.4 clays and 19.2 +/- 11.1 days, respectively (P = 0.001). In-hospital mortality was not different between the two groups (7.7% versus 2.6%, P = 0.20). The day of the monitored standing test in the transradial and non-transradial groups was 3.2 +/- 0.7 and 4.6 +/- 2.3, respectively (P < 0.0001). Multivariate logistic regression analysis identified a transradial approach as an independent predictor of short (<= 3 days) CCU stay (OR: 3.01, 95%CI: 1.16-7.83, P = 0.02). In conclusion, transradial PCI was associated with a shorter CCU stay in AMI patients >= 80 years old. Furthermore, transradial PCI facilitated early rehabilitation in this high risk population. (Int Heart J 2012; 53: 79-84)

Background: Hemodialysis (HD) is an important risk factor for progression of aortic valve stenosis (AS). However, there are varying degrees of disease progression among patients with AS on HD. The aim of this study was to find determinants of rapid progression of AS in patients on HD. Methods: We enrolled 30 patients with AS on HD with a mean follow-up period of 4 years. The peak pressure gradient (PPG) between the initial echocardiography and the last echocardiography at least 3 months interval (Delta PPG) was adopted as the indicator of AS progression. We divided the patients into two groups according to Delta PPG per year [rapid progression (Delta PPG >4.5 mmHg/year), slow progression (Delta PPG <4.5 mmHg/year)] and compared the clinical characteristics between the two groups. Results: Overall mean Delta PPG was 4.5 mmHg/year. Systolic blood pressure (SBP), serum calcium, and calcium-phosphate product were significantly higher in rapid progression group compared with slow progression group (p < 0.05). Conclusion: High systolic blood pressure, serum calcium, and calcium-phosphate product were associated with rapid progression of AS in patients on chronic HD. (C) 2011 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.

Objectives. The purpose of this study was to compare medical resource use, such as total device cost, total contrast volume, and total fluoroscopy time between the staged and simultaneous strategies for treating two-vessel disease (2VD) by percutaneous coronary intervention (PCI). Background. 2VD can be treated by the staged strategy or the simultaneous strategy. Compared to the staged strategy, the simultaneous strategy may reduce medical resource use. Methods. We identified a staged group (138 patients) and simultaneous group (62 patients) from our PCI database between January 1, 2008 and December 31, 2010. Total PCI device cost, total contrast volume, and total fluoroscopy time were compared between the two groups. Results. Total costs for the staged group and the simultaneous group given in United States dollars were $21,289 +/- 5633 and $ 16,571 +/- 5530, respectively (P<.0001). Total contrast volumes for the staged group and the simultaneous group were 299 +/- 79 mL and 194 +/- 62 mL, respectively (P<.0001). Total fluoroscopy times for the staged group and the simultaneous group were 60 +/- 27 minutes and 40 +/- 15 minutes, respectively (P<.0001). In multivariate analysis, the simultaneous strategy was significantly associated with low cost, small contrast volume, and short fluoroscopy time even after controlling for age, sex, acute coronary syndrome, and lesion complexity. Conclusions. Compared to the staged strategy to treat 2VD by PCI, the simultaneous strategy reduced medical resource use, i.e., total device cost, total contrast volume, and total fluoroscopy time.

Burr entrapment is a rare but serious complication during rotational atherectomy (RA). Although emergent surgical removal is a reliable option for this complication, surgical removal is invasive and takes several hours. Balloon inflation just proximal to the burr was the previously-reported nonsurgical option for burr removal. However, this method needed large guide catheter lumen (>= 8 Fr). We present a case of 67-year-old male on chronic hemodialysis. During RA for severe stenosis of the right coronary artery, the RA burr was entrapped. We cut off the drive shaft, the drive shaft sheath, and the RA wire together near the advancer, and then we removed the drive shaft sheath. After removing the drive shaft sheath, the 2.5 mm balloon easily entered the 7-Fr guide catheter. We inflated that balloon to a pressure of 18 atm. The burr was easily removed immediately after balloon deflation. Removal of the drive shaft sheath following balloon dilatation is a new, nonsurgical bailout method for a burr that becomes entrapped during RA. Since removal of the drive shaft sheath following balloon dilatation can be applied to 7 Fr as well as 6 Fr guide systems, this method may be of considerable benefit when operators use 7 Fr or 6 Fr systems. (C) 2011 Wiley-Liss, Inc.

Percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) increases forward blood flow, possibly resulting in an increase in lumen diameter. We investigated the determinants of luminal gain at the distal reference segment following PCI for CTO. Forty-eight consecutive patients who underwent PCI for CTO were included in this study. Clinical and angiographic data were obtained at baseline and follow-up (mean follow-up period: 251 +/- 73.6 days). Overall, the reference lumen diameter was 2.53 +/- 0.38 min at post-procedure and 2.38 +/- 0.84 mm at follow-up. The distal reference lumen diameter (segment 5 mm distal to the stent) was larger at follow-up than at post-procedure (1.64 +/- 0.64 and 1.38 +/- 0.51 mm, respectively, P < 0.05). Luminal gain (LG), in the distal reference segment, defined as an increase in lumen diameter from post-procedure to follow-up, was observed in 33 of 48 patients (69%). Univariate and multivariate logistic regression analyses were performed to identify the clinical and angiographic predictors of LG. Minimum lumen diameter and left ventricular ejection fraction at baseline were both significant predictors of LG in univariate and multivariate logistic regression analyses. Luminal gain was observed at the distal reference segment following PCI for CTO. Left ventricular ejection fraction may have an impact on the lumen diameter distal to lesions responsible for CTO. (Int Heart J 2011; 52: 270-273)

An 88-year-old male was referred to our medical center for the treatment of severe angina pectoris. Coronary angiography revealed severely calcified tight stenosis in the left main (LM), the left circumflex (LCX) ostium, and the proximal portion of the left anterior descending (LAD) artery (Medina 1, 1, 1). We performed T-stenting with two everolimus-eluting stents. Prior to T-stenting, we performed alternating rotational atherectomy (RA) of the vessel segments from the LM to LCX and from the LM to LAD. The effectiveness of alternating RA was confirmed by a "pendulous calcification" at the carina of the LM bifurcation. © 2011 Japanese Association of Cardiovascular Intervention and Therapeutics.

Acute aortic dissection (AAD) is associated with an inflammatory reaction, as evidenced by elevated inflammatory markers, including C-reactive protein (CRP). The association between the peak CRP level and long-term outcomes in type B AAD has not been systematically investigated. The purpose of this study was to investigate whether the peak CRP level during admission predicts long-term outcomes in type B AAD. We conducted a clinical follow-up study of type B AAD. We divided the study population into 4 groups according to the tertiles of peak CRP levels (T1: 0.60 to 9.37 mg/dL; T2: 9.61 to 14.87 mg/dL; T3: 14.90 to 32.60 mg/dL; and unavailable peak CRP group). Multivariate Cox regression analysis was applied to investigate whether the tertiles of peak CRP predict adverse events even after adjusting for other variables. A total of 232 type B AAD patients were included in this analysis. The median follow-up period was 50 months. CRP reached its peak on day 4.5 +/- 1.7. Mean peak CRP values in T1, T2, and T3 were 6.4 +/- 2.4, 12.0 +/- 1.5, and 19.5 +/- 4.0 mg/dL, respectively. There were 65 events (39 deaths and 26 aortic events) during the follow- up. T3 and T2 (versus T1) were strong predictors of adverse events (T3: hazard ratio: 6.02 [95% CI: 2.44 to 14.87], P=0.0001; T2: hazard ratio: 3.25 [95% CI: 1.37 to 7.71], P=0.01) after controlling for all of the confounding factors. In conclusion, peak CRP is a strong predictor for adverse long-term events in patients with type B AAD. (Hypertension. 2010;55:422-429.)

たこつぼ心筋症(transient left ventricular apical ballooning, takotsubo cardiomyopathy; TTC) では診断時, 冠動脈の有意狭窄を除外基準とすることが多い. しかしながら, 高齢者に多い病気であり, 最近, 冠動脈に有意狭窄のあるたこつぼ心筋症の存在もいわれるようになってきた. 症例は83歳, 女性. 普段から行っているわけではない, 緊張を伴った神社参拝, 豆まきという行事直後の食事, 飲酒をした際に著明な冷汗と意識が遠のく感覚を自覚したため, 救急要請となり当センターに救急搬送された. 急性冠症候群(acute coronary syndrome; ACS)が疑われ, 緊急心臓カテーテル施行. 左冠動脈前下行枝(left anterior descending artery; LAD)#7に90％狭窄を認めたため, 緊急経皮的冠動脈形成術(percutaneous coronary intervention; PCI)を行った. 直後の左室造影(left ventriculography; LVG)では, LADの支配領域に合致しない左心室基部の過収縮と心尖部の無収縮を認め, 高度冠動脈狭窄を合併したTTCと診断された. TTCとLAD病変の関与したACSは最も重要な鑑別点である. ACSとして判断されていた症例の中にも実際には詳細に検討すると, たこつぼ心筋症が潜んでいる可能性があることを示唆している. また, 診断方法の感度を考慮すると, 疾患概念による形体描写に基づかない命名の必要性が指摘されている. 病態解明の進歩が, 今後一層期待される.

It is considered that percutaneous cardiopulmonary support (PCPS)-associated thrombosis is rare on antithrombotic coated PCPS if anticoagulation therapy is appropriately performed. We experienced two cases in which the association between antithrombotic coated PCPS and venous thrombus formation was highly suspected. These cases suggest that PCPS-associated venous thrombus formation should be checked frequently during and after PCPS even if anticoagulation was appropriately performed. (C) 2009 Japanese College of Cardiology. Published by Elsevier Ireland Ltd. All rights reserved.

Recurrence of myocardial infarction, especially when occurring early after the prior one, carries a significant morbidity and mortality rate. The aim of this study was to investigate the characteristics of patients who experienced recurrence under secondary prevention therapy. Case record review identified myocardial infarction patients who had a history of previous myocardial infarction within 5 years. Hospital chart records, initial laboratory data, medications, and type of infarction were reviewed. Patients were divided into two groups according to the interval of recurrence: an early group (recurrence within 1 year), and a late group (recurrence after more than 1 year). A total of 89 patients were included in the analysis; 40 patients in the early group, and 49 patients in the late group. Mean age in the early group and late groups was 67.3 +/- 11.9 and 59.4 +/- 8.9, respectively (P = 0.001). Mean body mass index in the early and late groups was 22.1 +/- 3.6 and 25.0 +/- 3.3, respectively (P < 0.001). There were fewer current smokers in the early group (7.5% vs 44.9%, P < 0.001) and more stent thrombosis (17.5% vs 2%, P = 0.02), as compared with the late group. The in-hospital mortality rate tended to be higher in the early group (7.5% vs 0%, P = 0.09). Multiple logistic regression revealed that smoking status (odds ratio [OR] 0.09, 95% confidence interval [CI] 0.02-0.49, P = 0.005), HDL cholesterol level (5 mg/dl increase: OR 1.34, 95% CI 1.04-1.74, P = 0.03), and stent thrombosis (OR 35.59, 95% CI 2.13-595.49, P = 0.01) had significant associations with early recurrence. Early recurrence of myocardial infarction was associated with stent thrombosis, a higher HDL cholesterol level, and a lower frequency of smoking. Early recurrence had a trend toward higher mortality than late recurrence.

Background: The aim of this study was to characterize coronary plaque composition of non-target lesions in diabetic patients using virtual histology intravascular ultrasound (VH-IVUS). Methods and results: In 134 stable angina pectoris patients, plaque components of non-culprit (<50% in diameter stenosis) lesions in de nova target vessels were analyzed by VH-IVUS. Plaque characterization was compared between diabetic (n = 65) and non-diabetic groups (n=69). Diabetic patients were further divided into four groups according to estimated glomerular filtration rate (eGFR, ml/min): eGFR >= 70 (n = 20), 50 <= eGFR < 70 (n = 19), GFR < 50 (n = 18), and end stage renal disease (ESRD) on hemodialysis (HD) (n = 11). There was no significant difference in plaque composition between the diabetic and the non-diabetic patients except for the percentage of dense calcium (8.9% vs. 6.2%; p < 0.05). In the diabetic patients, the percent volume of necrotic core was 9.6%, 11.4%, 14.8%, and 20.8% in the eGFR >= 70, 50 <= eGFR < 70, eGFR < 50, and the ESRD on HD groups, respectively, showing significantly higher percentage in eGFR < 50 (p < 0.05 vs. eGFR >= 70) and ESRD on HD group (p < 0.001). Conclusions: Diabetic patients have significantly larger amount of dense calcium than non-diabetic patients in non-culprit coronary artery segments, and the plaque components of non-culprit lesions in diabetes are significantly different according to the decline in renal function. (C) 2009 Japanese College of Cardiology. Published by Elsevier Ireland Ltd. All rights reserved.

Background and Objective: Drug-eluting stents have been shown to reduce the incidence of restenosis and target vessel revascularization (TVR) compared with bare metal stents (BMSs); however, the long-term efficacy of sirolimus-eluting stent (SES) implantation in patients with acute coronary syndrome (ACS) has not been well established. We have investigated the long-term clinical outcome of SES in patients with ACS. Methods: Consecutive 245 patients with ACS treated by primary stenting within 24 hours after onset were enrolled. There were 128 patients treated with SES and 117 patients were treated with BMS. We evaluated the incidence of major cardiac events (MACE; total death, nonfatal myocardial infarction, TVR) at 3 years, comparing with 8-month clinical outcome. Results: Eight-month clinical follow-up shows a significantly lower incidence of TVR in the SES group, 3.1% in the SES group versus 9.4% in the BMS group (P = 0.04). At 3-year clinical follow-up, there was no significant difference in the rate of TVR between the two groups, 8.4% versus 12.4% (P = 0.37). Cumulative incidence of total MACE was 9.2% in the SES group compared with 15.9% in the BMS group (P = 0.18). Only one case of stent thrombosis was observed in the SES (late thrombosis), while two cases of stent thrombosis occurred in the BMS group (late and very late thrombosis; P = 0.55). Conclusion: SES implantation in patients with ACS is associated with favorable long-term clinical outcome with no excess of late stent thrombosis. Further long-term clinical follow-up will be warranted to confirm the safety and efficacy of SES. (J Interven Cardiol 2009;22:216-221).

BACKGROUND Type B acute aortic dissection (AAD) carries a high short- and midterm mortality rate; however, knowledge related to long-term outcome is largely incomplete. The objective of this study was to identify long-term predictors including anti hypertensive medications in type B AAD. METHODS We conducted a clinical follow-up study on 202 type B AAD patients. Univariate and multivariate Cox regression analyses were performed to identify predictors of mortality. RESULTS There were 44 postdischarge deaths in 202 consecutive type B AAD patients with a median follow-up of 55 months. In univariate Cox-regression analysis, age (10 year incremental: hazard ratio (HR) 1.82, 95% confidence interval (CI) 1.35-2.46, P < 0.0001), previous myocardial infarction or angina pectoris (HR 3.93, 95% Cl 1.72-8.99, P = 0.001), and impaired renal function (HR 4.90, 95% Cl 2.48-9.65, P < 0.0001) were predictors of death. Calcium channel blockers (CCBs), beta-blockers, and angiotensin-converting enzyme (ACE) inhibitors as anti hypertensive medications at discharge were predictors of increased survival. In multivariate Cox regression analysis, CCBs were a significant predictor of increased survival (vs. no anti hypertensive medication at discharge: HR 0.38, 95% Cl 0.15-0.97, P = 0.04). Impaired renal function was a significant predictor of death (HR 3.41, 95% Cl 1.58-7.33, P = 0.002). No anti hypertensive medication at discharge group was significantly associated with increased mortality (vs. 1 class of antihypertensive medication: HR9.51, 95% Cl 1.85-48.79, P = 0.007). CONCLUSIONS Impaired renal function was a predictor for adverse outcome in patients with type B AAD. The use of CCBs as anti hypertensive medication at discharge was associated with increased survival.

Background: Acute myocardial infarction (AMI) due to left main coronary artery disease is associated with significantly elevated morbidity and mortality. The aim of this study was to identify the predictors of in-hospital death from left main AMI complicated by cardiogenic shock. Methods: Clinical record review identified a total of 25 cases of left main AMI with cardiogenic shock. Patients' background characteristics, Laboratory data, and angiographic findings were analyzed according to the in-hospital mortality. Results: In this patient subset, in-hospital mortality (60%) was associated with a history of hypertension (p = 0.02) and a higher heart rate (p = 0.02). Furthermore, in-hospital mortality was also associated with a complete right bundle branch block (CRBBB) pattern in the admission ECG (p = 0.01) and low HCO(3)(-) (p = 0.0004). In step-wise logistic regression analysis, a CRBBB pattern (OR 48.59, 95% CI 1.34-1768.10, p=0.03) and low HCO(3)(-) (OR 0.62, 95% CI 0.40-0.94, p=0.02) were found to be independent predictors of mortality.

BACKGROUND As hypertension, obesity, and leanness are reported to be associated with poor cognitive function, it is possible that obesity or leanness in hypertensive patients may also be associated strongly with poor cognitive function. METHODS We recruited 184 elderly hypertensive patients comprising 93 very elderly (aged >= 80 years) and 91 younger elderly (aged 61-79 years) subjects. A mini-mental state examination (MMSE) and 24-h ambulatory blood pressure monitoring (ABPM) were performed in all participants. Patients were classified as either lean, normal physique, or obese according to the body mass index (BMI) quartile. The prevalence of poor cognitive function, total MMSE score, and MMSE subscores were compared between the groups. RESULTS The prevalence of poor cognitive function, total MMSE score, and MMSE subscore attention/calculation were significantly different between the groups both in the total study population and in the very elderly patients. The multiple logistic regression model showed that leanness was a significant determinant of poor cognitive function in both the total study population (odds ratio (OR) 2.54, 95% confidence interval (CI) 1.13-5.73, P= 0.02) and the very elderly patients (OR 3.94,95% CI 1.31-11.82, P= 0.01). Obesity was not a significant determinant in either the total study population, very elderly, or younger elderly groups. CONCLUSION While obesity in hypertensive elderly patients was not associated with poor cognitive function, leanness in hypertensive elderly patients was, especially in the very elderly.

Background In Stanford B acute aortic dissection (AAD), medical treatment is the choice of therapy in the acute phase, however, a portion of patients experience complications caused by serious clinical outcomes including aortic rupture and abdominal visceral ischemia. The objective of this study was to determine the predictors of in-hospital events in an Asian cohort of Stanford type 9 AAD. Methods and Results Hospital records were queried to identify patients that met following criteria: (1) AAD presenting within 14 days of symptom onset; and (2) computed tomography (CT) confirmation of a dissected descending aorta not involving the ascending aorta. An in-hospital event was defined as death, rupture/ impending rupture, or organ malperfusion. Patient characteristics, inflammatory markers, and CT findings were obtained from clinical case records and retrospectively analyzed. Two hundred and twenty patients with Stanford B AAD were identified. In-hospital events occurred in 15 patients (there were 8 deaths, and 5 patients need to undergo emergent surgery because of impending rupture or rupture, and 4 patients experienced organ malperfusion). In univariate logistic regression analysis, the non-thrombosed type (odds ratio (OR) 3.88, 95% confidence interval (0) 1.20-12.61, p=0.02) and maximum aortic diameter measured by an initial CT (each having a 5 mm increment: OR 1.61, 95% CI 1.20-2.15, p=0.001) were significant predictors of in-hospital events. In multiple logistic regression analysis, the only significant predictor was maximum aortic diameter measured by an initial CT (each having a 5 mm increment: OR 1.41, 95 % CI 1.04-1.92, p=0.03). Conclusion The results identified a large maximum aortic diameter as the independent predictor of in-hospital events in Stanford type B AAD. The non-thrombosed type might also help differentiate high-risk patients.

Background: It is reported that blood pressure (BP) variability increases with aging, and cognitive dysfunction may be related to BP variability; however, there are no data showing that exaggerated BP variability is associated with cognitive dysfunction or quality of life (QOL) in the older elderly. We investigated the relationships and the differences between ambulatory BP variability and cognitive function or QOL in younger elderly and very elderly. Methods: We recruited both 101 very elderly (aged >= 80 years) and 101 younger elderly (aged 61 to 79 years). Twenty-four-hour ambulatory blood pressure monitoring, mini-mental state examinations (MMSE), and Medical Outcome Study Short-Form 36 Items Health Survey (SF-36) were performed for all subjects. Results: The mean standard deviation (SD) of daytime systolic BP in young elderly was 17.2 +/- 4.6 mm Hg (mean SD SD of mean SD), and that in very elderly was 21.2 +/- 4.3 mm Hg. The MMSE score significantly decreased with the tertile of SD of daytime systolic BP in very elderly (P = .004) and young elderly (P = .03). In very elderly, there was no significant association between the SD of daytime systolic BP and each of eight SF-36 categories. On the other hand, in younger elderly, two of eight SF-36 categories decreased with the tertile of SID of daytime systolic BP (P = .001 for Vitality and P = .003 for Role emotion). Conclusions: Very elderly had larger BP variability than younger elderly. Exaggerated ambulatory BP variability was related to cognitive dysfunction in the elderly, especially in the very elderly, and was related to lower QOL in the younger elderly. Am J Hypertens 2007;20: 720-727 (c) 2007 American Journal of Hypertension, Ltd.

Noninvasive characterization of coronary plaques is challenging for cardiologists. The authors' goal was to explore the clinical feasibility of newly developed 16-slice computed tomography (CT) in tissue characterization of coronary arterial plaques in patients with acute coronary syndrome. Sixteen patients with acute coronary syndrome underwent 16-slice CT (Aquillion, Toshiba) and coronary arteriography with intravascular ultrasound (IVUS) within 7 days. Twenty-three plaques were classified by IVUS according to plaque echogenicity: 6 soft plaques, I I intermediate plaques, and 6 calcified plaques. Mean (+/- SD) CT numbers (Hounsfield units [HU]) of these 3 types of plaques were 50.6 +/- 14.8 HU, 131 +/- 21.0 HU, and 72 1 +/- 231 HU, respectively. Sixteen-slice CT facilitates noninvasive tissue characterization of coronary arterial plaques.

A 45-year-old woman presented with triple valve infective endocarditis and ventricular septal defect. There were vegetations on the tricuspid valve, pulmonary valve, and aortic valve. She had multiple complications such as nephrotic syndrome, severe anemia, congestive heart failure, and convulsion. Her general condition was extremely poor. Intensive medical therapy, such as blood transfusion, mechanical ventilation, and continuous venovenous hemofiltration, allowed her to tolerate surgery. Triple valve replacement and ventricular septal defect closure was successfully performed without major complication. She was ambulatory at the time of discharge.

Objectives. This study evaluated whether the use of Levovist™ improves endocardial border delineation during dobutamine stress echocardiography. Methods. Thirty patients (20 men and 10 women) were enrolled in this study. Dobutamine was infused intravenously using an incremental regimen of 5, 10, 20, 30, and 40 μg/kg/min, each dose for 3 min. Levovist (277 mg/ml), dissolved in 9 ml of 5% dextrose, was infused intravenously. Two ml was infused at rest, 10, and 20 μg/kg/min. Three ml was infused at peak dobutamine dosage. Echocardiograms were recorded on videotapes. A endocardial border delineation score index (EDST) was used for image analysis. The EDSI was obtained from each of 12 segments of the left ventricular wall (30 patients) in the rest and peak stress periods, before and after Levovist. Data from a total of 1,440 segments were analyzed separately. Results. The mean EDSI at rest was 2.2 ± 0.6 without contrast medium, and 2.4 ± 0.7 with contrast medium (p &lt 0.05). The mean EDSI during peak stress was 2.0 ± 0.7 without contrast medium, and 2.2 ± 0.6 with contrast medium (p &lt 0.05). The wall-by-wall EDSI revealed that the delineation of apical-septal, mid- and apical-lateral, apical-inferior, and apical-anterior segments was improved significantly with Levovist in the rest and peak stress periods. Conclusions. Delineation of the apical-septal, mid- and apical-lateral, apical-inferior, and apical-anterior segments was improved significantly with Levovist during dobutamine stress echocardiography.