藤田 英雄

Objectives This study aimed to assess the relation between stent edge restenosis (SER) and the distance from the stent edge to the residual plaque using quantitative intravascular ultrasound. Background Although percutaneous coronary intervention with drug-eluting stents has improved SER rates, determining an appropriate stent edge landing zone can be challenging in cases of diffuse plaque lesions. It is known that edge vascular response can occur within 2 mm from the edge of a bare metal stent, but the distance to the adjacent plaque has not been evaluated for drug-eluting stents. Methods A total of 97 proximal residual plaque lesions (plaque burden [PB] > 40%) treated with ever-olimus- eluting stents were retrospectively evaluated to determine the distance from the stent edge to the residual plaque. Results The SER group had significantly higher PB (59.1 +/- 6.1% vs. 51.9 +/- 9.1% for non-SER; P = 0.04). Higher PB was associated with SER, with the cutoff value of 54.74% determined using receiver operating characteristic (ROC) curve analysis. At this cutoff value of PB, the distance from the stent edge to the lesion was significantly associated with SER (odds ratio = 2.05, P = 0.035). The corresponding area under the ROC curve was 0.725, and the cutoff distance value for predicting SER was 1.0 mm. Conclusion An interval less than 1 mm from the proximal stent edge to the nearest point with the determined PB cutoff value of 54.74% was significantly associated with SER in patients with residual plaque lesions.

フリーアクセスを原則とするわが国の医療においては，拠点病院において外来患者の待ち時間と医師の外来業務負担が増加している．医療の現場では外来患者の待ち時間対策が重要な課題であり，これに対し「携帯情報端末を用いた外来患者案内システム（POGS）」を開発した．<br/> POGSは患者自身の携帯情報端末に時間・空間の制約なく外来案内情報を提供する．病院外にあらかじめ設定されたエリア内で患者自身の携帯情報端末からのオンライン再来受付が可能であり，さらに，再来受付後の患者の携帯情報端末には，診察進捗通知・診察呼出・支払案内等がプッシュ配信され，患者は随時，受診票・診察進捗等を確認することも可能である．<br/> 東京大学医学部附属病院の外来診療において協力患者10名（56.3±9.2歳）を対象にPOGSの実証試験を実施した．アンケート調査では，患者の待ち時間ストレスが高率（90％）に軽減されていることが確認された．診察呼出から診察室入室までの時間（呼出入室時間）についてPOGS利用群（n=20）では従来システム利用群（n=319）と比較して短縮される傾向（47±20秒vs 112±310秒, p=0.416, Wilcoxon rank sum test）があった．<br/> POGSは患者ストレス軽減効果のみならず，医師待ち時間および外来患者総待ち時間短縮効果を持つことが示唆される．

複数の医療施設を有効に連携させる方策は近年益々重要になり，特に循環器救急領域においては患者の重症度層別化により適切な診療を施す医療連携の仕組みが求められる．本研究では携帯端末を用い，画像診断クリニックを中心に救急医療連携をターゲットとした画像連携システムとして，診断画像等の医療情報に特化した即時性のある連携システム（ISSAM）を開発し，より緊密な医療連携を実現させることを目的とした．ISSAMは2つのデータベースパートとこれを連携し統合する医療連携サーバからなり，登録されたDICOM画像はLossless JPEG 画像へ変換されPDFファイルと共にPCの他携帯端末でも参照が可能である．画像診断クリニックを中心にISSAMを用いた性能評価試験を施行し，VPN接続したリモート環境からAndroid携帯端末を用いて冠動脈CT，心臓MRIの画像情報を従来のFAXによる連携と比較して短時間に参照し重症度の判断を行うことが可能であることが確認できた．今後，ISSAMを用い画像診断クリニックと病院間での救急搬送における医療連携において実証試験を行い，冠動脈CTや心臓MRIの迅速な画像診断による重症度の層別化により救急患者受け入れの適格性や患者の治療予後にいかなる変化をもたらすかについて臨床研究をベースとした医学的有用性エビデンスの構築を目指す．

Numerous diabetes-management systems and programs for improving glycemic control to meet guideline targets have been proposed, using IT technology. But all of them allow only limited - or no - real-time interaction between patients and the system in terms of system response to patient input few studies have effectively assessed the systems' usability and feasibility to determine how well patients understand and can adopt the technology involved. DialBetics is composed of 4 modules: (1) data transmission module, (2) evaluation module, (3) communication module, and (4) dietary evaluation module. A 3-month randomized study was designed to assess the safety and usability of a remote health-data monitoring system, and especially its impact on modifying patient lifestyles to improve diabetes self-management and, thus, clinical outcomes. Fifty-four type 2 diabetes patients were randomly divided into 2 groups, 27 in the DialBetics group and 27 in the non-DialBetics control group. HbA1c and fasting blood sugar (FBS) values declined significantly in the DialBetics group: HbA1c decreased an average of 0.4% (from 7.1 ± 1.0% to 6.7 ± 0.7%) compared with an average increase of 0.1% in the non-DialBetics group (from 7.0 ± 0.9% to 7.1 ± 1.1%) (P = .015) The DialBetics group FBS decreased an average of 5.5 mg/dl compared with a non-DialBetics group average increase of 16.9 mg/dl (P = .019). BMI improvement - although not statistically significant because of the small sample size - was greater in the DialBetics group. DialBetics was shown to be a feasible and an effective tool for improving HbA1c by providing patients with real-time support based on their measurements and inputs. © 2014 Diabetes Technology Society.

BACKGROUND: Restenosis, a condition in which the lesion vessel renarrows after a coronary intervention procedure, remains a limitation in management.Asurrogate biomarker for risk stratification of restenosis would be welcome. B-type natriuretic peptide (BNP) is secreted in response to pathologic stress from the heart. Its use as a biomarker of heart failure is well known however, its diagnostic potential in ischemic heart disease is less explored. Recently, it has been reported that processed forms of BNP exist in the circulation. We hypothesized that circulating processed forms of BNP might be a biomarker of ischemic heart disease. METHODS: We characterized processed forms of BNP by a newly developed mass spectrometry- based detection method combined with immunocapture using commercial anti-BNP antibodies. RESULTS: Measurements of processed forms of BNP by this assay were found to be strongly associated with presence of restenosis. Reduced concentrations of the aminoterminal processed peptide BNP(5-32) relative to BNP(3-32) [as the index parameter BNP(5-32)/BNP(3- 32) ratio] were seen in patients with restenosis [median (interquartile range) 1.19 (1.11-1.34), n=22] vs without restenosis [1.43 (1.22-1.61),n=83 P&lt 0.001] in a crosssectional study of 105 patients undergoing follow-up coronary angiography. A sensitivity of 100% to rule out the presence of restenosis was attained at a ratio of 1.52. CONCLUSIONS: Processed forms of BNP may serve as viable potential biomarkers to rule out restenosis. © 2013 American Association for Clinical Chemistry.

Background: Restenosis after percutaneous coronary intervention (PCI) is still a great concern even in the recent drug-eluting stent (DES) era. As less invasive and sensitive parameter to detect restenosis is needed, this study was aimed to assess whether the clinical implication of temporal change in plasma BNP levels might be a useful indicator of restenosis after DES implantation. Methods and results: 847 consecutive patients who underwent elective PCI using silorimus-eluting sent (SES) between 2005 and 2009 were analyzed. Primary endpoint was subsequent target-lesion revascularization (TLR) after PCI. There was no significant difference in either baseline (TLR + vs. TLR-: 107.2 +/- 172.2 vs. 96.2 +/- 175.5 pg/mL, P=0.53) or follow-up plasma B-type natriuretic peptide (BNP) levels (TLR + vs. TLR-: 88.6 +/- 111.6 vs. 68.5 +/- 226.0 pg/mL, P=0.35) between patients with and without subsequent TLR. Conversely, ratio of follow-up to baseline BNP was significantly higher in patients with TLR (TLR + vs. TLR-: 1.55 +/- 1.58 vs. 1.07 +/- 1.04, P&lt;0.001). Multivariate analysis using logistic regression showed log transformed BNP-ratio was an independent predictor of TLR (adjusted odds ratio (aOR): 1.94, 95%CI: 1.42-2.66, P&lt;0.001). A closer relationship between BNP elevation greater than 2-fold and subsequent TLR was found (aOR: 2.69, 95%CI: 1.27-5.69, P&lt;0.009). Furthermore, propensity score matching analysis showed that the incidence of subsequent TLR was significantly higher in patients with BNP elevation (P&lt;0.001). Conclusion: Serial measurement of plasma BNP levels and its change might be a useful approach to predict restenosis in patients without typical chest symptoms receiving SES. (c) 2012 Elsevier Ireland Ltd. All rights reserved.

Recent clinical studies reported the drug interaction between proton-pump inhibitors (PPI) and clopidogrel, which remains controversial. The aim of this study was to determine whether the concurrent use of PPI with clopidogrel or ticlopidine is associated with increased risk for adverse cardiovascular outcomes in patients with coronary artery disease (CAD) undergoing percutaneous coronary intervention (PCI). In this retrospective cohort study, we assessed the cardiovascular outcomes associated with the concurrent use of PPI and clopidogrel or ticlopidine in the well-characterized 1286 patients with CAD undergoing PCI in the University of Tokyo Hospital. In the Japanese patients with CAD undergoing PCI, the concurrent use of PPI was significantly associated with increased risk for major adverse cardiovascular events in the ticlopidine users (hazard ratio 2.63 95 % confidence interval 1.65-4.18 P &lt 0.001), but not in the clopidogrel users. In the clopidogrel users as well as the ticlopidine users, PPI use did not affect the occurrence of target lesion revascularization, but significantly increased the risk for new lesion formation in the coronary arteries, which required subsequent revascularization. The adverse cardiovascular effects of the concurrent use of PPI and ticlopidine were identified in the patients with CAD undergoing PCI. Also, new lesion formation in the coronary arteries was shown to be increased when PPI was coprescribed for the thienopyridine users. © 2012 Springer.

It is important for myocardial infarction patients to undergo immediate reperfusion of the affected coronary artery. In order to improve the prognosis, efforts to shorten the door to balloon time to within 90 minutes have been made. However, conventional methods such as faxing electrocardiograms (ECG) have not become widespread due to their high cost and lack of sharpness of the ECG. The "Doctor Car" (rapid response car system) of Kitasato University Hospital is now equipped with a Mobile Cloud ECG system. With this system, 12-lead ECG data obtained in the field are transmitted to the cloud server via a standard mobile telephone network. Since it uses an existing phone network, the cost of this system is low and it is fairly reliable. Cardiologists at the hospital read the ECG waveforms on the cloud server and decide whether emergency cardiac catheterization is necessary. In our first case using this Mobile Cloud ECG system, the door to balloon time could be shortened.

To improve emergency services for accurate diagnosis of cardiac emergency, we developed a low-cost new mobile electrocardiography system 'Cloud Cardiology®' based upon cloud computing for prehospital diagnosis. This comprises a compact 12-lead ECG unit equipped with Bluetooth and Android Smartphone with an application for transmission. Cloud server enables us to share ECG simultaneously inside and outside the hospital. We evaluated the clinical effectiveness by conducting a clinical trial with historical comparison to evaluate this system in a rapid response car in the real emergency service settings. We found that this system has an ability to shorten the onset to balloon time of patients with acute myocardial infarction, resulting in better clinical outcome. Here we propose that cloud-computing based simultaneous data sharing could be powerful solution for emergency service for cardiology, along with its significant clinical outcome. © 2013 IMIA and IOS Press.

To prevent unexpected sudden cardiac patient death due to drug-induced Long QT syndrome (LQTS), we seek to build a computerized early detection and warning system of QTc interval increase tendency. We built an ECG database system that holds the digital waveform data and related information of the ECGs performed in out hospital, and developed an experimental detection system of QTc increase tendency. Despite the several problems about the accuracy of detection, we succeeded in extracting a patient who seemed to be drug-induced LQTS. A combination of such a detection system with more accuracy and drug prescription database would contribute to the early detection of drug-induced LQTS. © 2013 IMIA and IOS Press.

[Background] In the clinical settings, quantity as well as quality of daily duties is increasingly demanded, where human resources are hardly satisfied in Japan. [Objective] To solve this imbalance problem, we specifically sought a practical solution in the catheter operation room using Android mobile tablets. [Methods] It was simply needed to install VNC software in PC terminals of our specially designed reporting system for adding to the new function of remote operation. [Results] Our experimental operations show that this enhancement achieved by Android and VNC remarkably decreased the amount of physical movement of co-medical members, resulting in increased attention to assisting operation. [Conclusion] Thus we propose that our solution is easy and cost-effective to improve efficiency in the medical facilities.

Objectives: A strong degree of co-existence between coronary artery disease (CAD) and abdominal aortic aneurysm (AAA) is widely acknowledged, however, it remains to be elucidated whether the existence of CAD is associated with an accelerated expansion rate of AAA. Also, the relationship between preoperative CAD and postoperative major adverse cardiovascular events (MACE) has not been examined in Japanese patients. The aim of this study was to investigate the deleterious effects of CAD on the progression of AAA and the onset of postoperative MACE after elective AAA repair. Methods and results: A retrospective cohort study of 665 consecutive Japanese patients who underwent elective surgical repair for infrarenal AAA at 2 high-volume Tokyo hospitals from 2003 through 2010 was performed. Preoperative CAD was shown to be a significant determinant of postoperative MACE (HR 2.29; 95% CI, 1.12-4.66; p = 0.02). In the analysis of 510 patients for whom there were at least 2 follow-up CT scans of the size of their AAA before repair, the existence of CAD was shown to be inversely associated with the accelerated expansion rate of AAA. Conclusion: This study on the patients undergone elective repair for infrarenal AAA identified an inverse association between the existence of CAD and progression of AAA as well as the significant impact of preoperative CAD on the occurrence of postoperative MACE after elective AAA repair. (C) 2012 Elsevier Ireland Ltd. All rights reserved.

Background: The ratio of early diastolic transmitral flow velocity (E) to tissue Doppler (TD) mitral annular early diastolic velocity (E/E'VEL-TD) has been widely used for the noninvasive assessment of LV diastolic filling pressures. However, it has been reported that E/E'VEL-TD is not accurate particularly when being applied to patients with advanced heart failure. Methods: Fifty-six ICU patients with decompensated heart failure underwent simultaneous echocardiography and PCWP measurements. Patients with elevated PCWP (n = 41) were compared with patients normal PCWP (n = 15) as well as age-matched healthy controls (n = 32). In the apical 4-chamber view, the ratio of E to speckle tracking (ST) mitral annular velocity (E/E'VEL-ST) and early diastolic global LV longitudinal strain rate (E/E'SR-ST) were evaluated as new surrogate markers of elevated PCWP. Results: Correlations with PCWP were observed for speckle tracking derived E/E'VEL-ST (r = 0.40,P = 0.002) and E/E'SR-ST (r = 0.56, P &lt; 0.001), although the traditional E/E'VEL-TD did not show a significant correlation (r = 0.23, P = 0.082). Compared with controls, patients with elevated PCWP had significant increases in all variables. The best cutoff values and diagnostic accuracies for identifying elevated PCWP were E/E'VEL-TD&gt;12 (Sensitivity/Specificity/area under the ROC curve: 0.58/0.90/0.78), E/E'VEL-ST &gt; 14 (0.60/0.85/0.80), and E/E'SR-ST &gt; 93 (0.80/0.88/0.89). Conclusion: Speckle tracking derived E/E'SR-ST may be a robust surrogate marker of elevated LV filling pressure. In ICU patients, E/E'SR-ST showed better correlation with PCWP and higher diagnostic accuracy than the tissue Doppler approach. (Echocardiography 2012;29:404-410)

Background: Macrocytosis, as a qualitative abnormality of erythrocytes, has not drawn attention as a prognostic indicator after PCI, while anemia, as a quantitative abnormality of erythrocytes, has been recognized as a predictor of adverse outcomes. The aim of this study was to perform prognostic risk stratification of patients after PCI based on the presence or absence of macrocytosis. Methods: The clinical records of 941 consecutive patients who underwent PCI at a single institution were retrospectively reviewed. The prognostic implication of macrocytosis was evaluated by univariate and multivariate Cox's proportional hazard regression analysis. Results: There were 130 (13.8%) patients with macrocytosis. A significantly higher all-cause and cardiac mortality, as well as incidence of composite adverse events were observed in the Macrocytic group. Kaplan-Meier analysis also showed a significantly poorer overall survival in patients with macrocytosis. Even after exclusion of anemic patients, this tendency was still observed. Furthermore, macrocytosis was significantly and independently associated with adverse outcomes after PCI (aHR of cardiac death: 3.45, 95%CI: 1.22-9.80, P = 0.019). Interestingly, fewer patients with macrocytosis were prescribed statins compared with those without it (33.8% vs. 47.1%, P = 0.005). Conclusions: The results of the study indicate that measuring mean corpuscular volume (MCV) as a qualitative index of erythrocytes might be helpful for a prognostic risk stratification of patients subjected to PCI. (C) 2011 Elsevier Ireland Ltd. All rights reserved.

This paper proposes a novel telemedicine system for type 2 diabetes patients. The proposed system supports the patient self-management via a set of telemedicine devices, consisting of health sensors and a smart phone. The proposed system covers not only the sensor data but also the diet (food) and exercise data. To capture the food information, we also developed the voice recognition module focusing on the food names. The basic feasibility of the system is practically demonstrated in the preliminary experiment. Copyright © 2012, Association for the Advancement of Artificial Intelligence. All rights reserved.

The 'evidence' in evidence-based medicine (EBM) is often limited to knowledge obtained from randomized controlled clinical trials (RCT). Most RCTs, however, have strict enrollment criteria which make patient background characteristics and clinical histories significantly different from those encountered in actual practice. Thus it is important to accumulate and analyze data obtained in daily practice to gain insight into a larger clinical picture. Recent developments in information technology and its lowered cost have enabled us to record clinical activity in much greater detail at a lower cost. These factors prompted us to design and develop a coronary angiography and intervention reporting system (CAIRS) to collect data and analyze outcomes of coronary intervention. The resulting advanced CAIRS can record detailed data on coronary angiographic and interventional procedures. To date, data on 10,025 cases of coronary angiography, of which 3,574 were interventional, have been collected over a 5.5 year period. There were 4,343 unique patients, 3,115 (71.7%) of which were male. The overall mean age was 67.0 +/- 11.5. The mean age of males was 66.3 +/- 11.4 and that of females was 69.0 +/- 11.4. About one-third of the patients never underwent a PCI procedure at our institution. For patients that underwent at least one PCI procedure at our institution, the prescription rate of stain increased from 50.8% in 2005 to 80.3% in 2011, while those of nitrate and ticlopidine decreased from 36.7% and 90.8% in 2005 to 21.3% and 0.8% in 2011, respectively. We have also implemented the same system at another institution and compared the data on stem usage between the two institutions, which revealed vastly different stent usage profiles. In conclusion, we have successfully developed and implemented an advanced coronary angiography and intervention reporting system which we call CAIRS. Implementing the same system at multiple institutions and analyzing data collected from several institutions will provide detailed and timely insight into the 'real world' of coronary angiography and interventional procedures and their outcome. (Int Heart J 2012; 53: 35-42)

症例は39歳女性。他院で乏突起膠星細胞腫瘍に対し開頭摘出術を施行後15日目に急性前壁心筋梗塞を発症し当院へ救急搬送された。緊急冠動脈造影にて左前下行枝(LAD)中間部に99%狭窄を認め、引き続き同病変へ経皮的冠動脈形成術を施行した。血管内エコーにて病変は冠動脈解離を伴っていることが明らかとなり、解離腔のエントリー閉鎖を目的にステントを留置した。しかし、ステント近位部に解離が拡大しLADの完全閉塞に陥ったため、さらなるインターベンションによる解離の拡大を懸念し手技を終了した。1週間後の冠動脈CTでは依然完全閉塞であったが、3ヵ月後には解離腔は狭小化し内腔は開存していた。特発性冠動脈解離は極めてまれな疾患であるが、若年女性の急性冠症候群の原因として念頭に置くべきである。(著者抄録)

Procedure-related coronary dissection is associated with an increased risk of major adverse cardiovascular events after percutaneous coronary intervention (PCI). In most patients with such an iatrogenic complication, further PCI or bypass surgery aimed at complete revascularization is performed. Moreover, conventional coronary angiography has been used as a standard modality in the follow-up of such patients. The present report describes a 70 year old female patient who was complicated by catheter-related extensive coronary dissection in the right coronary artery (RCA) when treated for an acute myocardial infarction. Although RCA flow was insufficient, we decided against revascularization and followed her medically without additional revascularization procedures. Her clinical course had been uneventful for 4 years. However, symptoms of effort angina developed and re-examinations were performed at approximately 5 years after the myocardial infarction. Although conventional coronary angiography failed to show the culprit lesion responsible for the angina symptoms, the superior spatial resolution of the coronary CT angiography clearly identified significant progression of the stenotic lesion in the true lumen of the dissected RCA. Thus, coronary CT angiography might be considered as a possible first-line follow-up modality in patients with procedure-related coronary dissection. (Int Heart J 2011; 52: 240-242)

Background: In patients with diabetic retinopathy (DR), vitreous hemorrhage (VH) is a common complication that threatens visual acuity and hence, quality of life. A considerable number of DR patients at risk of VH require coronary revascularization, but little is known about the prevalence of VH after coronary revascularization. Methods and Results: This study investigated 151 patients with DR who were followed up by ophthalmologists between April 2004 and September 2008, and underwent coronary revascularization (coronary artery bypass surgery n=36 or drug-eluting stent implantation n=115). At the time of coronary revascularization 56 had non-proliferative DR (NPDR) and 95 had proliferative DR (PDR). During an average follow-up of 531 days after revascularization, VH occurred in 24 (15.9%) patients, 18 (11.9%) of whom experienced VH within 6 months of the procedure. In VH patients, PDR rather than NPDR predominated as the background to VH (21 vs. 3, respectively). The 1-year prevalence of VH was higher in patients with PDR than in those with NPDR (22.0% vs. 1.9%, P=0.0055). Conclusions: VH is not a rare complication following coronary revascularization among patients with DR, especially in those with PDR. Thus, in terms of maintaining quality of life, VH after coronary revascularization needs further attention in these patients. (Circ J 2011; 75: 329-335)

Background: This study examines whether the serum concentration of cystatin C (Cys C) correlates with the severity of coronary artery disease (CAD) and whether it provides additional information on the risk for CAD in patients without chronic kidney disease (CKD) estimated by the creatinine-based glomerular filtration rate (GFR). Methods and Results: The relationship between serum Cys C and the severity of CAD in 526 patients was investigated. Based on GFR, patients were divided into those with and without CKD. The relationship of serum Cys C with the severity of CAD was examined. Serum Cys C was closely correlated with GFR in all cases and in CKD patients, but not in non-CKD patients. The average number of stenotic coronary arteries was significantly higher in the quartiles of higher concentration of Cys C as well as in those of GFR. In 348 patients (66%) the GFR was &gt;= 60ml.min(-1).1.73 m(-2). Those patients with increased Cys C (&gt;0.90 mg/L, 143 patients) had a significantly larger number of stenotic coronary arteries than those patients with normal Cys C. Conclusions: Among patients considered to be at low risk based on the estimated GFR using serum creatinine, those with high concentrations of Cys C could have severe CAD. Besides CKD, Cys C might serve as a marker of CAD severity. (Circ J 2010; 74: 2441-2447)

症例は79歳男性。72歳時3枝病変を認めるも保存的加療となった。2009年労作時胸痛が出現、冠動脈病変の進行と心機能低下を認め、前下行枝に対しバイパス術施行。術直後から持続性/非持続性心室頻拍(VT)が頻発、回旋枝へPCI施行後、Overdrive pacingとニフェカラント/ランジオロールの持続投与にても消失せず。薬物抵抗性のVTと判断、LVマッピング下に電気的焼灼術を2回施行。しかし敗血症を機にVT stormに至り、挿管管理下に再度pacingとニフェカラント/ランジオロール持続点滴を併用し、ICD植込み術を施行。アミオダロン+カルベジロール内服開始したが、点滴薬漸減するとVT出現するためソタロールを追加。以後VT消失したため前医に転院となった。虚血性心筋症の血行再建に伴う難治性VTに対し、アブレーションに加えアミオダロン/ソタロールの併用が奏効した症例を経験したので報告する。(著者抄録)

Background Clinical evidence suggests that intracoronary thrombus formation is associated with a high incidence of late restenosis after successful coronary intervention in patients with myocardial infarction (MI). However, little is known about the mechanism by which intracoronary thrombi play pathological roles. Methods and Results We analysed the cellular constituents of 108 thrombi aspirated from coronary lesions with a thrombectomy device in 62 patients who underwent emergent coronary intervention for the treatment of acute (&lt;24 h) or recent (24-72 h) ST-segment elevation MI (44 men, 18 women, aged 68.0619.3 years). Immunohistological analysis of aspirated thrombotic materials revealed that the content of platelets, as determined by immunostaining for CD42a, had a negative correlation with the time after the onset of chest pain (correlation coefficient -0.683, p&lt;0.01). Immunofluorescent staining for CD34 and breast cancer-resistant protein-1 (bcrp-1) detected primitive cells in intracoronary thrombi. Furthermore, the ratio of CD34-positive cells in intracoronary thrombi had a significant positive correlation with restenosis at follow-up coronary angiography (correlation coefficient 0.76, p=0.01). Conclusions The findings of this study indicate that the early accumulation of primitive cells in platelet aggregates may play a role in neointimal growth after successful coronary intervention in patients with acute coronary syndrome.

Background: The relationship between renal dysfunction and the severity of coronary artery disease (CAD) was examined. Methods and Results: The severity of CAD in 572 patients was graded according to the number of stenotic coronary arteries, and the estimated glomerular filtration rate (eGFR) was monitored for 3 years. Patients were stratified into 3 eGFR groups: normal (&gt;75 ml.min(-1).1.73 m(-2)), mild reduction (60-75) and chronic kidney disease (CKD: &lt;60). There were 161 patients in the CKD group. The average number of stenotic coronary arteries was larger in the CKD group than in the other groups (normal vs mild reduction vs CKD =1.35 +/- 0.07 (SE) vs 1.22 +/- 0.08 vs 1.69 +/- 0.08 vessel disease (VD), P&lt;0.001). During the 3-year follow-up, the renal function of 13.8% of the patients worsened. Those who showed more deterioration of eGFR had more severe CAD than those who did not (1.20 +/- 0.06 vs 1.61 +/- 0.06 VD, P&lt;0.001). Multivariate analysis revealed that the severity of CAD was independently and significantly associated with the deterioration of eGFR. Conclusions: Patients with CKD had more severe CAD, which may explain the high rate of cardiovascular events in these patients. Moreover, the prognosis of renal function was poor in patients with severe CAD, and CAD was found to be an independent risk factor for worsening of renal dysfunction. (Circ J 2010; 74: 786-791)

Background: The optimal revascularization strategy for unprotected left main coronary artery (ULMCA) disease in the era of drug-eluting stents (DES) has become more controversial between coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI). Methods and Results: Since April 2004, 89 patients underwent CABG, including 82 (92.1%) off-pump procedures and 63 patients underwent PCI with DES for ULMCA disease. Major adverse cardiac and cerebrovascular events (MACCE: death, acute myocardial infarction, stroke and repeat revascularization) and hospitalization costs were compared. Patients in the CABG group were likely to have multivessel disease and higher euroSCORE. The mean follow-up was 2.2±1.1 years in the CABG group and 1.6±0.8 years in the DES group (P&lt 0.001). The overall survival rate did not differ (P=0.288) between the groups (CABG: 93.4% and DES: 91.9% at 2 years). The MACCE-free survival rate was better (P=0.033) in the CABG group (CABG: 82.2% and DES: 62.6% at 2 years). Total hospitalization costs were lower (P=0.013) in the CABG group (median: 3,225 thousand yen) than in the DES group (median: 4,192 thousand yen). Conclusions: CABG might be associated with cost-effectiveness and could be still the first revascularization strategy for ULMCA disease.

今回われわれは, 両側腎動脈狭窄症 (RAS) による再発性の心不全と急性腎不全, あるいは治療抵抗性高血圧をきたした2症例を経験した.<BR>症例1: 72歳, 女性. 僧帽弁置換術後の低左心機能症例で心不全入院を繰り返していた. 今回心不全加療中に急性腎前性腎不全を発症して血液透析導入となり, その後両側RASの存在が判明した. 両腎とも8.5cm大と軽度萎縮していたが, 透析から離脱困難だったこともあり腎機能と血行動態の改善を目指してステント留置による経皮的腎動脈形成術 (PTRA) を施行した. 術直後より著明な腎機能の改善が得られ, 透析から離脱できるとともに慢性期の心不全の管理も容易となった.<BR>症例2: 63歳, 女性. 冠動脈3枝病変に対するバイパス術直前に, 両側RASによる難治性高血圧が顕在化した. 腎動脈エコー上, 腎硬化症の指標である腎抵抗係数は両側とも1.0と著明高値であったが, 薬物治療抵抗性の高血圧であったため両側RASに対してPTRA (ステント留置によるPTRA) を施行した. 術後血圧は著明に改善して降圧薬の減量が可能となり, その後冠動脈バイパス術が無事に施行された. 以上の2症例はいずれも症候性RASに対してPTRAが有効であった. 特異的な臨床徴候に乏しく見逃されることの多いRASとその病態, および適応をめぐっていまだ議論の多いPTRAを考えるうえで示唆に富む2症例であり, ここに報告する.

Objectives: We hypothesized that a large number of patients with diabetic retinopathy who could benefit greatly from early coronary artery bypass grafting would not be identified. Methods: Patients with diabetic retinopathy receiving ophthalmologic care as outpatients in our hospital in whom coronary artery disease was not previously suspected were referred randomly to the diabetic retinocoronary clinic and were asked to participate in diagnostic tests, including an exercise treadmill test and exercise thallium scintigraphy or coronary computed tomography. Patients who had type 1 diabetes mellitus, required hemodialysis, or both were excluded from this study. A definitive diagnosis of coronary artery disease was confirmed by means of coronary angiography. Results: Of 214 patients with diabetic retinopathy, 55 (25.7%) were confirmed as having significant stenotic coronary artery disease. Patients with angiographically confirmed coronary disease were older than those with negative results on diagnostic tests (62.2 +/- 9.8 vs 57.9 +/- 10.3 years, P = .01). Fifteen had 1-vessel disease, 17 had 2-vessel disease, 14 had 3-vessel disease, 1 had left main trunk plus 1-vessel disease, 2 had left main trunk plus 2-vessel disease, and 5 had left main trunk plus 3-vessel disease. Eight patients had left main trunk disease, and 18 patients with non-left main trunk disease had proximal left anterior descending coronary artery (LAD) disease. Forty-two patients showed indications of coronary revascularization (coronary artery bypass grafting in 17 and percutaneous coronary intervention in 25). During the entire follow-up (287.6 +/- 183.2 days) of 39 patients undergoing coronary revascularization, all were alive without myocardial infarction, but 8 experienced vitreous hemorrhage. Conclusions: Approximately 25% of patients with diabetic retinopathy receiving ophthalmologic care as outpatients have a significant stenotic coronary artery disease. Of the total diabetic population, a large number of patients with diabetic retinopathy who show strong indications for early coronary artery bypass grafting might well go unrecognized. (J Thorac Cardiovasc Surg 2010; 139: 92-7)

症例は72歳女性。61歳時に僧帽弁狭窄症に対し僧帽弁置換術が施行され、高血圧、慢性腎臓病とともに外来フォローされていた。陳旧性心筋梗塞、慢性心房細動もあり、2001年頃より、心不全増悪による入退院をくり返していた。2008年3月初旬、うっ血性心不全による入院後、利尿剤・カテコラミン等による加療中に腎機能悪化を認め、自尿確保も困難となったため、血液透析(HD)導入となった。その後、両側腎動脈の起始部に高度狭窄病変が存在することが判明し、再発性心不全および腎機能急性増悪の主因と考えられた。透析から離脱困難であったこともあり、腎機能および血行動態の改善を目的に経皮的腎動脈形成術(PTRA)を施行する方針となった。5月初旬、両側腎動脈狭窄症(RAS)に対しそれぞれPTRA(ステント留置)を行ったところ、著明な腎機能改善を認め、最終的にはHD離脱可能となった。その後、半年以上の経過観察中で明らかな心不全入院、腎機能再増悪なども認めておらず血圧コントロールも改善された。RASは特異的な臨床症状に乏しく見逃されがちであるが、他の動脈硬化性疾患とともに増加が予想されており、再発性うっ血性心不全や腎不全症例の病因を考える上でも本症例は貴重であると考え報告する。(著者抄録)