藤田 英雄

Objectives The aim of this study was to determine whether re-entrant circuits were associated with the ligament of Marshall (LOM). Background Peri-mitral atrial tachycardias (PMATs) following pulmonary vein isolation (PVI) or mitral valve surgery are common. Methods Six PMATs involving epicardial circuits were identified from 38 patients. Of these, 4 PMATs involved the LOM (PMAT-LOM, mean cycle length 308 ± 53 ms), as confirmed by the insertion of a 2-F electrode in the vein of Marshall (VOM). All patients underwent PVI and mitral isthmus ablation. The PMAT-LOMs were diagnosed based on left atrium (LA) activation maps that covered &lt 90% of tachycardia cycle length (TCL), and a difference between the post-pacing interval and TCL that was: 1) ≤20 ms at the VOM, the ridge between the left pulmonary vein and appendage, the anterior wall of the LA, and along the 6 to 11 o'clock direction of the mitral annulus and 2) &gt 20 ms at the distal coronary sinus (CS), the posterior wall of the LA, and the mitral isthmus ablation line (or noncapture). Catheter ablation was performed at the ridge for all PMAT-LOMs. Results Three tachycardias were successfully terminated at the ridge, which showed continuous fractionated potential lasting &gt 100 ms, confirming the bidirectional block of Marshall bundle (MB)-LA connections. The remaining tachycardia required ablation for the CS-MB connections, confirming bidirectional block of CS-MB connections. Conclusions PMAT-LOMs following PVI or valve surgery accounted for up to 11% of PMATs. The bidirectional block of either MB-LA or CS-MB connections is required to eliminate PMAT-LOMs.

A 60-year-old man was prescribed oral desmopressin (1-deamino-8-D-arginine vasopressin acetate trihydrate; DDAVP) for nocturnal polyuria. One week after starting to take desmopressin, he frequently felt chest pain while resting. Coronary angiography revealed no organic stenosis; however, an acetylcholine provocation test showed severe coronary spasm with ST elevation. He was diagnosed with coronary spastic angina, and we stopped the oral desmopressin and added diltiazem. While DDAVP should dilate the coronary vessels in healthy subjects, it may provoke coronary vasospasm in patients with endothelial dysfunction. We should be careful to avoid triggering coronary spasm when administering DDAVP to patients that may have potential endothelial dysfunction.

A 44-year-old woman, who had been previously diagnosed with coronary spastic angina and treated with standard medical therapy including calcium channel blockers, was admitted to our hospital due to chest pain at rest. Her chest pain attacks were concentrated just before and during menstruation. Despite the administration of an intravenous infusion of nitroglycerin and nicorandil, strong heart attacks with ST elevation occurred frequently after this admission. However, following continuous combined estrogen-progestin hormonal contraception use (estradiol plus dienogest), her attacks disappeared completely. Reduced estrogen levels before and during menstruation were speculated to be associated with her angina attacks.

Background: Diabetes self-management education is an essential element of diabetes care. Systems based on information and communication technology (ICT) for supporting lifestyle modification and self-management of diabetes are promising tools for helping patients better cope with diabetes. An earlier study had determined that diet improved and HbA1c declined for the patients who had used DialBetics during a 3-month randomized clinical trial. The objective of the current study was to test a more patient-friendly version of DialBetics, whose development was based on the original participants' feedback about the previous version of DialBetics. Method: DialBetics comprises 4 modules: data transmission, evaluation, exercise input, and food recording and dietary evaluation. Food recording uses a multimedia food record, FoodLog. A 1-week pilot study was designed to determine if usability and compliance improved over the previous version, especially with the new meal-input function. Results: In the earlier 3-month, diet-evaluation study, HbA1c had declined a significant 0.4% among those who used DialBetics compared with the control group. In the current 1-week study, input of meal photos was higher than with the previous version (84.8 ± 13.2% vs 77.1% ± 35.1% in the first 2 weeks of the 3-month trial). Interviews after the 1-week study showed that 4 of the 5 participants thought the meal-input function improved the fifth found input easier, but did not consider the result an improvement. Conclusions: DialBetics with FoodLog was shown to be an effective and convenient tool, its new meal-photo input function helping provide patients with real-time support for diet modification.

Urinary liver-type fatty acid-binding proteins (uL-FABP) have recently been recognized as a useful biomarker for predicting contrast-induced nephropathy. Although accumulating studies have evaluated short-term outcomes, its prognostic value for long-term renal prognosis in patients undergoing coronary angiography (CAG) has not been fully examined. This study aimed to evaluate the predictive value of uL-FABP for long-term renal outcome in patients with ischemic heart disease (IHD). Consecutive 24 patients with impaired renal function (serum creatinine >1.2 mg/dL) who underwent CAG were enrolled. uL-FABP was measured before CAG, 24 and 48 h after CAG. The changes in estimated glomerular filtration rate (eGFR) throughout CAG and at 1 year later were compared with the uL-FABP levels. The patients with a greater decrease in eGFR 1 year later had higher uL-FABP levels at all points, but only the value at 48 h after CAG reached statistical significance (lower vs. higher decreased eGFR group, 4.61 +/- 3.87 vs. 17.71 +/- 12.96; P < 0.01). Measurement of uL-FABP at 48 h after CAG (48h-uL-FABP) showed better correlation with the change in eGFR (pre-CAG uL-FABP vs. 48h-uL-FABP: R = 0.27, P = 0.20 vs. R = 0.65, P < 0.01). Moreover, the high-pre and high-48h-uL-FABP group showed a significantly larger decrease in eGFR compared with the high-pre and low-48h-uL-FABP group (change in eGFR; 8.12 +/- 4.06 vs. 1.25 +/- 2.23 mL/min/1.73 m(2), P < 0.01), although the baseline eGFR levels were similar between these two groups. In this pilot study, measurement of uL-FABP levels at 48 h after CAG may be useful in detecting renal damage, and in predicting 1-year renal outcome in IHD patients undergoing CAG.

BackgroundA clear indication and strategy for placement of retrievable inferior vena cava filters (IVCFs) have not been established. This study was designed to evaluate the efficacy and disadvantages of the retrievable IVCF use particularly in venous thromboembolism (VTE) patients with malignancy. HypothesisRetrievable IVCFs might be safe and useful in VTE patients with malignancy. MethodsThe study population consisted of 56 consecutive patients undergoing IVCF placement at our institution from January 1, 2008 to December 31, 2011. Prognostic data were retrospectively reviewed in April 2013. ResultsMean follow-up period was 584.6 (range, 1-1857) days. Twenty-six of the 56 patients had a malignancy. In 16 of the 30 patients without malignancy, the filter was retrieved, whereas the other 14 patients eventually received permanent implantation. There was no significant difference in the survival rate between the retrieval group and the nonretrieval group in the nonmalignancy patients (1-year survival rates, 94% vs 85%). In patients with malignancy, the nonretrieval group showed a significantly lower survival rate (P < 0.01). The 1-year and 2-year survival rates were 100% vs 46% and 100% vs 18%, respectively. There was no medical record of pulmonary thromboembolism occurrence or recurrence. All deaths in the patients with malignancy were malignancy related. In 4 of 5 malignancy patients who could undergo tumor resection surgery, adequate thrombus regression enabled us to retrieve the IVCF after surgery. ConclusionsPermanent use of a retrievable IVCF is relatively safe in short- or midterm follow-up regardless of malignancy status. Retrievable filter use might be reasonable in malignancy patients.

Early reperfusion by percutaneous coronary intervention (PCI) is the current standard therapy for ST-elevation myocardial infarction (STEMI). To achieve better prognoses for these patients, reducing the door-to-balloon time is essential. As we reported previously, the Kitasato University Hospital Doctor Car (DC), an ambulance with a physician on board, is equipped with a novel mobile cloud 12-lead ECG system. Between September 2011 and August 2013, there were 260 emergency dispatches of our Doctor Car, of which 55 were for suspected acute myocardial infarction with chest pain and cold sweat. Among these 55 calls, 32 patients received emergent PCI due to STEMI (DC Group). We compared their data with those of 76 STEMI patients who were transported directly to our hospital by ambulance around the same period (Non-DC Group). There were no differences in patient age, gender, underlying diseases, or Killip classification between the two groups. The door-to-balloon time in the DC group was 56.1 +/- 13.7 minutes and 74.0 +/- 14.1 minutes in the Non-DC Group (P < 0.0001). Maximum levels of CPK were 2899 +/- 308 and 2876 +/- 269 IU/L (P = 0.703), and those of CK-MB were 292 +/- 360 and 295 +/- 284 ng/mL (P = 0.423), respectively, in the 2 groups. The Doctor Car system with the Mobile Cloud ECG was useful for reducing the door-to-balloon time.

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.