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Key Clinical Message Pause following incessant tachycardia is often encountered in clinical practice. We encountered a rare arrhythmic condition mimicking tachycardia‐bradycardia syndrome. We hereby describe the step‐by‐step diagnostic process.

There is a concern about worsening anemia after atrial fibrillation (AF) ablation in anemic patients. We aimed to clarify whether or not patients with anemia who are on an oral anticoagulant therapy are more likely to lose blood after AF ablation.We studied AF patients in 3 cardiovascular centers who skipped a single dose of a direct oral anticoagulant prior to the ablation, and compared the drop in the hemoglobin level 24 hours after the procedure and bleeding complications between the patients with and without preexisting anemia.We identified 183 (15.7%) patients with anemia at baseline out of 1163 patients. The reduction in the hemoglobin level (-0.39±0.71 vs. -0.93±0.9 g/dL; p0.001) was smaller in the anemic than non-anemic patients. A fall in the hemoglobin level of ≥2 g/dL, which is a guideline-defined significant hemoglobin drop, was less common in anemic patients (1.6% vs. 11.3%; p0.001). A female gender [odds ratio (OR) 1.62, confidence interval (CI) 1.07-2.45; p=0.02], persistent or long-standing persistent versus paroxysmal AF (OR 1.67, CI 1.13-2.49; p=0.01), ORBIT score ≥3 (OR 3.5, CI 1.34-8.94; p=0.01), and preexisting anemia (OR 0.02, CI 0.004-0.14; p0.001) were independently associated with the fall in the hemoglobin level of ≥2 g/dL. No difference was noted in the rate of major bleeding complications (1.6% vs. 1.2%; p=0.72).Paradoxically, patients with preexisting anemia may be less likely to lose blood following AF ablation.

Background: There is a concern about worsening of anemia after atrial fibrillation (AF) ablation in anemic patients. We aimed to clarify whether or not patients with anemia who are on an oral anticoagulant therapy are more likely to lose blood after AF ablation. Methods: We studied AF patients in 3 cardiovascular centers who skipped a single dose of direct oral anticoagulants prior to the ablation, and compared the drop in the hemoglobin level 24 hours after the procedure and bleeding complications between the patients with and without preexisting anemia. Results: We identified 183 (15.7%) patients with anemia at baseline out of 1163 patients. The reduction in the hemoglobin level (-0.39±0.71 vs. -0.93±0.9 g/dL; P

The effects of disease management using telemonitoring for patients with heart failure (HF) remain controversial. Hence, we embedded care coordination and enhanced collaborative self-management through interactive communication via a telemonitoring system (collaborative management; CM). This study evaluated whether CM improved psychosocial status and prevented rehospitalization in patients with HF in comparison with self-management education (SM), and usual care (UC).We randomly allocated 59 patients into 3 groups; UC (n = 19), SM (n = 20), and CM (n = 20). The UC group received one patient education session, and the SM and CM groups participated in disease management programs for 12 months. The CM group received telemonitoring concurrently. All groups were followed up for another 12 months. Data were collected at baseline and at 6, 12, 18, and 24 months.The primary endpoint was quality of life (QOL). Secondary endpoints included self-efficacy, self-care, and incidence of rehospitalization. The QOL score improved in CM compared to UC at 18 and 24 months (P < 0.05). There were no significant differences among the 3 groups in self-efficacy and self-care. However, compared within each group, only the CM had significant changes in self-efficacy and in self-care (P < 0.01). Rehospitalization rates were high in the UC (11/19; 57.9%) compared with the SM (5/20; 27.8%) and CM groups (4/20; 20.0%). The readmission-free survival rate differed significantly between the CM and UC groups (P = 0.020).We conclude that CM has the potential to improve psychosocial status in patients with HF and prevent rehospitalization due to HF.

Among heart failure patients diagnosed as having exertional oscillatory ventilation (OV), some present with OV at rest that persists during exercise, and others develop OV only after the onset of exercise during cardiopulmonary exercise (CPX) testing. We tested whether or not there was any difference in the prognostic significance between the two abnormal breathing patterns.Patients with New York Heart Association class III-heart failure were categorized into the following 3 groups according to their ventilation pattern during the CPX: patients with an OV pattern at rest that persisted for ≥60% of the exercise test at an amplitude of ≥15% of the average resting value (group 1), patients with the same abnormal ventilatory pattern as group 1 that was observed only during exercise (group 2), and patients without any OV (group 3). The patients were followed-up for at least 2 years to assess the composite outcome of cardiac death or hospitalization for worsening heart failure.The occurrence of the composite outcome differed significantly across the groups with its highest occurrence in group 1 (21/29 [72.4%], 15/38 [39.5%] and 48/167 [28.7%]; log-rank P 0.001). In multivariate hazard analyses, an N-terminal pro-brain natriuretic peptide of900 pg/mL (hazard ratio [HR] = 1.72, P = 0.04), and group 1 (HR 2.03, P = 0.02) were independently associated with the composite outcome.Checking for the resting OV prior to incremental exercise during CPX testing may be helpful in risk-stratification among subjects with advanced heart failure.

Urinary liver-type fatty acid-binding protein (L-FABP) is a potential biomarker for acute kidney injury, and it in turn increases cardiovascular mortality. We tested whether the urinary L-FABP level predicted short- and mid-term outcomes in patients with acute heart failure.We enrolled consecutive patients with acute heart failure, and measured their urinary L-FABP levels before acute treatment. Worsening renal function (WRF), defined as both an absolute increase in the serum creatinine level of ≥0.3mg/dL and a ≥25% relative increase in its level from baseline, occurred in 37 (26.8%) of 138 patients. Patients with a urinary L-FABP level above the upper normal limit (8.4 µg/g creatinine) (n = 49; 35.5%) were more likely than those with a urinary L-FABP level within normal limits (n = 89; 64.5%) to develop WRF (n = 26 [53.1%] vs n = 11 [12.4%]; P.001). A urinary L-FABP level above the upper limit was independently associated with WRF (hazard ratio 1.8; P = .01). During 1 year of follow-up, 12 patients (8.7%) died, and urinary L-FABP level had no association with all-cause mortality. There was, however, a tendency toward a higher readmission rate in patients with a urinary L-FABP level above the upper normal limit who survived the index hospitalization (n = 46) than in those without an abnormal L-FABP level (n = 88; n = 13 [28.3%] vs n = 13 [14.8%]; log-rank P = .06).Increased urinary L-FABP level before treatment may predict WRF in patients with acute heart failure. Further investigation is warranted for its predictive ability of adverse outcomes.

We report a rare case of portal-hepatic venous shunt through an enormous portal aneurysm complicated by pulmonary hypertension. A 66-year-old woman was admitted to our hospital for hepatic encephalopathy. Chest roentgenography revealed pulmonary hypertension. Computed tomography and ultrasound examination demonstrated a shunt between the portal and hepatic veins through an enormous portal aneurysm. The diagnoses of portal-hepatic venous shunt and pulmonary hypertension were confirmed by hepatic venous catheterization and cardiac catheterization. Pulmonary hypertension might result from the effects of vasoconstrictive agents, which should be metabolized by the liver in normal subjects, passing through the intrahepatic shunt into the lung.

症例は32歳, 女性。第3子妊娠経過中, 平成8年1月ごろから感冒様症状が出現した。2月19日妊娠35週にて胸痛, 呼吸困難出現し当院産科紹介され, 直ちに帝王切開にて出産。その後, 母体は内科入院となった。入院後症状は徐々に軽快した。しかし, 3月6日再び呼吸困難出現し, 心エコーにて僧帽弁の収縮期左房内反転, 高度逆流, 左房内後尖に疣贅を認め, 心不全, 感染性心内膜炎と診断した。また, CTにて脾梗塞が認められ塞栓症状と考えられた。炎症所見軽快後転院し, 僧帽弁置換術が施行された。周産期の感染性心内膜炎はまれであり, その治療方針について文献的考察を加えて報告した。

N G -monomethyl- l -arginine ( l -NMMA), a specific inhibitor of nitric oxide (NO) synthesis, was used to investigate the effects of inhibition of NO synthesis on the coronary conductance and resistance vessels in hypercholesterolemic patients. Acetylcholine (3 and 30 μg/min) was administered to 10 hypercholesterolemic and 10 control patients before and after l -NMMA (25 μmol/min) infusion. Epicardial coronary diameter was measured by quantitative angiography, and coronary blood flow (CBF) was derived from Doppler flow-velocity and coronary diameter measurements. In hypercholesterolemic patients, acetylcholine-induced dilation of epicardial arteries was attenuated, and the percentage increase in CBF caused by acetylcholine was smaller than that in control patients. l -NMMA attenuated acetylcholine-induced dilation of epicardial arteries in control patients. l -NMMA had no effect on CBF responses to acetylcholine in both patient groups. l -NMMA significantly decreased the baseline coronary diameter and CBF in both groups. These results indicated that hypercholesterolemia impaired the acetylcholine-induced dilation of the conductance and resistance coronary vessels. This impairment in the conductance vessels was dependent on NO production; that of resistance vessels was not. The basal release of NO in conductance and resistance vessels was preserved in hypercholesterolemic patients.

Objectives. This study sought to investigate the role of nitric oxide, an endothelium-derived relaxing factor, in flow-mediated vasodilation in human epicardial coronary arteries. Background. Endothelium-derived relaxing factors may be released from the coronary artery endothelium in response to increases in blood flow. Methods. We studied the effect of the nitric oxide synthesis inhibitor NG-monomethyl-l-arginine (l-NMMA) on the flow-mediated vasodilation of epicardial coronary arteries in 12 patients, using quantitative angiographic and Doppler flow velocity measurements. Adenosine at 100 μg/min was infused into the left anterior descending coronary artery to test the dilator response of the proximal artery to increases in blood flow. Acetylcholine at 3 and 30 μg/min was infused into the left coronary ostium to determine endothelium-dependent vasodilation of the proximal left anterior descending artery. Adenosine and acetykholine were infused before and after the intracoronary infusion ofl-NMMA (25 μg/min for 5 min). Results. Infusion ofl-NMMA caused a significant decrease in the baseline diameter of the proximal left anterior descending artery (from 2.90 ± 0.14 to 2.74 ± 0.13 mm [mean ± SEM], p < 0.01). Adenosine increased coronary blood flow Wore and afterl-NMMA (+3995 ± 27.5% and +511.9 ± 33.3%, respectively). Flow-mediated vasodilation was observed in the proximal left anterior descending artery before and afterl-NMMA (+9.2 ± 1.5%, p < 0.01 and +8.6 ± 2.1%, p < 0.01, respectively). A dose of 3 μg/min of acetylcholine significantly dilated the proximal left anterior descending artery beforel-NMMA (+7.6 ± 1.0%, p < 0.01), but acetylcholine-induced vasodilation was attenuated afterl-NMMA (−1.8 ± 1.0%). Conclusions. Our data suggest that nitric oxide modulates basal coronary artery tone but that mediators other than nitric oxide may be responsible for the flow-mediated vasodilation of human epicardial coronary arteries.