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An early diastolic flow from the left ventricular apex to the base can be shown in patients with hypertrophic cardiomyopathy (HCM). This tiny flow or a diastolic paradoxic jet flow is important to detect on echocardiography because of its association with cardiovascular adverse events. We report an asymptomatic 44-year-old man with mid-ventricular obstructive HCM, in which a diastolic paradoxic jet flow was observed not only in the left ventricle but also in the right ventricle. The diastolic paradoxic jet flow in the right ventricle started approximately 110 ms after the onset of the second heart sound, lasted for almost 95 ms, and disappeared in coincidence with the third heart sound; the onset was later and the duration was similar, compared with the diastolic paradoxic jet flow in the left ventricle. He had been doing well without any medication for months and later lost to follow-up. J Med Cases. 2020;11(3):57-60 doi: https://doi.org/10.14740/jmc3210

A diastolic paradoxical jet flow, often seen in patients with hypertrophic cardiomyopathy, is a unique flow from the apex toward the base of the left ventricle during isovolumic relaxation. To date, this phenomenon appears to have been noninvasively detected only on echocardiograms. We report the case of a 43-year-old man with hypertrophic cardiomyopathy and a diastolic paradoxical jet flow, in whom cardiac auscultation revealed a soft S4, a systolic ejection murmur, and a low-pitched early diastolic murmur immediately after S2 at the apex. On comparing his echocardiographic findings with those on phonocardiograms and apexcardiograms, we confirmed that the unusual murmur coincided with the diastolic jet flow. To our knowledge, this is the first case in which heart murmurs associated with a diastolic paradoxical jet flow have been clearly described. Because these flows can increase the risk of adverse outcomes, detecting any associated murmurs by methods other than echocardiography is worthwhile, even in the era of advanced imaging techniques.

Acute myocardial infarction (AMI) at left main trunk (LMT) is a deteriorated condition with high in-hospital morbidity and mortality; however, detailed data regarding AMI patients with LMT as culprit lesion (LMT-AMI patients) undergoing primary percutaneous coronary intervention (PCI) has been still limited. Using the AMI-Kyoto Multi-Center Risk Study database, clinical background, angiographic findings and results of primary PCI were retrospectively compared between primary PCI-treated LMT-AMI patients without in-hospital death (survivors, n = 21) and those with in-hospital death (non-survivors, n = 19). The survivors had higher values of estimated glomerular filtration rate (eGFR) and systolic blood pressure at admission and lower prevalence of Killip grade 4 than the non-survivors. Pre-procedural thrombolysis in myocardial infarction (TIMI) flow grade ≥2 at the initial coronary angiography (CAG) and post-procedural TIMI flow grade 3 at the final CAG were more frequent in the survivors, compared with the non-survivors. In contrast, age and gender did not differ significantly between the two groups. On multivariate analysis, higher eGFR and Killip grade 4 at admission were found to be independent in-hospital prognostic factors in the LMT-AMI patients. Admission eGFR and Killip grade 4 are tightly associated with in-hospital prognosis in LMT-AMI patients undergoing primary PCI.

Potential risk for early development of atherosclerosis in patients with antecedent-Kawasaki disease (KD) is now attracting more attention. A 47-year-old man was admitted to our hospital because of calcification exclusively in the proximal segment of left anterior descending coronary artery (LAD) on chest CT. Coronary CT revealed a severe stenosis at the inlet of the aneurysm with eggshell-like calcification in the proximal LAD, highly suspecting the presence of coronary sequelae of KD. During the rotational atherectomy-based interventional procedure, optical frequency domain imaging, a new generation of optical coherence tomography, clearly depicted lipid deposition in the culprit lesion.

A 74-year-old man with single coronary artery and history of previous coronary artery bypass graft (CABG) was admitted to our hospital with worsening angina. Because of high risk of redo-CABG, we performed transradial percutaneous coronary intervention against the just proximal left anterior descending coronary artery (LAD) stenosis coexisting with short main trunk, anomalous right coronary artery deriving from the mid LAD and patent left internal thoracic artery-distal LAD graft. Under the guidance of IVUS, we successfully implanted an everolimus-eluting stent from the main trunk ostium to the proximal LAD without complications.

Data regarding clinical efficacy of thrombectomy in patients with acute myocardial infarction (AMI) have been still limited in Japan. Using the AMI-Kyoto Multi-Center Risk Study database, the clinical background characteristics, angiographic findings, primary percutaneous coronary intervention (PCI) results and in-hospital prognoses were retrospectively compared between AMI patients with totally occluded infarct-related artery (IRA) (TIMI flow grade 0) undergoing thrombus aspiration during primary PCI (with-aspiration patients, n = 568) and those without thrombus aspiration (without-aspiration patients, n = 266). The with-aspiration patients were more likely to have higher TIMI grade in the IRA immediately after primary PCI, and had a lower in-hospital mortality rate than the without-aspiration patients. According to a multivariate analysis, thrombectomy as well as stent usage was found to be independent predictor of final TIMI flow grade ≥2 in the IRA, and the final TIMI flow grade ≥2 in the IRA was found to be an independent factor for in-hospital survival. These results suggest that among real-world, unselected Japanese AMI patients with totally occluded IRA on initial coronary angiography, thrombus aspiration is an effective adjunctive therapy during primary PCI to improve final epicardial coronary flow in the IRA, which might lead to better in-hospital prognosis.

Arteriovenous fistula (AVF) after trans-radial catheterization is an extremely rare complication. A 61-year-old man experienced a painful swelling in the left radial punctured site. The findings of vascular ultrasound and angiography led to a diagnosis of an iatrogenic radial AVF. We performed continuous compression using a hemostatic band for 24 h after which the radial AVF completely disappeared without vessel occlusion, and no relapse occurred. Eight cases of catheterization-induced radial AVF have been mentioned in the literature, but the treatment has not been noninvasive in any case. This is the first report of an iatrogenic radial AVF that was noninvasively repaired using continuous low-pressure compression with a hemostatic band. Learning objective: Arteriovenous fistula (AVF) after trans-radial catheterization is a rare complication. The literature reports only 8 cases of catheterization-induced radial AVF and no patient has been cured noninvasively. This is the first report of an iatrogenic radial AVF that was repaired noninvasively. We believe that continuous low-pressure compression using a hemostatic band is an effective therapeutic option for this complication.>

Data regarding relationship between pulse pressure (PP) at admission and in-hospital outcome in patients with acute myocardial infarction (AMI) undergoing primary percutaneous coronary intervention (PCI) are still lacking. A total of 1413 primary PCI-treated AMI patients were classified into quintiles based on admission PP (

SummaryBackgroundData regarding the relationship between systolic blood pressure (SBP) at admission and in-hospital outcome in patients with acute myocardial infarction (AMI) undergoing primary percutaneous coronary intervention (PCI) are still lacking in Japan.Methods and resultsA total of 1475 primary PCI-treated AMI patients were classified into quintiles based on admission SBP (

Although cisplatin is indispensable for the chemotherapy treatment of many malignancies, cisplatin-associated thrombosis is attracting increasing attention. However, experience of primary percutaneous coronary intervention (PCI) and intravascular ultrasound imaging (IVUS) for coronary thrombosis, possibly due to cisplatin-based chemotherapy, has been limited. Case 1 with postoperative gastric cancer developed acute myocardial infarction (AMI) on the sixth day of the second chemotherapy course with conventional doses of cisplatin and tegafur gimeracil oteracil potassium. Emergency coronary angiography (CAG) showed a filling defect in the proximal left anterior descending coronary artery (LAD) concomitant with no reflow in the distal LAD. Case 2 with advanced lung cancer and brain metastasis suffered AMI on the fifth day of the first chemotherapy course with conventional doses of cisplatin and gemcitabine. Emergency CAG delineated a total occlusion in the proximal right coronary artery. In both cases, thrombectomy using aspiration catheter alone obtained optimal angiographic results and subsequent IVUS revealed no definite atherosclerotic plaque, while slow flow still remained even after selective intra-coronary infusion of vasodilator in the case 1. These cases suggest that primary PCI using thrombus-aspiration catheter might be safe and effective for coronary thrombosis due to cisplatin-based chemotherapy.

SummaryBackgroundSeveral clinical studies have demonstrated an inverse relationship between systolic blood pressure (SBP) at admission and in-hospital mortality in patients hospitalized for acute myocardial infarction (AMI). However, data on the relation between admission SBP and in-hospital prognosis in AMI patients are still lacking in Japan.Methods and resultsA total of 1211 AMI patients were classified into quintiles based on SBP at hospital admission (

Experience of primary percutaneous coronary intervention (PCI) for young adults with acute myocardial infarction (AMI) due to sequelae of Kawasaki disease (KD) has been extremely limited. In the present report on three young adults (two males and one female; age 20-35 years) with AMI, we performed primary PCI and intravascular ultrasound imaging (IVUS). Case 1 underwent thrombectomy alone in the proximal left circumflex coronary artery, and subsequent IVUS depicted a large aneurysm with an asymmetrically intimal thickening and a residual thrombus in the culprit. Case 2 underwent balloon dilation with adjunctive intracoronary thrombolysis in the proximal left anterior descending coronary artery (LAD), and IVUS during follow-up coronary angiography (CAG) delineated a regressed giant aneurysm with a markedly intimal thickening in the culprit. Case 3, with past history highly suggesting KD, underwent balloon dilation in the proximal LAD, and follow-up CAG as well as IVUS revealed a neoaneurysmal formation in the culprit. In all of the patients, PCI was angiographically effective at the acute phase without complication. Follow-up CAG performed 3-6 months after the procedure revealed no restenosis in all three cases, but a new coronary aneurysm still remained in case 3. Although case 1 and case 2 had no obvious history of KD, the vessel wall morphology from IVUS closely resembled the coronary sequelae after KD, suggesting that they might have antecedent incomplete KD. These cases suggest that primary PCI against coronary sequelae of KD in young AMI patients might be safe and effective in the short term.

(Echocardiography 2010;27:1291-1295)Key words: coronary artery aneurysm, diagnosis, transthoracic echocardiographyCoronary artery fistula (CAF) is an unusualcongenital or acquired coronary vessel abnor-mality and conventional coronary angiography(CAG) has been the gold standard of diagnos-tic image analysis for CAF. Recent accumulatingcase reports have shown that multidetector com-puted tomography (MDCT) could be an alterna-tiveimagingmodalityofchoiceforCAFbyitshightemporal and spatial resolution power.

Summary Background Coronary angiography (CAG) has been the mainstay of diagnostic image analysis for coronary artery fistula (CAF). However, it is difficult to fully delineate this complex vessel structure including coronary trees, particularly in cases with large CAF, by this method. Case reports In the present 3 cases with large CAF, contrast-enhanced multidetector computed tomography (MDCT) was performed to examine the whole coronary vessel structure including CAF. Selective CAG was also undertaken. In all 3 cases, based on the echocardiographic findings and the characteristic heart murmur, presence of CAF was suspected. However, transthoracic echocardiography as well as CAG alone could not define the whole abnormal vessel structure precisely. Moreover, CAG could not obtain clear images of the coronary artery with large CAF, because of contrast-steal. In contrast, MDCT could not only define CAF in detail but also depict coronary artery adjacent to CAF. On the basis of the MDCT findings, in cases 1 and 3, surgical exclusions were undertaken without and with coronary artery bypass grafting, respectively. Conclusions Contrast-enhanced MDCT might be useful for the diagnosis of large CAF and for the estimation of the coronary artery adjacent to CAF, which is absolutely indispensable for surgical treatment.

Background: Organic coronary artery stenosis is a significant prognostic factor in patients with coronary spastic angina (CSA), so the present study was focused on assessing the impact of intermediate fixed stenosis at sites of provoked spasm on the long-term outcomes of CSA patients. Methods and Results: CSA patients diagnosed on the basis of ergonovine-provoked spasm were enrolled and the clinical background and long-term prognosis of CSA patients with intermediate fixed stenosis at the site of provoked spasm (with-fixed-stenosis group, n=37) and those without fixed stenosis (without-fixed-stenosis group, n=126) were retrospectively compared. During the follow-up period (average 4.01 years for with-fixed-stenosis, 4.47 years for without-fixed-stenosis), the with-fixed-stenosis group had a significantly lower event-free survival rate, as well as a higher frequency of admission for unstable angina and percutaneous coronary intervention than the without-fixed-stenosis group, whereas the survival rate did not differ significantly between the 2 groups. In the multivariate analysis, intermediate fixed stenosis at the site of provoked spasm was a predictor of long-term major adverse cardiac events (MACE). Conclusions: Intermediate fixed stenosis at the site of ergonovine-provoked spasm is an independent risk factor for MACE during the long-term period in CSA patients. (Circ J 2009; 73: 699 - 704)

Background It remains uncertain whether obesity is an independent risk factor for coronary heart disease in young adults, as well as adults, in Japan. Methods and Results In the present study, 1,260 cases of acute myocardial infarction (AMI) and 3,775 community controls were recruited from the AMI-Kyoto Multi-Center Risk Study and Kyoto Citizen's Health and Nutrition Study, respectively. Obesity and other risk factors were retrospectively examined between cases and controls in each subgroup of young males (20-40 years), middle-aged males or females (40-60 years), older males or females (60-80 years), and very old males or females (80-100 years). In young, middle-aged, and older males, as well as in older females, cases had a higher body mass index (BMI) than controls. In young males, as well as in middle-aged and older females, cases had a higher prevalence of smoking than controls. Except for very old males, the prevalences of hypercholesterolemia, hypertension, and diabetes mellitus were higher in each subgroup of cases than in controls. Multivariate logistic regression analysis revealed that obesity (BMI ≥25) was an independent risk for AMI in young and middle-aged males, but not in females, whereas smoking was an independent risk for AMI in middle-aged and older females as well as in older males. Conclusions Obesity is significantly associated with AMI, independent of the classic coronary risk factors, in young and middle-aged males. These findings support the current emphasis on controlling obesity to prevent coronary events in young Japanese male adults. (Circ J 2006; 70: 1525 - 1530)

Background The prevalence and clinical manifestations of acute myocardial infarction (AMI) in young patients in Japan have not been fully investigated. Methods and Results In the present study, 1651 AMI patients were enrolled in the AMI-Kyoto Multi-Center Risk Study between January 2000 and June 2004. Of these, the clinical background, risk factors, angiographic findings, acute results of primary percutaneous coronary intervention (PCI) and in-hospital outcomes for 27 young patients

Cardiorenal anemia syndrome has recently been receiving greater attention; however, data regarding the relationship between chronic kidney disease (CKD)/anemia on presentation and in-hospital outcome in patients with acute myocardial infarction (AMI) undergoing primary percutaneous coronary intervention (PCI) are still limited in Japan.A total of 1,447 primary PCI-treated AMI patients were classified into 4 groups according to the presence of CKD and/or anemia on hospital admission (with CKD/with anemia n = 222, with CKD/without anemia n = 299, without CKD/with anemia n = 151, without CKD/without anemia n = 775). Angiographic acute results of primary PCI were similar among the 4 groups. The patients with CKD had a significantly higher in-hospital overall mortality rate than the patients without CKD, and in the presence or absence of CKD, patients with anemia tended to have a higher in-hospital mortality rate than the patients without anemia. According to a multivariate analysis, anemia on admission was found to be an independent predictor of in-hospital mortality, whereas admission CKD and admission eGFR were statistically not independent predictors. Moreover, the multivariable adjusted odds ratio of in-hospital death in AMI patients with CKD alone was 1.855 (95% CI 0.929-3.706), and that in AMI patients with CKD/with anemia was 3.384 (95% CI 1.697-6.748).These results suggest that among real-world, unselected Japanese AMI patients undergoing primary PCI, the combination of CKD and anemia on admission confers significant adverse effects on in-hospital mortality.

Objective The predictors of in-hospital outcomes after primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) complicated with heart failure or cardiogenic shock at presentation remain unclear. Methods Using the AMI-Kyoto Multi-Center Risk Study database, the clinical background characteristics, angiographic findings, primary PCI results, and in-hospital prognoses were retrospectively compared between primary PCI-treated AMI patients with a Killip class status of ≥2 (Killip 2-4 patients, n=390) and those with a Killip class 1 status (Killip 1 patients, n=1,057). Results The Killip 2-4 patients were more likely to have a higher age and proportion of women and exhibited a higher prevalence of previous myocardial infarction, diabetes mellitus and chronic kidney disease or anemia on admission, lower systolic blood pressure (SBP) values on admission, a higher rate of multivessels or left main trunk as the culprit artery, a larger number of diseased vessels, a lower Thrombolysis In Myocardial Infarction (TIMI) grade in the infarct-related artery (IRA) before/after primary PCI and a significantly higher in-hospital mortality rate than the Killip 1 patients. According to a multivariate analysis, age was found to be an independent positive predictor of in-hospital mortality, while admission SBP was an independent positive predictor of in-hospital survival in both groups. In contrast, anemia on admission was found to be an independent predictor of in-hospital death, while the TIMI 3 flow in the IRA after PCI was found to be an independent factor for survival in the Killip 2-4 patients, but not the Killip 1 patients. Conclusion Anemia on admission and the final TIMI 3 flow in the IRA are critical determinants of in-hospital death in AMI patients with a Killip class status of ≥2 undergoing primary PCI.

To analyze the recent change in the long-term survival of patients with dilated cardiomyopathy (DCM), the present study comprised consecutive 111 patients with ejection fraction50% and left ventricular end-diastolic diameter58 mm. who were admitted to hospital from January 1983 to December 1994. The patients were divided into 2 groups: group A who were diagnosed before 1989 and group B diagnosed after 1990. Basic characteristics at diagnosis, including age, NYHA functional class, left ventricular end-diastolic diameter and ejection fraction, were similar between these 2 groups. Calculated survival rate at 5 years was 90.0% in group B in contrast to 62.3% in group A. Event-free survival also improved in group B. In group B, beta-blockers and angiotensin converting enzyme inhibitors were more frequently used than in group A (p0.0001) whereas digitalis and other positive inotropic agents were significantly less used. Left ventricular ejection fraction was significantly improved during the follow-up period in patients treated with beta-blockers compared with those not treated with beta-blockers. These data indicate a significant improvement in the survival of patients with dilated cardiomyopathy after 1990, which may be explained by the change of medical treatment, especially the use of beta-blockers.

The septal perforators in hypertrophic cardiomyopathy (HCM) show systolic compression. The compression is thought to be related to the malpositioned septal perforators, but its relation to the development of myocardial ischemia remains controversial.We examined echocardiographically the blood flow and course of the major septal perforator in 142 consecutive patients with HCM; of these, 94 underwent coronary angiography to assess systolic compression of the septal perforators and 110 had thallium-201 scintigraphy. We then analyzed the relation of the findings in comparison with the results in 15 patients with valvular aortic stenosis (AS).The major septal perforator was visualized in 82 patients with HCM and in 8 patients with AS. The visualization did not depend on the pressure gradient between the left ventricle and aorta in the HCM patients, but did in the AS patients. In AS the perforator always showed a normal course near to, and convexly toward, the right ventricle. In 71 of the 82 HCM patients, the perforator was distant from the right-sided endocardium of the ventricular septum and often convex toward the left. The greater the leftward deviation, the higher was the grade of compression. In 48 of the 82 patients with HCM and in all of the 8 patients with AS who showed the flow signal, the septal perforator showed systolic retrograde flow; in the patients with HCM there was a significant correlation (r = 0.54, P.05) between the peak velocity and the degree of leftward deviation. Furthermore, higher degrees of the leftward deviation and higher degrees of the systolic compression of the major perforator were each associated with a higher incidence of exercise-induced defect of thallium-201.The echocardiographic, angiographic, and scintigraphic findings in HCM may be closely related to one another. We speculate that the series of abnormalities is initiated by a high intramural pressure and impedance on the septal perforators due to their deviation toward the left.

Chronic Thromboembolic Pulmonary Hypertension (CTEPH) is known as a serious disease with poor prognosis. Pulmonary endarterectomy (PEA) is a treatment option, however, suitable indication is restricted within the proximal lesions and few hospitals routinely perform PEA. In the present situation, we

Background Downsized devices for less invasive endovascular treatment are gaining more attention. Case report An 82-year-old woman was admitted to our hospital with pain and swelling in left lower extremity. Ultrasonography showed much thrombus at the left common femoral, superficial femoral, and popliteal veins, confirming a diagnosis of acute deep vein thrombosis (DVT). For lack of therapeutic effect of systemically administered anticoagulative and thrombolytic agents, we performed catheter intervention against DVT. After insertion of a 4.5 French guiding sheath (Parent Plus, Medikit, Tokyo, Japan) into left popliteal vein, venography showed a total occlusion of the common femoral vein. Even after thrombectomy by aspiration catheter, balloon dilation, and catheter-induced thrombolysis, severe stenosis at the proximal site of the left common iliac vein remained. After confirming the presence of iliac vein compression syndrome (IVCS) by intravascular ultrasound imaging, we successfully implanted a Zilver ® stent (Cook Inc., Bloomington, IN, USA) in the common-external iliac vein through a 4.5 French guiding sheath, leading to an optimal venous-return flow. Conclusions The present case suggests that in addition to thrombus aspiration, Zilver stent implantation using a 4.5 French guiding sheath has the potential to serve as a minimally invasive strategy for the treatment of IVCS complicated with iliofemoral DVT. Learning objective: During the interventional treatment of deep vein thrombosis, we should pay attention to procedure-related venous valve dysfunction in addition to bleeding complications and pulmonary embolism. From the point of view, downsized catheter devices might have some advantage with lesser prevalence of those complications.>

Background: Predictors of in-hospital outcome after primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) requiring mechanical support devices such as intra-aortic balloon pumping (IABP) and/or percutaneous cardiopulmonary support (PCPS) remain unclear. Methods and Results: Using the AMI-Kyoto Multi-Center Risk Study database, clinical background, angiographic findings, results of primary PCI, and in-hospital prognosis were retrospectively compared between primary PCI-treated AMI patients requiring mechanical assist devices (with-IABP/PCPS patients, n=275) and those without (without-IABP/PCPS patients, n=1,510). The with-IABP/PCPS patients were more likely to have a larger number of diseased vessels, lower Thrombolysis In Myocardial Infarction (TIMI) grade in the infarct-related artery (IRA) before/after primary PCI, and a significantly higher in-hospital mortality rate than the without-IABP/PCPS patients. On multivariate analysis, the number of diseased vessels ≥2 or diseased left main trunk (LMT) at initial coronary angiography (CAG) was the independent positive predictor of the in-hospital mortality in the with-IABP/PCPS patients, not in the without-IABP/PCPS patients, whereas acquisition of TIMI 3 flow in the IRA immediately after primary PCI was the negative predictor in the without-IABP/PCPS patients, not in the with-IABP/PCPS patients. Conclusions: The number of diseased vessels ≥2 or diseased LMT at initial CAG is an independent risk factor of in-hospital death in primary PCI-treated AMI patients requiring mechanical support devices. (Circ J 2010; 74: 1152 - 1157)

Background Recurrent acute myocardial infarction (AMI) is a deteriorated condition with high in-hospital morbidity and mortality, but the predictors of in-hospital outcome after primary percutaneous coronary intervention (PCI) for repeat AMI remain unclear. Methods and Results Using the AMI-Kyoto Multi-Center Risk Study database, clinical background, angiographic findings, results of primary PCI, and in-hospital prognosis were retrospectively compared between primary PCI-treated AMI patients with previous myocardial infarction (MI) (repeat-MI patients, n=235) and those without previous MI (first-MI patients, n=1,550). The repeat-MI patients had higher prevalence of Killip class ≥3 at admission, larger number of diseased vessels, and a significantly higher in-hospital mortality rate than the first-MI patients. On multivariate analysis, number of diseased vessels ≥2 or diseased left main trunk (LMT) on initial coronary angiography was the independent positive predictor of in-hospital mortality in the repeat-MI patients, not in the first-MI patients, whereas acquisition of Thrombolysis In Myocardial Infarction 3 flow in the infarct-related artery immediately after primary PCI and elapsed time

Background Several clinical studies have demonstrated an inverse relationship between hospital volume of primary percutaneous coronary interventions (PCI) and in-hospital mortality. However, the relationships among hospital primary PCI volume, angiographic results, and in-hospital prognosis in patients with acute myocardial infarction (AMI) have not been fully investigated in Japan. Methods and Results Using the AMI-Kyoto Multi-Center Risk Study database between January 2000 and December 2005, hospitals were classified into quintiles based on their annual volume of primary PCI. The fifth quintile of hospitals was labeled as high-volume, and the other quintiles were combined and defined as low-volume. Although patients undergoing primary PCI in high-volume hospitals (high-volume group, n=764) had a larger number of diseased vessels at initial coronary angiography and lower Thrombolysis In Myocardial Infarction (TIMI) flow grade in the infarct-related artery before PCI, compared with those in low-volume hospitals (low-volume group, n=1,021), the rates of achieving TIMI flow grade 3 just after PCI in the high-volume group was significantly higher than that in the low-volume group. The overall in-hospital mortality did not differ between the 2 groups. On multivariate analysis, in AMI patients undergoing primary PCI, Killip class ≥3 at admission, multivessel disease or left main trunk (LMT) as culprit lesion, number of diseased vessels ≥2 or diseased LMT, and age were the independent positive predictors of in-hospital mortality, whereas the TIMI flow grade 3 after primary PCI and elapsed time

This unusual case of Takayasu arteritis presenting as acute myocardial infarction could be defined by ultrasonography and 18-fluorodeoxyglucose positron emission tomography (18F-FDG PET) coregistered with computed tomography (CT). A 55-year-old male was admitted to our hospital with continuous chest pain and left-side neck pain. After primary percutaneous coronary intervention, elevation of inflammatory markers persisted and dull pain in the left side of the neck continued. Ultrasonography revealed characteristic wall thickening of the left common carotid artery and subsequent 18F-FDG PET with CT depicted positive uptake in the left common carotid artery and the vessel wall of the ascending aorta, confirming the diagnosis of Takayasu arteritis. Three months after angioplasty, follow-up cardiac catheterization was performed. Coronary angiography showed no restenosis. During the catheterization, angiography confirmed the mild stenosis in the long segment of the left common carotid artery and the left subclavian artery as well as the focal narrowing and the dilation of the abdominal aorta. This case shows that ultrasonography in the cervical region and combined 18F-FDG PET with CT may be useful in the diagnosis and evaluation of Takayasu arteritis. In addition, we should pay attention to underlying disease even in middle-aged or older male patients with acute myocardial infarction.

Obesity is an established risk factor for coronary heart disease. However, data on the relationship between obesity and prognosis following acute myocardial infarction (AMI) are still lacking in Japan.In the present study, 1,458 AMI patients were enrolled in the AMI-Kyoto Multi-Center Risk Study between January 2000 and December 2003. Among survivors of hospitalized AMI, clinical characteristics and medium-term prognosis were retrospectively compared between 240 normal weight male patients [body mass index (BMI) 18.5-25.0 kg/m2, normal weight group], and 116 obese male patients (BMIor = 25.0 kg/m2, obese group), who could be followed up after hospital discharge. The obese group were younger and had higher prevalence of smoking and hypercholesterolemia than the normal weight group. The two groups had similar angiographic findings and outcomes of primary percutaneous coronary intervention. During the follow-up period (mean 2.18 years for normal weight, 2.15 years for obese), overall mortality rate as well as event-free survival rate did not differ significantly between the two groups. Multivariate analysis showed the presence of previous myocardial infarction, diabetes mellitus, and age were predictors of medium-term mortality, but BMI was not.These results suggest that obesity is not associated with increased medium-term mortality and cardiac morbidity in Japanese male survivors hospitalized for AMI.

Background Primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) is performed in hospitals without on-site coronary artery bypass graft surgery in the `real world'. However, data on the in-hospital outcomes of primary PCI performed at hospitals with and without on-site cardiac surgery are still lacking in Japan. Methods and Results In the present study, 2,230 AMI patients were enrolled in the AMI-Kyoto Multi-Center Risk Study between January 2000 and December 2005. Of these, 1,817 patients underwent primary PCI. Excluding patients without adequate data, we retrospectively compared clinical background, coronary risk factors, angiographic findings, acute results of primary PCI and in-hospital prognosis between patients undergoing primary PCI in hospitals without on-site cardiac surgery (without surgery group, n=792) and those in hospitals with (with surgery group, n=993). The without surgery group had higher prevalence of previous myocardial infarction, Killip class ≥3 at admission and multivessels as a culprit lesion than the with surgery group. The without surgery group was more likely to have lower frequency of stent usage and lower thrombolysis in myocardial infarction flow grade just after PCI, whereas it was more likely to have intra-aortic balloon pumping and temporary pacing during procedures. The overall in-hospital mortality did not differ between the 2 groups. On multivariate analysis, in AMI patients undergoing primary PCI, Killip class ≥3 at admission, multivessels or left main trunk (LMT) as culprit lesions, number of diseased vessels ≥2 or diseased LMT, and age were the independent predictors of the in-hospital mortality, but the presence of on-site cardiac surgery was not. Conclusions These results suggest that in-hospital outcomes in AMI patients undergoing primary PCI at hospitals without on-site cardiac surgery are comparable to those at hospitals with on-site cardiac surgery in Japan. (Circ J 2007; 71: 1208 - 1212)

Obesity may be linked with coronary atherosclerosis in young males. This study investigated the etiology of acute myocardial infarction (AMI) in young Japanese male patients with or without obesity.This retrospective study included 2,230 AMI patients enrolled in the AMI-Kyoto Multi-Center Risk Study between January 2000 and December 2005. Clinical background, risk factors, angiographic findings, acute results of primary percutaneous coronary intervention (PCI), and in-hospital outcome were evaluated in 33 young male patients40 years old. The study group was divided into the obese group [body mass index (BMI)or =25, n=21] and non-obese group (BMI25, n=12). Four of the 12 non-obese patients had underlying disease (Kawasaki disease 2, Buerger's disease 1, drug abuse 1). The non-obese group had a higher prevalence of underlying disease than the obese group. The non-obese group had a higher incidence of left anterior descending coronary artery as culprit lesion and higher Thrombolysis in Myocardial Infarction (TIMI) grade flow in the infarct-related artery before primary PCI. The acquisition rates of TIMI 3 flow after primary PCI and in-hospital outcome did not differ between the two groups.Non-obese young AMI male patients have a higher frequency of underlying disease. Most young male AMI patients were obese, suggesting that obesity may be important in the pathogenesis of AMI in young male adults.

Background Data on the medium- and long-term prognosis of young Japanese patients with acute myocardial infarction (AMI) are still lacking. Methods and Results In the present study, 1,458 AMI patients were enrolled in the AMI-Kyoto Multi-Center Risk Study between January 2000 and December 2003. Of these, clinical characteristics and medium-term prognosis were retrospectively compared in 21 young patients

Reverse redistribution (RR) of technetium-99m tetrofosmin (TF) in patients with acute myocardial infarction (AMI) has been considered a sign of salvaged myocardium. We examined the time evolution of the RR pattern during a 6-month period and the clinical implications of RR. TF myocardial SPET was performed in 22 patients 1 week, 1 month and 3–6 months after AMI. Myocardial images were obtained 30 min and 180 min after the injection of TF. Regional uptake of TF was rated using a four-point scoring system. RR was defined as an increase of more than 1 point in the regional score on images obtained at 180 min. Echocardiography was performed to assess regional wall motion at the same time as TF imaging. RR observed at 1 week tended to disappear after 1 month and 3–6 months. The incidence of regional wall motion abnormality was reduced in patients with RR compared with that in patients with fixed defects. Recovery of abnormal regional wall motion occurred earlier in segments with disappearance of RR than in those without disappearance of RR. It is concluded that RR may reflect salvaged myocardium and that disappearance of RR may indicate earlier recovery of salvaged myocardium.

In conclusion, 50 μg of intracoronary ATP exhibited a vasodilator potency similar to that of papaverine without producing any marked changes in hemodynamics or a prolongation of the QTc. Intracoronary ATP may therefore be safer than papaverine for measuring CFR; more conclusive evidence about the safety of intracoronary ATP will have to await the conclusion of larger trials.

SummaryBackgroundPredictors of suboptimal coronary flow in the infarct-related artery (IRA) after stent-based primary percutaneous coronary intervention (PCI) in patients with acute myocardial infarction (AMI) have not been fully investigated.Methods and resultsUsing the AMI-Kyoto Multi-Center Risk Study database, we retrospectively compared clinical manifestations and in-hospital prognosis between AMI patients undergoing stent-based primary PCI with final Thrombolysis In Myocardial Infarction (TIMI) grade ≤2 in the IRA (nonoptimal group, n=69) and those with final TIMI grade 3 (optimal group, n=1200). The nonoptimal group had higher prevalence of Killip class ≥3 at admission, higher frequency of mechanical support devices during procedures, larger value of maximal creatine phosphokinase, and a significantly higher in-hospital mortality rate (27.5% for nonoptimal vs. 9.0% for optimal, P

Summary Background Recurrent acute myocardial infarction (AMI) is a disastrous condition with high in-hospital morbidity and mortality. However, the relation between location of previous myocardial infarction (MI) and in-hospital outcome in repeat-AMI patients undergoing primary percutaneous coronary intervention (PCI) remains unclear. Methods and results Using the AMI-Kyoto Multi-Center Risk Study database, clinical background, angiographic findings, results of primary PCI, and in-hospital prognosis were retrospectively compared between primary PCI-treated AMI patients with previous anterior MI (anterior group, n = 151) and those with previous non-anterior MI (non-anterior group, n = 157). Clinical backgrounds, angiographic findings, results of primary PCI, and in-hospital outcome did not differ significantly between the two groups. On multivariate analysis, Killip class ≥3 at admission, number of diseased vessels ≥2 or diseased left main trunk at initial coronary angiography, and age were the independent predictors of in-hospital mortality in the recurrent-AMI patients, but not the anterior location of previous MI. Conclusions These results suggest that among recurrent-AMI patients undergoing primary PCI, in-hospital prognosis mostly depends on the severity of acute heart failure at the onset and the residual myocardial ischemia rather than previous MI sites.