Coronary artery revascularization in an adult with coronary aneurysms probably secondary to childhood Kawasaki disease

Kawasaki disease is an acute febrile illness affecting mainly infants and children. The fatal complication of Kawasaki disease is coronary involvement pertaining to coronary artery aneurysms. Surgical experience of adults that had childhood Kawasaki disease with coronary lesion has been rarely reported. We experienced coronary artery bypass grafting in a 44 year old man with no risk factors for atherosclerosis but with coronary lesions possibly secondary to Kawasaki disease. Coronary artery sequelae of Kawasaki disease may become part of a cause of coronary disease in young adults and we should recognize this condition in such patients with coronary disease but no coronary risk factors.     

Myocardial contrast echocardiography versus dobutamine echocardiography for predicting functional recovery after acute myocardial infarction treated with primary coronary angioplasty

OBJECTIVES: We sought to compare myocardial contrast echocardiography with low dose dobutamine echocardiography for predicting 1-month recovery of ventricular function in acute myocardial infarction treated with primary coronary angioplasty. BACKGROUND: The relation between myocardial perfusion and contractile reserve in patients with acute myocardial infarction, in whom anterograde flow is fully restored without significant residual stenosis, is still unclear. METHODS: Thirty patients with acute myocardial infarction treated successfully with primary coronary angioplasty underwent intracoronary contrast echocardiography before and after angioplasty and dobutamine echocardiography 3 days after the index infarction. One month later, two-dimensional echocardiography and coronary angiography were repeated in all patients and contrast echocardiography in 18 patients. RESULTS: After coronary recanalization, 26 patients showed myocardial reperfusion within the risk area, although 4 did not. At 1-month follow-up, all patients had a patient infarct-related artery without significant restenosis. Both left ventricular ejection fraction and wall motion score index within the risk area significantly improved in the patients with reperfusion ([mean +/- SD] 38 +/- 8% vs. 48 +/- 12%, p < 0.005; and 2.35 +/- 0.5 vs. 2 +/- 0.6, p < 0.001, respectively), but not in those with no reflow. Of the 72 nonperfused segments before angioplasty, 27 showed functional improvement at follow-up. Myocardial contrast echocardiography had a sensitivity and a negative predictive value similar to dobutamine echocardiography in predicting late functional recovery (96% vs. 89% and 89% vs. 93%, respectively), but a lower specificity (18% vs. 91%, p < 0.001), positive predictive value (41% vs. 86%, p < 0.001) and overall accuracy (47% vs. 90%, p < 0.001). CONCLUSIONS: Microvascular integrity is a prerequisite for myocardial viability after acute myocardial infarction. However, contrast enhancement shortly after recanalization does not necessarily imply a late functional improvement. Thus, contractile reserve elicited by low dose dobutamine is a more accurate predictor of regional functional recovery after reperfused acute myocardial infarction than microvascular integrity.     

Probability of relapse after recovery from an episode of depression.

Examined relapse rates in those individuals who have experienced an episode of unipolar depression as a function of the number of previous episodes, gender, age at onset of the episode (40), time since a previous episode, and depression level at time of interview. From 6,742 participants, 2,046 were interviewed; of these 1,130 had at least one, 513 reported a second and 173 reported a third episode. The probability for relapse was positively related to number of previous episodes, being female, depression level at time of interview, but not to age at onset (40). Women were also more likely to have more severe episodes. Participants with elevated depression symptoms reported a greater number of previous episodes. Following the first episode, there was a decline in hazard rate for men but not women; following the second episode, there was no change in vulnerability for men; for women, the results were ambiguous. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Angiographically documented coronary artery disease in asymptomatic middle aged men suspected of silent ischaemic heart disease

One hundred and fourteen asymptomatic middle aged men, with a positive stress test, underwent coronary angiography at Armed Forces Institute of Cardiology/National Institute of Heart Diseases (AFIC/NIHD), Rawalpindi. Of these, 66 (58%) were found to have significant disease (> 50% luminal narrowing in at least one of the major epicardial arteries) while 48 (42%) had normal coronary arteries. Of the former, 27 (41%) had 1-vessel CAD, 18 (27%) had 2-vessel CAD and 21 (32%) had 3-vessel CAD. There were significantly more hypertensives, hyperlipidaemics and diabetics in CAD group, while other risk factors were the same. The overall risk factor prevalence was low. The major reasons for performing coronary angiography were a positive stress test done as part of routine annual medical checkup and resting ECG changes of enough significance to warrant further investigations. It is concluded that the presence of significant coronary artery disease can be silent in a large number of asymptomatic middle aged men, especially those who have conventional risk factors.     

Pericardial effusion after primary percutaneous transluminal coronary angioplasty in first Q-wave acute myocardial infarction

To evaluate the incidence and clinical significance of infarction-associated pericardial effusion in patients with successful primary percutaneous transluminal coronary angioplasty, we studied 214 consecutive patients with a first Q-wave acute myocardial infarction. Based on 9 clinical variables, multivariate analysis was performed to determine the important variables related to the occurrence of pericardial effusion. Pericardial effusion was detected by echocardiography in 45 patients (21%); pericardial rub (p <0.001), number of advanced asynergic segments (p <0.001), ventricular aneurysmal motion (p = 0.03), and pulmonary capillary wedge pressure (p = 0.04) were found to be the important variables related to pericardial effusion. Among 45 patients with pericardial effusion, 29 patients with no pericardial rub had significantly higher pulmonary capillary wedge pressure than those with pericardial rub, whereas 16 patients with pericardial rub had a higher incidence of angiographic no reflow and ventricular aneurysmal motion than those without pericardial rub. Patients with pericardial effusion and a pericardial rub had a higher mortality rate than those without pericardial effusion (19% vs 3%; p = 0.02). Thus, pericardial effusion is still a relatively common clinical finding after primary percutaneous transluminal coronary angioplasty, and those with pericardial effusion and a pericardial rub were associated with more severe transmural myocardial damage and higher in-hospital mortality.     

Teesside coronary survey: an epidemiological study of acute attacks of myocardial infarction

A 12-month epidemiological survey of attacks of acute myocardial infarction was carried out in a large urban population. The incidence and mortality at all ages and in both sexes were examined. Altogether, 1938 attacks were diagnosed--an overall incidence of 4-89 per 1000 population. The 28-day fatality rate was 50-5%. A third of the patients were treated at home and these patients had a lower fatality rate than those in hospital, a difference that could not be attributed to age, sex, or severity of attack. Half of the deaths that were witnessed occurred suddenly and a further 21% occurred within the next two hours. The median time to patients coming under care was about three hours. As used at present, coronary care units are unlikely to improve fatality rates. Future advances in treatment must take place outside hospital and will require re-education of the public and the general practitioner.     

Immediate eradication of Helicobacter pylori in patients with previously documented peptic ulcer disease: clinical and economic effects

The introduction of adenovirus 5 E1A into the SKOV3ip1 ovarian cancer cell line was shown previously to suppress HER2/neu expression and reduce the malignant potential of these cells (Yu et al., Cancer Res., 53: 891-898, 1993). In this report, we show that reduction of p185 in cells stably expressing E1A protein was coincident with increased sensitivity to cytotoxic agents. The LD50 of cisplatin was reduced 6-fold, and the LD50 of paclitaxel and doxorubicin was reduced 10-fold in E1A-expressing cells compared with control cells. The growth of SKOV3ip1 and control cells was unchanged in the presence of 150 ng/ml of tumor necrosis factor-alpha, whereas the growth of E1A-expressing cells was reduced by 30 to 40%. When we used a physiologically obtainable concentration of paclitaxel (0.5 microM), DNA laddering consistent with apoptotic cell death was seen after a 24-h exposure in the E1A-expressing cells, whereas laddering and DNA fragmentation were only detected in DNA from control cells after longer exposure (48 h) at a 20-fold higher concentration of paclitaxel. The SKOV3ip1 cells do not express p53 protein; hence, the induction of apoptosis by paclitaxel is through a p53-independent pathway. Despite their diverse mechanisms of action, the cytotoxic effects of cisplatin, doxorubicin, paclitaxel, and tumor necrosis factor-alpha were enhanced by the expression of E1A proteins in the SKOV3ip1 ovarian cancer cells. This suggests that these agents share a common final pathway of cell killing, which may represent a potential therapeutic target in resistant ovarian cancers.     

A comparison of thrombolytic therapy with primary coronary angioplasty for acute myocardial infarction. Myocardial Infarction Triage and Intervention Investigators

BACKGROUND: Several relatively small randomized trials have shown that primary angioplasty results in a better short-term outcome than thrombolytic therapy in patients with acute myocardial infarction. These results, however, have not been duplicated other than in investigational trials. METHODS: We compared mortality during hospitalization and long-term mortality, as well as the use of resources, among 1050 patients in a primary-angioplasty group and 2095 patients in a thrombolytic-therapy group. Patients were selected from the Myocardial Infarction Triage and Intervention Project Registry cohort of 12,331 consecutive patients admitted with acute myocardial infarction to 19 Seattle hospitals between 1988 and 1994. Because of the potential for selection bias, several subgroup analyses were performed that included patients eligible for thrombolysis, high-risk patients, and patients in the primary-angioplasty group who were treated at hospitals with high volumes of angioplasty. RESULTS: There was no significant difference in mortality during hospitalization or long-term follow-up between patients in the thrombolytic-therapy group and those in the primary-angioplasty group (mortality during hospitalization, 5.6 percent and 5.5 percent, respectively; P=0.93; adjusted hazard ratio for the risk of death within three years after primary angioplasty, 0.95; 95 percent confidence interval, 0.8 to 1.2). There was also no significant difference in mortality between high-risk subgroups of patients in the two treatment groups. The rates of procedures and costs were lower among patients in the thrombolytic-therapy group both at the time of hospital discharge and after three years of follow-up (30 percent fewer coronary angiograms, 15 percent fewer coronary angioplasties, and 13 percent lower costs after three years of follow-up). CONCLUSIONS: In a community setting, we observed no benefit in terms of either mortality or the use of resources with a strategy of primary angioplasty rather than thrombolytic therapy in a large cohort of patients with acute myocardial infarction.     

Rupture of a previously documented small asymptomatic intracranial aneurysm in a patient with autosomal dominant polycystic kidney disease. Case report

Intracranial aneurysms are common extrarenal manifestations of autosomal dominant polycystic kidney disease (ADPKD). Although their natural history is not completely understood, small asymptomatic intracranial aneurysms in patients with ADPKD often are not treated but are followed with serial magnetic resonance (MR) angiography. The authors report the unique case of a patient with ADPKD who bled from a previously documented asymptomatic 3-mm intracranial aneurysm. This 42-year-old man with ADPKD suffered a subarachnoid hemorrhage (SAH) from a 7-mm left pericallosal artery aneurysm. This aneurysm was clipped and the patient made an excellent recovery. An irregular asymptomatic 3-mm right middle cerebral artery (MCA) aneurysm had also been demonstrated on angiography. While the patient was considering elective surgery for the MCA aneurysm, he suffered a hemorrhage from this lesion 10 weeks after the initial SAH. The aneurysm was clipped and the patient made a satisfactory recovery (he was moderately disabled). In this report the authors indicate that small asymptomatic intracranial aneurysms are not always innocuous in patients with ADPKD, and they suggest that treatment should be strongly considered for these lesions in this group of patients when there is a history of SAH or the aneurysm is irregular in appearance. Because MR angiography studies may not adequately define the configuration of small aneurysms and irregularity may easily be missed, conventional angiography is recommended for patients with ADPKD who are found to have an intracranial aneurysm on screening with MR angiography.     

Myocardial perfusion imaging in the setting of coronary artery stenosis and acute myocardial infarction using venous injection of a second-generation echocardiographic contrast agent

BACKGROUND: We hypothesized that by producing excellent myocardial opacification, venous injection of FS-069 coupled with intermittent harmonic imaging (IHI) can be used to determine the presence and severity of coronary stenoses during hyperemia, the size of the risk area during coronary occlusion, and the extent of myocardial salvage after reperfusion. METHODS AND RESULTS: Twelve dogs were imaged both continuously and intermittently (every end systole) in the fundamental (2 MHz) and harmonic (transmit at 2 and receive at 4 MHz) modes. FS-069 (1 mL) was injected intravenously for all stages and modes of imaging. Myocardial video intensity was severalfold (P<.01) higher during IHI than all other modes of imaging. Perfusion defects were difficult to measure during continuous and intermittent fundamental imaging and during continuous harmonic imaging. In comparison, the defects were clearly demarcated during IHI. When this mode was used, the magnitude of perfusion mismatch during hyperemia in the presence of a coronary stenosis correlated closely with the magnitude of flow mismatch when radiolabeled microspheres were used (r=.94). The perfusion defect sizes during coronary occlusion and reperfusion also correlated closely with postmortem risk area (r=.89) and infarct size (r=.96), respectively. CONCLUSIONS: Venous injection of FS-069 coupled with IHI produces excellent myocardial opacification. This approach can be used to determine the severity of coronary stenoses during hyperemia, the size of the risk area during coronary occlusion, and the extent of myocardial salvage after reperfusion. This approach, therefore, holds promise in the clinical setting.     

Alpha-adrenergic blockade improves recovery of myocardial perfusion and function after coronary stenting in patients with acute myocardial infarction

BACKGROUND: AMI reperfusion by thrombolysis does not improve TIMI flow and LV function. The role of infarct-related artery (IRA) stenosis and superimposed changes in coronary vasomotor tone in maintaining LV dysfunction must be elucidated. METHODS AND RESULTS: Forty patients underwent diagnostic angiography 24 hours after thrombolysis. Seventy-two hours after thrombolysis, the culprit lesion was dilated with coronary stenting. During angioplasty, LV function was monitored by transesophageal echocardiography. Percent regional systolic thickening was quantitatively assessed before PTCA, soon after stenting, 15 minutes after stenting, and after phentolamine 12 microg/kg IC (n=10), the alpha1-blocker urapidil 600 microg/kg IV (n=10), or saline (n=10). Ten patients pretreated with beta-blockers received urapidil 10 mg IC. Coronary stenting significantly improved thickening in IRA-dependent and in non-IRA-dependent myocardium (from 27+/-15% to 38+/-16% and from 40+/-15% to 45+/-15%, respectively). Simultaneously, TIMI frame count decreased from 39+/-11 and 40+/-11 in the IRA and non-IRA, respectively, to 23+/-10 and 25+/-7 (P<0.05). Fifteen minutes after stenting, thickening worsened in both IRA- and non-IRA-dependent myocardium (to 19+/-14% and 28+/-14%, P<0.05), and TIMI frame count returned, in both the IRA and non-IRA, to the values obtained before stenting. Phentolamine and urapidil increased thickening to 36+/-17% and 41+/-14% in IRA and to 48+/-11% and 49+/-17% in non-IRA myocardium respectively, and TIMI frame count decreased to 16+/-6 and to 17+/-5, respectively. Changes were attenuated with beta-blocker pretreatment. CONCLUSIONS: Our finding that alpha-adrenergic blockade attenuates vasoconstriction and postischemic LV dysfunction supports the hypothesis of an important role of neural mechanisms in this phenomenon.     

Seasonal distribution of acute myocardial infarction in the second National Registry of Myocardial Infarction

OBJECTIVES: This observational study sought to determine whether cases of acute myocardial infarction (AMI) reported to the second National Registry of Myocardial Infarction (NRMI-2) varied by season. BACKGROUND: The existence of circadian variation in the onset of AMI is well established. Examination of this periodicity has led to new insights into pathophysiologic triggers of atherosclerotic plaque rupture. Although a seasonal pattern for mortality from AMI has been previously noted, it remains unclear whether the occurrence of AMI also displays a seasonal rhythmicity. Documentation of such a pattern may foster investigation of new pathophysiologic determinants of plaque rupture and intracoronary thrombosis. METHODS: We analyzed the number of cases of AMI reported to NRMI-2 by season during the period July 1, 1994 to July 31, 1996. Data were normalized so that seasonal occurrence of AMI was reported according to a standard 90-day length. RESULTS: A total of 259,891 cases of AMI were analyzed during the study period. Approximately 53% more cases were reported in winter than during the summer. The same seasonal pattern (decreasing occurrence of reported cases from winter to fall to spring to summer) was seen in men and women, in different age groups and in 9 of 10 geographic areas. In-hospital case fatality rates for AMI also followed a seasonal pattern, with a peak of 9% in winter. CONCLUSION: The present results suggest that there is a seasonal pattern in the occurrence of AMIs reported to NRMI-2 that is characterized by a marked peak of cases in the winter months and a nadir in the summer months. This pattern was seen in all subgroups analyzed as well as in different geographic areas. These findings suggest that the chronobiology of seasonal variation in AMI may be affected by variables independent of climate.     

HLAs and risk of acute graft-vs.-host disease after marrow transplantation from an HLA-identical sibling

A growing number of European initiatives focusing on the evaluation and monitoring of substance abuse prevention is observed. At the beginning of the 90s a team from the Institute of Psychiatry and Neurology in Warsaw, Poland, began a project designed for the promotion of evaluation in the field of substance abuse prevention. The project included outcome studies on popular school-based programs and development of teaching materials and publications to popularize the concept and methods of evaluation. As results of the project several outcome studies were completed, several scales for evaluating alcohol prevention programs were developed, a number of articles and a handbook on evaluation were published.     

Association of an acute reduction in lipoprotein(a) with coronary artery restenosis after percutaneous transluminal coronary angioplasty

BACKGROUND: Lipoprotein(a) [Lp(a)], which structurally resembles-tissue-type plasminogen, is reported to be associated with coronary atherosclerosis. We examined whether the acute change in Lp(a) by percutaneous transluminal coronary angioplasty (PTCA) is related to restenosis after PTCA. METHODS AND RESULTS: We measured serum Lp(a) and other lipid parameters (triglycerides and total, LDL, and HDL cholesterol) before and 1 day after PTCA in 143 procedures and 3 days after and 4 months after PTCA in 62 procedures. Quantitative coronary angiography was performed, and restenosis was defined according to three criteria: (1) clinical recurrence of ischemic symptoms, (2) a final stenosis > 50%, and (3) an absolute decrease in minimal lumen diameter > 1/2 of the acute gain in the dilated segment. Restenosis was recognized in 25.9%, 35.7%, and 38.5% of the cases 4 months after PTCA for each criterion, respectively. Although triglyceride and LDL, HDL, and total cholesterol levels were similar in the restenosis and no-restenosis groups before PTCA, Lp(a) was significantly higher in the restenosis group. We found a significant reduction in Lp(a) in the restenosis but not the no-restenosis group 1 day after PTCA. At 3 days after and 4 months after PTCA, Lp(a) was similar in the two groups. A multivariate-analysis revealed that the absolute change in Lp(a) (before versus 1 day after PTCA) to be the sole significant predictor of restenosis among the clinical, angiographic, and plasma lipid parameters examined. CONCLUSIONS: Lp(a) levels were significantly higher in the restenosis group, and they fell significantly after PTCA in the restenosis group.     

False aneurysm of the left ventricle and coronary aneurysms in Beh?et disease

A false left ventricular aneurysm and coronary artery aneurysm were discovered in a 29 year old patient with Beh?et's syndrome. The operation under cardiopulmonary bypass consisted of closing the neck of the false aneurysm by an endo-aneurysmal approach with a Gore-Tex patch. The coronary artery aneurysms were respected. There were no postoperative complications. Cardiac involvement is rare in Beh?et's syndrome (6%). The originality of this case is the association of two aneurysmal pathologies: the coronary and ventricular aneurysms due to the angiitis and the myocardial fragility induced by ischaemia.     

Randomized trial of an oral platelet glycoprotein IIb/IIIa antagonist, sibrafiban, in patients after an acute coronary syndrome: results of the TIMI 12 trial. Thrombolysis in Myocardial Infarction

In fMRI studies, Gaussian filtering is usually applied to improve the detection of activated areas. Such lowpass filtering enhances the signal to noise ratio. However, undesirable secondary effects are a bias on the signal shape and a blurring in the spatial domain. Neighboring activated areas may be merged and the high resolution of the fMRI data compromised. In the temporal domain, activation and deactivation slopes are also blurred. We propose an alternative to Gaussian filtering by restoring the signal using a spatiotemporal Markov Random Field which preserves the shape of the transitions. We define some interaction between neighboring voxels which allows us to reduce the noise while preserving the signal characteristics. An energy function is defined as the sum of the interaction potentials and is minimized using a simulated annealing algorithm. The shape of the hemodynamic response is preserved leading to a better characterization of its properties. We demonstrate the use of this approach by applying it to simulated data and to data obtained from a typical fMRI study.     

Myocardial perfusion SPET in the detection of coronary artery disease in orthotopic heart transplantation

BACKGROUND: Thallium-201 (201Tl) reinjection after conventional redistribution imaging is a standard procedure, resulting in enhanced 201Tl redistribution which is compatible with viable myocardium. Although this method significantly improves identification of viable myocardium, it increases the investigation time by approximately 1 h. Thus, this technique is suboptimal from the standpoint of patient convenience, since its routine performance may be impractical in a high-volume nuclear medicine laboratory. HYPOTHESIS: This study was undertaken to evaluate the efficacy of an early 201Tl reinjection and imaging protocol in combination with sublingual nitroglycerin, to detect myocardial ischemia and/or viability, and to reduce the need for conventional (4 h) redistribution imaging. MATERIALS AND METHODS: In this study, 62 consecutive coronary patients, referred for the detection of possible myocardial ischemia and/or viability, were involved (mean age 55 years, range 41-70). Of those, 50 had previous angina attacks, with 42 having a history of previous myocardial infarction; 10 patients had coronary artery bypass grafting; and the remaining 2 had atypical chest pain. Immediately after the completion of the initial postexer-cise imaging, 0.3 mg sublingual nitroglycerin followed by the reinjection of 1 m Ci of 201Tl were administered, and two further sets of images were acquired 1 h and 4 h later. RESULTS: In each set of images, a total of 496 segments were analyzed. On postexercise imaging, 305 (61%) segments demonstrated defects of which 198 (65%) showed enhanced thallium uptake, 97 (32%) did not change, and 10 (3%) showed reverse redistribution on 1 h reinjection imaging (IRI). Of the 97 persistent defects, only 17 (6%) showed fill-in of 201Tl on 4 h redistribution imaging (CRI), while 12 (4%) segments showed reverse redistribution. On the other hand, after analyzing the 62 patients of the 1 h IRI, 17 (27%) remained unchanged while in only 1 patient (6%) of 17 the diagnosis changed from myocardial necrosis to ischemia after analysis of the 4 h CRI. CONCLUSION: These results indicate that early postexercise reinjection of 201Tl in combination with sublingual nitroglycerin followed by 1 h image acquisition may prove useful for a comprehensive and convenient assessment of myocardial ischemia and/or viability.