心血管疾患と診断

The majority of acute viral myocarditis cases are subclinical and self-limiting in both adults and children. However, acute fulminant myocarditis (AFM) has a fatal course due to the rapid development into acute heart failure, cardiogenic shock or serious arrhythmias. Cardiac thrombus formation is an important factor affecting the prognosis of these patients. We present a patient who was diagnosed as AFM with multiple free floating intracardiac thrombi and aimed to explore the clinical characteristics and the treatment of AFM.

Background: In spite of its potential clinical prognostic significance, only a small number of studies have been conducted to date involving neonatal cardiac troponin-I as an early indicator of significance respiratory dysfunction.

Objective: Aim of this study was to evaluate the clinical significance cardiac troponin-I as marker of cardiorespiratory failure in term newborns. Methods: Cardiac troponin-I level was determined in serum (at 24-48 hours after birth) in 55 term neonates with respiratory distress and 36 healthy, term newborns. The cardiac troponin-I level is correlated with the total duration of oxygen and ventilatory therapy (expressed in days) in both groups with (13/55) or without (32/55) deaths.

Results: Newborns with respiratory distress had a significantly higher level of cardiac troponin-I, compared to the control group, with the largest increase in cardiac troponin-I observed in mechanically ventilated patients (31/55). The length of applied respiratory support was positively correlated with the level of cardiac troponin-I in survivors of respondents, while in the group of children who died the level of cardiac troponin-I was negatively correlated with total duration of respiratory support, and the number of days to death.

Conclusions: The increase in cardiac troponin-I could indicate the development of severe respiratory failure in term neonates with respiratory distress.

Background: The greater saphenous vein is still frequently used as a conduit for coronary artery bypass grafting (CABG). Previously, veins were harvested through a single continuous skin incision, commonly referred to as open vein harvesting (OVH), while endoscopic vein harvesting (EVH) techniques have become increasingly popular. However, the postoperative consumption of healthcare resources remains uncertain. Therefore, the present study performed a systematic review, with meta-analysis, of outcomes relating to consumption of healthcare resources and clinical effectiveness following EVH and OVH for CABG.

Methods: A systematic search was performed in five databases. OVH was defined as the use of open harvesting techniques using a single continuous incision, and all studies comparing EVH to OVH for CABG were eligible.

Results: EVH was associated with increased duration of surgery, no difference in the length of stay in intensive care units, a reduced total length of stay in hospital, a reduced need for antibiotic treatment for leg wound infections, a reduced need for follow-up visit(s) at general practitioners/out-patient clinics, a reduced need for visit(s) by the homecare nurses, a reduced need for revision(s) of the leg wound, a reduced need for readmission(s) related to leg wounds complications and no difference in repeat cardiac catheterization(s). Furthermore, EVH reduced pain intensity approximately five days postoperatively, but not 30 days postoperatively. EVH did not increase the occurrence of mid-term myocardial infarction, recurrence of chest pain, repeat revascularization and mid-term allcause mortality.

Conclusions: EVH provides safe clinical outcomes compared to OVH while reducing the short-term postoperative resource consumption. This article provides a formal synthesis of the available data on clinical effectiveness and consumption of healthcare resources following EVH and OVH for CABG, hence enabling future investigation of the long-term cost-effectiveness of methods.

The potential utility of stem cell therapies for vascular regeneration provides a novel disease-modifying approach towards vasculopathies such as coronary artery disease, peripheral vascular disease and diabetic retinopathy. Stem cell therapies can potentially replace damaged vascular tissue, attenuate further vascular damage, and release soluble factors that act in a paracrine or endocrine manner to facilitate repair and reversal of the pathology that underlies the genesis and propagation of damage within the vasculature. This review critically considers the role of stem cell therapeutics in vascular regeneration.

A 34 year old female with undiagnosed myasthenia gravis (MG) presented with shortness of breath and weakness. She was diagnosed with community acquired pneumonia and myasthenic crisis (MC). Her hospital course was complicated by hypoxemic respiratory failure requiring intubation with echocardiography revealing a hyper-dynamic apex and basilar hypokinesis consistent with Reverse Takotsubo Cardiomyopathy (RTCM). We present the first published case of RTCM from MC and review the existing cases of stress induced cardiomyopathies in MG patients.

Systemic autoimmune diseases (SADs) are associated with significantly enhanced cardiovascular (CV) morbidity and mortality due to a cluster of risk factors. Among them we find traditional markers of CV risk but also specific risk factors principally related to inflammation and autoimmunity. Therefore, CV involvement assessment in those diseases is more and more important and several authors have been studying for the last years that phenomenon. The most important goal for all of them is CV prevention and follow-up of subjects with such abnormalities; in particular, CV burden is mainly due to atherosclerosis (ATS). So, in order to achieve the best CV prevention program a very early diagnose of ATS in these patients (pts) is fundamental, especially in those phases of disease in which no symptoms are present and clinical manifestations are not clearly visible. In this review, our aim was to find the best marker for identifying early ATS in systemic autoimmune diseases (SADs) by starting our long experience in this field.

Objective: To evaluate the clinical course of patients treated for multiple perforations, complex femoral artery pseudoaneurysms.

Methods: Seven patients with multiple perforations, complex pseudoaneurysms after femoral artery access for interventional procedures were treated. Ultrasound-guided thrombin injection (UGTI) was first used for treatment. Patients failing repeated UGTIs were treated with fibrin sealant injections.

Results: Five of the seven patients treated with UGTIs had rapid thrombus formation within the pseudoaneurysm. Two patients refractory to UGTI had successful treatment using fibrin sealant injection. There were no complications and the overall cure rate was 100%.

Conclusions: Treatment of complex femoral artery pseudoaneurysms is safe and effective. UGTI and fibrin sealant are useful in the treatment of complex pseudoaneurysms.

Mercury toxicity is highly correlated with hypertension, coronary heart disease (CHD), myocardial infarction (MI), stroke and other cardiovascular disease. Mercury has a high affinity for sulfhydryl (-SH) groups, which inactivates numerous enzymatic reactions, amino acids, and sulfur-containing antioxidants [NAC (n-acetyl cysteine, ALA (alpha lipoic acid), GSH (glutathione)], with subsequent decreased oxidant defense and increased oxidative stress. Mercury binds to metallothionein and substitutes for zinc, copper, and other trace metals reducing the effectiveness of metalloenzymes. Mercury induces mitochondrial dysfunction with reduction in ATP, depletion of glutathione, and increased lipid peroxidation. Selenium and fish containing omega 3 fatty acids or omega 3 fatty acids supplements with DHA and EPA antagonize mercury toxicity. The overall vascular effects of mercury include increased oxidative stress, inflammation, reduced oxidative defense, thrombosis, vascular smooth muscle dysfunction and hypertrophy, endothelial dysfunction, dyslipidemia, immune and mitochondrial dysfunction. The clinical consequences of mercury toxicity include hypertension, CHD, MI, cardiac arrhythmias, reduced heart rate variability, increased carotid IMT and carotid artery obstruction, CVA, generalized atherosclerosis, renal dysfunction, renal insufficiency and proteinuria. Pathological and biochemical findings correlate with the clinical manifestations of mercury toxicity. Mercury diminishes the protective effect of fish and omega-3 fatty acids. Mercury inactivates COMT (catecholamine 0 methyl transferase), which increases serum and urinary epinephrine, norepinephrine, and dopamine. This effect will increase blood pressure and may be a clinical clue to mercury- induced heavy metal toxicity. Mercury toxicity should be evaluated in any patient with hypertension, CHD, MI, CVD, CVA or other vascular disease. Specific testing for acute and chronic toxicity and total body burden using hair, toenail, urine and serum should be done with both baseline and provocation methods.

Trauma is one of the most common causes of death worldwide. Penetrating cardiac injury (PCI) is highly lethal and represents an increasingly important form of traumatic injury. We describe a 25 year-old man suffered stab wound and PCI, as a result of which he underwent surgical thoracotomy for tamponade. He was discharged in good clinical condition and no cardiac perforation was detected. Two weeks later, he presented to our center with prolonged chest pain. Electrocardiography (ECG) and cardiac biomarkers confirmed myocardial damage. Echocardiography showed hypokinesia and thinning (0.6 mm) of the inferoapical wall segment and mildly reduced left ventricular systolic function. Angiography revealed patent left main coronary artery, LAD, left circumflex, and right coronary artery, along with an abnormal aneurysmal structure at the distal part of the LAD. Coil embolization of the distal LAD pseudoaneurysm was performed which was placed to occlude the proximal entry site of the pseudoaneurysm. Angiography confirmed the disappearance of the pseudoaneurysm. The patient was discharged after 48 hours. Follow-up angiography after two months showed no residual leakage across the vessel. Coil embolization of a distal coronary pseudoaneurysm can be performed as an alternative procedure instead of surgical ligation of the small vessels, with good results. It should be emphasized that one should occlude both proximal and distal entry sites to avoid blood leakage.