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Patients with acute myocardial infarction (AMI) triaged as life-threatening are transferred to our emergency medical care center (EMCC). However, data on these patients remain limited. We aimed to compare the characteristics and AMI prognosis of patients transferred to our EMCC with those transferred to our cardiovascular intensive care unit (CICU) using whole and propensity-matched cohorts.We analyzed the data of 256 consecutive AMI patients transferred from the scene to our hospital by ambulance between 2014 and 2017. The EMCC and CICU groups comprised 77 and 179 patients, respectively. There were no significant between-group age or sex differences. Patients in the EMCC group had more disease severity score and had the left main trunk identified as the culprit more frequently (12% versus 0.6%, P < 0.001) than those in the CICU group; however, the number of patients with multiple culprit vessels did not differ. The EMCC group had a longer door-to-reperfusion time (75 [60, 109] minutes versus 60 [40, 86] minutes, P< 0.001) and a higher in-hospital mortality (19% versus 4.5%, P < 0.001), especially from non-cardiac causes (10% versus 0.6%, P < 0.001), than the CICU group. However, peak myocardial creatine phosphokinase did not significantly differ between the groups. The EMCC group had a significantly higher 1-year post-discharge mortality than the CICU group (log-rank, P = 0.032); this trend was maintained after propensity score matching, although the difference was not statistically significant (log-rank, P = 0.094).AMI patients transferred to the EMCC exhibited more severe disease and worse overall in-hospital and non-cardiac mortality than those transferred to the CICU.

DOI： 10.1536/ihj.22-654

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Although the primary percutaneous coronary intervention (PCI) is an established treatment for acute ST-elevation myocardial infarction (STEMI), relevant guidelines do not recommend it for recent-STEMI cases with a totally occluded infarcted related artery (IRA). However, PCI is allowed in Japan for recent-STEMI cases, but little is known regarding its outcomes. We aimed to examine the details and outcomes of PCI procedures in recent-STEMI cases with a totally occluded IRA and compared the findings with those in acute-STEMI cases.Among the 903 consecutive patients admitted with acute coronary syndrome, 250 were treated with PCI for type I STEMI with a totally occluded IRA. According to the time between symptom onset and diagnosis, patients were divided into the recent-STEMI (n = 32) and acute-STEMI (n = 218) groups. The background, procedure details, and short-term outcomes were analyzed. No significant differences between the groups were noted regarding patient demographics, acute myocardial infarction severity, or IRA distribution. Although the stent number and type were similar, significant differences were observed among PCI procedures, including the number of guidewires used, rate of microcatheter or double-lumen catheter use, and application rate of thrombus aspiration. The thrombolysis rate in the myocardial infarction flow 3-grade post-PCI did not differ significantly between the groups. Both groups had a low frequency of procedure-related complications. The in-hospital mortality rates were 0% and 4.6% in the recent-STEMI and acute-STEMI groups, respectively (P > 0.05).Although recent-STEMI cases required complicated PCI techniques, their safety, success rate, and in-hospital mortality were comparable to those of acute-STEMI cases.

DOI： 10.1536/ihj.22-656

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Language：Japanese   Publisher：(一社)日本集中治療医学会  

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Language：Japanese   Publisher：(一社)日本脈管学会  

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BACKGROUND: In acute aortic dissection, weekend admissions are reported to be associated with increased mortality compared with weekday admissions. OBJECTIVE: This study aimed to determine whether patients with acute type A aortic dissection (ATAAD) admitted on weekends had higher in-hospital mortality than those admitted on weekdays in the Tokyo metropolitan area, where we developed a patient-transfer system for aortic dissection. METHODS: Data were collected during the first year after our transfer system began (cohort I) and in the subsequent years from 2013 to 2015 (cohort II). RESULTS: We studied 2,339 patients (500 in cohort I; 1,839 in cohort II) with ATAAD. Patients with weekend admissions had higher in-hospital mortality than those with weekday admissions in cohort I. In association with increased interfacility transfer during weekends and reduced mortality at non-high-volume centers, the in-hospital mortality in the weekend group improved from 37.2% in cohort I to 22.2% in cohort II (P < 0.001). After inverse probability weighting adjustment, weekend admission was associated with higher in-hospital mortality in cohort I (odds ratio: 2.28; 95% confidence interval: 1.48 to 3.52; P < 0.001), but not in cohort II (odds ratio: 0.96; 95% confidence interval: 0.75 to 1.22; P = 0.731). On multivariable analyses, weekend admission was associated with higher in-hospital mortality in combined cohort I+II; the associations between weekend admission and mortality were not significant in cohort II. CONCLUSIONS: We found a significant reduction in in-hospital mortality in patients with weekend admissions for ATAAD. No mortality difference between weekend and weekday admissions was observed in the later years of the study.

DOI： 10.1016/j.jacasi.2021.11.010

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Background The association between female sex and poor outcomes following surgery for type A acute aortic dissection has been reported; however, sex-related differences in clinical features and in-hospital outcomes of type B acute aortic dissection, including classic aortic dissection and intramural hematoma, remain to be elucidated. Methods and Results We studied 2372 patients with type B acute aortic dissection who were enrolled in the Tokyo Acute Aortic Super-Network Registry. There were fewer and older women than men (median age [interquartile range]: 76 years [66-84 years], n=695 versus 68 years [57-77 years], n=1677; P<0.001). Women presented to the aortic centers later than men. Women had a higher proportion of intramural hematoma (63.7% versus 53.7%, P<0.001), were medically managed more frequently (90.9% versus 86.3%, P=0.002), and had less end-organ malperfusion (2.4% versus 5.7%, P<0.001) and higher in-hospital mortality (5.3% versus 2.7%, P=0.002) than men. In multivariable analysis, age (per year, odds ratio [OR], 1.06 [95% CI, 1.03-1.08]; P<0.001), hyperlipidemia (OR, 2.09 [95% CI, 1.13-3.88]; P=0.019), painlessness (OR, 2.59 [95% CI, 1.14-5.89]; P=0.023), shock/hypotension (OR, 2.93 [95% CI, 1.21-7.11]; P=0.017), non-intramural hematoma (OR, 2.31 [95% CI, 1.32-4.05]; P=0.004), aortic rupture (OR, 26.6 [95% CI, 14.1-50.0]; P<0.001), and end-organ malperfusion (OR, 4.61 [95% CI, 2.11-10.1]; P<0.001) were associated with higher in-hospital mortality, but was not female sex (OR, 1.67 [95% CI, 0.96-2.91]; P=0.072). Conclusions Women affected with type B acute aortic dissection were older and had more intramural hematoma, a lower incidence of end-organ malperfusion, and higher in-hospital mortality than men. However, female sex was not associated with in-hospital mortality after multivariable adjustment.

DOI： 10.1161/JAHA.121.024149

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BACKGROUND: High coronary thrombus burden has been associated with unfavorable outcomes in patients with ST-segment elevation myocardial infarction (STEMI), the optimal management of which has not yet been established. METHODS: We assessed the adjunctive catheter-directed thrombolysis (CDT) during primary percutaneous coronary intervention (PCI) in patients with STEMI and high thrombus burden. CDT was defined as intracoronary infusion of tissue plasminogen activator (t-PA; monteplase). RESULTS: Among the 1849 consecutive patients with STEMI, 263 had high thrombus burden. Moreover, 41 patients received t-PA (CDT group), whereas 222 did not receive it (non-CDT group). No significant differences in bleeding complications and in-hospital and long-term mortalities were observed (9.8% vs. 7.2%, p = 0.53; 7.3% vs. 2.3%, p = 0.11; and 12.6% vs. 17.5%, p = 0.84, CDT vs. non-CDT). In patients who underwent antecedent aspiration thrombectomy during PCI (75.6% CDT group and 87.4% non-CDT group), thrombolysis in myocardial infarction grade 2 or 3 flow rate after thrombectomy was significantly lower in the CDT group than in the non-CDT group (32.2% vs. 61.0%, p < 0.01). However, the final rates improved without significant difference (90.3% vs. 97.4%, p = 0.14). CONCLUSIONS: Adjunctive CDT appears to be tolerated and feasible for high thrombus burden. Particularly, it may be an option in cases with failed aspiration thrombectomy.

DOI： 10.3390/jcm11010262

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BACKGROUND: An inter-arm difference in blood pressure (IADBP) is characteristic of acute aortic dissection (AAD), but the importance of which arm exhibits lower blood pressure (BP) and the mechanism underlying IADBP are not well understood. METHODS: We identified consecutive patients with chest and/or back pain and suspected acute cardiovascular disease whose BP had been measured in both arms. We retrospectively compared the characteristics of such patients with AAD (n=93) to those without AAD (non-AAD group, n=122). Additionally, we separately compared patients with type A AAD (TAAD group, n=58) or type B AAD (TBAD group, n=35) to the non-AAD group. The characteristics analyzed were patient background and IADBP-related factors, including systolic BP (SBP) in the right arm (R) and left arm (L), and R-L or L-R as IADBP. Computed tomography (CT) findings of AD extending to the brachiocephalic artery (BCA) and/or left subclavian artery (LSCA) were examined in patients with an IADBP. RESULTS: In a comparison of the TAAD group and non-AAD group, the prevalences of R <130 mm Hg (38% vs. 19%, p=0.009), L-R >15 mm Hg (19% vs. 8%, p=0.047), L-R >20 mm Hg (14% vs. 4%, p=0.029) were higher in the TAAD group. Multivariate analysis showed that L-R >15 mm Hg with R <130 mm Hg was independently associated with TAAD (OR 25.97, 95% CI 2.45-275.67, p=0.007). However, IADBP-related factors were not associated with TBAD. AAD patients with L-R >20 mm Hg all had TAAD, and all aortic dissection extended to the BCA just before the right common carotid artery on CT. CONCLUSIONS: IADBP was characterized by R<L with low R in TAAD but was not associated with TBAD.

DOI： 10.1272/jnms.JNMS.2021_88-605

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OBJECTIVES: We investigated the various pre- and postoperative complications related to early (30-day) mortality after open surgery for acute type A aortic dissection. METHODS: Data from the Tokyo Acute Aortic Super-network database spanning January 2015 to December 2017 were retrospectively reviewed. Pre- and postoperative factors related to early postoperative mortality were assessed in 1504 of 2058 (73.0%) consecutive patients [age: 66.6 (SD: 13.5) years, male: 52.9%] who underwent acute type A aortic dissection repair. RESULTS: The early mortality rate following surgical repair was 8.9%. According to multivariable analysis, male sex [odds ratio (OR) 1.670, 95% confidence interval (CI) 1.063-2.624, P = 0.026], use of percutaneous circulatory assist devices (n = 116, 7.7%) including extracorporeal membrane oxygenators or intra-aortic balloon pumps (OR 4.857, 95% CI 2.867-8.228, P < 0.001), shock (n = 162, 10.8%) (OR 3.06, 95% CI 1.741-5.387, P < 0.001), cardiopulmonary arrest (n = 41, 2.7%) (OR 7.534, 95% CI 3.407-16.661, P < 0.001), coronary ischaemia (n = 36, 2.3%) (OR 2.583, 95% CI 1.042-6.404, P = 0.041) and cerebral ischaemia (n = 59, 3.9%) (OR 2.904, 95% CI 1.347-6.261, P = 0.007) were independent preoperative risk factors for early mortality, while cardiac tamponade (n = 34, 2.3%) (OR 10.282, 95% CI 4.640-22.785, P < 0.001), cerebral ischaemia (n = 80, 5.3%) (OR 2.409, 95% CI 1.179-4.923, P = 0.016) and mesenteric ischaemia (n = 15, 1.0%) (OR 44.763, 95% CI 13.027-153.808, P < 0.001) were independent postoperative risk factors. CONCLUSIONS: Not only critical preoperative conditions but also postoperative cardiac tamponade and vital organ ischaemia are risk factors for early mortality after acute type A aortic dissection repair.

DOI： 10.1093/ejcts/ezab146

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DOI： 10.1111/1346-8138.15974

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BACKGROUND: In the modern US cardiovascular intensive care unit (CICU), the incidence of non-cardiovascular disorders has increased and non-cardiovascular disorders are associated with an increase in morbidity and mortality. In Japan, however, data regarding the association between non-cardiovascular disorders and outcomes in the CICU are limited. METHODS: This study examined 490 consecutive admissions to a closed CICU at the Nippon Medical School Hospital from January to December 2017. Characteristics, diagnoses, treatments, and outcomes of admitted patients were identified. RESULTS: The most common primary diagnosis was acute coronary syndrome (50.4%), followed by acute heart failure (20.0%), arrhythmia (6.7%), and non-cardiovascular diseases (3.7%). The mortality rate and median length of stay (LOS) in the CICU were 4.7% and 4 (interquartile range, 2-8) days, respectively. Of all patients, 42.2% (n = 207) developed non-cardiovascular complications such as acute respiratory failure, acute kidney injury, or sepsis during CICU stay. Multivariate logistic regression analysis revealed that acute respiratory failure and sepsis were significantly associated with mortality in the CICU (odds ratio, 11.014 and 25.678, respectively; both p<0.05). The multiple linear regression analysis showed that acute kidney injury was significantly associated with LOS in the CICU (β=0.144, p = 0.002). CONCLUSIONS: Approximately half of patients admitted to the CICU had non-cardiovascular disorders including non-cardiovascular disease and non-cardiovascular complications, which were significantly associated with mortality and LOS in the CICU.

DOI： 10.1016/j.jjcc.2021.03.002

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Vascular Ehlers-Danlos syndrome (vEDS) causes fatal vascular complications due to vascular fragility. However, invasive therapeutic procedures are generally avoided except in emergencies. We report a case of vEDS presenting with rapid expansion of a hepatic arterial aneurysm successfully treated using prophylactic endovascular therapy. A 43-year-old woman with vEDS confirmed by genetic testing was hospitalized for a symptomatic hepatic arterial aneurysm that expanded rapidly within a week. Prophylactic coil embolization was then successfully performed. Although the general applicability of this approach cannot be determined, prophylactic endovascular therapy can clearly be an option for arterial aneurysms at high risk of rupture.

DOI： 10.3400/avd.cr.20-00144

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OBJECTIVES: Several factors determining differences between types A and B aortic dissection (AD) have been reported; however, little data exist examining their differences in left ventricular hypertrophy (LVH). We compared the prevalence of LVH in patients with types A and B AD. METHODS: We retrospectively analyzed 334 patients with acute AD (227 type A; 107 type B). Concentric hypertrophy (CH; increased left ventricular mass index [LVMI] and relative wall thickness [RWT]) is one of four types of left ventricular (LV) geometry thought to be most associated with hypertension. We compared LVMI and the prevalence of CH in patients with types A or B AD. Multivariate logistic regression analyses of variables associated with type B AD were performed. RESULTS: Comparing type A and B AD, LVMI (95 ± 26 vs.107 ± 28, p <0.001) and prevalence of CH (26% vs. 44%, p = 0.001) were higher in type B AD. In multivariate analysis, CH was an independent factor associated with type B AD (odds ratio: 2.62, confidence interval: 1.54-4.47, p <0.001). CONCLUSIONS: Our data suggested LVH was more prevalent in type B than in type A AD. Considering LVH usually results from hypertension, patients with type B AD may be more affected by hypertension than those with type A.

DOI： 10.5761/atcs.oa.20-00137

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BACKGROUND: Spontaneous isolated dissection of abdominal visceral arteries without aortic dissection is rare and its pathology and prognosis are not yet clear; therefore, therapeutic strategies for this disease have not been established. The present multi-institution investigational study analyzed the clinical features of patients with spontaneous isolated dissection of abdominal visceral arteries. METHODS: A total of 36 patients diagnosed as spontaneous isolated dissection of abdominal visceral arteries from January 2010 to October 2016 were enrolled. The medical data of the patients were retrospectively reviewed. Imaging characteristics were evaluated. Spontaneous isolated dissection of abdominal visceral arteries was detected on upper abdominal computed tomography examination in almost patients, and was detected on magnetic resonance imaging in one patient. RESULTS: Of the 36 cases, 26 cases involved the superior mesenteric artery dissection, nine involved the celiac artery, two involved the splenic artery, one involved the common hepatic artery, one involved the gastroduodenal artery and one involved the left gastric artery. Among the 36 patients, 20 had hypertension and 14 were current smokers. Additionally, only one patient had diabetes and four patients had dyslipidemia. Moreover, 32 cases complained of pain including abdominal pain and back pain, one had cough and three had no symptoms. Of the 36 patients, 34 cases (94.4%) were treated conservatively, and two (5.6%) required intravascular treatment. All patients were discharged without complications. CONCLUSIONS: Our findings indicate that hypertension and smoking might be closely involved in the pathogenesis of spontaneous isolated dissection of abdominal visceral arteries, whereas dyslipidemia and diabetes might be less involved. Additionally, few asymptomatic patients were accidentally diagnosed, indicating that the absence of symptoms cannot be used to rule out the presence of this disease. Randomized clinical trials cannot be performed because a considerable number of cases are required. Therefore, detailed descriptions of clinical features, as provided in our report, are important.

DOI： 10.14740/jocmr3916

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Type III collagen is the major protein in the walls of blood vessels and hollow organs; it is decreased in patients with vascular Ehlers-Danlos syndrome (EDS). A 52-year-old man was admitted for severe back pain, and right hemothorax was suspected by chest computed tomography. Immediately after embolization for bleeding bronchial artery, aortic dissection occurred and was treated conservatively in the intensive-care unit. Vascular EDS with a mutation of COL3A1 cDNA (c.3175G>A) was diagnosed. When vascular EDS is suspected, the patient should be treated prophylactically, and a genetic examination should be performed to confirm the diagnosis.

DOI： 10.2169/internalmedicine.2983-19

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Acute aortic dissection (AAD) cases are thought to have high blood pressure (BP) on admission; however, little data are available on BP prior to admission. The purpose of this study was to investigate systolic blood pressure (SBP) very early after symptom onset and before hospital transfer in patients with AAD to determine whether SBPs were high, and also whether SBPs were higher or lower compared with SBPs at hospital admission. We obtained results using three-year data derived from the Tokyo Acute Aortic Super Network Database. First, we selected 830 patients with AAD for which the "duration from symptom onset to first medical contact by ambulance crews" (SO-FMC) was within 60 min. We examined the SBPs of such patients. Next, we selected 222 patients with AAD whose SBPs were measured both at FMC, within 15 min after symptom onset, and at hospital admission, and compared SBPs at FMC with those at hospital admission. Among types A (n = 190) and B (n = 117), in patients with an SO-FMC ≤ 15 min, the median SBP was 100 mmHg and 178 mmHg (p < 0.001), respectively; 9% and 50% (p < 0.001) of such patients, respectively, exhibited an SBP ≥ 180 mmHg; and 43% and 10% (p < 0.001) of such patients, respectively, had an SBP < 90 mmHg. Of patients with types A (n = 124) and B (n = 98) AAD whose SBPs were measured both at FMC, within 15 min after symptom onset, and at hospital admission, SBPs at FMC were higher than those at hospital admission for the SBP ≥ 180 mmHg subgroups of both type A (194 mmHg vs. 159 mmHg, p < 0.001) and type B (199 mmHg vs. 186 mmHg, p < 0.001). Approximately 10 min after symptom onset and before hospital transfer, the measured SBPs of many patients with type A AAD were not necessarily high. However, the SBPs of cases with type B AAD were high as previously reported for SBP on admission. In addition, for the subgroup of SBP ≥ 180 mmHg at FMC within 15 min after symptom onset, SBPs at FMC were significantly higher than those at hospital admission for both types A and B; the higher SBP at symptom onset may have been partially associated with being a trigger of AD.

DOI： 10.1007/s00380-019-01419-9

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We discuss the etiology of aortic dissection (AD) from various points of view. The development of AD requires two pathological conditions: medial degeneration and mechanical wall stress. First, histopathological findings of medial degeneration are hypothesized to be due to a loss of elastic fibers and interconnecting elastic fibers. Damage to the vasa vasorum plays a key role in creating an entry site. The clinical causes of medial degeneration include hypertension, aortic aneurysms, obstructive sleep apnea, and connective tissue disorders. Second, mechanical wall stress is supposedly induced by shear stress caused by blood flow, together with hypertension and aortic root movement. Further investigation is necessary in the search for mechanisms responsible for medial degeneration prior to AD development.

DOI： 10.1007/s11748-019-01066-x

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A 64-year-old man was admitted for evaluation of back pain. He did not have a Marfan syndrome (MFS)-like appearance, and had a history of a type B aortic dissection and total arch replacement. A connective tissue disorder had been suspected because of the histologic findings of the resected aortic wall. On admission, a computed tomography (CT) scan demonstrated a three-channeled aortic dissection (3ch-AD) measuring 63 mm in diameter. We planned to perform elective surgery during his hospitalization. On the fourth hospital day, he complained of severe back pain, and enhanced CT scan revealed an aortic rupture. The patients with 3ch-AD often have MFS. However, even if they do not have an MFS-like appearance, clinicians should consider fragility of the aortic wall in patients with 3ch-AD. If the aortic diameter is enlarged, early surgery is recommended. In particular, if a connective tissue disorder is obvious or suspected, emergent surgery is warranted.

DOI： 10.5761/atcs.cr.17-00066

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Language：Japanese   Publisher：(一社)日本心臓病学会  

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DOI： 10.21037/jtd.2017.07.05

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Cardiac tamponade is an important and potentially lethal complication of acute pericarditis. However, recurrence of cardiac tamponade is rare when it is treated appropriately. We present a 49-year-old man with bacterial pericarditis and recurrent cardiac tamponade, which was caused by the rupture of an upper part of the left atrium (LA). According to the autopsy findings, bacteremia from Staphylococcus aureus developed on a substrate of poorly controlled diabetes mellitus and spread to the pericardium via the blood. Subsequently, tissue necrosis developed from the pulmonary trunk and aorta to the LA, leading to recurrence of cardiac rupture and cardiac tamponade.

DOI： 10.1272/jnms.84.133

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Previous reports have shown that serum elastin fragments (SEFs) may be a useful biomarker for the diagnosis of an acute aortic dissection (AAD). However, because the reference interval of SEFs has not been established, it has not been determined whether SEFs are really useful for the diagnosis of AAD. The purpose of this study was to determine the usefulness of measuring SEFs for the diagnosis of AAD. A total of 42 consecutive patients aged 68 ± 18 years who were diagnosed with an AAD were studied. Patient background and SEF levels were examined on admission. SEF levels were also measured in patients undergoing a medical examination (n = 531, age 54 ± 17 years) to compare with those with an AAD. In the control group, SEF levels increased with age (R = 0.725, p <0.001). Then, we defined the upper limit of the reference interval of SEF levels as the 97.5th percentile of control SEF grouped by decade of life from the sixth to ninth decade. The overall risk of AAD exceeding the upper limit of the reference interval at each decade was 10% (4 of 42). For patients in their 60s and 70s, median SEF levels in the AAD group (89 [77 to 104], 93 [60 to 123] ng/ml, respectively) were not significantly higher than those in the control group (79 [68 to 92], 90 [79 to 106] ng/ml, respectively; p = 0.081 and 0.990, respectively). Our data suggest that measuring SEF levels may not be useful in the diagnosis of an AAD as the upper limit of the reference interval of the SEF level was unexpectedly higher.

DOI： 10.1016/j.amjcard.2016.07.052

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Language：Japanese   Publisher：(一社)日本脈管学会  

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Language：Japanese   Publisher：(一社)日本脈管学会  

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Language：Japanese   Publisher：(公財)日本心臓財団  

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Other Link： https://search.jamas.or.jp/index.php?module=Default&action=Link&pub_year=2016&ichushi_jid=J00679&link_issn=&doc_id=20160727210038&doc_link_id=%2Fah2sinzd%2F2016%2F004807%2F040%2F0844-0844%26dl%3D2&url=https%3A%2F%2Fwww.medicalonline.jp%2Fjamas.php%3FGoodsID%3D%2Fah2sinzd%2F2016%2F004807%2F040%2F0844-0844%26dl%3D2&type=MedicalOnline&icon=https%3A%2F%2Fjk04.jamas.or.jp%2Ficon%2F00004_5.gif

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Objective A fever is observed in approximately one-third of cases of acute aortic dissection (AAD); however, the causes remain unclear. We investigated the mechanism of a fever in AAD by measuring the serum concentrations of inflammatory markers, mediators of coagulation and fibrinolysis, and procalcitonin, a marker of bacterial infection. Methods We retrospectively studied 43 patients with medically treated AAD without apparent infection. Patients were divided into those with (Group A; n=19) and without (Group B; n=24) a maximum body temperature >38°C. We established which patients fulfilled the criteria for systemic inflammatory response syndrome (SIRS), and its relationship with a fever was examined. Mediators of inflammation, coagulation and fibrinolysis were compared by a univariate analysis. Factors independently associated with a fever were established by a multivariate analysis. Results The criteria for SIRS were fulfilled in a greater proportion of patients in Group A (79%) than in Group B (42%, p=0.001). There was no difference in the procalcitonin concentration between Groups A and B (0.15±0.17 ng/mL vs. 0.11±0.12 ng/mL, respectively; p=0.572). Serum procalcitonin concentrations lay within the normal range in all patients in whom it was measured, which showed that the fever was caused by endogenous mediators. On the multivariate analysis, there was a borderline significant relationship between a fever and the prothrombin time-International Normalized Ratio (p=0.065), likely reflecting the extrinsic pathway activity initiated by tissue factor. Conclusion Our findings suggest that a fever in AAD could be caused by SIRS, provoked by endogenous mediators that influence the extrinsic coagulation pathway without elevating the serum procalcitonin concentration.

DOI： 10.2169/internalmedicine.55.5924

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Language：Japanese   Publisher：医学図書出版(株)  

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77歳、男性、近医にて高血圧症、COPDにて加療中であった。2014年10月、心窩部痛を主訴に近医を受診、循環器内科受診を勧められていたが放置。3日後に呼吸困難が出現し当院へ救急搬送された。12誘導心電図でII、III、aVF誘導のST上昇を、経胸壁心臓病超音波検査(TTE)で下壁の壁運動低下を認め、Trop Tも陽性であり、ST上昇型心筋梗塞と診断。緊急冠動脈造影を行ったところ、右冠動脈segment 2が完全閉塞しており同部位に薬剤溶出性ステントを留置した。術中に徐脈を契機にショックとなり経静脈的一時ペーシング、IABPを開始した。その後、一時ペーシング、IABPと順次離脱できたが、第13病日朝に突然胸部違和感が出現し、直後に心停止となった。TTEにて心嚢液貯留を認め、心破裂の合併を疑い心嚢ドレナージを行ったが効果なく死亡した。下壁梗塞発症2週間後に起きた心破裂であり啓発的な症例と考え、病理解剖所見、文献的考察を加え報告する。(著者抄録)

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Language：Japanese   Publisher：(一社)日本心臓病学会  

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Language：Japanese   Publisher：(一社)日本集中治療医学会  

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BACKGROUND: In practice, patients with acute aortic dissection (AAD) are generally divided into 2 groups according to the status of the false lumen: non-communicating or communicating. The similarities and differences between the 2 groups, however, have not been fully determined in a large population. METHODS AND RESULTS: We studied 502 patients with Stanford type B AAD. Clinical background at symptom onset was compared, and similarities and differences characterized, for patients with non-communicating (NC group, n=288) vs. communicating (C group, n=214) false lumens. Time of day (00.00-06.00 hours, 06.00-12.00 hours, 12.00-18.00 hours, and 18.00-24.00 hours) and extent of physical activity (extreme exertion, slight exertion, at rest, and sleeping) at symptom onset were similar between groups. Patients in the NC group were older (mean age, 71±11 years vs. 64±14 years, P<0.01) and had lower prevalence of distally extended aortic dissection (26% vs. 8%, P<0.01) and deaths in hospital (2% vs. 7%, P=0.011) than those in the C group. CONCLUSIONS: At symptom onset, clinical circumstances and physical activity were similar between the groups, and old age and a background of DeBakey IIIa aortic dissection may be associated with determination of false lumen status. The outcome in the NC group was better than in the C group.

DOI： 10.1253/circj.CJ-14-0828

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BACKGROUND: Few reports are available on the characteristics of electrical storms of ventricular tachycardia (VT storm) refractory to intravenous (IV) amiodarone. METHODS AND RESULTS: IV-amiodarone was administered to 60 patients with ventricular tachyarrhythmia between 2007 and 2012. VT storms, defined as 3 or more episodes of VT within 24 h, occurred in 30 patients (68±12 years, 7 female), with 12 having ischemic and 18 non-ischemic heart disease. We compared the clinical and electrocardiographic characteristics of the patients with VT storms suppressed by IV-amiodarone (Effective group) to those of patients not affected by the treatment (Refractory group). IV-amiodarone could not control recurrence of VT in 9 patients (30%). The Refractory group comprised 5 patients with acute myocardial infarctions. Although there was no difference in the VT cycle length, the QRS duration of both the VT and premature ventricular contractions (PVCs) followed by VT was narrower in the Refractory group than in the Effective group (140±30 vs. 178±25 ms, P<0.01; 121±14 vs. 179±22 ms, P<0.01). In the Refractory group, additional administration of IV-mexiletine and/or Purkinje potential-guided catheter ablation was effective. CONCLUSIONS: IV-amiodarone-refractory VT exhibited a relatively narrow QRS tachycardia. The narrow triggering PVCs, suggesting a Purkinje fiber origin, may be treated by additional IV-mexiletine and endocardial catheter ablation.

DOI： 10.1253/circj.CJ-15-0213

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Language：Japanese   Publisher：医学図書出版(株)  

84歳、男性。2013年10月、腹痛を主訴に近医を受診。意識消失発作も認め、当院消化器外科へ紹介された。腹部に拍動性腫瘤が触知されたため腹部単純CTを施行したところ、腎動脈下に87×82mmの腹部大動脈瘤が認められた。血圧は不安定で急速補液により一時的に上昇を認めるのみであり、腹部大動脈瘤破裂が強く疑われた。造影CTでは腹腔内と後腹膜への造影剤漏出が認められたため、腹部大動脈瘤破裂と診断し外科的治療の方針とした。しかし、血行動態が安定せず手術室への移動が困難であったため、大動脈閉塞バルン(intra-aortic balloon occlusion:IABO)を破裂した腹部大動脈瘤より中枢側の下行大動脈に留置した。収縮期血圧は140mmHg台まで上昇し、降圧薬を使用しながら手術室へと移動し、腎動脈下人工血管置換術および下腸間膜動脈再建術を施行した。IABOは腹腔内出血などに使用されるデバイスであるが、腹部大動脈瘤破裂にも有効であった。啓発的な症例と考え文献的考察を加えて報告する。(著者抄録)

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Other Link： https://search.jamas.or.jp/default/link?pub_year=2014&ichushi_jid=J00001&link_issn=&doc_id=20150217290039&doc_link_id=%2Faa6icutc%2F2014%2F0038s1%2F042%2F5119-5122%26dl%3D0&url=https%3A%2F%2Fwww.medicalonline.jp%2Fjamas.php%3FGoodsID%3D%2Faa6icutc%2F2014%2F0038s1%2F042%2F5119-5122%26dl%3D0&type=MedicalOnline&icon=https%3A%2F%2Fjk04.jamas.or.jp%2Ficon%2F00004_2.gif

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There is currently no reliable method of predicting the success of weaning from intra-aortic balloon pumping (IABP). The aim of this study was to investigate the ability of serum N-terminal pro-brain natriuretic peptide (NT-proBNP) level to predict the success of weaning from IABP. Consecutive patients scheduled for weaning from IABP were prospectively enrolled. NT-proBNP levels were measured at baseline (before the start of weaning) and cessation (just before cessation of IABP). Changes in NT-proBNP level between baseline and cessation were analyzed in 2 groups of patients: those who were successfully weaned and those who were not successfully weaned for any reason, including a decision to discontinue weaning, worsening of pulmonary edema after cessation of IABP, or unstable hemodynamics after cessation of IABP. A total of 30 patients were enrolled (mean age 66 ± 12 years, 16 men, 16 with acute myocardial infarctions, and 14 with acute exacerbation of chronic heart failure). Median (interquartile range) baseline NT-proBNP levels were not significantly different between the successful and unsuccessful weaning groups (4,200 [1,400 to 8,752] pg/ml vs (5,620 [2,035 to 13,950] pg/ml, p = 0.30). In the unsuccessful weaning group, the median NT-proBNP level was significantly higher at cessation (9,995 [2,920 to 15,100] pg/ml) than at baseline (p = 0.008). All patients with decreases in NT-proBNP level between baseline and cessation were successfully weaned from IABP. In conclusion, these results show that NT-proBNP levels were useful for predicting the success of weaning from IABP. If the NT-proBNP level increases during weaning from IABP, more intense management should be considered.

DOI： 10.1016/j.amjcard.2014.06.027

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Language：Japanese   Publisher：(一社)日本心臓病学会  

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Language：Japanese   Publisher：(一社)日本心臓病学会  

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Language：Japanese   Publisher：(一社)日本心臓病学会  

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Language：Japanese   Publisher：(一社)日本心臓病学会  

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Language：Japanese   Publisher：日本内科学会-関東地方会  

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Language：Japanese   Publisher：(一社)日本内科学会  

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Language：Japanese   Publisher：(一社)日本集中治療医学会  

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Language：Japanese   Publisher：(一社)日本集中治療医学会  

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An 81-year-old female complaining of severe back pain was admitted to hospital and diagnosed with acute type A aortic dissection with a thrombosed false lumen. Aggressive antihypertensive therapy was selected. On day 8, computed tomography showed pulmonary artery thrombus, and transthoracic echocardiography showed a 76×70 mm worm-like floating right heart thrombus. Thrombolytic therapy is reported to be the optimal treatment for patients with pulmonary embolism and floating right heart thrombus, but is contraindicated in acute aortic dissection. The patient underwent surgical thrombectomy, which revealed thrombus entrapped in the Chiari network. An inferior vena cava filter was placed. The patient recovered uneventfully and was discharged home after initiation of warfarin therapy.

DOI： 10.5761/atcs.cr.13-00218

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Patients with acute type B aortic dissection (ABAD) are often treated medically. However, ABAD is a potentially serious emergency if complicated by acute organ ischemia. The therapeutic strategy for ABAD with visceral malperfusion remains controversial. Because emergent surgery has a high mortality rate, emergent endovascular treatment can be performed instead. We report a case of endovascular fenestration with stenting for visceral malperfusion in ABAD. One stent was inserted across the intimal flap to keep the fenestrated site open, and another stent was placed into the narrowed true lumen. This therapeutic strategy may be feasible for ABAD with acute malperfusion.

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Language：Japanese   Publisher：医学図書出版(株)  

75歳、男性、冠危険因子:高血圧症、脂質異常症、喫煙歴。2012年10月、当院整形外科にて頸椎椎弓形成術を施行、麻酔覚醒後に胸痛を自覚。心電図にてV1～V4にST上昇、心臓超音波で前壁中隔の壁運動低下を認めST上昇型心筋梗塞(STEMI)と診断。しかし、頸椎椎弓形成術直後であり抗血小板薬や抗凝固薬の投与は硬膜外血腫など重篤な出血性合併症の可能性が懸念された。整形外科医と議論し、出血リスクは高いがドレーン挿入中であり、出血量のモニタリングが可能、出血性合併症が生じてもドレナージ効果により麻痺が生じにくいとの判断で再灌流療法を行う方針とした。冠動脈造影を施行したところ、左前下行枝#7が完全閉塞しており、病変形態からバルーンのみでの治療は困難と考えベアメタルステントを留置しTIMI 3で終了した。術後、抗血小板薬2剤併用を継続も出血性合併症なく独歩退院した。術直後にSTEMIを発症し重篤な出血性合併症が懸念され、治療方針の決定に苦慮した。啓発的な症例と考え文献的考察を加え報告する。(著者抄録)

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Other Link： https://search.jamas.or.jp/default/link?pub_year=2013&ichushi_jid=J00001&link_issn=&doc_id=20140123580039&doc_link_id=%2Faa6icutc%2F2013%2F0037s1%2F040%2F5125-5128%26dl%3D0&url=https%3A%2F%2Fwww.medicalonline.jp%2Fjamas.php%3FGoodsID%3D%2Faa6icutc%2F2013%2F0037s1%2F040%2F5125-5128%26dl%3D0&type=MedicalOnline&icon=https%3A%2F%2Fjk04.jamas.or.jp%2Ficon%2F00004_2.gif

Language：Japanese   Publisher：(一社)日本心臓病学会  

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DOI： 10.1016/j.ijcard.2012.08.037

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Recently, interferon gamma release assays (IGRAs) have become an important clinical tool for detecting latent tuberculosis. However, IGRA results may impede making a diagnosis. We herein present an interesting case of miliary tuberculosis with a nonspecific IGRA reaction due to hemophagocytosis.

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A 79-year-old man with a 3-month history of lymphedema of the lower limbs, and diabetes mellitus, was admitted to our hospital for suspected deep venous thrombosis. Several hours after admission, leg pain and purpura-like skin color appeared. On the 2nd hospital day, he was referred to our department for possible acute occlusive peripheral artery disease (PAD) and skin necrosis with blisters; however, computed tomography with contrast showed no occlusive lesions. He had already developed shock and necrotizing deep soft-tissue infections of the left lower leg. Laboratory findings revealed renal dysfunction and coagulation system collapse. Soon after PAD was ruled out, clinical findings suggested necrotizing deep soft-tissue infections, shock state, disseminated intravascular coagulation, and multiple organ failure. These symptoms led to a high suspicion of the well-recognized streptococcal toxic shock syndrome (STSS). With a high suspicion of STSS, we detected Group G β-hemolytic streptococci (GGS) from samples aspirated from the leg bullae, and the species was identified as Streptococcus dysgalactiae subsp. equisimilis (SDSE) by 16S-ribosomal RNA sequencing. However, unfortunately, surgical debridement was impossible due to the broad area of skin change. Despite adequate antimicrobial therapy and intensive care, the patient died on the 3rd hospital day. The M-protein gene (emm) typing of the isolated SDSE was revealed to be stG6792. This type of SDSE is the most frequent cause of STSS due to GGS in Japan. We consider it to be crucial to rapidly distinguish STSS from acute occlusive PAD to achieve life-saving interventions in patients with severe soft-tissue infections.

DOI： 10.1007/s10156-012-0375-x

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Language：Japanese   Publisher：(一社)日本脈管学会  

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Although patients with abdominal aortic aneurysm (AAA) often have other cardiovascular diseases (CVDs), the exact prevalence remains unclear. We aimed to determine the prevalence and predictors of coexistent silent atherosclerotic cardiovascular diseases (SACVDs) in patients with AAA without a history of CVD. Consecutive 157 patients with AAA (mean age, 73 years), without any previous history of CVD, were included. Silent myocardial ischemia (SMI), cerebrovascular disease (CeVD), peripheral artery disease (PAD), and thoracic aortic aneurysm (TAA) without symptoms coexisted in 29.3%, 25.5%, 15.9%, and 8.3%, respectively. The significant predictors of SMI were diabetes mellitus (P = .025) and male sex (P = .048). The significant predictor of silent CeVD was older age (P = .039). The borderline predictors of asymptomatic PAD and TAA were diabetes mellitus (P = .056) and AAA size (P = .053), respectively. Even with no previous symptomatic CVD, patients with AAA have high prevalence of coexistent SACVD.

DOI： 10.1177/0003319711419359

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DOI： 10.1016/j.ijcard.2011.10.039

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Stanford type B acute aortic dissection is sometimes complicated with compressed true lumen of the descending aorta (Dynamic obstruction) and stenosis of a major aortic branch (Static obstruction), which cause organ malperfusion. In such a case, medical therapy alone is usually not effective and endovascular treatments are required including stent implantation and balloon fenestration. However, it is difficult to determine which strategy should be selected, that is, only stent implantation at dissected branch or simultaneous fenestration with stent implantation. We report a case of a 54-year-old man with lower leg ischemia due to type B aortic dissection, who was successfully treated with stent implantation plus balloon fenestration. This case suggests that balloon fenestration plus stent implantation should be considered when static obstruction in the aortic branches is accompanied by dynamic obstruction in the descending aorta.

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When pulmonary embolism (PE) develops, circulatory collapse and hypoxia are caused at the same time. The rapid and proper use of extracorporeal life support (ECLS) can improve the mortality rate of patients with collapsed massive PE. No study has examined the influence of treatment that involved adding catheter based-intervention to ECLS with massive collapsed PE. Thirty-five patients with massive PE were examined, and 10 of these patients were placed on ECLS. Eight of the 10 patients placed on ECLS for massive PE were female, and the median age was 61 years. Seven patients had in-hospital onset PE and 3 patients out-of-hospital onset PE. Their underlying conditions were a cerebral infarction (3 patients), coronary artery disease (5 patients), collagen disease (one patient), postoperative state (3 patients), and lung disease (2 patients). Pulmonary angiographic findings showed that a filling defect or complete occlusion was observed in all 10 patients in the proximal lobular arteries, 6 of which had large thrombi stretching to the main pulmonary arteries. All patients underwent thrombolysis. Percutaneous catheter embolus fragmentation and/or thrombectomy were undertaken in 7 patients. All patients required red blood cell transfusion for cannulation site bleeding. The mean duration of ECLS bypass was 48 ± 44 hours. The 30 day mortality rate was 30%. The current study clarified the characteristics of patients with massive PE requiring ECLS. These patients have extensive pulmonary thromboemboli, thus, the aggressive use of catheter-based intervention appears to have beneficial effects for massive PE requiring ECLS.

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BACKGROUND: Because it remains unclear whether noninvasive ventilation (NIV) is an effective therapy for cardiogenic pulmonary edema secondary to acute myocardial infarction (AMI), we retrospectively evaluated our experience with NIV in the treatment of pulmonary edema secondary to AMI and other cardiac conditions. METHODS AND RESULTS: The study group included 206 patients with cardiogenic pulmonary edema, divided into an AMI group (53 patients) and a non-AMI group (153 patients). The weaning rate from NIV was similar in the AMI and non-AMI groups (90.6% vs. 90.8%, P=0.950). Heart rate, blood pressure, and respiratory rate decreased significantly 1h after initiation of NIV in both groups, and were maintained until weaning from NIV. The frequency of endotracheal intubation after weaning from NIV was higher in the AMI group than in the non-AMI group (7.5% vs. 0.7%, P=0.016), although the overall frequency of intubation was similar in both groups. The in-hospital mortality rate was similar in the AMI and non-AMI groups (13.1% vs. 9.8%, P=0.489). CONCLUSIONS: NIV effectively improved vital signs and oxygenation and lowered the intubation rate in patients with cardiogenic pulmonary edema of all etiologies, including AMI. The outcome in patients with AMI treated with NIV depends primarily on the severity of the course of AMI and not on the severity of acute respiratory failure.

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A 61-year-old man without a Marfan-like phenotype was admitted to the hospital because of acute Stanford type A aortic dissection. The patient underwent surgical repair with total arch replacement. Histological examination of the excised aorta showed a connective tissue abnormality, which could have contributed to the development of aortic dissection. The cause of the connective tissue abnormality could not be determined through physical examination. Recently, however, many novel gene mutations have been found to be related to aortic diseases that do not always produce physical signs and symptoms. In this case, unknown causes of connective tissue abnormalities might be existed.

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BACKGROUND: Although the existence of the young patients with aortic disease not fulfilling the diagnostic criteria for Marfan syndrome (MFS) has been known, the etiology of their disease has not yet been elucidated. The purpose of the present study was to elucidate the genetic and clinical features of the young patients with aortic disease not having MFS. METHODS AND RESULTS: Eighty young adult patients with aortic disease were examined. They were divided into a definite MFS (n=51) and a non-definite MFS group (n=29) according to the Ghent nosology. Clinical and genetic characteristics were compared between the 2 groups. Among 29 non-definite MFS probands, 1 (3%) FBN1, 2 (7%) TGFBR1, and 3 (10%) TGFBR2 mutations were found, and 4 ACTA2 mutations were found in the 23 probands examined without FBN1, TGFBR1, or TGFBR2 mutations. In total, more than 10 out of 29 (34%) probands in the non-definite MFS group were associated with genetic mutations. Skeletal involvement was less frequent in the non-definite than in the definite MFS group (7% vs 82%, P<0.01). CONCLUSIONS: In the probands with aortic diseases in young who cannot be diagnosed with MFS, mutations other than FBN1 mutations accounted for at least one-third of all causes of aortic disease.

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PURPOSE: Loeys-Dietz syndrome (LDS) is a connective tissue disease caused by mutations in the genes encoding the transforming growth factor-beta receptor (TGFBR). LDS is associated with aneurysms or dissections of the aorta similar to Marfan syndrome (MFS) as well as arterial tortuosity and aneurysms in the peripheral arteries. The purpose of this study was to evaluate the arterial diseases of LDS to differentiate it from MFS. MATERIALS AND METHODS: A total of 10 LDS patients with an identified mutation in TGFBR (6 male, 4 female; mean age 36.3 years) and 20 MFS patients with an identified mutation in fibrilin-1 who were age- and sex-matched to the LDS subjects (12 male, 8 female; mean age 37.1 years) were reviewed. The prevalence of vertebral arterial tortuosity (VAT) and peripheral aneurysm (PAN) was studied using computed tomography angiography. RESULTS: In all, 9 of the 10 LDS patients had VAT, and five PANs were observed in 3 patients. In contrast, 8 (40%) of the MFS patients had VAT, and 1 patient had a PAN. LDS had a higher prevalence of VAT (P = 0.017) by Fisher's exact test. CONCLUSION: The VAT was highly prevalent among LDS patients. Thus, the presence of VAT has the potential to differentiate LDS from MFS.

DOI： 10.1007/s11604-010-0420-6

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Antiphospholipid syndrome is characterized with arterial and venous thrombosis. In this article, a 38-year-old man presented with headache and swelling of his left limb, which had lasted for 2 months. Duplex ultrasonography showed thrombosis of the left femoral vein. Cerebral magnetic resonance imaging also showed cerebral sinus thrombosis. Serological examination showed that antiphospholipid syndrome was the underlying disease condition in this patient. Despite adequate anticoagulant therapy, deep vein thrombosis and cerebral sinus thrombosis exacerbated, resulting in inferior vena cava occlusion, papilloedema, and abducent nerve paralysis. Optic canal decompression and cistern-peritoneal shunt operation were performed, following which his neurological symptoms were relieved. The occurrence of cerebral sinus thrombosis as initial presentation of antiphospholipid syndrome is extremely rare and remains a diagnostic challenge. Although the clinical presentation is highly variable, the diagnosis should be considered in patients with antiphospholipid syndrome presenting with recent unusual headaches. Improved diagnosis and treatment strategy may ultimately improve the clinical outcome of these patients. © 2009 SAGE Publications.

DOI： 10.1177/0003319707309310

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Approximately 20% of aortic aneurysm and/or dissection (AAD) cases result from inherited disorders, including several systemic and syndromatic connective-tissue disorders, such as Marfan syndrome, Ehlers-Danlos syndrome, and Loeys-Dietz syndrome, which are caused by mutations in the FBN1, COL3A1, and TGFBR1 and TGFBR2 genes, respectively. Nonsyndromatic AAD also has a familial background, and mutations of the ACTA2 gene were recently shown to cause familial AAD. In the present study, we conducted sequence analyses of the ACTA2 gene in 14 unrelated Japanese patients with familial thoracic AAD (TAAD), and in 26 with sporadic and young-onset TAAD. Our results identified three mutations of ACTA2, two novel [p.G152_T205del (c.616+1G>T), p.R212Q] and one reported (p.R149C), in the 14 patients with familial TAAD, and a novel mutation (p.Y145C) of ACTA2 in the 26 sporadic and young-onset TAAD patients, each of which are considered to be causative for TAAD. Some of the clinical features of these patients were the same as previously reported, whereas others were different. These findings confirm that ACTA2 mutations are important in familial TAAD, while the first sporadic and young-onset TAAD case with an ACTA2 mutation was also identified.

DOI： 10.1002/humu.21081

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BACKGROUND: Aortic aneurysms are found in 5-20% of patients with acute aortic dissection (AAD). Coexisting aortic aneurysms might potentially influence the incidence of AAD. The purpose of this study was to elucidate the role of coexistent aortic aneurysms in AAD. METHODS AND RESULTS: A total of 140 patients with AAD were enrolled in the present study. Clinical characteristics of the patients were evaluated in relation to the locations of aortic segments affected by the dissection as well as of the coexistent aortic aneurysm. Among the 140 study patients, 34 (24%) had true aortic aneurysms. Patients with coexistent aortic aneurysm were significantly older than those without (72 +/- 11 years vs 65 +/- 14 years, P=0.012) and had higher incidence of thrombosed false lumen (62% vs 38%, P=0.017), and coronary artery disease (26% vs 8%, P=0.006). Twenty-two of these 34 (65%) patients had a thoracic aortic aneurysm (TAA), and this frequency of TAA was much higher than that observed in the general population. Furthermore, among all patients with AAD, 12 patients (9%) might be associated with development of AAD. CONCLUSIONS: The current study showed that nearly one-quarter of AAD patients had coexisting true aortic aneurysms, and suggests that TAA are likely to be associated with development of AAD.

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DOI： 10.1016/j.athoracsur.2009.02.036

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Diagnosis of Marfan syndrome (MS) is made according to the Ghent nosology, which is based on data from European and American populations. The validity of applying the Ghent nosology to other than Western populations is an ongoing discussion because there may be racial differences in basic physical features. The validity of applying the Ghent nosology to patients other than Westerners suspected of having MS was examined. One hundred thirteen Japanese patients who were suspected of having MS and underwent genetic analysis were examined to see whether they fulfilled the Ghent nosology. Of 113 patients, MS was diagnosed in 58 patients/51 probands. Of these 51 probands, 46 (90%) showed mutations in the Fibrillin-1 gene(FBN1) and were enrolled in this study. The frequency of each manifestation of Ghent nosology in the Japanese population was compared with those reported in the FBN1 Universal Mutation Database that was mainly obtained from the Western population (n = 1,013 probands). Frequencies were lower in the Japanese population than the Western population of the manifestations of arm span to height ratio >1.05 (20% vs 55%; p <0.01), scoliosis (40% vs 53%; p <0.05), reduced extension at elbows (2% vs 16%; p <0.05), and joint hypermobility (46% vs 63%; p <0.05). In conclusion, we found a lower frequency of skeletal manifestations of MS in Japanese patients than reported in the database for Western patients with MS. It was possible that the diagnosis of MS according to the Ghent nosology for Japanese patients was underestimated, especially for skeletal involvements.

DOI： 10.1016/j.amjcard.2008.12.037

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BACKGROUND: Exercise training improves walking ability in patients with peripheral arterial disease (PAD), but whether exercise training improves the long-term outcome of these patients remains unknown. METHODS AND RESULTS: Participants were 118 PAD patients who were enrolled in a 12-week supervised exercise program. The long-term outcomes of 64 patients who completed the training were compared with the outcomes of 54 patients who did not. The primary endpoint was cardiovascular mortality, and the secondary endpoint was cardiovascular morbidity. Mean follow-up was 5.7+/-3.9 years. The cardiovascular death-free rate was higher in patients who completed the training program than in those who did not (P=0.022). Multivariate analysis showed independent predictors of cardiovascular death were age over 70 years, diabetes mellitus, maximum walking distance, history of coronary revascularization, and completion of training program. The cardiovascular event-free rate was also higher in patients who completed the training program (P=0.048). CONCLUSIONS: Supervised exercise training improved cardiovascular mortality and morbidity in patients with PAD, which suggests that exercise training should be considered as a secondary prevention strategy for these patients.

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Language：English   Publishing type：Research paper (international conference proceedings)   Publisher：SPRINGER-VERLAG TOKYO  

DOI： 10.1007/978-4-431-99237-0_36

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BACKGROUND: Medical therapy gives excellent short-term outcomes for patients with Stanford type B acute aortic dissection. However, the affected aorta is often compromised by aneurysmal dilatation and rupture, resulting in poor long-term outcome. The present study investigated which antihypertensive treatment may prevent long-term aortic events in these patients. METHODS AND RESULTS: The study group comprised 78 consecutive patients with Stanford type B acute aortic dissection who were treated medically and followed-up for an average of 873+/-548 days. The optimal hypertensive drug regimen to reduce aortic events was determined by multivariate analyses. Of the 78 patients, 73 (94%) were discharged from hospital with medical therapy, and aortic events occurred in 13 (18%) of them (aortic rupture/recurrent dissection in 2 (3%); aortic expansion >or=60 mm in 7 (10%), rapid aortic expansion >or=10 mm/year in 3 (4%), and development of visceral/limb ischemia in 1 (1%)) during follow-up. By multivariate analysis, patients given angiotensin-converting enzyme inhibitor (ACEI) were less likely to have long-term aortic events than those without (odds ratio: 0.18, 95% confidence interval: 0.04-0.85). CONCLUSIONS: Use of ACEI is associated with a reduced risk of long-term aortic events in patients with medically treated type B aortic dissection.

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DOI： 10.1161/CIRCULATIONAHA.107.747089

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Previous studies have indicated that medical therapy provides excellent outcomes for patients with uncomplicated Stanford type B acute aortic dissection. However, affected aortas are often compromised by aneurysmal dilatation and rupture, resulting in poor outcomes. The purpose of this study was to determine predictors of aortic events in patients with Stanford type B acute aortic dissection receiving conservative medical therapy. The study group consisted of 78 consecutive patients with Stanford type B acute aortic dissection who were admitted to the hospital within 48 hours of onset. These patients were treated medically and followed up for 1 year. Aortic events were defined as rupture, recurrent dissection, aortic expansion with diameter>or=60 mm, rapid aortic expansion at a rate of >or=10 mm/yr, and the development of visceral or limb ischemia. Predictors of these events were determined using multivariate analyses. During 1-year follow-up, aortic events were observed in 13 (17%) patients, including aortic rupture in 3 (4%), aortic diameter>or=60 mm in 4 (5%), rapid expansion of the aorta in 3 (4%), and the development of visceral or limb ischemia in 3 (4%). On multivariate analysis, fibrinogen-fibrin degradation product level>or=20 microg/ml (odds ratio 7.802, 95% confidence interval 1.405 to 43.335) on admission was the only independent predictor of aortic events at 1 year. In conclusion, careful monitoring is required for patients with medically treated Stanford type B acute aortic dissection associated with fibrinogen-fibrin degradation product level>or=20 microg/ml on admission.

DOI： 10.1016/j.amjcard.2007.12.036

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BACKGROUND: Percutaneous peripheral intervention (PPI) for superficial femoral artery (SFA) stenosis is associated with a high restenosis rate. Whether PPI improves the long-term outcome of patients with SFA occlusive disease remains to be determined. METHODS AND RESULTS: A review was done of 107 patients with SFA occlusive disease. Fifty-five patients received PPI for SFA (ie, PPI group) and 52 patients received conservative medical therapy (ie, control group). Clinical records were searched for adverse events (eg, death, limb amputation, re-hospitalization, new onset of coronary artery disease and cerebrovascular disease) for an average of 30.6+/-17.7 months. At follow-up, only 5 patients (9.1%) in the PPI group experienced improved limb symptoms compared with baseline, and 6 patients (10.9%) showed ischemic skin ulcer or gangrene. In addition, 2 of these 6 patients were unsuccessful PPI cases complicated with distal embolization and perforation. In the control group, 3 patients (5.8%) presented with improved limb symptoms, and an equal number of patients had worsening of symptoms. Although 2 patients showed ischemic skin ulcers at follow-up, both patients had these lesions at baseline. Adverse events were observed more frequently in the PPI group than the control group (69.1% vs 46.2%, p<0.05). This was mainly due to a higher frequency of re-hospitalization in the PPI group than in controls (52.7% vs 15.4%, p<0.001). CONCLUSIONS: The current study demonstrates that PPI for patients with SFA occlusive disease does not provide superior long-term benefits compared with conservative medical therapy, and that medical therapy will continue to remain the primary treatment strategy for this group of patients.

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Differences in atherosclerotic profiles between patients with thoracic aortic aneurysm (TAA) and patients with abdominal aortic aneurysm (AAA) have not been studied. We retrospectively studied the clinical records of 343 consecutive patients (132 TAA and 211 AAA) who were admitted to our hospital for elective repair of aortic aneurysms between July 2001 and December 2004. Clinical variables were compared between patients with TAA and those with AAA by using a univariate analysis, and those achieving statistical significance were subsequently assessed in a multivariate analysis. The incidence of coronary artery disease (CAD) (53% vs 23%, p <0.0001), 3-vessel coronary disease (41% vs 10%, p <0.0001), male gender (86% vs 74%, p <0.01), smoker (88% vs 76%, p <0.01), chronic obstructive pulmonary disease (COPD) (30% vs 15%, p <0.01), and diabetes mellitus (39% vs 23%, p <0.01) were significantly higher in patients with AAA than in those with TAA. In contrast, the incidence of hypertension (91% vs 81%, p <0.05), saccular-type aneurysm (61% vs 7%, p <0.0001), and body mass index (24.1 +/- 3.1 vs 23.2 +/- 3.5, p <0.05) were significantly higher in patients with TAA than in those with AAA. Multivariate stepwise logistic analysis revealed that CAD (odds ratio [OR] 3.65; 95% confidence interval [CI] 2.12 to 6.42; p <0.0001), COPD (OR 2.05; 95% CI 1.11 to 3.89; p <0.05), and diabetes mellitus (OR 1.85; 95% CI 1.06 to 3.27; p <0.05) were associated with AAA, and that body mass index (OR 9.39; 95% CI 2.0 to 46.8; p <0.01), hypertension (OR 3.09; 95% CI 1.48 to 6.87; p <0.01), and cerebral infarction (OR 2.83; 95% CI 1.25 to 6.50; p <0.05) were associated with TAA. In conclusion, atherosclerotic profiles are significantly different between patients with TAA and patients with AAA. This result suggests the possibility that mechanisms underlying the development of aortic aneurysms may differ between TAA and AAA, and, from the perspective of prevention, provides further stimulus for the modification of key risk factors for atherosclerosis.

DOI： 10.1016/j.amjcard.2007.10.039

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A 30-year-old man with severe back and abdominal pain was referred to our hospital because of a recurrence of acute type B aortic dissection. A computed tomography scan showed a 3-channel dissection and a severe narrowing of the true lumen of the descending aorta to the abdominal aorta because of the expansion of the newly formed second false lumen. Although laboratory testing, including creatine phosphokinase, lactate dehydrogenase, and lactate levels, indicated no visceral ischemia, abdominal pain requiring narcotics treatment had to be continued for more than 1 week. Based on the symptoms and computed tomography findings, the patient finally underwent aortic replacement, fenestration, and a reconstruction of the inferior mesenteric artery, after which the abdominal pain disappeared. Operative findings confirmed a pale shrunken intestine, indicative of mesenteric ischemia. The present case is a good demonstration revealing that mesenteric ischemia still remains a diagnostic challenge, and suggests that currently available laboratory markers are not sensitive enough to detect the presence of ischemia. A strong clinical suspicion for mesenteric ischemia may be the only key to preventing a catastrophic outcome in this condition.

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BACKGROUND: Nifekalant is a class III antiarrhythmic drug, which is usually used for suppression of ventricular tachycardia (VT) and fibrillation. We studied the efficacy of nifekalant for acute conversion of atrial flutter (AFL) in a prospective, open label study in the intensive care unit (ICU) of cardiovascular medicine. METHODS: This study consisted of 31 patients. Twenty-six patients (84%) suffered from structural heart diseases. AFL was developed in 15 patients (48%) while on antiarrhythmic therapy with class IA or IC drugs (I-AFL group) for suppressing atrial fibrillation (AF) and in the remaining patients without such drugs (S-AFL group). Patients with prolonged QT interval, hypokalemia were excluded. All patients received one dose of 0.3 mg/kg of nifekalant over 10 minutes under continuous ambulatory monitoring. Four patients with common AFL in each group received nifekalant during electrophysiologic (EP) study. RESULTS: Nifekalant had an overall AFL conversion efficacy of 77.4% within 60 minutes. Eleven patients in S-AFL group (68.8%) and 13 patients in I-AFL group (86.7%) could be converted with mean conversion times of 10.8 +/- 6.2 and 15.0 +/- 8.0 minutes, respectively (n.s.). Conversion rate was significantly higher in patients with a short duration of arrhythmia. The two modes of AFL termination were mainly demonstrated and the preferential mode significantly differed between the two groups. One patient in each group with excessive QT prolongation (6.5%) developed torsade de pointes (TdP), requiring electrical shock in one patient (3.3%). CONCLUSIONS: Nifekalant can be used for conversion of AFL with a potent efficacy even in patients with structural heart diseases. However, caution should be required for developing TdP.

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BACKGROUND: Mutations in the genes for transforming growth factor-beta receptor (TGFBR) have been identified in patients with Marfan syndrome (MFS) and Marfan-like connective tissue disorders. There are several syndromes associated with mutations in TGFBR genes, including Loeys-Dietz syndrome (LDS), MFS2, Furlong syndrome, and Shprintzen-Goldberg syndrome. However, with the exception of the first report by Loeys et al, the phenotypic features of patients with TGFBR gene mutations have not been precisely reported. METHODS AND RESULTS: A total of 18 patients suspected of having MFS were recruited and 7 were diagnosed with MFS and mutations in FBN1. Among the remaining 11 patients, 1 patient had mutations in TGFBR1, 2 had mutations in TGFBR2, and 1 had mutations in COL3A1. The clinical manifestations of the 3 patients with TGFBR gene mutations were examined according to the list of 36 clinical features described in the first report by Loeys et al. The clinical manifestations of these 3 patients differed from those previously observed in patients with MFS2, Furlong syndrome, and Shprintzen-Goldberg syndrome. Thus, the most probable diagnosis of these 3 patients was LDS, despite the fact that they presented with only a fraction of the 36 clinical features associated with LDS. CONCLUSIONS: Although the number of the patients was limited, the findings support the notion that mutations in the TGFBR gene may be associated with greater phenotypic heterogeneity than previously reported.

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BACKGROUND: The short-term clinical benefits of bone marrow mononuclear cell transplantation have been shown in patients with critical limb ischemia. The purpose of this study was to assess the long-term safety and efficacy of bone marrow mononuclear cell transplantation in patients with thromboangiitis obliterans. METHODS AND RESULTS: Eleven limbs (3 with rest pain and 8 with an ischemic ulcer) of 8 patients were treated by bone marrow mononuclear cell transplantation. The patients were followed up for clinical events for a mean of 684+/-549 days (range 103 to 1466 days). At 4 weeks, improvement in pain was observed in all 11 limbs, with complete relief in 4 (36%). Pain scale (visual analog scale) score decreased from 5.1+/-0.7 to 1.5+/-1.3. An improvement in skin ulcers was observed in all 8 limbs with an ischemic ulcer, with complete healing in 7 (88%). During the follow-up, however, clinical events occurred in 4 of the 8 patients. The first patient suffered sudden death at 20 months after transplantation at 30 years of age. The second patient with an incomplete healing of a skin ulcer showed worsening of the lesion at 4 months. The third patient showed worsening of rest pain at 8 months. The last patient developed an arteriovenous shunt in the foot at 7 months, which spontaneously regressed by 1 year. CONCLUSIONS: In the present unblinded and uncontrolled pilot study, long-term adverse events, including death and unfavorable angiogenesis, were observed in half of the patients receiving bone marrow mononuclear cell transplantation. Given the current incomplete knowledge of the safety and efficacy of this strategy, careful long-term monitoring is required for future patients receiving this treatment.

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BACKGROUND: Elevated B-type natriuretic peptide (BNP) levels show prognostic significance in patients with non-ST elevation acute coronary syndromes, but the underlying pathophysiology remains unclear. METHODS: Two hundred and eighteen consecutive patients with non-ST elevation acute coronary syndromes were studied retrospectively. We compared clinical characteristics between groups with plasma BNP levels above or below the median value, and performed multiple logistic regression analysis to identify independent predictors of supramedian BNP levels. RESULTS: Patients with supramedian BNP (>or=134 pg/ml) were more likely to be elderly (>or=75 years) with diabetes, prior myocardial infarction, and a history of coronary artery bypass grafting. They also had higher cardiac marker levels, a higher Killip class, a lower left ventricular ejection fraction, renal insufficiency (creatinine>or=1.5 mg/dl), and more 3-vessel disease. In multivariate analysis, the strongest independent predictor of supramedian BNP levels was 3-vessel disease (chi(2)=12.1), followed by old age (chi(2)=10.3), renal insufficiency (chi(2)=5.0), higher Killip class (chi(2)=4.2), and lower left ventricular ejection fraction (chi(2)=4.1). All 11 patients dying in hospital had supramedian BNP levels. Its elevation reflected the risk of 3-vessel disease and coronary artery bypass grafting regardless of troponin status. CONCLUSION: In unselected patients with non-ST elevation acute coronary syndromes, an increase of BNP is correlated with the extent of myocardial ischemia, age, renal insufficiency, and ventricular dysfunction. It may be a useful biomarker integrating conventional risk factors for risk stratification in this population.

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BACKGROUND: Experimental study has shown that blunted arterial baroreflex function markedly attenuated inotropic responses to a phosphodiesterase inhibitor (PDEI) even in normal hearts. However, whether arterial baroreflex function is related to the inotropic responsiveness to a PDEI has not been clarified in human heart failure (HF). HYPOTHESIS: The goal of this study was to examine the relationship between inotropic responses to a PDEI and arterial baroreflex sensitivity in human HF. METHODS: Twelve patients with HF were examined, and hemodynamic responses to milrinone (12.5, 25, and 50 microg/kg, intravenous injection) and arterial baroreflex sensitivity were assessed by pulse interval-left ventricular (LV) systolic pressure slope using nitroglycerin and phenylephrine. RESULTS: Milrinone (25 microg/kg) significantly increased LV dP/dt. Arterial baroreflex sensitivity was only one predictor of inotropic responses to milrinone by multivariate analysis; a strong positive correlation was also found between LV dP/dt and baroreflex sensitivity (y = 6.656X - 3.326, r = 0.93, p = 0.000). CONCLUSION: Inotropic effects of milrinone, a PDEI, correlated significantly with arterial baroreflex sensitivity, suggesting that the more baroreflex function was impaired, the more the inotropic effect of a PDEI was depressed in human HF.

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BACKGROUND: The clinical implications of applying the new criteria of acute myocardial infarction (AMI) with cardiac troponins in terms of their diagnostic and prognostic impact in patients with suspected acute coronary syndromes (ACS) have not been well evaluated. METHODS AND RESULTS: The study group comprised 973 consecutive patients who were diagnosed as having ACS with or without ST elevation (STE). They were divided into 3 groups: unstable angina (UA) group (n=195) representing patients with no significant elevations of creatine kinase (CK) and troponin T (TnT); TnT-myocardial infarction (MI) group (n=170) with TnT elevation and no CK elevation (additionally detected AMI by the new criteria); CK-MI group (n=608) with significant elevation of CK (AMI by the old criteria). In the TnT-MI group, 140 (76%) patients had non-STE ACS. In-hospital mortality rates for STE ACS were 0%, 2.5% and 9.7% in the UA, TnT-MI and CK-MI groups, respectively. The corresponding values for non-STE ACS were 1.8%, 4.6%, and 16.5%, respectively (p<0.0001), suggesting a pivotal role of TnT. In multiple logistic regression analysis, significant CK elevation was selected as an independent predictor of in-hospital death in concurrence with age > or =75 years, prior MI, shock and low left ventricular ejection fraction in non-STE ACS. CONCLUSIONS: The new criteria result in a substantial increase in the diagnosis of AMI from non-STE ACS in particular. They assist greatly in detailed risk stratification of ACS patients, notably in cooperation with the old CK criteria.

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BACKGROUND: A rapid laboratory test for diagnosis of acute aortic dissection (AAD) has not been available. We performed this prospective study to determine the utility of a rapid bedside D-dimer (DD) assay for detection of AAD. METHODS AND RESULTS: Patients with suspected AAD were recruited and their DD levels were measured by rapid bedside assay. They were divided into 2 groups according to enhanced computed tomography findings: an AAD group (n = 30) and a non-AAD group (n = 48). The median DD level was higher in the AAD group (1.80 microg/ml) than in the non-AAD group (0.42 microg/ml) (p = 0.000). The rapid bedside DD assay showed 100% sensitivity, 54% specificity, 58% positive predictive value and 100% negative predictive value for detection of AAD with a normal DD level of up to 0.5 microg/ml. The combination of DD level >0.5 microg/ml and systolic blood pressure > or = 180 mmHg showed 86% positive predictive value for detection of AAD. Conclusions We conclude that the rapid bedside DD assay is a highly sensitive method for early exclusion of AAD in patients with chest and/or back pain suggestive of AAD. Acute aortic dissection is highly probable if a rapid DD assay shows the elevated DD level with systolic blood pressure > or = 180 mmHg on admission.

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BACKGROUND: Acute massive or submassive pulmonary embolism (PE) has high mortality, but the clinical course according to the location of onset (ie, in-hospital or out-of-hospital) is unknown. METHODS AND RESULTS: In the present study 56 consecutive patients with acute massive or submassive PE were studied retrospectively and a comparison made of the clinical characteristics, and outcomes between in-hospital onset (Group A) and out-of-hospital onset (Group B). Patients in Group A (n=28) had more frequent comorbidities with hemodynamic instability (54% vs 4%, p<0.0001) and temporary risk factors (93% vs 11%, p<0.0001), whereas patients in Group B (n=28) had a longer duration of symptoms (median: 5.5 days vs 0.5 day; p<0.0001), and had higher systolic pulmonary artery pressure (63+/-17 mmHg vs 46+/-12 mmHg, p=0.0006). Although in-hospital mortality did not differ between the 2 groups, the recurrence rate was higher in Group B (23% vs 0%, p=0.03). CONCLUSIONS: Patients who had in-hospital onset of PE had mostly temporary risk factors, unstable hemodynamics and a lower recurrence rate compared with the cases of out-of-hospital onset. In cases of in-hospital onset, prompt diagnosis and suitable treatment is needed to prevent fatalities and cases of out-of-hospital onset should be followed carefully for recurrence.

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OBJECTIVE: To determine the most effective treatment, we performed a detailed comparative study of the clinical course of patients with type B aortic dissection with a patent or thrombosed false lumen who did not undergo surgery in the acute period. We examined the effect of patency of the false lumen on outcome. METHODS: Computed tomography scans of 138 patients with type B acute aortic dissection were reviewed. Of 138 patients, 110 were medically treated and survived the acute period. We focused on the outcome of these 110 patients, 62 with medically treated thrombosed false lumen (thrombosed group) and 48 with medically treated patent false lumen (patent group). We investigated factors influencing outcome among the 110 patients. The follow-up period was up to 10 years after the onset of aortic dissection. The three study endpoints were death from any cause, dissection-related death (aortic rupture, perioperative death, or death due to organ ischemia), and a dissection-related event (aortic rupture or surgery). In the patent group, we investigated factors influencing long-term outcome. RESULTS: Patency of the false lumen was an independent risk factor for dissection-related death (P = 0.038, hazard ratio=5.6, confidence interval=1.1-28) and for a dissection-related event (P = 0.000, hazard ratio=7.6, confidence interval=2.7-22) but not for death from any cause (P = 0.769, hazard ratio=1.2, confidence interval=0.45-2.91). In the patent group, location of the most dilated aortic segment at the distal arch was an independent risk factor for dissection-related death (P = 0.026, hazard ratio=13.6, confidence interval=1.4-135) and for a dissection-related event (P = 0.048, hazard ratio=2.6, confidence interval=1.0-6.9). CONCLUSIONS: Patency of the false lumen is a strong independent prognostic factor for type B aortic dissection. Location of the most dilated aortic segment at the distal arch is a significant risk factor in the patients with a patent false lumen.

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We have reported that percutaneous cardiopulmonary assist systems (PCPS) are effective in treating life-threatening cardiogenic shock that is intractable to treatment with intraaortic balloon pumping (IABP). However, there are few clinical indices that can be used to evaluate the effectiveness of PCPS. End-tidal carbon dioxide (ET-CO(2)) content reflects pulmonary blood flow. We monitored ET-CO(2) continuously and determined whether we could use it as a new index to evaluate the effectiveness of PCPS. Seventeen patients with cardiogenic shock were intubated and evaluated by ET-CO(2) monitoring during PCPS. The etiology of shock included acute myocardial infarction (n=10), acute myocarditis (n=2), recent coronary artery bypass graft (n=1), cardiac rupture (n=1), hypertrophic obstructive cardiomyopathy complicated by ventricular fibrillation (n=1), left atrial myxoma (n=1) and artificial valve malfunction (n=1). PCPS was extremely effective in 10 of 17 patients (58.8%), and they recovered from the cardiogenic shock. The remaining 7 patients did not recover from shock, and died during PCPS. Six of ten patients who recovered from shock were successfully weaned from PCPS and 4 patients had good long-term survival. In the cases where PCPS was effective, the ET-CO(2) measured soon after the beginning of PCPS was significantly higher than in the cases in which PCPS was ineffective. Furthermore, the ET-CO(2) content increased gradually with the improvement in hemodynamics. In contrast, ET-CO(2) content remained low if PCPS was not effective. The ET-CO(2) represents a useful predictor of survival or death and is also a good index for weaning in patients treated with PCPS.

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Language：Japanese   Publisher：日本内科学会-関東地方会  

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Language：English   Publisher：ELSEVIER SCIENCE INC  

DOI： 10.1016/S0828-282X(09)70101-1

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Language：English   Publisher：Japanese Circulation Society  

CiNii Books

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Language：English   Publishing type：Research paper, summary (international conference)   Publisher：ELSEVIER SCIENCE INC  

Web of Science

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Language：English   Publishing type：Research paper, summary (international conference)   Publisher：LIPPINCOTT WILLIAMS & WILKINS  

Web of Science

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Language：English   Publishing type：Research paper, summary (international conference)   Publisher：ELSEVIER SCIENCE INC  

Web of Science

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Language：English   Publishing type：Research paper, summary (international conference)   Publisher：ELSEVIER SCIENCE INC  

Web of Science

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Language：English   Publishing type：Research paper, summary (international conference)   Publisher：ELSEVIER SCIENCE INC  

Web of Science

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Language：English   Publishing type：Research paper, summary (international conference)   Publisher：ELSEVIER SCIENCE INC  

Web of Science

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Language：English   Publishing type：Research paper, summary (international conference)   Publisher：LIPPINCOTT WILLIAMS & WILKINS  

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Language：Japanese   Publisher：(一社)日本集中治療医学会  

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Language：Japanese   Publisher：Japan Heart Foundation  

DOI： 10.11281/shinzo1969.38.8_796

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Other Link： https://search.jamas.or.jp/index.php?module=Default&action=Link&pub_year=2006&ichushi_jid=J00679&link_issn=&doc_id=20060818280007&doc_link_id=10.11281%2Fshinzo1969.38.8_796&url=https%3A%2F%2Fdoi.org%2F10.11281%2Fshinzo1969.38.8_796&type=J-STAGE&icon=https%3A%2F%2Fjk04.jamas.or.jp%2Ficon%2F00007_3.gif

Language：Japanese   Publisher：(一社)日本循環器学会  

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Language：Japanese   Publisher：(一社)日本心臓病学会  

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Language：Japanese   Publisher：(一社)日本循環器学会  

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Language：English   Publisher：Japanese Circulation Society  

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Language：Japanese   Publisher：日本医科大学医学会  

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Language：Japanese   Publisher：(一社)日本循環器学会  

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Language：Japanese   Publisher：(一社)日本循環器学会  

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Language：English   Publisher：(一社)日本心臓病学会  

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Language：Japanese   Publisher：(NPO)日本不整脈学会  

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Language：Japanese   Publisher：(一社)日本循環器学会  

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Language：Japanese   Publisher：(一社)日本集中治療医学会  

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Language：Japanese   Publisher：(一社)日本循環器学会  

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Language：Japanese   Publisher：(一社)日本循環器学会  

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Language：Japanese   Publisher：(一社)日本循環器学会  

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Language：Japanese   Publisher：医学図書出版(株)  

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Language：English   Publisher：Japanese Circulation Society  

CiNii Books

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Language：Japanese   Publisher：(一社)日本循環器学会  

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Language：Japanese   Publisher：臨床心臓電気生理研究会  

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