An adult case of kawasaki disease with multiplex coronary aneurysms and0 myocardial infarction: The role of transesophageal echocardiography

Kawasaki disease (mucocutaneous lymph node syndrome) is an acute inflammatory disease that primarily affects infants and young children. in spite of proper therapy, coronary aneurysms develop in 10 to 25% of cases. Adult diagnosis of coronary aneurysm, presumably caused by Kawasaki disease, is rare. A 37-year-old male patient with previous inferior wall myocardial infarction (MI) was admitted with an acute anterior wall MI. Coronary angiography, performed 2 weeks after successful thrombolytic therapy, showed right coronary artery occlusion and multiplex (left main, left anterior descending, left circumflex, right coronary artery) giant coronary aneurysms. Transthoracic echocardiography was unable to detect the aneurysms. Transesophageal echocardiography (TEE) visualized a large left main coronary aneurysm with an occlusive thrombus and measured low flow velocity (0.2 m/s) in the proximal left anterior descending artery. At 4 weeks control, TEE showed marked regression of the thrombus, and it was not detectable after 6 months of oral anticoagulation with acenocumarol (International Normalized Ratio: 3-3.5) and standard postinfarction therapy. After 2 years of follow-up, the patient has no symptoms, and myocardial ischemia could not be provoked by stress tests [treadmill, dipyridamole single-photon emission computed tomography (SPECT)]. We conclude that, for diagnosis and follow-up of adult Kawasaki disease, transesophageal echocardiography is indicated. The importance and efficacy of long-term anticoagulant treatment should be emphasized in this disease.     

Hypoxia-Inducible Factor 1-Alpha Release After Intracoronary Versus Intramyocardial Stem Cell Therapy in Myocardial Infarction

We have investigated the effect of stem cell delivery on the release of hypoxia-inducible factor 1 alpha (HIF-1α) in peripheral circulation and myocardium in experimental myocardial ischemia. Closed-chest, reperfused myocardial infarction (MI) was created in domestic pigs. Porcine mesenchymal stem cells (MSCs) were cultured and delivered (9.8?±?1.2?×?10⁶) either percutaneously NOGA-guided transendocardially (Group IM) or intracoronary (Group IC) 22?±?4 days post-MI. Pigs without MSC delivery served as sham control (Group S). Plasma HIF-1α was measured at baseline, immediately post- and at follow-up (FUP; 2 h or 24 h) post-MSC delivery by ELISA kit. Myocardial HIF-1α expression of infarcted, normal myocardium, or border zone was determined by Western blot. Plasma level of HIF-1α increased immediately post-MI (from 278?±?127 to 631?±?375 pg/ml, p?<?0.05). Cardiac delivery of MSCs elevated the plasma levels of HIF-1α significantly (p?<?0.05) in groups IC and IM immediately post-MSC delivery, and returned to baseline level at FUP, without difference between the groups IC and IM. The myocardial tissue HIF-1α expression in the infarcted area was higher in Group IM than in Group IC or S (1,963?±?586 vs. 1,307?±?392 vs. 271?±?110 activity per square millimeter, respectively, p?<?0.05), while the border zone contained similarly lower level of HIF-1α, but still significantly higher as compared with Group S. Trend towards increase in myocardial expression of HIF-1α was measured in Group IM at 24 h, in contrast to Group IC. In conclusion, both stem cell delivery modes increase the systemic and myocardial level of HIF-1α. Intramyocardial delivery of MSC seems to trigger the release of angiogenic HIF-1α more effectively than does intracoronary delivery.     

Simultaneous Improvement in Aortic Distensibility and Coronary Flow Velocity Reserve after Successful Coronary Interventions

Objective: Deteriorations in coronary flow velocity reserve (CFR) and aortic distensibility have been demonstrated in coronary artery disease. The objective of the present study was a simultaneous echocardiographic evaluation of the CFR and aortic distensibility indices before and after successful percutaneous coronary interventions (PCI) in patients with left anterior descending coronary artery (LAD) disease. Methods: The study population, comprising 12 patients (4 women and 8 men) with significant proximal LAD stenosis, were compared with matched controls. Transesophageal echocardiography (TEE) was carried out to evaluate the CFR and aortic distensibility indices (the aortic elastic modulus E(p) and Young's circumferential static elastic modulus E(s)) before and after PCI to the LAD. The subjects underwent TEE on average 8 ± 11 days before PCI and 25 ± 6 weeks after PCI. Results: An improvement in CFR was demonstrated in patients with LAD stenosis after successful PCI (1.71 ± 0.36 vs. 2.08 ± 0.28, P < 0.05), which paralleled the decreases in E(p) (936 ± 544 mmHg vs. 567 ± 184 mmHg, P < 0.05) and E(s) (10,207 ± 6,295 mmHg vs. 5,831 ± 2,010 mmHg, P < 0.05) during the follow‐up. Conclusion: The aortic distensibility improves in parallel with the increase in CFR in patients with LAD stenosis after successful PCI. (Echocardiography 2010;27:311‐316)     

Use of generalized transfer function-derived central blood pressure for the calculation of baroreflex gain

BACKGROUND: Peripheral blood pressure measurement underestimates pressure changes during baroreflex testing, resulting in an overestimation of baroreflex gain. This error might be reduced by measuring central blood pressure; the invasive measurement, however, may represent ethical and practical problems. The solution may be the derivation of central blood pressure from the peripheral pulse using a generalized transfer function. METHODS: In the current study, we tested the agreement between catheter-measured and generalized transfer function derived central blood pressure measurements and corresponding baroreflex gains. ECG and blood pressure waveforms were monitored continuously during a phenylephrine-induced pressure rise in 22 subjects undergoing cardiac catheterization. Pressure was measured with a catheter positioned in the aorta and with applanation tonometry in the radial artery. Radial pressure waveforms were subject to a generalized transfer function built in the SphygmoCor device to derive central pressure waveforms. Radial tonometric signal was calibrated with catheter-measured (invasive) and sphygmomanometric (noninvasive) pressures. Baroreflex gains were calculated from the linear regressions between heart period and systolic pressure changes. RESULTS: When radial tonometric signal was calibrated invasively, there was no group difference between baroreflex gains calculated from SphygmoCor-derived and catheter-measured pressures (8.2 +/- 1.2 vs. 7.2 +/- 1.2 ms/mmHg, P = NS). When radial tonometric signal was calibrated noninvasively, however, baroreflex gains calculated from SphygmoCor-derived pressures overestimated those calculated from catheter-measured pressures. CONCLUSION: Using a generalized transfer function is an accurate method to derive central pressure changes for baroreflex gain calculation. The technique, however, requires invasive pressure measurements for calibration, leaving the problem of a fully noninvasive central pressure measurement unresolved.     

Auto-oxidation test for the determination of lipid peroxidation capacity of liver tissue homogenates of young and old mice]

The activity of superoxide dismutase (SOD) and the lipid-peroxidation capacity, i.e., the autoxidation of lipids during incubation at 37 degrees C for 3 h under aerobic conditions was measured in liver tissue homogenates of young (1.5-month-old) and old (24-month-old) inbred female Balb/c mice. The lipid peroxidation capacity was found to be significantly higher in young mice than in old ones. The pretreatment of young mice with allopurinol, a specific inhibitor of xanthine oxidase, remarkably decreased the lipid peroxidation capacity without any modification of SOD activity. SOD levels were equal in young and old mice. Our results suggest that the lipid peroxidation capacity of liver tissue depends, not only on the level of polyunsaturated fatty acids, but, in general, also on the state of a finely regulated counterbalance of pro- and antioxidant factors. The autoxidation test seems to be a suitable in vitro method for measuring the lipid peroxidation capacity of liver tissue.     

Formulation of an intermediate product from human serum albumin for the production of a solid dosage form.

The main objective of this study was to evaluate and to increase the processibility of a model protein (human serum albumin (HSA)) for preparation of an intermediate for a solid dosage form. The applicability of the solid forms is easier, and therefore their formulation is a promising method for the application of proteins. The layering of powdered cellulose with HSA solutions of different concentrations in a fluid bed apparatus with the top spray method was applied. The yield of this technique was very good, independently of the concentration of the applied solution. The HSA covered the particles (the HSA layer formed was smooth), but it caused aggregation of the cellulose particles, and spray-dried microparticles also formed. The proportion of optimum-sized particles (200-315 microm) decreased. The largest amount was detected for the samples prepared with liquid containing 15% HSA (about 2 times higher than the second best). Not only the size, but also the shape of the particles was changed. The alteration in this parameter caused a change in the flowability. This was likewise the best for the samples prepared with the liquid containing 15% HSA. The concentration of HSA in the fraction containing smaller particles was higher, because of the abrasion of the particles and the enrichment of the spray-dried HSA. The distribution of HSA in the large particles was uneven. The layering of powder cellulose can be applied to produce an intermediate from HSA for solid dosage forms, but the appropriate concentration of this protein solution must be optimized previously because HSA can act as a binder. The formation of large agglomerates must be eliminated, because the distribution of the active agent in these is very inhomogeneous. The present results indicated that the best value can be achieved with liquid containing between 12.5% (most homogeneous distribution of HSA) and 15% HSA (best flowability).     

Lipid peroxidation and superoxide dismutase activity in muscle and erythrocytes in adult muscular dystrophies and neurogenic atrophies

Summary Lipid peroxidation (LP) and superoxide dismutase (SOD) activity were determined in erythrocytes and skeletal muscle obtained from patients with limb-girdle and facioscapulohumeral muscular dystrophies, neurogenic atrophies and from age-matched control subjects. Neither lipid peroxidation nor SOD activity in erythrocytes of patients differed from control values. SOD activity and LP in muscle specimens were also normal in types of neurogenic atrophy. Lipid peroxidation in the muscle from patients with adult types of muscular dystrophy had a tendency to be increased. The values were widely scattered, the highest being obtained in the older patients with long duration of disease.     

The Effect of Aortic Valve Replacement on Coronary Flow Reserve in Patients with a Normal Coronary Angiogram

Background: In patients with aortic stenosis and a normal coronary angiogram, a coronary flow reserve (CFR) is impaired. The aim of the present study was to examine the effect of aortic valve replacement (AVR) on the CFR after a long-term follow-up. Patients and Methods: 30 patients with aortic stenosis and a normal coronary angiogram were enrolled in the study. CFR measurements were made on 21 patients 123 - 137 days before and 497 - 167 days after AVR. CFR measurements were carried out according to a standard protocol, with a vasodilator stimulus dipyridamole (0.56 mg/kg for 4 min) and peak diastolic velocity measurements at 6 min. Results: Initially, the average peak gradient of aortic stenosis was 89.5 - 22.4 mm Hg. After AVR, it decreased to 26.2 - 9 mm Hg. Left ventricular mass was significantly lower after AVR: 354.9 - 107.9 g versus 223.8 - 73.6 g (p < 0.001). The average baseline diastolic velocity measured by pulsed Doppler in the left anterior descending coronary artery amounted to 62.2 - 25.5 cm/s before and 40.1 - 13.6 cm/s after AVR. The difference was statistically significant (p < 0.01). The average diastolic velocity at maximum stress equaled 117 - 42.8 cm/s pre- and 91.5 - 34 cm/s postoperatively (p < 0.005). The calculated CFR before AVR amounted to 1.96 - 0.5 and increased to 2.37 - 0.8 postoperatively. The difference was statistically significant (p < 0.05). Conclusion: Prosthetic AVR is of considerable benefit concerning the CFR in patients with a normal coronary angiogram after a long-term follow-up. Hintergrund: Bei Patienten mit Aortenklappenstenose und anatomisch normalem Koronarsystem ist die Koronarflussreserve (CFR) vermindert. Ziel dieser Studie war, die Auswirkungen von Aortenklappenersatzoperationen (AVR) auf die CFR im Langzeitverlauf zu untersuchen. Patienten und Methodik: 30 Patienten mit Aortenklappenstenose wurden in die Studie einbezogen. Die CFR wurde bei 21 Patienten 123 - 137 Tage vor und 497 - 167 Tage nach AVR mit einer standardisierten echokardiographischen Methode transösophageal bestimmt. Die Doppler-Messungen erfolgten im Normalzustand und nach maximaler Vasodilatation durch 4-min-Infusion von 0,56 mg/kg Dipyridamol. Ergebnisse: Der durchschnittliche Druckgradient über den Aortenklappen lag bei 89,5 - 22,4 mm Hg vor und 26,2 - 9 mm Hg nach AVR. Das linksventrikuläre Gewicht war nach der Operation signifikant vermindert (354,9 - 107,9 vs. 223,8 - 73,6 g; p < 0.001). Die durchschnittliche diastolische Geschwindigkeit in den Ramus-interventricularis-anterior-Arterien lag präoperativ bei 62,2 - 25,5 cm/s und postoperativ bei 40,1 - 13,6 cm/s (p < 0.01). Die durchschnittliche diastolische Geschwindigkeit bei maximaler Vasodilatation betrug 117 - 42,8 cm/s vor und 91,5 - 34 cm/s nach AVR (p < 0.05). Der kalkulierte CFR-Wert lag präoperativ bei 1,96 - 0,5 und erhöhte sich nach der Operation auf 2,37 - 0,8 (p < 0,05). Schlussfolgerung: Die Implantation von Aortenklappenprothesen hat eine positive Wirkung auf die CFR von Patienten mit anatomisch normalen Koronararterien.