A case of aneurysm of the inferior left ventricular wall

Aneurysms of the inferior left ventricular wall represent only a small fraction of all aneurysms that have been reported in surgical series. And in comparison to anterior left ventricular aneurysms, a comparatively higher percentage of reported inferior wall aneurysms was classified as false. A 73-year-old male was admitted for acute inferior myocardial infarction. Three weeks after admission, cardiac catheterization was carried out. Coronary arteriography revealed triple vessel disease and left ventriculography showed an aneurysm of the inferior left ventricular wall, whose feature near the mitral annulus was multiple fenestrations. Left ventricular aneurysmectomy and aortocoronary bypass grafting to the left anterior descending artery were simultaneously performed under cardiopulmonary bypass with moderate hypothermia. The pathological feature was a true aneurysm. The postoperative course was uneventful.     

Heart remodeling produced by aortic stenosis promotes cardiomyocyte apoptosis mediated by collagen V imbalance

Cardiac remodeling (CR) is a structural change of the heart due to chronic hemodynamic overload related to changes in both myocyte and extracellular matrix (ECM). We investigated that the imbalance of collagen V promotes cardiomyocyte apoptosis that contributes to heart failure and cell death. Aortic stenosis was induced surgically and male Wistar rats were randomized to 18 weeks (Sham 18?w, n?=?12; AoS 18?w, n?=?12) and severe of heart failure (Sham HF, n?=?12; AoS HF, n?=?12) groups. Functional and structural echocardiogram, immunohistochemistry for Ki-67, TUNEL assay and Immunofluorescence for collagen were performed. Our main results were: (1) Progressive reduction of cardiac functional capacity due to cardiac remodeling with decreased eject fraction in heart failure; (2) Imbalance of collagen deposition with increased, crowded and irregular collagen I in situ expression; (3) Dysregulation of dynamic control of collagen fibers with exposed epitopes of collagen V; (4) Additional apoptosis that are dependent to cardiac injury. The collagen V expression in cardiac remodeling is for the first time described and may be related to additional apoptosis and autoimmune response. Our findings suggest a critical role of collagen V in cardiac remodeling to modulate and promote heart failure and death.     

A case of cytokeratin 20-positive large-cell neuroendocrine carcinoma of the breast

We report a rare case of large-cell neuroendocrine carcinoma of the breast. A 63-year-old woman was admitted to our hospital with a firm mass in the right breast. Mammography revealed a high-density mass with specula, and ultrasonography showed a heterogeneous hypoechoic mass with irregular margin and posterior acoustical shadowing. She underwent breast-conserving surgery with axillary lymph node dissection. Histopathologically, the tumor consisted of large cells with polygonal and prominent nuclei and a small amount of eosinophilic cytoplasm, and these cells showed palisading arrangement with fibrous stroma. The tumor cells were positive for neuroendocrine markers such as NSE, synaptophysin, CD56 (NCAM), but not for chromogranin A. Interestingly, the tumor cells showed reactivity for cytokeratin 20 but not for cytokeratin 7. The immunostaining pattern is different from the usual adenocarcinoma of the breast. The patient received postoperative radiotherapy and was given adjuvant chemotherapy. She has remained disease-free for 44?months.     

Prognostic and clinical significance of newly acquired complete right bundle branch block in Japan Airline pilots

OBJECTIVE: The purpose of this study was to evaluate the prognostic and clinical significance of newly acquired complete right bundle branch block (CRBBB) in airline pilots. PATIENTS: This study included pilots with acquired CRBBB, identified from a group of over 2,700 Japan Airline pilots. When the pilots applied for employment, a past medical history, physical examination, electrocardiogram, and chest radiograph were obtained. The pilots with ECG abnormality including CRBBB were not included in the study because of hiring requirements. RESULTS: Thirty-six pilots with CRBBB were identified between 1983 and 2002. All pilots with CRBBB were evaluated for the presence of ischemic heart disease by treadmill exercise testing, echocardiogram and exercise thallium scintigraphy. Twelve individuals underwent coronary angiography. The mean age of pilots was 44.4 +/- 5.8 years. The mean observation period was 10.9 +/- 5.7 years. For each of the 36 study subjects, Holter electrocardiogram and echocardiogram were obtained every 6 months after the CRBBB was detected. Exercise stress testing was performed every year. Exercise thallium scintigraphy was performed every 2 years to detect ischemic heart disease. During the observation period, two pilots stopped flying temporarily because of frequent ventricular premature beats and one pilot stopped flying permanentaly because of atrial fibrillation. During the follow-up period, no cardiovascular events were observed in pilots with CRBBB who had no underlying ischemic heart disease. CONCLUSION: Acquired CRBBB does not confer a poor prognosis, particularly in young men working as a pilot if there is no evidence of ischemia on exercise stress testing, echocardiography and exercise thallium scintigraphy.     

Infarct Size as Predictor of Systolic Functional Recovery after Myocardial Infarction

Background

The effects of modern therapy on functional recovery after acute myocardial infarction (AMI) are unknown.

Objectives

To evaluate the predictors of systolic functional recovery after anterior wall AMI in patients undergoing modern therapy (reperfusion, aggressive platelet antiaggregant therapy, angiotensin-converting enzyme inhibitors and beta-blockers).

Methods

A total of 94 consecutive patients with AMI with ST-segment elevation were enrolled. Echocardiograms were performed during the in-hospital phase and after 6 months. Systolic dysfunction was defined as ejection fraction value < 50%.

Results

In the initial echocardiogram, 64% of patients had systolic dysfunction. Patients with ventricular dysfunction had greater infarct size, assessed by the measurement of total and isoenzyme MB creatine kinase enzymes, than patients without dysfunction. Additionally, 24.5% of patients that initially had systolic dysfunction showed recovery within 6 months after AMI. Patients who recovered ventricular function had smaller infarct sizes, but larger values of ejection fraction and E-wave deceleration time than patients without recovery. At the multivariate analysis, it can be observed that infarct size was the only independent predictor of functional recovery after 6 months of AMI when adjusted for age, gender, ejection fraction and E-wave deceleration time.

Conclusion

In spite of aggressive treatment, systolic ventricular dysfunction remains a frequent event after the anterior wall myocardial infarction. Additionally, 25% of patients show functional recovery. Finally, infarct size was the only significant predictor of functional recovery after six months of acute myocardial infarction.     

Predictors of right ventricle dysfunction after anterior myocardial infarction

Background

Regardless significant therapeutic advances, mortality and morbidity after myocardial infarction (MI) are still high. For a long time, the importance of right ventricle (RV) function has been neglected. Recently, RV dysfunction has also been associated with poor outcomes in the setting of heart failure. The shape, location, and contraction conditions make the RV chamber assessment technically challenging.

Methods

Our study identified clinical characteristics and left ventricle (LV) echocardiographic data performed 3-5 days after MI that could be associated with RV dysfunction (RV fractional area change [FAC] < 35%) 6 months after MI.

Results

The RV dysfunction group consisted of 11 patients (RV FAC 29.4% ± 5.2) and the no RV dysfunction group of 71 patients (RV FAC 43.7% ± 5.1); (P < 0.001). Both groups presented the same baseline clinical characteristics. Left atrium (LA), interventricular septum (IVS), and left ventricular posterior wall (LVPW) were larger in RV dysfunction than in no RV dysfunction. Conversely, E wave deceleration time (EDT) was lower in RV dysfunction when compared with no RV dysfunction. Left atrium_adj (adjusted by gender, age, infarct size, and body mass index) (odds ratio [OR], 1.22; confidence interval [CI], 1.016-1.47; P = 0.032), interventricular septum_adj (OR, 1.49; CI, 1.01-2.23; P = 0.044), and E wave deceleration time_adj (OR, 0.98; CI, 0.97-0.98; P = 0.029) assessed soon after MI predicted RV failure after 6-months.

Conclusions

LV diastolic dysfunction, resulting from anterior MI and assessed 3-5 days after the event, may play an important role in predicting RV dysfunction 6 months later.