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Background and aims: It has been proven that a disturbance in angiogenesis contributes to the progression of myocardial interstitial fibrosis in idiopathic dilated cardiomyopathy (DCM). This study was designed to evaluate the relationship between serum activity of angiogenic factors and myocardial ultrasonic tissue characterization in patients with DCM. Methods and results:We studied 30 patients with DCM and 15 healthy control subjects. Serum levels of vascular endothelial growth factor (VEGF), interleukin (IL)-4 and IL-13 were measured using enzyme-linked immunosorbent assay. We determined calibrated myocardial integrated backscatter (IB) as the value of myocardial interstitial fibrosis using ultrasonic tissue characterization and also quantified the magnitude of cyclic variations in IB (CV-IB). Serum levels of VEGF and IL-13 were significantly higher in patients with DCM than in control subjects (both Pb0.05). Calibrated IB was significantly higher and CV-IB was markedly lower in patients with DCM than in control subjects (both Pb0.01). In patients with DCM, the levels of IL-13 significantly correlated with calibrated IB (r=0.520, P=0.018). In addition, there was a significant negative correlation between levels of VEGF and CV-IB (r=À0.611, P=0.007). Conclusion: The increase in serum VEGF and IL-13 may be closely related to alterations in myocardial texture in DCM.

Augmentation index (AI), brachial-ankle pulse wave velocity (baPWV) and cardio-ankle vascular index (CAVI) are available for the assessment of arterial stiffness in clinical practices. However, influences of meal intake on these indices are still poorly understood. The aim of this study is to elucidate the effects of daily meal intake on pulse wave indices in patients with type 2 diabetes. We studied 17 patients with type 2 diabetes. AI was measured at fasting, 60 and 120 min after a commercial mixed meal (500 kcal) intake. The baPWV and CAVI were measured at fasting and 80-100 min after meal intake. All pulse indices decreased significantly after meal intake (AI, 89.3 ± 9.7% to 77.9 ± 9.4%, 82.0 ± 8.4%, Po0.001; baPWV, 1652 ± 286-1586±240 cm s -1 , P¼0.002; CAVI, 9.52±0.92-9.20±0.89, P¼0.037). D 120 (value 120 min after meal intakeÀfasting value) AI correlated significantly with age, body weight, D 120 systolic blood pressure (SBP), D 120 diastolic blood pressure, D 120 pulse pressure, D 120 heart rate and fasting AI. D (postprandial valueÀfasting value) baPWV correlated significantly with fasting baPWV, D SBP, D pulse pressure and HbA1c. In contrast, D CAVI did not correlate with any clinical variables. In conclusion, postprandial decreases in AI, baPWV and CAVI can lead to underestimate arterial stiffness in patients with type 2 diabetes. Postprandial changes in AI and baPWV, but not CAVI, are associated with changes in hemodynamic variables after daily meal intake.

In the evaluation of intermediate lesions in the LAD, CFVR as assessed by CE-TTDE could accurately predict the presence of ischemia on stress thallium imaging, whereas angiographic stenosis did not yield reliable results.

ercutaneous transluminal septal myocardial ablation (PTSMA) for hypertrophic obstructive cardiomyopathy (HOCM) to reduce left ventricular outflow tract (LVOT) obstruction was first reported by Sigwart in 1995 1 as an alternative treatment to medical therapy, 2 dual chamber pacing 3 and surgical myectomy. 4 Knight et al 5 and Seggewiss et al 6 have both reported that PTSMA significantly reduces LVOT obstruction and improves the symptoms in HOCM, but it has also been reported that permanent pacemaker implantation was required in 20% of the patients because of complete atrioventricular block associated with this procedure. Faber et al 7 reported that myocardial contrast echocardiography (MCE) for target vessel selection in PTSMA improved both the acute and chronic results. We describe a case of HOCM treated by PTSMA in which intraprocedural selective MCE was very helpful in identifying the culprit septal branch. Case ReportA 67-year-old woman visited the outpatient clinic complaining of dyspnea and chest discomfort on exertion. She had a family history of hypertrophic cardiomyopathy in her son, who died suddenly 1 year ago. She had a 4/6 ejection murmur at the left third interspace and the chest X-ray showed a slightly enlarged left ventricle. The ECG confirmed left ventricular hypertrophy with strain and the echocardiogram showed asymmetrical septal hypertrophy with systolic anterior movement of the mitral valve and grade II mitral regurgitation. The left ventricular outflow tract (LVOT) gradient was approximately 150 mmHg by Doppler echocardiography. Thus, she was diagnosed as having HOCM. Her New York Heart Association (NYHA) functional class was III. Medical therapy with metoprolol (120 mg/day), diltiazem (90 mg/day) and disopyramide (300 mg/day) was started, and the LVOT gradient was reduced to approximately 100 mmHg. However, her symptoms were refractory to medical therapy and the NYHA functional A 67-year-old woman with hypertrophic obstructive cardiomyopathy that was refractory to medical treatment underwent percutaneous transluminal septal myocardial ablation (PTSMA). The septal branch supplying the myocardium involved in the left ventricular outflow tract (LVOT) obstruction was identified by selective myocardial contrast echocardiography (MCE). MCE for the third and largest septal branch opacified the right side of the mid-septal myocardium and MCE for the second septal branch opacified the right side of the basal portion of the septal myocardium. Finally, contrast agent was injected into the first, small branch, which opacificied the myocardium protruding into the LVOT. Subsequently, septal myocardial ablation for this vessel with intracoronary alcohol was performed, followed by a reduction of the LVOT gradient and successful, dramatic improvement in the patient's clinical condition. Selective MCE was very useful to identify the appropriate septal branch for PTSMA and enabled maximal effect of this treatment with minimal myocardial damage. (

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We describe the case of a 59-year-old male. His first percutaneous coronary intervention (PCI) using a bare metal stent was performed for a 90% stenosis in the mid portion of the left anterior descending artery (LAD). However, we performed re-PCI because in-stent restenosis developed during a chronic stage. After the first dilatation of the restenotic lesion, using a cutting balloon, the stenosis at the ostium of the septal branch, which takes off from the stent strut, became exacerbated. Therefore, after selective guidewire insertion to the septal branch, we performed balloon inflation. Unfortunately, a coronary dissection and perforation developed in the septal branch and a coronary arteriovenous shunt was also formed. Additional inflation for in-stent restenosis with a perfusion balloon provided successful occlusion of the ostium of the septal branch and the shunt flow disappeared. After careful re-selection of a guide wire into the septal branch, the perforated portion was then dilated using a small-sized conventional balloon. Finally, reperfusion of the septal branch was accomplished without any angiographic sign of coronary dissection, perforation or shunt. We herein report a rare case of coronary arteriovenous shunt formation due to the dissection and perforation of a coronary artery.

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