No abstract

Using our "echo-dynamography", blood flow structure and flow dynamics during ventricular systole were investigated in 10 normal volunteers. The velocity vector distribution demonstrated blood flow during ejection was laminar along the ventricular septum. The characteristic flow structure was observed in each cardiac phases, early, mid- and late systole and was generated depending on the wall dynamic events such as peristaltic squeezing, hinge-like movement of the mitral ring plane, bellows action of the ventricle and dimensional changes in the funnel shape of the basal part of the ventricle, which were disclosed macroscopically by using the new technology of high speed scanning echo-tomography and microscopically by the strain rate distribution measured by phase tracking method. The pump function was reflected on the changes in the flow structure represented by the flow axis line distribution and the acceleration along the flow axis line. The acceleration of the ejection had three modes, "A", "B" and "C", and generated by the wall dynamic events. "A" appeared from the apical to the outflow area along the main flow axis line, "B" along the anterior mitral leaflet and the branched flow axis line, and "C" generated by the high speed vortex behind the mitral valve. The magnitude of the acceleration was estimated quantitatively from the velocity gradient along the flow axis line. Macroscopic and microscopic asynchrony in the myocardial contraction and extension appeared systematically in the local part of the ventricular wall, which was helpful for making the flow structure and for performing the smooth pump function.

While primary percutaneous coronary intervention (PCI) has significantly contributed to improve the mortality in patients with ST segment elevation myocardial infarction even in cardiogenic shock, primary PCI is a standard of care in most of Japanese institutions. Whereas there are high numbers of available facilities providing primary PCI in Japan, there are no clear guidelines focusing on procedural aspect of the standardized care. Whilst updated guidelines for the management of acute myocardial infarction were recently published by European Society of Cardiology, the following major changes are indicated; (1) radial access and drug-eluting stent over bare metal stent were recommended as Class I indication, and (2) complete revascularization before hospital discharge (either immediate or staged) is now considered as Class IIa recommendation. Although the primary PCI is consistently recommended in recent and previous guidelines, the device lag from Europe, the frequent usage of coronary imaging modalities in Japan, and the difference in available medical therapy or mechanical support may prevent direct application of European guidelines to Japanese population. The Task Force on Primary Percutaneous Coronary Intervention of the Japanese Association of Cardiovascular Intervention and Therapeutics (CVIT) has now proposed the expert consensus document for the management of acute myocardial infarction focusing on procedural aspect of primary PCI.

Primary Percutaneous Coronary Intervention (PCI) has significantly contributed to reducing the mortality of patients with ST-segment elevation myocardial infarction (STEMI) even in cardiogenic shock and is now the standard of care in most of Japanese institutions. The Task Force on Primary PCI of the Japanese Association of Cardiovascular Interventional and Therapeutics (CVIT) society proposed an expert consensus document for the management of acute myocardial infarction (AMI) focusing on procedural aspects of primary PCI in 2018. Updated guidelines for the management of AMI were published by the European Society of Cardiology (ESC) in 2017 and 2020. Major changes in the guidelines for STEMI patients included: (1) radial access and drug-eluting stents (DES) over bare-metal stents (BMS) were recommended as a Class I indication, (2) complete revascularization before hospital discharge (either immediate or staged) is now considered as Class IIa recommendation. In 2020, updated guidelines for Non-ST-Elevation Myocardial Infarction (NSTEMI) patients, the followings were changed: (1) an early invasive strategy within 24 h is recommended in patients with NSTEMI as a Class I indication, (2) complete revascularization in NSTEMI patients without cardiogenic shock is considered as Class IIa recommendation, and (3) in patients with atrial fibrillation following a short period of triple antithrombotic therapy, dual antithrombotic therapy (e.g., DOAC and single oral antiplatelet agent preferably clopidogrel) is recommended, with discontinuation of the antiplatelet agent after 6 to 12 months. Furthermore, an aspirin-free strategy after PCI has been investigated in several trials those have started to show the safety and efficacy. The Task Force on Primary PCI of the CVIT group has now proposed the updated expert consensus document for the management of AMI focusing on procedural aspects of primary PCI in 2022 version.

cute myocardial infarction (AMI) is confirmed by angiographic evidence of coronary artery occlusion, which is usually caused by a thrombus or by atherosclerosis. 1 A thrombus located close to the orifice of the coronary artery in the ascending aorta in connection with AMI is rare, 2,3 but we report such a case and discuss the thrombogenetic role of risk factors and the therapeutic strategy of thrombolysis. Case ReportA 52-year-old woman complained of chest pain in the morning of 13 September 1993 and was transferred to a local hospital with suspected AMI diagnosed by electrocardiography (Fig 1). She was immediately referred to us. She smoked 20 cigarettes per day, and was taking hormone supplement therapy (Ovulen), which consisted of mestranol (50 g/tablet) and ethynodiol diacetate (1 mg/tablet), for menopausal symptoms of flushing and mental irritability. In addition, for the past 20 years she had taken the contraceptive pill occasionally to treat uterine endometriosis. Moreover, she had had a mentally stressful day before the cardiac event because of trouble with her family. However, she had been well without a history of cardiac symptoms before this episode.On admission, the pulse rate was 120 beats/min and regular, and peripheral pulses were normal. She looked pale and her blood pressure was 82/65 mmHg.Emergency cardiac catheterization revealed that the right coronary artery (RCA) was well developed without luminal stenoses, but the left coronary artery (LCA) was not apparent. The left sinus of Valsalva was searched for the orifice of the LCA, but it could not be found, so contrast media was injected into the left sinus of Valsalva and then into the proximal ascending aorta. Angiography revealed a large filling defect protruding from the aortic wall close to where the LCA opens into the ascending aorta (Figs 2-4).Intraaortic balloon counterpulsation was promptly performed, followed by the intravenous tissue plasminogen activator, alteplase, first by rapid intravenous injection of 2.4×10 6 IU/L, and then by drip infusion of 21.6×10 6 IU/L within 1 h.One hour after beginning the thrombolytic therapy, the patient suddenly became free of chest pain, but developed cardiogenic shock with ventricular tachycardia. Full cardiac resuscitation with repeated electrical countershocks was performed and she eventually recovered sinus rhythm. After recovery, she underwent echocardiography, but evidence of thrombus around the orifice of the LCA could not be detected.Laboratory data, such as platelet count, hematocrit and serum cholesterol level, were within normal limits, and antithrombin III was 24.3 ng/ml. Peak creatine kinase, aspartate aminotransferase, alanine aminotransferase and lactate dehydrogenase were 11,000 IU/L, 1,280 IU/L, 250 IU/L and 5,700 IU/L, respectively.One month later, we performed follow-up cardiac cath- A 52-year-old woman suffered from acute massive myocardial infarction in association with a large thrombus in the ascending aorta. She was a moderate smoker and was taking hormone supplement therapy fo...