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Reversible Left Ventricular Dysfunction due to Hypothyroidism and Severe Obstructive Sleep Apnea; A Case Report
S184 Journal of Cardiac Failure Vol. 18 No. 10S October 2012 he experienced nocturnal dyspnea and a routine annual health check revealed bilateral pleural effusion and bilateral hilar lymph adenopathy. He was diagnosed with congestive heart failure and visited our hospital on January 26th. He was admitted that day and 5 days later coronary angiography was performed. The results showed normal coronary arteries but the subsequent Ga scintigraphy revealed accumulation of Ga in the hilar lymph nodes bilaterally. The patient’s serum lysozyme level was found to be elevated and he was diagnosed with cardiac sarcoidosis by cardiac biopsy. We treated this patient with cardiac rehabilitation and steroids, ARB, and b blocker. His heart failure improved gradually and he was discharged on March 24th 2012. This patient reacted to treatment very favorably, with a quick improvement in his condition. The authors conclude that the combination of drugs and exercise therapy contributed to this improvement, as opposed to treatment with steroids alone.
severe pulmonary hypertension. The pulmonary capillary wedge pressure and the right atrial (RA) pressure were normal. Continuous intravenous epoprostenol therapy was initiated, resulting in improvement in mPAP (65mmHg) and CI (2.32L/min/m2). The normalization of TFP-V1 was accompanied by the improvement of clinical condition. In this patient, the chest CT performed around the same time as cardiac catheterization showed improvement in the RA dimensions at the level of the fourth intercostal space, decreasing from 34.8cm2 to 24.8cm2; therefore, it was suggested that TFP-V1 was reflected in RA enlargement. We similarly investigated 20 other pulmonary hypertension patients. There was a significant negative correlation between TFP-V1 and RA dimensions. Furthermore, TFP-V1 showed negative correlation with mPAP and CI. Generally, the negative component of P wave in lead V1 is an evidence of volume overload in left atrium; our study suggested that it is also found in pulmonary hypertension, indicating RA enlargement and severe pulmonary hypertension.
P-102 A Case of Female Danon Disease with Rapidly-deteriorated Heart Failure Heading for Heart Transplantation YUICHIRO IIDA, HISAHITO SHINAGAWA, TAKAYUKI INOMATA, TOYOJI KAIDA, TOSHIMI KOITABASHI, TOHRU IZUMI Department of Cardio-angiology, Kitasato University, School of Medicine, Kanagawa, Japan Background: Danon disease is an X-linked systemic disorder, characterized by cardiomyopathy, mental retardation and skeletal myopathy affecting young men. Female patients, however, are often diagnosed as idiopathic dilated cardiomyopathy (IDCM) because of the later-onset and isolated cardiac symptoms. Case Report: We report a 40-year-old female who was diagnosed as IDCM three years ago with severely-impaired left ventricular (LV) function. Cardiac magnetic resonance demonstrated marked late Gadolinium enhancement in extended LV wall and endomyocardial biopsy specimen from LV showed severe cardiomyocyte degeneration without intracellular vacuoles typical for lysosomal glycogen storage diseases. In spite of optical medical pharmacotherapy with cardiac resynchronization therapy, LV function has been rapidly deteriorated leading to end-stage HF dependent on intravenous inotropics, waiting for heart transplantation. Genetic testing her son affecting Danon disease provided a clue to her diagnosis through a nucleotide substitution in the lysosome-associated membrane protein 2 gene. Conclusion: Danon disease should be suspected in the middle-aged female manifesting as DCM having family members of male teenager with LV hypertrophy, because of its discouraged cardiac prognosis.
P-103 Angiosarcoma of the Pulmonary Artery Diagnosed by Delayed Enhancedment of MRI YOSUKE KAYAMA1, TAKUYA YOSHINO2, TATSUYA KOYAMA1, SHINGO SEKI1, MICHIHIRO YOSHIMURA2 1 Division of Cardiology, Internal Medicine, Katsushika Medical Center Jikei University School of Medicine, Tokyo, Japan, 2Division of Cardiology, Internal Medicine, Jikei University School of Medicine, Tokyo, Japan Primary pulmonary angiosarcoma is rare tumor, with fewer than 80 cases reported in Japan. The prognosis of subjects was very poor. Most patients die within 6 to 24 months of a diagnosis of pulmonary angiosarcoma. The benefits of the multimodality treatment such as chemotherapy and radiation therapy are unclear. Surgical resection remains the best treatment option at present. Therefore, it is important to accurately diagnose primary pulmonary angiosarcoma immediately using non-invasive modalities. Therefore, it is desirable that a means of early detection and diagnosis of such malignant tumors can be established. We present here a case of a Primary pulmonary angiosarcoma with right ventricular failure that was diagnosed by characteristic images of echocardiography and enhanced magnetic resonance image (MRI). This approach also enabled to differentiate between thrombus and malignant tumors before attempting surgery therapy. After resection, pathological examination revealed a intimal sarcoma of pulmonary artery. 10 months later, the patients died with progressive right ventricular heart failure in spite of several treatments for sarcoma.
P-104 A Case of Pulmonary Arterial Hypertension Improved with Normalization of a Prominent Negative Component of P Wave in Lead V1 HIROAKI OBATA, HIROMI KAYAMORI, MASATO ODA, TAKESHI KASHIMURA, HARUO HANAWA, MAKOTO KODAMA Division of Cardiology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan A 30-year-old man was hospitalized for progressive dyspnea and diagnosed with idiopathic pulmonary arterial hypertension. The electrocardiogram obtained at admission showed a prominent negative component of P wave in lead V1, and the P terminal force in lead V1 (TEP-V1) was -0.312mVsec. The mean pulmonary arterial pressure (mPAP574mmHg) and the cardiac index (CI51.74L/min/m2) revealed
P-105 A Rare Case with Fatal Pulmonary Tumor Thrombotic Microangiopathy YUTAKA MIURA, YOSHIHIRO FUKUMOTO, KOICHIRO SUGIMURA, KIMIO SATO, KOTARO NOCHIOKA, TATSUO AOKI, SHUNSUKE TATEBE, SAORI YAMAMOTO, HIROAKI SHIMOKAWA Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan Case: 27 years-old, female. Clinical History: In April, 2011, she suffered from exertional dyspnea, and admitted to the hospital nearby. Echocardiography showed right ventricular dilatation and severe tricuspid valve regurgitation. Right heart catheterization showed elevated mean pulmonary arterial pressure (mPAP, 39 mmHg). After the diagnosis of pulmonary hypertension, her hemodynamic values were gradually deteriorated (blood pressure 100/60 mmHg with 5 mg/kg/min of dobutamine), and she was transferred to our hospital. We started her treatment with percutaneous cardiopulmonary support (PCPS), intravenous prostacycline and oral sildenafil; however, we were unable to obtain any hemodynamic improvement. Then, we added ambrisentan and imatinib, with which we were able to discontinue the 6-weeks PCPS treatment. As she had slight fever, bloody sputum, and high levels of tumor markers, we performed PET examination, which revealed the only mild uptake in the abdominal and mediastinal lymph nodes. We then performed abdominal echography and GI fiber examination, without any findings of malignancies. On September 20th, 2011, she passed away due to the respiratory failure, rapidly elevated mPAP, and hemodynamic disruption. Autopsy examination demonstrated the presence of multiple emboli of signet ring cells in the pulmonary small arteries, a compatible finding with pulmonary tumor thrombotic microangiopathy (PTTM). Conclusion: We experienced a rare case of fatal PTTM resistant to intensive care.
P-106 The Patient after CRT that Making a Graph of Body Weight Dramatically Reduced Hospitalization NAOKI NOZAKI Ayase Heart Hospital, Tokyo, Japan This case is 72 yrs old female. She was diagnosed as dileted cardiomyopathy in 1993 and she had been taking a medicine for chronic heart failure(CHF). Left ventricular systolic function was diffse severe hypokinesis (EF 33%) with dissynchrony. Although CRT-D implantation was performed in Dec. 2006, she had been hospitalized for worsening CHF over and over (4 times in 2007, 5 times in 2008, 1 time in 2009, 5 times in 2010, 3 times in 2011). Repeated guidance of restriction for salt and water intake was not effective. Whenever her hospitalization, her condition was easily improved by oxgen supply and using diuretics during 2 or 3 days. When she was discharged in April 2011, we tought her making a simple line graph of her own body weight every day. We also explained her appropriate body weight. She brings her body weight graph every consultation. Ever since, her condition has been stable and she has never been hospitalized for over 1 yr. Conclusion: In this case, not the record of body weight itself, but making line graph of own body weight significantly reduced her hospitalization.
P-107 Reversible Left Ventricular Dysfunction due to Hypothyroidism and Severe Obstructive Sleep Apnea; A Case Report TASUKU YAMAGUCHI, YOSHIFUMI TAKATA, YASUHIRO USUI, YOSUKE NISHIHATA, KOTA KATO, KAZUKI SHIINA, AKIRA YAMASHINA Department of Cardiology, Tokyo Medical University, Tokyo, Japan A 42 years old man was introduced to our hospital with suspicion of obstructive sleep apnea syndrome (OSAS). He was not obese but had a chief complaint of excessive daytime sleepiness. A polysomnography showed an apnea-hypopnea index (AHI) of 46.3/hr and an arousal index of 47.9/hr, he therefore was diagnosed as severe OSAS. The first laboratory examination showed high level of creatine kinase
The 16th Annual Scientific Meeting (2912 U/l), which lead to the detection of primary hypothyroidism (TSH 138.4 IU/ ml, FT3 0.45pg/ml, FT4 0.12ng/dl). Although a plasma brain natriuretic peptide level was rather low (4.6pg/ml), marked left ventricular (LV) dysfunction without an abnormal accumulation of pericardial effusion was revealed by echocardiography. Cardiac magnetic resonance imaging did not detect any high signal areas in T2 image and delayed enhanced areas. In accordance with an initiation of thyroid hormone replacement therapy and continuous positive airway pressure (CPAP), his sleepiness and general fatigue obviously decreased with body weight reduction by more than 5kg. After five months, the echocardiography showed a great improvement in LV ejection fraction from 25% to 57% and LV systolic dimension from 45mm to 37mm. The second polysomnographic findings without CPAP use also showed a certain amelioration of severity of sleep-disordered breathing. Here, we describe an interesting case with reversible LV dysfunction due to hypothyroidism and severe obstructive sleep apnea.
JHFS
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hypothesized that elevated biomarkers may aid to clarify their role. Method and Results: We studied 216 patients admitted for AHF from 2006 to 2010. Physical finding were recorded at admission. 56.0% patients had non-ischemic HF. Composite endpoint of rehospitalization for AHF or death was met in 37.0%. Patients with pulmonary rales and S3 had worse prognosis compared to those without (Figure). Both discharge BNP and troponin T was significantly higher in patients who presented with pulmonary rales (p50.034 and p!0.001) and S3 (p!0.001). Conclusion: Patients with pulmonary rales and S3 met higher rate of adverse outcome, and the findings seem to be related to persistently elevated biomarkers at steady state.
P-108 The Effects of Tolvaptan for Neurohormonal Factor and Hemodynamics of the Patients with Heart Failure NORIYUKI KAWAURA1, KAZUAKI UCHINO1, KATSUMI MATSUMOTO1, HIDEYUKI OGAWA1, TAKESHI TAKAMURA1, TERUYASU SUGANO1, TOMOAKI ISHIGAMI1, TOSHIYUKI ISHIKAWA1, KAZUO KIMURA2, SATOSHI UMEMURA1 1 Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan, 2Division of Cardiology, Yokohama City University Medical Center, Yokohama, Japan Background: Tolvaptan is a newly developed diuretics that function as vasopressin2 receptor antagonist. Thus, the effects of tolvaptan for patients with heart failure is still unclear. Aim: To evaluate the effects of tolvaptan for neurohormonal factors of patients with heart failure. Method: 14 patients hospitalized for heart failure (mean age 69.5612.5 years; 69.3% male) were received tolvaptan. Clinical status, physical exams and neurohormonal factors associated with heart failure at day 1 and day 7 after receiving tolvaptan were investigated. Result: Compared day 1 with day 7, tolvaptan significantly decreased hANP (349.9 vs. 210.7 pg/ml; p50.023), BNP (661 vs. 497 pg/ml; p50.018) and dopamine (49 vs. 32 pg/ml; p50.042). Serum Na (137.5 vs. 140.0 mEq/l; p50.081), ADH (3.1 vs. 6.4 pg/ml; p50.068), urine Na (50 vs. 72 mEq/l; p50.057) and urine osmotic pressure (251 vs. 326; p50.052) was increased, but not significantly. And body weight (51.0 vs. 49.0 kg; p50.052) was decreased, not significantly. Hemodynamic parameters (systolic blood pressure 113 vs. 118 mmHg; p50.715, heart rate 83.9 vs. 79.3 bpm; p50.262) and renal function (eGFR 49.7 vs. 51.7 ml/min/1.73m2; p50.453) were no significant differences between the day 1 and day 7. Conclusion: In short term use, tolvaptan was effective diuretics for patients with heart failure and had small effect on hemodynamic parameters and renal function.
P-109 The Role of Serum Sodium Concentration Levels on Tolvaptan Therapy in Patients with Heart Failure HIDETO SAKO, SHIN-ICHIRO MIURA, EIJI YAHIRO, KEJIRO SAKU Department of Cardiology, Fukuoka University Hospital, Fukuoka, Japan Objectives: The aim of this study was to evaluate whether the levels of elevated serum sodium (Na) determine the efficacy and safety of tolvaptan in acute phase of heart failure (HF). Methods: Twenty HF patients [age 73612 years, left ventricular (LV) ejection fraction 47618%, serum creatinine 2.161.4 mg/dl] treated with tolvalpan (1164 mg) were included. The levels of serum Na, urine volume and body weight were measured at 0, 12, 24, 48, 60, 72 and 168 hours after treatment. We also investigated whether these factors have an influence on the efficacy and safety of tolvaptan. Results: Cardiovascular events had not been found during tolvaptan treatment (16613 days). The patients were divided into an increasing group [dNa(+) group, n511] and a decreasing group [dNa(-) group, n59] according to the changes in the levels of serum Na after 60 hours. dNa(+) group showed a higher urinary volume and body weight loss than dNa(-) group. In the efficacy of acute phase, urinary volume was significantly associated with the patients who had 4 factors (history of HF, diabetes, LV hypertrophy and serum creatinineO2.5mg/dl) by a multivariate regression analysis. Conclusions: Tolvaptan is a potentially useful in the treatment of HF, and the levels of serum Na at 60 hours might be a useful marker of judging the efficacy of tolvaptan.
P-110 Association Between Baseline Physical Findings and Persistently Elevated Biomarker Level after Acute Heart Failure SAYOKO NEGI, SHUN KOHSAKA, KIMI KOIDE, YUJI NAGATOMO, HIROYUKI MOTODA, KENSUKE KIMURA, MOTOAKI SANO, TSUTOMU YOSHIKAWA, KEIICHI FUKUDA Keio Universiy School of Medicine, Tokyo, Japan Background: Previous studies have reported association between physical findings and patient’s long-term prognosis in acute heart failure (AHF). We
P-111 Inotrope Use and Serum High Sensitive Troponin-I in Acute Decompensated Heart Failure SATOSHI KOYAMA1, YUKIHITO SATO1, YOHEI TANADA2, HIDEAKI INAZUMI1, HISAYOSHI FUJIWARA1, YOSHIKI TAKATSU1 1 Department of Cardiovascular Medicine, Hyogo Prefectural Amagasaki Hospital, Amagasaki, Japan, 2Graduate School of Medicine Kyoto University, Kyoto, Japan Objective: Inotrope use and high cardiac troponin concentration were both known as prognostic markers for patients with acute heart failure syndrome. However, the relationship between these two parameters was not studied well. Method: Consecutive 114 acute heart failure patients (male 51%, median 74 [70-82] years) were included our prospective observational study. Clinical characteristics, parameters, blood and urine samples on the days of admission, day 4, and day 7 were collected. 31 of 114 patients required continuous infusion of inotrope for heart failure treatment. Adjusted by these baseline parameters, 31 matched pairs were compared. Result: Serum troponin-I concentration decreased through the course of heart failure (median 0.038, 0.030, 0.028ng/mL, days 1, 4, and 7 respectively, p50.0001). The factors independently related to use of inotrope were hypotension (with inotrope vs. without, 122(624.7) mmHg p!0.001) vs. 145(624.5) mmHg, higher bilirubin concentration (0.8 [0.7-0.13] mg/dL vs. 0.7 [0.5-1.1] mg/dL, p50.036), and higher cardiac troponin-I (0.072 [0.034-0.190] ng/mL vs 0.031 [0.017-0.075] ng/mL, p50.021) on admission. Serum troponin-I concentration more decreased in patients treated without inotrope compared to those treated with inotrope (p50.049). Conclusion: Hyoptention, bilirubinemia and higher troponin concentration on admission were independent predictors of need for inotropes for acute heart failure treatment. After adjustment of these factors, inotrope use disturbed decrease of cardiac troponin-I in the therapeutic course of acute decompensated heart failure.
P-112 Association Between Obesity and Clinical Characteristics in Patients with Acute Heart Failure MASATO MATSUSHITA1, AKIHIRO SHIRAKABE1, NORITAKE HATA1, TAKURO SHINADA1, NOBUAKI KOBAYASHI1, KAZUNORI TOMITA1, MASAFUMI TSURUMI1, YOSHIYA YAMAMOTO1, KYOICHI MIZUNO2 1 Intensive Care Unit, Nippon Medical School Chiba Hokusoh Hospital, Chiba, Japan, 2 Department of Medicine, Division of Cardiology, Hepatology, Geriatrics and Integrated Medicine, Nippon Medical School, Tokyo, Japan Backgrounds: There have been few reports about the relationship between obesity and clinical findings of acute heart failure (AHF). Methods: Five-hundred and ninety-two patients who were admitted to the intensive care unit were analyzed. Patients were assigned to non-obesity group (n5451, BMI!25, group-N) or obesity group (n5141, BMIO25, group-O). The clinical findings on admission and outcome were evaluated. Results: The age was significantly younger in group-O than in group-N (67.3612.1 vs 73.4610.5years-old). Systolic blood pressure (SBP) was significantly higher in group-O
severe pulmonary hypertension. The pulmonary capillary wedge pressure and the right atrial (RA) pressure were normal. Continuous intravenous epoprostenol therapy was initiated, resulting in improvement in mPAP (65mmHg) and CI (2.32L/min/m2). The normalization of TFP-V1 was accompanied by the improvement of clinical condition. In this patient, the chest CT performed around the same time as cardiac catheterization showed improvement in the RA dimensions at the level of the fourth intercostal space, decreasing from 34.8cm2 to 24.8cm2; therefore, it was suggested that TFP-V1 was reflected in RA enlargement. We similarly investigated 20 other pulmonary hypertension patients. There was a significant negative correlation between TFP-V1 and RA dimensions. Furthermore, TFP-V1 showed negative correlation with mPAP and CI. Generally, the negative component of P wave in lead V1 is an evidence of volume overload in left atrium; our study suggested that it is also found in pulmonary hypertension, indicating RA enlargement and severe pulmonary hypertension.
P-102 A Case of Female Danon Disease with Rapidly-deteriorated Heart Failure Heading for Heart Transplantation YUICHIRO IIDA, HISAHITO SHINAGAWA, TAKAYUKI INOMATA, TOYOJI KAIDA, TOSHIMI KOITABASHI, TOHRU IZUMI Department of Cardio-angiology, Kitasato University, School of Medicine, Kanagawa, Japan Background: Danon disease is an X-linked systemic disorder, characterized by cardiomyopathy, mental retardation and skeletal myopathy affecting young men. Female patients, however, are often diagnosed as idiopathic dilated cardiomyopathy (IDCM) because of the later-onset and isolated cardiac symptoms. Case Report: We report a 40-year-old female who was diagnosed as IDCM three years ago with severely-impaired left ventricular (LV) function. Cardiac magnetic resonance demonstrated marked late Gadolinium enhancement in extended LV wall and endomyocardial biopsy specimen from LV showed severe cardiomyocyte degeneration without intracellular vacuoles typical for lysosomal glycogen storage diseases. In spite of optical medical pharmacotherapy with cardiac resynchronization therapy, LV function has been rapidly deteriorated leading to end-stage HF dependent on intravenous inotropics, waiting for heart transplantation. Genetic testing her son affecting Danon disease provided a clue to her diagnosis through a nucleotide substitution in the lysosome-associated membrane protein 2 gene. Conclusion: Danon disease should be suspected in the middle-aged female manifesting as DCM having family members of male teenager with LV hypertrophy, because of its discouraged cardiac prognosis.
P-103 Angiosarcoma of the Pulmonary Artery Diagnosed by Delayed Enhancedment of MRI YOSUKE KAYAMA1, TAKUYA YOSHINO2, TATSUYA KOYAMA1, SHINGO SEKI1, MICHIHIRO YOSHIMURA2 1 Division of Cardiology, Internal Medicine, Katsushika Medical Center Jikei University School of Medicine, Tokyo, Japan, 2Division of Cardiology, Internal Medicine, Jikei University School of Medicine, Tokyo, Japan Primary pulmonary angiosarcoma is rare tumor, with fewer than 80 cases reported in Japan. The prognosis of subjects was very poor. Most patients die within 6 to 24 months of a diagnosis of pulmonary angiosarcoma. The benefits of the multimodality treatment such as chemotherapy and radiation therapy are unclear. Surgical resection remains the best treatment option at present. Therefore, it is important to accurately diagnose primary pulmonary angiosarcoma immediately using non-invasive modalities. Therefore, it is desirable that a means of early detection and diagnosis of such malignant tumors can be established. We present here a case of a Primary pulmonary angiosarcoma with right ventricular failure that was diagnosed by characteristic images of echocardiography and enhanced magnetic resonance image (MRI). This approach also enabled to differentiate between thrombus and malignant tumors before attempting surgery therapy. After resection, pathological examination revealed a intimal sarcoma of pulmonary artery. 10 months later, the patients died with progressive right ventricular heart failure in spite of several treatments for sarcoma.
P-104 A Case of Pulmonary Arterial Hypertension Improved with Normalization of a Prominent Negative Component of P Wave in Lead V1 HIROAKI OBATA, HIROMI KAYAMORI, MASATO ODA, TAKESHI KASHIMURA, HARUO HANAWA, MAKOTO KODAMA Division of Cardiology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan A 30-year-old man was hospitalized for progressive dyspnea and diagnosed with idiopathic pulmonary arterial hypertension. The electrocardiogram obtained at admission showed a prominent negative component of P wave in lead V1, and the P terminal force in lead V1 (TEP-V1) was -0.312mVsec. The mean pulmonary arterial pressure (mPAP574mmHg) and the cardiac index (CI51.74L/min/m2) revealed
P-105 A Rare Case with Fatal Pulmonary Tumor Thrombotic Microangiopathy YUTAKA MIURA, YOSHIHIRO FUKUMOTO, KOICHIRO SUGIMURA, KIMIO SATO, KOTARO NOCHIOKA, TATSUO AOKI, SHUNSUKE TATEBE, SAORI YAMAMOTO, HIROAKI SHIMOKAWA Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan Case: 27 years-old, female. Clinical History: In April, 2011, she suffered from exertional dyspnea, and admitted to the hospital nearby. Echocardiography showed right ventricular dilatation and severe tricuspid valve regurgitation. Right heart catheterization showed elevated mean pulmonary arterial pressure (mPAP, 39 mmHg). After the diagnosis of pulmonary hypertension, her hemodynamic values were gradually deteriorated (blood pressure 100/60 mmHg with 5 mg/kg/min of dobutamine), and she was transferred to our hospital. We started her treatment with percutaneous cardiopulmonary support (PCPS), intravenous prostacycline and oral sildenafil; however, we were unable to obtain any hemodynamic improvement. Then, we added ambrisentan and imatinib, with which we were able to discontinue the 6-weeks PCPS treatment. As she had slight fever, bloody sputum, and high levels of tumor markers, we performed PET examination, which revealed the only mild uptake in the abdominal and mediastinal lymph nodes. We then performed abdominal echography and GI fiber examination, without any findings of malignancies. On September 20th, 2011, she passed away due to the respiratory failure, rapidly elevated mPAP, and hemodynamic disruption. Autopsy examination demonstrated the presence of multiple emboli of signet ring cells in the pulmonary small arteries, a compatible finding with pulmonary tumor thrombotic microangiopathy (PTTM). Conclusion: We experienced a rare case of fatal PTTM resistant to intensive care.
P-106 The Patient after CRT that Making a Graph of Body Weight Dramatically Reduced Hospitalization NAOKI NOZAKI Ayase Heart Hospital, Tokyo, Japan This case is 72 yrs old female. She was diagnosed as dileted cardiomyopathy in 1993 and she had been taking a medicine for chronic heart failure(CHF). Left ventricular systolic function was diffse severe hypokinesis (EF 33%) with dissynchrony. Although CRT-D implantation was performed in Dec. 2006, she had been hospitalized for worsening CHF over and over (4 times in 2007, 5 times in 2008, 1 time in 2009, 5 times in 2010, 3 times in 2011). Repeated guidance of restriction for salt and water intake was not effective. Whenever her hospitalization, her condition was easily improved by oxgen supply and using diuretics during 2 or 3 days. When she was discharged in April 2011, we tought her making a simple line graph of her own body weight every day. We also explained her appropriate body weight. She brings her body weight graph every consultation. Ever since, her condition has been stable and she has never been hospitalized for over 1 yr. Conclusion: In this case, not the record of body weight itself, but making line graph of own body weight significantly reduced her hospitalization.
P-107 Reversible Left Ventricular Dysfunction due to Hypothyroidism and Severe Obstructive Sleep Apnea; A Case Report TASUKU YAMAGUCHI, YOSHIFUMI TAKATA, YASUHIRO USUI, YOSUKE NISHIHATA, KOTA KATO, KAZUKI SHIINA, AKIRA YAMASHINA Department of Cardiology, Tokyo Medical University, Tokyo, Japan A 42 years old man was introduced to our hospital with suspicion of obstructive sleep apnea syndrome (OSAS). He was not obese but had a chief complaint of excessive daytime sleepiness. A polysomnography showed an apnea-hypopnea index (AHI) of 46.3/hr and an arousal index of 47.9/hr, he therefore was diagnosed as severe OSAS. The first laboratory examination showed high level of creatine kinase
The 16th Annual Scientific Meeting (2912 U/l), which lead to the detection of primary hypothyroidism (TSH 138.4 IU/ ml, FT3 0.45pg/ml, FT4 0.12ng/dl). Although a plasma brain natriuretic peptide level was rather low (4.6pg/ml), marked left ventricular (LV) dysfunction without an abnormal accumulation of pericardial effusion was revealed by echocardiography. Cardiac magnetic resonance imaging did not detect any high signal areas in T2 image and delayed enhanced areas. In accordance with an initiation of thyroid hormone replacement therapy and continuous positive airway pressure (CPAP), his sleepiness and general fatigue obviously decreased with body weight reduction by more than 5kg. After five months, the echocardiography showed a great improvement in LV ejection fraction from 25% to 57% and LV systolic dimension from 45mm to 37mm. The second polysomnographic findings without CPAP use also showed a certain amelioration of severity of sleep-disordered breathing. Here, we describe an interesting case with reversible LV dysfunction due to hypothyroidism and severe obstructive sleep apnea.
JHFS
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hypothesized that elevated biomarkers may aid to clarify their role. Method and Results: We studied 216 patients admitted for AHF from 2006 to 2010. Physical finding were recorded at admission. 56.0% patients had non-ischemic HF. Composite endpoint of rehospitalization for AHF or death was met in 37.0%. Patients with pulmonary rales and S3 had worse prognosis compared to those without (Figure). Both discharge BNP and troponin T was significantly higher in patients who presented with pulmonary rales (p50.034 and p!0.001) and S3 (p!0.001). Conclusion: Patients with pulmonary rales and S3 met higher rate of adverse outcome, and the findings seem to be related to persistently elevated biomarkers at steady state.
P-108 The Effects of Tolvaptan for Neurohormonal Factor and Hemodynamics of the Patients with Heart Failure NORIYUKI KAWAURA1, KAZUAKI UCHINO1, KATSUMI MATSUMOTO1, HIDEYUKI OGAWA1, TAKESHI TAKAMURA1, TERUYASU SUGANO1, TOMOAKI ISHIGAMI1, TOSHIYUKI ISHIKAWA1, KAZUO KIMURA2, SATOSHI UMEMURA1 1 Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan, 2Division of Cardiology, Yokohama City University Medical Center, Yokohama, Japan Background: Tolvaptan is a newly developed diuretics that function as vasopressin2 receptor antagonist. Thus, the effects of tolvaptan for patients with heart failure is still unclear. Aim: To evaluate the effects of tolvaptan for neurohormonal factors of patients with heart failure. Method: 14 patients hospitalized for heart failure (mean age 69.5612.5 years; 69.3% male) were received tolvaptan. Clinical status, physical exams and neurohormonal factors associated with heart failure at day 1 and day 7 after receiving tolvaptan were investigated. Result: Compared day 1 with day 7, tolvaptan significantly decreased hANP (349.9 vs. 210.7 pg/ml; p50.023), BNP (661 vs. 497 pg/ml; p50.018) and dopamine (49 vs. 32 pg/ml; p50.042). Serum Na (137.5 vs. 140.0 mEq/l; p50.081), ADH (3.1 vs. 6.4 pg/ml; p50.068), urine Na (50 vs. 72 mEq/l; p50.057) and urine osmotic pressure (251 vs. 326; p50.052) was increased, but not significantly. And body weight (51.0 vs. 49.0 kg; p50.052) was decreased, not significantly. Hemodynamic parameters (systolic blood pressure 113 vs. 118 mmHg; p50.715, heart rate 83.9 vs. 79.3 bpm; p50.262) and renal function (eGFR 49.7 vs. 51.7 ml/min/1.73m2; p50.453) were no significant differences between the day 1 and day 7. Conclusion: In short term use, tolvaptan was effective diuretics for patients with heart failure and had small effect on hemodynamic parameters and renal function.
P-109 The Role of Serum Sodium Concentration Levels on Tolvaptan Therapy in Patients with Heart Failure HIDETO SAKO, SHIN-ICHIRO MIURA, EIJI YAHIRO, KEJIRO SAKU Department of Cardiology, Fukuoka University Hospital, Fukuoka, Japan Objectives: The aim of this study was to evaluate whether the levels of elevated serum sodium (Na) determine the efficacy and safety of tolvaptan in acute phase of heart failure (HF). Methods: Twenty HF patients [age 73612 years, left ventricular (LV) ejection fraction 47618%, serum creatinine 2.161.4 mg/dl] treated with tolvalpan (1164 mg) were included. The levels of serum Na, urine volume and body weight were measured at 0, 12, 24, 48, 60, 72 and 168 hours after treatment. We also investigated whether these factors have an influence on the efficacy and safety of tolvaptan. Results: Cardiovascular events had not been found during tolvaptan treatment (16613 days). The patients were divided into an increasing group [dNa(+) group, n511] and a decreasing group [dNa(-) group, n59] according to the changes in the levels of serum Na after 60 hours. dNa(+) group showed a higher urinary volume and body weight loss than dNa(-) group. In the efficacy of acute phase, urinary volume was significantly associated with the patients who had 4 factors (history of HF, diabetes, LV hypertrophy and serum creatinineO2.5mg/dl) by a multivariate regression analysis. Conclusions: Tolvaptan is a potentially useful in the treatment of HF, and the levels of serum Na at 60 hours might be a useful marker of judging the efficacy of tolvaptan.
P-110 Association Between Baseline Physical Findings and Persistently Elevated Biomarker Level after Acute Heart Failure SAYOKO NEGI, SHUN KOHSAKA, KIMI KOIDE, YUJI NAGATOMO, HIROYUKI MOTODA, KENSUKE KIMURA, MOTOAKI SANO, TSUTOMU YOSHIKAWA, KEIICHI FUKUDA Keio Universiy School of Medicine, Tokyo, Japan Background: Previous studies have reported association between physical findings and patient’s long-term prognosis in acute heart failure (AHF). We
P-111 Inotrope Use and Serum High Sensitive Troponin-I in Acute Decompensated Heart Failure SATOSHI KOYAMA1, YUKIHITO SATO1, YOHEI TANADA2, HIDEAKI INAZUMI1, HISAYOSHI FUJIWARA1, YOSHIKI TAKATSU1 1 Department of Cardiovascular Medicine, Hyogo Prefectural Amagasaki Hospital, Amagasaki, Japan, 2Graduate School of Medicine Kyoto University, Kyoto, Japan Objective: Inotrope use and high cardiac troponin concentration were both known as prognostic markers for patients with acute heart failure syndrome. However, the relationship between these two parameters was not studied well. Method: Consecutive 114 acute heart failure patients (male 51%, median 74 [70-82] years) were included our prospective observational study. Clinical characteristics, parameters, blood and urine samples on the days of admission, day 4, and day 7 were collected. 31 of 114 patients required continuous infusion of inotrope for heart failure treatment. Adjusted by these baseline parameters, 31 matched pairs were compared. Result: Serum troponin-I concentration decreased through the course of heart failure (median 0.038, 0.030, 0.028ng/mL, days 1, 4, and 7 respectively, p50.0001). The factors independently related to use of inotrope were hypotension (with inotrope vs. without, 122(624.7) mmHg p!0.001) vs. 145(624.5) mmHg, higher bilirubin concentration (0.8 [0.7-0.13] mg/dL vs. 0.7 [0.5-1.1] mg/dL, p50.036), and higher cardiac troponin-I (0.072 [0.034-0.190] ng/mL vs 0.031 [0.017-0.075] ng/mL, p50.021) on admission. Serum troponin-I concentration more decreased in patients treated without inotrope compared to those treated with inotrope (p50.049). Conclusion: Hyoptention, bilirubinemia and higher troponin concentration on admission were independent predictors of need for inotropes for acute heart failure treatment. After adjustment of these factors, inotrope use disturbed decrease of cardiac troponin-I in the therapeutic course of acute decompensated heart failure.
P-112 Association Between Obesity and Clinical Characteristics in Patients with Acute Heart Failure MASATO MATSUSHITA1, AKIHIRO SHIRAKABE1, NORITAKE HATA1, TAKURO SHINADA1, NOBUAKI KOBAYASHI1, KAZUNORI TOMITA1, MASAFUMI TSURUMI1, YOSHIYA YAMAMOTO1, KYOICHI MIZUNO2 1 Intensive Care Unit, Nippon Medical School Chiba Hokusoh Hospital, Chiba, Japan, 2 Department of Medicine, Division of Cardiology, Hepatology, Geriatrics and Integrated Medicine, Nippon Medical School, Tokyo, Japan Backgrounds: There have been few reports about the relationship between obesity and clinical findings of acute heart failure (AHF). Methods: Five-hundred and ninety-two patients who were admitted to the intensive care unit were analyzed. Patients were assigned to non-obesity group (n5451, BMI!25, group-N) or obesity group (n5141, BMIO25, group-O). The clinical findings on admission and outcome were evaluated. Results: The age was significantly younger in group-O than in group-N (67.3612.1 vs 73.4610.5years-old). Systolic blood pressure (SBP) was significantly higher in group-O