皿井 正義

An 80-year-old asymptomatic man presented with ST-segment elevation in leads V1 to V5. Coronary CT angiography showed that microfistulae arising from multiple arteries may have led to myocardial infarction from intracoronary thromboembolism within the dilated left anterior descending (LAD). (C) 2013 Society of Cardiovascular Computed Tomography. All rights reserved.

A 62-year-old woman Underwent percutaneous transhepatic obliteration of a giant portal-systemic shunt. Just after inserting a coil into the shunt, it slipped through the giant shunt and migrated to the right atrium. CT showed coil migration into the coronary sinus. (C) 2013 Society of Cardiovascular Computed Tomography. All rights reserved.

Background: The role of combined evaluation of myocardial perfusion imaging (MPI; by single-photon emission computed tomography) and computed tomography angiography (CTA) for risk stratification of coronary artery disease was evaluated. For CTA, the extent of luminal stenosis, and also the features of high-risk plaques (HRP, including positive remodeling and low attenuation) were evaluated. Methods and Results: A total of 304 patients (65 +/- 11 years, male 72%, median follow-up: 24 months) who underwent CTA and MPI were enrolled in the study. Summed stress scores and summed difference scores (SDS) for MPI, stenosis, and HRP were evaluated, and event rates were compared. Cardiac events were defined as acute coronary event including cardiac death or non-fatal acute myocardial infarction, and unstable angina requiring revascularization. Of 304 patients, 51 (16.8%) underwent early revascularization. In the remaining 253 patients, an event occurred in 11 (4.3%). HRP (hazard ratio [HR], 4.75, P=0.00171) and stenosis (+) with SDS >0 (HR, 4.58, P=0.0461) were). HRP (hazard ratio [HR], 4.75, P=0.00171) and stenosis (+) with SDS >0 (HR, 4.58, P=0.0461) were significant independent predictors of cardiac event. The event rate for stenosis (+) with SDS >0 was significantly higher than others (log-rank P=0.0490). The event rates were significantly different between HRP(+) and HRP(-) (16.1% vs. 2.7%, log-rank P=0.0013). Conclusions: HRP on CTA was an independent predictor of acute coronary events, as was stenosis (+) with SDS >0, and HRP had increased prognostic value over stenosis and abnormal MPI findings. (Circ J 2013; 77: 411-417)

Computed tomography angiography (CTA) is commonly employed for exclusion of coronary artery disease and demonstration of the extent of coronary vascular involvement. It has been recently proposed that coronary artery plaques could be visualized noninvasively. This review article focused on the high risk plaque detected by CTA. Plaque characteristics of acute coronary syndrome (ACS) was compared to sable angina pectoris (SAP). The presence of positive remodeling (ACS 87 %, SAP 12 %, p &lt 0. 0001), low attenuation plaque (LAP) (ACS 79 %, SAP 9 %, p &lt 0. 0001), and spotty calcification (ACS 63 %, SAP 21 %, p = 0. 0005) were significantly more frequent in the culprit ACS lesions. Furthermore, in asymptomatic patients, presence of positively remodeling and LAP portends a greater risk for development of acute coronary events (hazard ratio = 22. 8, CI = 6. 9-75. 2, p &lt 0. 001). Possibility of drug intervention to high risk plaque was also reported. Serial CTA assessment allows for evaluation of interval change in morphological plaque characteristics and can be employed for assessment of efficacy of therapeutic intervention. Use of statin results in substantial reduction in LAP volume (follow-up: 4. 9 ± 7. 8 versus baseline: 1. 3 ± 2. 3 mm3, p = 0. 02) forwards stabilization of plaques. Although not recommended currently as a population-based strategy, CT angiographic examination may help identify very high risk asymptomatic subjects. © 2013 Japanese Association of Cardiovascular Intervention and Therapeutics.

Objective To study the usefulness of combined risk stratification of coronary CT angiography (CTA) and myocardial perfusion imaging (MPI) in patients with previous coronary-artery-bypass grafting (CABG). Design A retrospective, observational, single centre study. Setting and patients 204 patients (84.3% men, mean age 68.77.6) undergoing CTA and MPI. Main outcome measures CTA defined unprotected coronary territories (UCT; 0, 1, 2 or 3) by evaluating the number of significant stenoses which were defined as the left main trunk 50% diameter stenosis, other native vessel stenosis 70% or graft stenosis 70%. Using a cut-off value with receiver-operating characteristics analysis, all patients were divided into four groups: group A (UCT=0, summed stress score (SSS)<4), group B (UCT1, SSS<4), group C (UCT=0, SSS4) and group D (UCT1, SSS4). Results Cardiac events, as a composite end point including cardiac death, non-fatal myocardial infarction, unstable angina requiring revascularisation and heart-failure hospitalisation, were observed in 27 patients for a median follow-up of 27.5months. The annual event rates were 1.1%, 2%, 5.7% and 12.9% of patients in groups A, B, C and D, respectively (log rank p value <0.0001). Adding UCT or SSS to a model with significant clinical factors including left ventricular ejection fraction, time since CABG and Euro SCORE II improved the prediction of events, while adding UCT and SSS to the model improved it greatly with increasing C-index, net reclassification improvement and integrated discrimination improvement. Conclusions The combination of anatomical and functional evaluations non-invasively enhances the predictive accuracy of cardiac events in patients with CABG.

心臓サルコイドーシスの診断は容易ではなく，早期診断は予後を左右する．心臓核医学検査のテクネシウム心筋血流製剤である99mTc-MIBI （以下MIBI）の洗い出し率（washout rate; WOR）が注目されている．ミトコンドリア心筋症では，WORの高度な亢進が報告されている．虚血性心疾患，心不全，心筋症でもWORの亢進が報告されているが，心臓サルコイドーシスでの報告は今までにない．ステロイド治療群と未治療群の比較では，WOR と血中ACE値（ACE）はステロイド治療群で有意に低値であったが，左室駆出率に差はなかった．ステロイド治療前後にMIBI検査を施行した5 例では，ステロイド治療により，WORとACEは低下した．ステロイド治療開始後にMIBI検査を2 回施行した5 例では，WORとACEは上昇傾向を認めた．MIBIのWORの変化はACEと同じ傾向を示したので，心臓サルコイドーシスの活動性の評価やステロイド治療の効果判定に利用できる可能性が示唆された．

INTRODUCTION Myocardial scintigraphy with I-123-15-(p-iodophenyl)-3-methyl pentadecanoic acid (I-123-BMIPP) is used to evaluate impaired fatty acid metabolism. B-type natriuretic peptide (BNP), which is secreted by the ventricular myocardium on stretching and/or pressure overload, is a useful cardiac biomarker. This study aimed to evaluate the usefulness of I-123-BMIPP imaging and serum BNP levels in patients with heart failure (HF). METHODS 113 patients with HF were enrolled. There were 68 patients with ischaemic heart disease (IHD) and 22 with overt HF. Cardiac scintigraphy was performed 7 +/- 3 days after admission, and heart-to-mediastinum (H/M) count ratios on early and delayed images and washout rates (WR) of I-123-BMIPP were recorded. Serum BNP levels were recorded on the day of I-123-BMIPP imaging. The ejection fraction (EF) was calculated just before cardiac scintigraphy using conventional echocardiography. RESULTS The mean BNP level and EF were 282 pg/mL and 47%, respectively, with significant correlation between them. The mean H/M count ratios on early and delayed images were 2.29 and 1.93, respectively, showing significant positive correlations with EF (r = 0.31, p = 0.0006). The WR was significantly correlated with EF (r = -0.36, p < 0.0001) and BNP levels (r = 0.33, p = 0.003), and mean WR was significantly higher in patients with overt HF compared to those without (p < 0.001). Patients with IHD had significantly higher EFs than those with non-IHD (p = 0.03). CONCLUSION The evaluation of impaired myocardial metabolism using I-123-BMIPP scintigraphy and serum BNP levels appears to be useful for the evaluation of severity of HF.

Background: The differences in the coronary plaque characteristics between patients with mild chronic kidney disease (CKD) (estimated glomerular filtration rate [eGFR] 30-59 ml . min(-1) . 1.73 m(-2)) and those without CKD (eGFR >= 60) by 320-row area detector computed tomography (CT) have not been studied. Methods and Results: We enrolled 487 patients undergoing coronary CT angiography with suspected stable coronary artery disease (mean age: 66.6 +/- 10.8 years, 131 with mild CKD) and analyzed 6,352 segments. All coronary plaques were characterized for the presence of vessel remodeling, plaque consistency and the disposition of coronary calcification, and a plaque with positive vessel remodeling and/or low-attenuation was defined as high risk. The number of diseased segments per patient was higher in mild CKD patients than in those without CKD (4.61 +/- 3.83 vs. 2.95 +/- 3.11, P<0.0001). The prevalence of severe stenosis (>= 70% luminal diameter) was significantly higher in cases of mild CKD than in no CKD (35.1% vs. 19.4%, P=0.0003), but there was no significant difference in the prevalence of high-risk plaque (13.0% vs. 9.8%, P=0.3189). Conclusions: The severity of coronary artery stenosis was higher in the patients with mild CKD, though there was no significant difference in the prevalence of high-risk plaque. We suggest that the high risk of coronary events in patients with CKD is related to the severity of stenosis rather than to the characteristics of plaque. (Circ J 2012; 76: 1436-1441)

Objective: Following acute myocardial infarction (AMI) the area of myocardial perfusion and metabolism mismatch is designated as dysfunctional viable myocardium. 123I-beta-methyl iodophenyl pentadecanoic acid (BMIPP) is clinically very useful for evaluating myocardial fatty acid metabolism, and 99mTc-Tetrofosmin (TF) is a widely used tracer for myocardial perfusion. This study was designed to evaluate the degree of discrepancy between BMIPP and TF at the subacute state of AMI. Methods: Fifty-two patients (aged 59 ± 10 years mean 46 years) with AMI were enrolled, and all of them underwent percutaneous coronary intervention (PCI). Patients were classified according to ST-T change and PCI timing. 123I-beta-methyl iodophenyl pentadecanoic acid and TF cardiac scintigraphy were performed on 7 ± 3.5 days of admission using a dual headed gamma camera. Perfusion and fatty acid metabolism defect were scored on a 17 segments model. Results: The mean BMIPP defect score on early and delayed images were 16.67 ± 10.19 and 16.25 ± 10.40, respectively. The mean TF defect score was 10 ± 7.69. Defect score of BMIPP was significantly higher than that of the TF (P &lt 0.0001 95% CI 4.32-7.02), and there was a strong correlation between perfusion and metabolism defect score (r = 0.89, P &lt 0.00001). Forty-seven (90%) patients showed mismatched defect (BMIPP &gt TF), and 5 (10%) patients showed matched defect (BMIPP = TF). Mismatched defect score (MMDS) was significantly higher in patients with ST-segment elevation myocardial infarction (STEMI) than that of non-ST-segment elevation myocardial infarction (NSTEMI) (P &lt 0.041 95% CI 0.11-5.19). Conclusion: At the subacute state of AMI, most of the patients showed perfusion-metabolism mismatch, which represents the dysfunctional viable myocardium, and patients with STEMI showed higher mismatch. © 2012. Cardiological Society of India. All rights reserved.

Aims Pathological and clinical optical coherence tomography (OCT) studies have indicated that acute coronary syndrome (ACS) lesions have either ruptured fibrous caps (RFC-ACS) or intact fibrous caps (IFC-ACS). Although computed tomographic (CT) angiographic characteristics of RFC-ACS include low-attenuation plaques and positive plaque remodelling, features associated with IFC-ACS have not been previously described. The aim of this study was to assess the CT characteristics of IFC-ACS lesions. Methods and results Seventy-four patients with ACS/stable angina consented to multimodality imaging, of which 66 underwent CT angiography. Of these, 57 culprit lesions in 57 patients were evaluated with sufficient image quality from all four of OCT, angioscopy, intravascular ultrasound, and CT angiography. Intraluminal thrombus was assessed by OCT/angioscopy, and culprit lesions further classified by OCT-based demonstration of fibrous cap integrity. Of 35 culprit lesions with ACS, OCT revealed IFC with thrombus in 10 (29%) and RFC in the remaining 25 (71%); all 22 lesions with stable angina had intact fibrous caps. Fibrous caps were significantly thinner in RFC-ACS than IFC-ACS and stable angina (45 +/- 12, 131 +/- 57, and 321 +/- 146 mu m, respectively; P = 0.001). CT angiography revealed that low-attenuation plaques were more frequently observed in RFC-ACS than IFC-ACS and stable angina (88, 40, and 18%; P = 0.001) lesions. Similarly, positive remodelling was more predominantly seen in RFC-ACS than IFC-ACS and stable angina (96, 20, and 14%; P = 0.001). However, none of the specific CT angiography features clearly distinguished IFC-ACS from stable lesions. Conclusion In contrast to the situation with RFC-ACS, distinct culprit lesion characteristics associated with non-rupture-related mechanisms are not identified by CT angiography. It will therefore not be possible to differentiate plaques likely to develop IFC-ACS from stable plaques.

Coronary computed tomography angiography (CTA) can assess plaque characteristics and plaque size noninvasively. The purpose of this study was to investigate whether coronary CTA before percutaneous coronary intervention (PCI) can predict the no-reflow phenomenon during PCI. Seventy-eight patients [acute coronary syndrome (ACS) = 43, stable angina pectoris (SAP) = 35, male/female = 72/6, age: 65 +/- A 10 years] who underwent 16- or 64-slice CTA in the 4 weeks before PCI were enrolled. The low attenuation plaque size on CTA was compared between patients with (NR+) and without the no-reflow phenomenon (NR-). No-reflow phenomenon was observed in 11 patients, including 10 patients with ACS and 1 patient with SAP. Low attenuation plaque was detected in 9 (82%) NR(+) lesions and 35 (52%) NR(-) lesions. The length of low attenuation plaque was significantly longer in NR(+) than in NR(-) patients (9.0 +/- A 6.5 vs. 1.6 +/- A 2.7 mm, p < 0.0001). On step-wise regression analysis, ACS (p = 0.036, 95% CI = 0.009-0.258) and the presence of low attenuation plaque with a length > 4.7 mm (p < 0.001, 95% CI = 0.447-0.778) were significant independent predictors of NR(-) no-reflow phenomenon. Low attenuation plaque with lesion length of > 4.7 mm on coronary CTA and ACS were the significant predictors for the no-reflow phenomenon during PCI. Coronary CTA assessment before PCI would be useful to predict coronary events during PCI in advance.

OBJECTIVES This study sought to assess, by serial computed tomography angiography (CTA), the effect of statin treatment on coronary plaque morphology. BACKGROUND In addition to the assessment of luminal stenosis, CTA also allows characterization of plaque morphology. Large, positively remodeled plaques with large necrotic cores have been reported as indicators of plaque instability. METHODS CTA was performed in 32 patients (26 men, ages 64.3 +/- 8.5 years). Of these, 24 received fluvastatin after the baseline study; 8 subjects who refused statin treatment were followed as the control subjects. Serial imaging was performed after a median interval of 12 months. All vessels were examined in every subject, and a 10-mm-long segment was identified for comparison before and after intervention. Total plaque volume, low attenuation plaque (LAP) volume, lumen volume, and remodeling index were calculated. RESULTS In the statin-treated patients, the total plaque volume (92.3 +/- 37.7 vs. 76.4 +/- 26.5 mm(3), p < 0.01) and LAP volume (4.9 +/- 7.8 vs. 1.3 +/- 2.3 mm(3), p = 0.01) were significantly reduced over time; however, there was no change in the lumen volume (63.9 +/- 25.3 vs. 65.2 +/- 26.2 mm(3), p = 0.59). On the other hand, no change was observed in the CTA characteristics in the control subjects, including total plaque volume (94.4 +/- 21.2 vs. 98.4 +/- 28.6 mm(3), p = 0.48), LAP volume (2.1 +/- 3.0 vs. 2.3 +/- 3.6 mm(3), p = 0.91), and lumen volume (80.5 +/- 20.7 vs. 75.0 +/- 16.3 mm(3), p = 0.26). The plaque volume change (-15.9 +/- 22.2 vs. 4.0 +/- 14.0 mm(3), p +/- 0.01) and LAP volume change (-3.7 +/- 7.0 vs. 0.2 +/- 1.5 mm(3), p = 0.01) were significantly greater in the statin than the control group. The lumen volume (1.3 +/- 15.6 vs. -5.5 +/- 13.1 mm(3), p = 0.24) and remodeling index (-2.4 +/- 6.8% vs. -0.3 +/- 6.5%, p = 0.53) did not show the significant differences between the 2 groups. The decrease in the plaque volume was due to reduction in the LAP volume (R = 0.83, p < 0.01), and was not related to any changes in the lumen volume (R = 0.21, p = 0.24). CONCLUSIONS This preliminary study suggests that serial CTA evaluation of coronary plaques allows for the assessment of interval change in the plaque morphology. Statin treatment results in decreases in the plaque and necrotic core volume. The features known to be associated with plaque instability. (J Am Coll Cardiol Img 2010;3:691-8) (c) 2010 by the American College of Cardiology Foundation

The evolution of the oxidative metabolism of C-11 acetate parallels the recovery of left ventricular (LV) contraction following acute myocardial infarction (AMI). This study was designed to unravel, for the first time, the impact of the global washout rate (WR) of I-123-beta-methyl-p-iodophenylpentadecanoic acid (BMIPP) on the recovery of LV function following AMI, as evidenced from conventional echocardiography. Twenty consecutive patients (age: 58 +/- 13 years; 16 males and 4 females) with ST-segment elevation myocardial infarction (STEMI) were enrolled and all of them underwent successful percutaneous coronary intervention (PCI). I-123-BMIPP cardiac scintigraphy was performed at 7 +/- 3 days after admission. The WR was calculated from the polar map and the regional BMIPP defect score was calculated using a 17 segment model. Echocardiography was performed within 24 h of admission and at 3 months to record the ejection fraction (EF), the wall motion score index (WMSI), the ratio of the mitral inflow velocity to the early diastolic velocity (E/E') and the myocardial performance index (MPI). The mean global WR of the BMIPP was 22.12 +/- 7.22%, and it was significantly correlated with the improvement of the WMSI (r = 0.61, P < 0.004). However, the relative changes of the EF, E/E' and MPI were not correlated with the WR. The BMIPP defect score (18 +/- 10) was significantly correlated with the WMSI on admission (r = 0.74, P = 0.0002), but the defect score was not correlated with the relative changes of any of the echocardiographic parameters. We proved that the WR of the BMIPP is a promising indicator of improvement of the LV wall motion (WMSI) following ST-segment elevation myocardial infarction and successful reperfusion.

Background: Myocardial fatty acid metabolic imaging with beta-methyl iodophenyl pentadecanoic acid (BMIPP) and perfusion imaging with tetrofosmin (TF) combined can predict post ischemic salvageable myocardium and persistent left ventricular (LV) dysfunction. This study was designed for the first time to assess systolic, diastolic and global LV dysfunction considering BMIPP and TF mismatched defect score (MMDS), and comparing this approach with the conventional Doppler echocardiography. Methods: Thirty four patients with first acute myocardial infarction (AMI) were enrolled, and all of them underwent percutaneous coronary intervention (PCI). BMIPP and Tetrofosmin (TF) scans were performed at 7+/-3.5 days of admission. Echocardiography was performed within 24 h of admission, at an interval of 1 and 3 months. MMDS was compared with systolic: ejection fraction (EF), wall motion score index (WMSI), fractional shortening (FS); diastolic: mitral valve deceleration time (MVDT), E/E', left atrial volume index (LAVI); combined systolic and diastolic parameter: left ventricular myocardial performance index (LVMPI). Results: A good correlation was observed between BMIPP and TF defect score (p<0.00001), and in 31 (91%) patients BMIPP defect score was higher than that of TF. The MMDS showed significant correlation with EF (r=-0.64, p=<0.00001), WMSI (r=0.61, p<0.0001), and FS(r=-0.65, p<0.00001), LAVI (r=-0.32, p<0.05), and LVMPI (r=0.37, p<0.02) during follow up echocardiography at 1 month. MVDT and E/E' did not correlate with MMDS. Conclusion: Perfusion-metabolism mismatched defect score was well correlated with the evolution of global left ventricular dysfunction following AMI evidenced from conventional Doppler echocardiography. (C) 2008 Elsevier Ireland Ltd. All rights reserved.

I-123-beta-methyl-iodophenyl pentadecanoic acid (BMIPP) and Tc-99m-Tetrofosmin (TF) mismatch designated as stunned myocardium having both systolic and diastolic components. The degree of mismatch might reflect subsequent functional improvement, and this study was designed to unravel the impact of mismatched defect score (MMDS) on recovery of both systolic and diastolic function following acute myocardial infarction (AMI). Forty patients with recent AMI were recruited, and all of them underwent emergency percutaneous coronary intervention. Echocardiography and BMIPP and TF cardiac scintigraphy were performed on 7 +/- A 3 days of admission. Follow up echocardiography was performed after 3 months. MMDS were compared with the systolic [ejection fraction (EF) and wall motion score index (WMSI)] and diastolic [peak velocity of early diastolic filling of mitral inflow/peak early diastolic velocity of the mitral annulus(E/E') and left atrial volume index(LAVI)] parameters. BMIPP defect score was significantly higher than the TF defect score and there was a strong positive correlation between them (r = 0.90, P < 0.00001). Thirty-two (80%) patients showed mismatched defect and rest 8(20%) showed matched defect. Of 32 patients 24(75%), 22(69%), 19(59%), and 20(62.5%) showed improved EF, WMSI, E/E' and LAVI respectively. Conversely out of 8 only 2(25%), 1(12.5%), and 2(25%) patients showed improvement of EF, WMSI and LAVI, respectively. E/E' was not improved in patients with matched defect. MMDS were significantly correlated with the improvement of EF (r = -0.46, P = 0.002), WMSI (r = 0.41, P = 0.007), E/E' (r = 0.56, P < 0.0002), and LAVI (r = 0.44, P = 0.004). Mismatched defect score could predict the approximate amount of viable dysfunctional myocardium, and the degree of mismatch showed a significant correlation with the improvement of both systolic and diastolic function.

Fatty acid oxidation is the most efficient mode of myocardial energy production which requires a large amount of oxygen. Thus, alteration of fatty acid oxidation is considered to be a sensitive marker of ischaemia and myocardial damage. I-123-BMIPP (I-123-beta-methyl-p-iodophenylpentadecanoic acid) is a newly-investigated single-photon branching free fatty acid radiopharmaceutical with slow metabolism; thus, it is well-suited for single-photon emission computed tomography (SPECT). Assessment of fatty acid metabolism by radionuclide techniques has a potential role for the early detection of myocardial ischaemia and the assessment of the severity of ischaemic heart disease. Although stable patients with a healed myocardial infarction may have a relatively good prognosis, risk stratification in the predischarge period should be valuable for deciding upon appropriate management. In this respect, the presence of discordant BMIPP uptake relative to Tl-201 perfusion appears to be the best predictor of future cardiac events among all other cardiovascular imaging modalities. Since discordant BMIPP uptake correlates well with redistribution on stress Tl-201 imaging and perfusion-metabolism mismatch on positron emission tomography, it is considered that such BMIPP and Tl-201 discordance may identify a high-risk subgroup among patients with acute myocardial infarction. A BMIPP scan may reflect prior severe ischaemia after recovery of perfusion, the so-called "ischaemic memory". Gated BMIPP SPECT has been recently introduced for simultaneous assessment of myocardial metabolism and ventricular function. Such a new technique seems to be valuable for a better understanding of the pathophysiological state of heart failure and cardiomyopathy.