Is the combination therapy of IKr-channel blocker and left stellate ganglion block effective for intractable ventricular arrhythmia in a cardiopulmonary arrest patient?

Background: We have previously reported that the defibrillation success rate of intravenous nifekalant hydrochloride (NIF), a pure IKr-channel (IKr: the rapid components of the delayed rectifier potassium current) blocker, was more than 75% for lidocaine-resistant ventricular tachycardia and fibrillation (VT/VF) in patients with out-of-hospital cardiopulmonary arrest (CPA). However, there was no effective treatment for the remaining 25% of patients in whom defibrillation was unsuccessful. We hypothesised that the combination therapy of NIF and left stellate ganglion block (LSGB) was useful for defibrillation in NIF-resistant VT/VF and investigated its efficacy in a retrospective study. Methods and results: We investigated sequentially 272 out-of-hospital CPA patients treated at Tokai University between April and December 2006. VT/VF occurred in 55 patients on arrival or during cardiopulmonary resuscitation (CPR). On the basis of our CPR algorithm, NIF was administered (0.15-0.3 mg/kg, i.v.) after the first direct-current cardioversion. NIF-resistant VT/VFs were observed in 15 out of 55 patients and LSGB was performed on 11 of these with administration of NIF. Sinus rhythm was restored in 7 patients following LSGB (64%) and complete recovery was achieved in 2 patients. In the non-LSGB group, however, all the patients died. Conclusions: The combination therapy of intravenous NIF and LSGB was useful for defibrillation in intractable VT/VF. It is a potential and innovative treatment strategy for IKr-channel blocker resistant VT/VF. (Cardiol J 2007; 14: 355-365

Skuteczność terapii złożonej polegającej na podaniu blokera kanału IKr oraz wykonaniu blokady zwoju gwiaździstego w leczeniu opornych arytmii komorowych u chorych z zatrzymaniem krążenia

Wstęp: W poprzednich doniesieniach autorzy niniejszej pracy dowiedli, że współczynnik skuteczności defibrylacji przy jednoczesnym dożylnym podaniu chlorowodorku nifekalantu (NIF) - selektywnego blokera kanałów szybkiej składowej opóźnionego prostującego prądu potasowego (IKr) wynosił powyżej 75% dla opornego na lignokainę częstoskurczu lub migotania komór (VT/VF) w przebiegu pozaszpitalnego zatrzymania krążenia (CPA). Jednakże dla pozostałych 25% chorych, u których wykonana defibrylacja okazała się nieskuteczna, nie znaleziono efektywnych metod leczenia. Autorzy niniejszej pracy sugerują, że zastosowanie złożonej terapii polegającej na dożylnym podaniu NIF oraz wykonaniu blokady lewego zwoju gwiaździstego (LSGB) jest użyteczne w przypadku defibrylacji VT/VF opornego na działanie NIF. Na podstawie własnych badań retrospektywnych podjęto także próbę oceny skuteczności tej terapii. Metody i wyniki: Do badania włączono kolejnych 272 chorych przyjętych do Kliniki Kardiologii Uniwersytetu Tokai w okresie od kwietnia do grudnia 2006 roku z powodu pozaszpitalnego zatrzymania krążenia. U 55 pacjentów (podczas przyjęcia lub też w przebiegu resuscytacji krążeniowo-oddechowej) stwierdzono VT/VF. Zgodnie z samodzielnie wypracowanymi przez autorów pracy algorytmami prowadzenia resuscytacji krążeniowo-oddechowej NIF (w dawce 0,15-0,3 mg/kg) podawano dożylnie po pierwszej próbie kardiowersji. Oporne na działanie NIF częstoskurcze komorowe/migotania komór wystąpiły u 15 spośród 55 pacjentów. U 11 chorych z powyższej grupy wykonano LSGB oraz podano dożylnie NIF. U 7 osób (64%) po zabiegu LSGB uzyskano powrót rytmu zatokowego. Całkowity powrót do zdrowia zanotowano u 2 chorych. Jednakże w grupie, w której nie wykonano zabiegu blokady lewego zwoju gwiaździstego (grupa nie-LSBG), zmarli wszyscy pacjenci. Wnioski: Terapia złożona polegająca na dożylnym podaniu NIF oraz wykonaniu LSGB okazała się użyteczna w przypadku defibrylacji opornego VT/VF. Jest to potencjalna i innowacyjna strategia leczenia opornego na selektywne blokery kanałów IKr częstoskurczu komorowego/ migotania komór. (Folia Cardiologica Excerpta 2007; 2: 524-536

Laparoscopic and Endoscopic Cooperative Surgery for Plexiform Angiomyxoid Myofibroblastic Tumor

Plexiform angiomyxoid myofibroblastic tumor (PAMT) is a recently described distinctive gastric mesenchymal entity with a peculiar plexiform pattern, bland spindle cells and a myxoid stroma rich in arborizing blood vessels. In this study, we report a new case of this rare gastric tumor resected by laparoscopic and endoscopic cooperative surgery (LECS). A 39-year-old Japanese man was admitted with a gastric mass. Gastroscopy showed an elevated mass in the anterior wall of the gastric antrum. Endoscopic ultrasound examination revealed a focal hypoechoic lesion protruding into the lumen. A partial gastrectomy by LECS was performed, and the patient made an uneventful recovery and remains well 9 months later. The tumor in this case depicted all the typical histopathologic and immunochemical features of gastric PAMT (c-kit negative and smooth muscle actin-positive). Especially, it was characterized by multiple nodules protruding outward within the serosa. Therefore, it is important that the resection line is determined on the serosa to ensure the complete resection of these nodules together

Neurally mediated syncope diagnosis based on adenylate cyclase activity in Japanese patients.

The study aims to clarify the mechanism in patients with neurally mediated syncope (NMS), focusing on the adenylate cyclase (AC) activity level in lymphocytes. This study included 40 subjects: 22 healthy volunteers and 18 NMS patients. We investigated the changes in AC activity that occur during of syncope at rest and during the head-up tilt (HUT) test. We obtained 8 mL of blood at rest time and four times during the HUT test. Then, we measured the AC activity and the test reagent was added to the lymphocytes (10,000) and reacted for 30 min at room temperature. We were able to determine the standard value of AC activity when adrenaline (AD) and isoproterenol (IP) were added to lymphocytes. The results of our study showed one of the causes of NMS has a difference in AC activity level and classification of the patients into two different types of NMS was possible: either the vasodepressor type (VT) or mixed type (MT). At rest time, VT patients showed significantly higher AC activity (AD; 100 μM: p = 0.005, IP; 50 μM: p = 0.02) and MT patients showed significantly lower AC activity (AD; 10 μM: p = 0.02, IP; 50 μM: p = 0.004) than the average AC activity in healthy volunteers. Moreover, VT patients had significantly higher AC activity than healthy volunteers at the four points of the HUT test. MT patients had significantly lower AC activity (AD: p = 0.04 and IP: p = 0.04) than healthy volunteers at the rest time of HUT. Our study showed a significant difference in AC activities between NMS patients and healthy volunteers at rest. Therefore, a detailed NMS diagnosis can be made by examining AC activity levels in blood taken at rest time

Inducibility of Ventricular Arrhythmia 1 Year Following Treatment with Heavy Ion Irradiation in Dogs with Myocardial Infarction

Background: Targeted external heavy ion irradiation (THIR) of rabbit hearts 2 weeks after myocardial infarction (MI) reduced the vulnerability of fatal ventricular tachyarrhythmias (VT/VF) in association with the increased connexin43 (Cx43). Increased Cx43 was maintained for at least 1 year in normal rabbits, but the long-term antiarrhythmic effects in the MI model are unknown. We investigated the propensity for late potentials and VT/VF inducibility.Methods: Intracoronary injection of microspheres was performed to induce nontransmural MI in anesthetized eight beagles. Four beagles were treated with THIR (12C6+, 15 Gy) 2 weeks later (MI + THIR group), and four without THIR served as controls (MI group). Signal-averaged electrocardiography, programmed electrical stimulation, immunohistochemical analysis, and echocardiograms were performed at 1 year.Results: Filtered QRS duration was exacerbated after MI and remained unchanged for 1 year in the MI group (118 ± 1.4 ms), but significantly returned toward baseline in the MI + THIR group (109 ± 6.9 ms). Similarly, root mean square voltage of the last 40 ms was exacerbated after MI, but recovered after THIR. VT/VF inducibility decreased to 25% in the MI + THIR group compared with 100% in the MI group. Immunostaining Cx43 expression in cardiac tissues significantly increased by 24–45% in the MI + THIR group. Left ventricular ejection fractions remained within the normal range in both groups.Conclusion: A single exposure of the dog heart to 12C irradiation attenuated vulnerability to ventricular arrhythmia after the induction of MI for at least 1 year through the modulation of Cx43 expression