Hemodynamic Effects of Positive end-expiratory Pressure on Right Ventricular Diastolic Function in Patients with Acute Myocardial Infarction

The effects of positive end-expiratory pressure (PEEP) on the right ventricular (RV) diastolic function in patients with congestive heart failure (CHF) due to acute myocardial infarction (AMI) are unknown. The aim in this study was to investigate PEEP associated variations in RV diastolic function in CHF due to AMI. The subjects comprised the control group (26 subjects) and the AMI group (36 subjects) classified as 20 patients with pulmonary capillary wedge pressure (PCWP) < 18 mmHg (CHF-low PCWP group) and 16 patients with PCWP≧18mmHg (CHF-high PCWP group). PEEP was applied for 30 minutes at 0, 5, 10 and 15 cmH_20. Two-dimensional echocardiography with continuous and pulse wave Doppler studies was performed. RV diastolic functional parameters included the ratio of peak early tricuspid valve filling and peak atrial filling velocities, the decelation time of the tricuspid E valve and the RV isovolumic relaxation time. In the control and CHF-low PCWP groups, right atrial pressure, mean pulmonary arterial pressure (mPAP), total pulmonary resistance (TPR) and systemic vascular resistance (SVR) increased, output (CO) decreased and RV diastolic functional parameters worsened significantly at the transition from 10 to 15 cmH_20 PEEP. In the CHF-high PCWP group, mPAP, TPR and SVR decreased, while CO increased and RV diastolic functional parameters improved significantly at the transition from 10 to 15 cmH_20 PEEP. From these findings, it is clear that PEEP induced hemodynamic deterioration and reduces RV diastolic function in intact and mildly failing hearts. On the other hand, in severely failing hearts, PEEP effers hemodynamic improvement and ameliorates RV diastolic function. It appears possible to predict responses to PEEP by determining RV diastolic function in CHF. Therefore, we conclude that evaluation of the RV diastolic function during PEEP is highly important in terms of recognizing the effectiveness of PEEP therapy in CHF

キュウセイ シンキンエン ガ ウタガワレ, ハツネツ ニヨリ ケンザイカ シタ ムショウコウセイ Brugadaショウコウグン ノ イチレイ

Brugada症候群は,重症不整脈を発症する症候群であるが,特異な心電図所見が明らかでなく診断に苦慮することがある.今回,発熱時心電図上ST上昇を認め,心筋炎を疑われ精査でBrugada症候群と診断した1例と,本邦で報告された発熱時顕在化した本症候群16例を検討した.症例は42歳男性,感冒症状とともに心電図所見でI.aV_R, aV_L, V_(1-4)のST上昇を認め急性心筋炎を疑われ入院した.心臓超音波検査でごく軽度心機能低下,心筋生検では異常なく,冠動脈造影では有意な狭窄はなかった.pilsicainide負荷でcoved型ST上昇を示し,電気生理学検査で容易に心室細動が誘発され,植込み型除細動器の植込み術が施行された.発熱時顕在化例で,高齢者群では高率に失神を発症した.Brugada症候群は発熱時顕在化することがあり,軽快により正常化するが,発熱と同時に失神や心室性不整脈が見られることがあり,十分な配慮が必要である.Brugada syndrome is a disease associated with severe arrhythmia but without specific ECG characteristics, which makes diagnosis difficult. We report the case of a patient with Brugada syndrome who had a ST segment elevation accompanied by fever, and we investigate 16 additional Japanese patients with Brugada syndrome that was recognized by fever. The patient was a 42-year-old man who showed ST segment elevation associated with cold symptoms and was admitted after diagnosis of myocarditis. Echocardiography exhibited slight cardiac dysfunction, but a myocardial biopsy showed no abnormalities and no significant stenosis was found in coronary angiography. After administration of pilsicainide, the patient showed covedtype ST segment elevation, and ventricular fibrillation was induced during an electrophysiological study ; therefore, an implantable cardioverter defibrillator (ICD) was installed. Among the patients with Brugada syndrome recognized by fever, many elderly patients showed syncope. In conclusion, Brugada syndrome frequently appears in fever and attention should be paid to elderly patients because they frequently develop fever and syncope simultaneously

マンセイ シンフゼン カンジャ ノ ジュウショウド ニヨル ヤカン ムコキュウ ト テイサンソ ケッショウ ノ ヒカク

慢性心不全(CHF)患者の重症度による夜間の酸素飽和度(SaO_2)と無呼吸の比較について検討を行うために安定した慢性軽症心不全患者6例(男4例,女2例63±5.2歳,左室駆出率:49.8±3.4%,NYHA class:IかII,mild-CHF群)と安定慢性重症心不全患者11例(男9例,女2例,62±11.9歳,左室駆出率:25.6±8.6%,NYHA class:III,severe-CHF群)患者を対象とし,両群を比較することにより検討を行った.全例において室内空気下にパルスオキシメーターを用いて24時間のSaO_2と脈拍数を連続記録した.そして夜間のSaO_2が3%あるいは4%以上低下した1時間あたりの回数(3%ODI,4%ODI),SaO_2の最低値を各々分析した.さらにポリソムノグラフィーを用いてSaO_2と睡眠に関する全てのデータを連続的に記録分析した.その結果,severe-CHF群のODIはmild-CHF群に比して有意に高値であった(4%ODI;5.8±5.1 vs 0.6±0.5,p<O.01.3%ODI;8.6±7.1 vs 1.0±O.9,p<0.01.).severe-CHF群のSaO_2の最低値はmild-CHF群に比して有意に低かった(82.2±7.1 vs 91.7±1.0%,p<0.01).severe-CHF群の夜間無呼吸は全例にみられ,大多数が中枢型であった(74.0±3.6%).以上より安定した重症心不全では夜間に低酸素血症と無呼吸がみられ,これらが臨床病像の悪化に影響していることが示唆される.Background : Patients with chronic heart failure (CHF) commonly experience Cheyne- Stokes respiration, central apnea, or obstructive apnea during sleep associated with oxygen desaturation. Nocturnal oxygen therapy and nasal continuous positive airway pressure (NCPAP) reduce sleep-disordered breathing in stable CHF. However, the relation between sleep apnea and nocturnal desaturation inpatients with severe, stable CHF in Japan is unknown. Objectives : To examine nocturnal oxygen saturation (SaO_2) and sleep apnea in Japanese patients with severe, stable CHF. Methods : The subjects were 11 patients with severe, stable CHF (9 men and 2 women, LVEF=25.6±8.6%, NYHA class=III, severe CHF group) and 6 with mild, stable CHF (4 men and 2 women, LVEF=49.8±3.4 %, NYHA class=I or II, mild CHF group). SaO_2 was continuously recorded with a pulse oximeter under room air, and 4 % and 3 % SaO_2 dip rate per hour (GDIs) and the SaO_2 nadir were analyzed. In addition, SaO_2 and sleep variables were continuously recorded with a polysomnograph. Results : ODI frequency in the severe CHF group was significantly higher than that in the mild CHF group (4% ODI, 5.8±5.1 vs 0.6±0.5 times/hour, respectively, p<0.01;3 % ODI, 8.6±7.1 vs 1.0±0.9 times/hour, respectively, p<0.01.). SaO_2 nadir in the severe CHF group was significantly lower than that in the mild CHF group (82.2±7.1 vs 91.7±1.0 %, p<0.01). All severe patients had sleep apnea, predominantly of the central type (74.0±3.6%). Conclusion : The frequency of nocturnal hypoxemia and apnea increases in patients with severe, stable CHF. Nocturnal hypoxemia and apnea may adversely effect the clinical status of these patients

Cystic Kidney Diseases That Require a Differential Diagnosis from Autosomal Dominant Polycystic Kidney Disease (ADPKD)

Autosomal dominant polycystic kidney disease (ADPKD) is the most common hereditary cystic kidney disease, with patients often having a positive family history that is characterized by a similar phenotype. However, in atypical cases, particularly those in which family history is unclear, a differential diagnosis between ADPKD and other cystic kidney diseases is important. When diagnosing ADPKD, cystic kidney diseases that can easily be excluded using clinical information include: multiple simple renal cysts, acquired cystic kidney disease (ACKD), multilocular renal cyst/multilocular cystic nephroma/polycystic nephroma, multicystic kidney/multicystic dysplastic kidney (MCDK), and unilateral renal cystic disease (URCD). However, there are other cystic kidney diseases that usually require genetic testing, or another means of supplementing clinical information to enable a differential diagnosis of ADPKD. These include autosomal recessive polycystic kidney disease (ARPKD), autosomal dominant tubulointerstitial kidney disease (ADTKD), nephronophthisis (NPH), oral-facial-digital (OFD) syndrome type 1, and neoplastic cystic kidney disease, such as tuberous sclerosis (TSC) and Von Hippel-Lindau (VHL) syndrome. To help physicians evaluate cystic kidney diseases, this article provides a review of cystic kidney diseases for which a differential diagnosis is required for ADPKD