高血圧患者におけるアンジオテンシン II-レニンフィードバック機構に対するL/N型カルシウムチャネル拮抗薬の影響

Objectives. Cilnidipine, an L-/N-type calcium channel blocker (CCB), has unique organ-protective properties due to suppression of hyperactivity in the sympathetic nervous system and renin-angiotensin system (RAS). In this study, we hypothesized that cilnidipine might exert a renoprotective effect by suppressing the RAS. Methods. A total of 25 hypertensive patients receiving a RAS inhibitor were randomly assigned to a cilnidipine (n = 12) or amlodipine (n = 13) group. The effects of cilnidipine on proteinuria and angiotensin II–renin feedback were assessed. Results. After 6 months of treatment, both systolic and diastolic blood pressures were significantly reduced to a similar extent in both groups. The urine albumin-to-creatinine ratio was significantly lower in the cilnidipine group (p < 0.05) than in the amlodipine group. Amlodipine increased plasma angiotensin I and angiotensin II levels (p < 0.05), whereas cilnidipine did not. Interestingly, the cilnidipine group had a higher ratio of angiotensin-(1–7) (Ang-(1–7)) to angiotensin II in plasma than the amlodipine group (p < 0.05). Conclusions. The L-/N-type CCB cilnidipine, but not amlodipine, decreased urinary albumin excretion in hypertensive patients. Cilnidipine also increased the ratio of Ang-(1–7) to angiotensin II in plasma, which might be one factor underlying its beneficial effects

Antegrade slow pathway mapping of typical atrioventricular nodal reentrant tachycardia based on direct slow pathway capture

Background: Radiofrequency (RF) ablation of typical atrioventricular nodal reentrant tachycardia (tAVNRT) is performed without revealing out the location of antegrade slow pathway (ASp). In this study, we studied a new electrophysiological method of identifying the site of ASp. Methods: This study included 19 patients. Repeated series of very high-output single extrastimulations (VhoSESts) were delivered at the anatomical slow pathway region during tAVNRT. Tachycardia cycle length (TCL), coupling interval (CI), and return cycle (RC) were measured and the prematurity of VhoSESts [ΔPM (= TCL – CI)] and the prolongation of RCs [ΔPL (= RC – TCL)] were calculated. Pacing sites were classified into two categories: (i) ASp capture sites [DSPC(+) sites] were calculated. Pacing sites were classified into two categories: (i) ASp capture sites [DSPC(+) sites, where two different RCs were shown, and ASp non-capture sites [DSPC(-) sites], where only one RC was shown. RF ablation was performed at DSPC(+) sites and/or sites with catheter-induced mechanical trauma (CIMT) to ASp. Results: DSPC(+) sites were shown in 13 patients (68%). RF ablation was successful in all patients without any degree of atrioventricular block nor recurrence. Total number of RF applications was 1.8 ± 1.1. Minimal distance between successful ablation sites and DSPC(+)/CIMT sites and His bundle (HB) electrogram recording sites was 1.9 ± 0.8 mm and 19.8 ± 6.1 mm, respectively. ΔPL of more than 92.5 ms, ΔPL/TCL of more than 0.286, and ΔPL/ΔPM of more than 1.565 could identify ASp with sensitivity of 100%, 91.1%, and 88.9% and specificity of 92.9%, 97.0%, and 97.6%, respectively. Conclusions: Sites with ASp capture and CIMT were close to successful ablation sites and could be useful indicators of tAVNRT ablation

Bicuspid aortic valve endocarditis complicated by perivalvular abscess

A 37-year-old man presenting with fever and chest pain was admitted to our hospital. Electrocardiogram showed sinus tachycardia and complete left bundle branch block. Transthoracic echocardiogram showed infective endocarditis in the bicuspid aortic valve, complicated by multiple hyperechoic vegetations and severe aortic regurgitation. Blood cultures were negative and intravenous empiric antibiotic therapy was begun. However, fever lasted for 7 days and follow-up echocardiography revealed a newly emerged perivalvular abscess. The patient eventually underwent an urgent aortic root replacement that confirmed the echocardiographic findings. Our case report emphasizes that all patients with suspected aortic valve endocarditis should undergo early and followup echocardiographic studies

ジュウショウ シンフゼン カンジャ ニオケル サンソ リョウホウ ト Adaptive-servo ventilator ノ コウカ ノ ケントウ ハイドウミャクセイ ハイコウケツアツ ニ トモナウ ウシンフゼン ニ タイシテ ノ Adaptive-servo ventilator ノ コウカ

Pulmonary arterial hypertension（PAH）, including idiopathic or connective tissue diseaserelated PAH is very poor prognosis. Recently it has been reported that Adaptive-servo ventilator（ASV）is useful device for improving congestive heart failure compared with oxygen therapy however, it has not been clear whether ASV is useful not only in congestive heart failure but also in PAH patients. We experienced a drug therapy-resistant PAH patient, whose subjective symptom and pulmonary arterial pressure were ameliorated by ASV. We also found that ASV was also effective on improving subjective symptoms and on decreasing pulmonary arterial pressure in ６patients with PAH. These findings suggest that ASV is a useful and new device in patients with drug therapy-resistant PAH

プロテインC カッセイ テイカ オ ハイケイ トシ オートマチックシャ エノ ヘンコウ オ ケイキ ニ ハイケッセン ソクセンショウ オ ハッショウ シタ タクシー ウンテンシュ ノ イチレイ

A ６２-year-old man, who was a taxi-driver, presented to our hospital for further examination and treatment of deep venous thrombosis（DVT）suspected in another clinic. Before ３ months of consultation, he had changed his taxi from manual transmission car to automatic transmission car. Around the same time, he had complained progressively worsening left pedal edema and pain. When he consulted our hospital, blood examination showed elevated D-dimer and deficiency of protein C. A venous ultrasound showed an occlusive DVT in left lower extremity through an external iliac vein. A contrast-enhanced computed tomography showed bilateral pulmonary embolism（PE） and extensive thrombus in the left lower extremity. Following hospitalization, an inferior vena cava （IVC）filter was placed in an infrarenal IVC position, and anticoagulant therapy was initiated with heparin and warfarin. His DVT and PE were managed successfully with anticoagulant therapy, and pedal edema was improved. Besides some risk factors of thrombogenicity such as age and deficiency of protein C, sitting position for long hours and decreased motion of left leg might have triggered off the thrombus formation in the left lower extremity. This report demonstrates the importance of careful follow-ups to long-distance drivers with risk factors of thrombus formation, especially about clutch operation