Autopsy Case Report of Severe COVID-19 Pneumonia at a General Municipal Hospital

We present the autopsy procedure and findings of severe coronavirus disease 2019 (COVID-19) pneumonia in an 85-year-old man. The patient required intubation immediately after admission for severe COVID-19 pneumonia. He had severe hypoxia that did not improve despite treatment with remdesivir, corticosteroids, and appropriate mechanical ventilation. On day 13, the patient developed sudden hypercapnia. His renal dysfunction subsequently worsened and became associated with hyperkalemia, and he passed away on day 15. An autopsy was performed to clarify the cause of the hypercapnic hypoxia. None of the medical personnel involved in the autopsy developed symptoms of COVID-19. Histologic examination showed various stages of diffuse alveolar damage throughout the lungs, with intra-alveolar hemorrhage in the upper zones. Microscopic examination of the kidneys revealed acute tubular necrosis. There was no significant systemic thrombosis. The autopsy findings were consistent with those typical of COVID-19.

Clinical valuables related to resolution of complete or advanced atrioventricular block after steroid therapy in patients with cardiac sarcoidosis

BACKGROUND

Prediction of atrioventricular block (AVB) resolution after steroid therapy in patients with cardiac sarcoidosis (CS) is difficult.

METHODS

We identified 24 patients with CS and complete or advanced AVB receiving steroid therapy. AVB resolution was assessed by reviewing surface electrocardiogram and the percentage of ventricular pacing required on subsequent device interrogation reports.

RESULTS

AVB resolution was noted in eight (33%) patients 1 year after receiving steroid therapy. Univariate Cox regression analysis demonstrated that left ventricular ejection fraction (LVEF) (hazard ratio [HR] 1.07, 95% confidence interval [CI] 1.01-1.14, P = .016), interval from recognized AVB to start of steroid therapy (HR 0.98, 95% CI 0.95-0.99, P < .001), and lysozyme (HR 1.51, 95% CI 1.12-2.19, P = .013) were significantly associated with resolution of AVB. Combination of area under the curve (AUC) of each variable that was significantly related to resolution of AVB (AUC, 0.969; 95% CI 0.921-1.000, P < .001) was tended to be higher compared with each variable alone.

CONCLUSIONS

A shorter interval from recognition of AVB to start of steroid therapy, higher LVEF, and higher lysozyme levels were significantly associated with resolution of AVB after steroid therapy in patients with CS. The combination of each variable could be able to distinguish patients with resolution of AVB from those without.

Clinical significance of left atrial geometry in dilated cardiomyopathy patients: A cardiovascular magnetic resonance study

Background

Clinical significance of left atrial (LA) function and geometry in patients with dilated cardiomyopathy (DCM) remains uncertain.

Hypothesis

LA geometric parameters assessed by cardiac magnetic resonance (CMR) predict the prognosis in patients with DCM.

Methods

The present study included patients with DCM and sinus rhythm who underwent CMR between December 2007 and April 2018. LA volume was measured using CMR. LA sphericity index was computed as the ratio of the measured maximum LA volume by the volume of a sphere with maximum LA length diameter.

Results

We included 255 patients in this study. During the mean follow‐up of 3.92 years, hospitalization for HF occurred in 37 patients. The LA sphericity index was significantly higher in patients with hospitalization for HF than in those without (0.78 ± 0.35 vs. 0.58 ± 0.18, p < .001). Multivariable Cox regression analysis identified a higher LA sphericity index as an independent predictor of hospitalization for HF. Patients were categorized based on the median of LA sphericity index. The Kaplan–Meier curve showed that patients with a high LA sphericity index (≥0.57) had a significantly higher risk of hospitalization for HF than those with a low LA sphericity index (<0.57).

Conclusion

LA sphericity index was an independent predictor of hospitalization for HF. Assessment of LA geometric parameters might be useful for risk stratification in patients with DCM.

Late gadolinium enhancement for re-worsening left ventricular ejection fraction in patients with dilated cardiomyopathy

Aims

This study aimed to evaluate the clinical parameters including late gadolinium enhancement (LGE) of cardiovascular magnetic resonance to predict re‐worsening of left ventricular ejection fraction (LVEF) in patients with dilated cardiomyopathy (DCM).

Methods and results

We included 138 patients with recent‐onset DCM who had an LVEF <45% and underwent LGE of cardiovascular magnetic resonance imaging at diagnosis and echocardiography at the yearly follow‐up [median 6 (4–8.3) years]. Initial LVEF recovery was defined as LVEF increase >10% from baseline, resulting in LVEF ≧45% after treatment. The patients were divided into three groups: (i) improved (n = 83, 60%), defined as those with sustained LVEF ≧45%; (ii) re‐worsening (n = 39, 28%), those with >5% decrease and LVEF <45% after the initial LVEF recovery; and (iii) not‐improved (n = 16, 12%), those without initial LVEF recovery. The primary endpoint was a composite of hospitalization for heart failure or sudden cardiac death. In baseline, LGE was observed in 70 patients. The LGE area was significantly larger in the re‐worsening and not‐improved groups than that in the improved group (P < 0.001). Loess curves of long‐term LVEF trajectories showed that LVEF in the re‐worsening group increased in the first 2 years and slowly declined thereafter. Multivariate logistic regression analysis demonstrated that LGE area [odds ratio (OR) 1.09, 95% confidence interval (CI) 1.03–1.16, P = 0.004], B‐type natriuretic peptide (OR 1.49, 95% CI 1.05–2.21, P = 0.030) level at the initial recovery, and LVEF (OR 0.91, 95% CI 0.86–0.97, P = 0.004) at the initial LVEF recovery were independent predictors of re‐worsening of LVEF. During a median follow‐up of 2273 (interquartile range: 1634–3191) days, the primary endpoint was observed in 31 (22%) patients. Univariate Cox proportional hazards analysis demonstrated that the risk of experiencing the primary event in the re‐worsening group was significantly higher (hazard ratio: 4.30, 95% CI 1.63–11.31, P = 0.003) than that in the improved group and was lower than that in the not‐improved group (hazard ratio: 0.33, 95% CI 0.15–0.72, P = 0.006).

Conclusions

Re‐worsening of LVEF was observed in 28% of patients with recent‐onset DCM who showed an initial improvement in LVEF. High LGE burden, higher B‐type natriuretic peptide level, and lower LVEF at the initial LVEF recovery were independent predictors of re‐worsening of LVEF in patients with DCM. Careful observation is recommended for patients with a high risk for re‐worsening of LVEF, even in those with an initial LVEF recovery.

Prognostic implications of late gadolinium enhancement for re-worsening left ventricular ejection fraction in patients with dilated cardiomyopathy: a longitudinal study of left ventricular function

Background

Re-worsening left ventricular ejection fraction (LVEF) after initial recovery occurs in some patients with dilated cardiomyopathy (DCM). However, prevalence and predictors of re-worsening LVEF in longitudinal follow-up are unclear. Late gadolinium enhancement of cardiovascular magnetic resonance (LGE-CMR) can evaluate the damage of myocardial tissue.

Purpose

This study sought to evaluate the clinical parameters including LGE-CMR to predict re-worsening LVEF in patients with recent-onset DCM.

Methods

We included patients with recent-onset DCM who had an LVEF &lt;45% and underwent LGE-CMR at diagnosis. We performed yearly echocardiographc follow-up [median 6 [4–8.3] years]. Initial LVEF recovery defined as patients increased in &gt;5% LVEF from baseline and had an LVEF≥45% after medical therapy. Patients were divided into three groups: (1) Improved: defined as those with sustained LVEF ≥45% after initial LVEF recovery; (2) Re-worse: those with decreased &gt;5% and had an LVEF &lt;45% after initial LVEF recovery. and (3) Not-improved: those with no initial LVEF recovery during follow-up. To evaluate the prognostic factors for Re-worsening LVEF after initial LVEF recovery, multivariate logistic regression analysis performed between the Improved group and the Re-worse group. Cardiac events defined as hospitalization due to heart failure and sudden death.

Results

Of 138 patents, 82 patients (59%) were the Improved group, 42 patients (30%) were the Re-worse group, and 14 (10%) were the Not-improved group. Loess curves of long-term LVEF trajectories showed that LVEF in the Re-worse group increased first 2 years and declined slowly thereafter (Fig. 1A). Re-worsening LVEF occurred 4.5±2.2 years after initial LVEF recovery. Multivariate logistic regression analysis demonstrated that LGE area at baseline (Odds ratio: 1.09, 95% confidence interval (CI) 1.02–1.18, p=0.014) and Log brain natriuretic peptide (BNP) at initial LVEF recovery (Odds ratio: 1.53, 95% confidence interval (CI) 1.01–2.31, p=0.042) were independent predictors for Re-worsening LVEF. Kaplan Meier analysis demonstrated that the risk of cardiac events in the Re-worse group was significantly higher (hazard ratio: 3.93, 95% CI 1.49–10.36, p=0.006) than in the Improved group and lower risk than in the Not-improved group (hazard ratio: 0.28, 95% CI 0.12–0.62, p=0.002) (Fig. 1B).

Conclusion

Re-worsening LVEF occurred in 30% of patients in patients with recent-onset DCM. LGE area and BNP at initial LVEF recovery were independently associated with re-worsening LVEF after initial LVEF recovery.

Figure 1

Funding Acknowledgement

Type of funding source: None

Clinical and Prognostic Values of ALBI Score in Patients With Acute Heart Failure

BACKGROUND

Although liver dysfunction is one of the common complications in patients with acute heart failure (AHF), no integrated marker has been defined. The albumin-bilirubin (ALBI) score has recently been proposed as a novel, clinically-applicable scoring system for liver dysfunction. We investigated the utility of the ALBI score in patients with AHF compared to that for a preexisting liver dysfunction score, the Model of End-Stage Liver Disease Excluding prothrombin time (MELD XI) score.

METHODS

We evaluated ALBI and MELD XI scores in 1,190 AHF patients enrolled in the prospective, multicentre Registry Focused on Very Early Presentation and Treatment in Emergency Department of Acute Heart Failure study. The associations between the two scores and the clinical profile and prognostic predictive ability for 1-year mortality were evaluated.

RESULTS

The mean MELD XI and ALBI scores were 13.4±4.8 and -2.25±0.48, respectively. A higher ALBI score, but not higher MELD XI score, was associated with findings of fluid overload. After adjusting for pre-existing prognostic factors, the ALBI score (HR 2.11, 95% CI: 1.60-2.79, p<0.001), but not the MELD XI score (HR 1.02, 95% CI: 0.99-1.06, p=0.242), was associated with 1-year mortality. Likewise, area under the receiver-operator-characteristic curves for 1-year mortality significantly increased when the ALBI score (0.71 vs. 0.74, p=0.020), but not the MELD XI score (0.71 vs. 0.72, p=0.448), was added to the pre-existing risk factors.

CONCLUSIONS

The ALBI score is potentially a suitable liver dysfunction marker that incorporates information on fluid overload and prognosis in patients with AHF. These results provide new insights into heart-liver interactions in AHF patients.

Clinical Considerations When Introducing Sodium-Glucose Co-Transporter 2 Inhibition in Patients With Heart Failure

Background: In patients with heart failure (HF), discontinued medical therapy because of adverse events (AE) is associated with high mortality. Patients with type 2 diabetes mellitus (T2DM) treated with sodium-glucose co-transporter 2 inhibitors (SGLT2i) have a lower risk of HF, but AE sometimes occur with the introduction of SGLT2i. In order to use SGLT2i safely in patients with HF, we investigated factors associated with AE following the introduction of SGLT2i. Methods and Results: AE were defined as hypotension or an increase in serum creatinine ≥0.3 mg/dL by the fifth day after SGLT2i introduction. Sixty-four hospitalized patients with HF and T2DM treated with an SGLT2i were enrolled in this study. Patients were divided into 2 groups: with AE (n=13, 20.3%) and without (n=51, 79.7%). On logistic regression analysis, female sex, hemoglobin ≥15.2 g/dL, serum creatinine ≥1.05 mg/dL, and cardiac index on echocardiography ≤2.15 L/min/m2, were significantly associated with AE. A scoring system was constructed to predict AE according to significant variables (area under the receiver operating characteristic curve, 0.83; P<0.001) and the cut-off point was 2 points. Conclusions: Female sex, hemoconcentration, kidney injury, and low cardiac output were associated with AE at SGLT2i initiation in patients with HF. Using this scoring system, introduction of SGLT2i could be done safely in patients with HF.

Endothelial C-Type Natriuretic Peptide Acts on Pericytes to Regulate Microcirculatory Flow and Blood Pressure

BACKGROUND

Peripheral vascular resistance has a major impact on arterial blood pressure levels. Endothelial C-type natriuretic peptide (CNP) participates in the local regulation of vascular tone, but the target cells remain controversial. The cGMP-producing guanylyl cyclase-B (GC-B) receptor for CNP is expressed in vascular smooth muscle cells (SMCs). However, whereas endothelial cell-specific CNP knockout mice are hypertensive, mice with deletion of GC-B in vascular SMCs have unaltered blood pressure.

METHODS

We analyzed whether the vasodilating response to CNP changes along the vascular tree, ie, whether the GC-B receptor is expressed in microvascular types of cells. Mice with a floxed GC-B ( Npr2) gene were interbred with Tie2-Cre or PDGF-Rβ-Cre ^ERT2 lines to develop mice lacking GC-B in endothelial cells or in precapillary arteriolar SMCs and capillary pericytes. Intravital microscopy, invasive and noninvasive hemodynamics, fluorescence energy transfer studies of pericyte cAMP levels in situ, and renal physiology were combined to dissect whether and how CNP/GC-B/cGMP signaling modulates microcirculatory tone and blood pressure.

RESULTS

Intravital microscopy studies revealed that the vasodilatatory effect of CNP increases toward small-diameter arterioles and capillaries. CNP consistently did not prevent endothelin-1-induced acute constrictions of proximal arterioles, but fully reversed endothelin effects in precapillary arterioles and capillaries. Here, the GC-B receptor is expressed both in endothelial and mural cells, ie, in pericytes. It is notable that the vasodilatatory effects of CNP were preserved in mice with endothelial GC-B deletion, but abolished in mice lacking GC-B in microcirculatory SMCs and pericytes. CNP, via GC-B/cGMP signaling, modulates 2 signaling cascades in pericytes: it activates cGMP-dependent protein kinase I to phosphorylate downstream targets such as the cytoskeleton-associated vasodilator-activated phosphoprotein, and it inhibits phosphodiesterase 3A, thereby enhancing pericyte cAMP levels. These pathways ultimately prevent endothelin-induced increases of pericyte calcium levels and pericyte contraction. Mice with deletion of GC-B in microcirculatory SMCs and pericytes have elevated peripheral resistance and chronic arterial hypertension without a change in renal function.

CONCLUSIONS

Our studies indicate that endothelial CNP regulates distal arteriolar and capillary blood flow. CNP-induced GC-B/cGMP signaling in microvascular SMCs and pericytes is essential for the maintenance of normal microvascular resistance and blood pressure.

Time-to-Furosemide Treatment and Mortality in Patients Hospitalized With Acute Heart Failure

BACKGROUND

Acute heart failure (AHF) is a life-threatening disease requiring urgent treatment, including a recommendation for immediate initiation of loop diuretics.

OBJECTIVES

The authors prospectively evaluated the association between time-to-diuretic treatment and clinical outcome.

METHODS

REALITY-AHF (Registry Focused on Very Early Presentation and Treatment in Emergency Department of Acute Heart Failure) was a prospective, multicenter, observational cohort study that primarily aimed to assess the association between time to loop diuretic treatment and clinical outcome in patients with AHF admitted through the emergency department (ED). Door-to-furosemide (D2F) time was defined as the time from patient arrival at the ED to the first intravenous furosemide injection. Patients with a D2F time <60 min were pre-defined as the early treatment group. Primary outcome was all-cause in-hospital mortality.

RESULTS

Among 1,291 AHF patients treated with intravenous furosemide within 24 h of ED arrival, the median D2F time was 90 min (IQR: 36 to 186 min), and 481 patients (37.3%) were categorized as the early treatment group. These patients were more likely to arrive by ambulance and had more signs of congestion compared with the nonearly treatment group. In-hospital mortality was significantly lower in the early treatment group (2.3% vs. 6.0% in the nonearly treatment group; p = 0.002). In multivariate analysis, earlier treatment remained significantly associated with lower in-hospital mortality (odds ratio: 0.39; 95% confidence interval: 0.20 to 0.76; p = 0.006).

CONCLUSIONS

In this prospective multicenter, observational cohort study of patients presenting at the ED for AHF, early treatment with intravenous loop diuretics was associated with lower in-hospital mortality. (Registry focused on very early presentation and treatment in emergency department of acute heart failure syndrome; UMIN000014105).

Tafamidis for the Treatment of Hereditary Transthyretin Amyloid Cardiomyopathy: A Case Report

Tafamidis meglumine is a novel medicine that has been shown to slow the progression of peripheral neurological impairment in patients with hereditary transthyretin amyloidosis (ATTR). However, the efficacy of tafamidis against ATTR-related cardiac amyloidosis remains unclear. A 72-year-old woman had cardiac hypertrophy and axonopathy in her lower legs. Endomyocardial biopsy revealed an infiltrative cardiomyopathy consistent with amyloidosis. Immunostaining and genetic studies confirmed the diagnosis of ATTR, and tafamidis was started subsequently. Two years after the initiation of tafamidis treatment, electromyography demonstrated no change in the axonopathy in her lower legs; however, electrocardiography displayed QRS prolongation, and echocardiography disclosed an increase in interventricular septal thickness. Endomyocardial biopsy indicated that transthyretin amyloid infiltration of the myocardium was not reduced. In this case, there was no apparent progression of axonopathy, although there were signs of worsening amyloid cardiomyopathy during the treatment with tafamidis.

Temporal change of myocardial tissue character is associated with left ventricular reverse remodeling in patients with dilated cardiomyopathy: A cardiovascular magnetic resonance study

BACKGROUND

Prognostic significance of temporal change in myocardial tissue characterization by cardiovascular magnetic resonance (CMR) has not been elucidated in patients with non-ischemic dilated cardiomyopathy (DCM).

METHODS AND RESULTS

Sixty-eight patients with newly-diagnosed DCM who underwent CMR including late gadolinium enhancement (LGE) both at baseline and during follow-up period were enrolled. LGE score was defined by a signal intensity of ≥5 standard deviations above the remote reference myocardium mean. Left ventricular reverse remodeling (LVRR) defined as a LV ejection fraction increase of ≥10% and a decrease in indexed LV end-diastolic diameter of ≥10% compared to those at baseline was detected in 38% of the patients. There was no significant difference in LGE score between baseline and follow-up (5.8% vs. 7.3%; p=0.38). The change in LGE area (delta-LGE) was significantly lower in patients with LVRR than those without (-0.5%±3.4% vs. 3.0±7.4%; p=0.02). On the other hand, T2 ratio during the follow-up significantly reduced (1.95±0.48 vs. 1.67±0.56; p<0.01); however, there was no significant difference in the change in T2 ratio between patients with LVRR and those without (-0.29±0.73 vs. -0.27±0.66; p=0.88). Multivariate logistic analysis indicated that baseline LGE score [odds ratio; 0.78; 95% confidence interval (CI) 0.66 to 0.90; p<0.01] together with delta-LGE (odds ratio; 0.77; 95% CI 0.61 to 0.92; p=0.01) were independently associated with subsequent LVRR (p<0.01).

CONCLUSIONS

The temporal change of LGE-CMR score during the clinical course was significantly correlated with following LVRR.

Morphological changes in mitochondria during mechanical unloading observed on electron microscopy: a case report of a bridge to complete recovery in a patient with idiopathic dilated cardiomyopathy

The recovery of the cardiac function under mechanical support has not been well documented from a histopathological point of view. We herein report a case of idiopathic dilated cardiomyopathy in which the patient showed a complete recovery of the systolic function following treatment with a left ventricular assist device (LVAD) for deteriorated heart failure. A light microscopic observation showed marked regression of hypertrophic myocytes with significant intracellular vacuolization and scarcity at the time of LVAD implantation after the administration of mechanical support. Furthermore, an electron microscopic observation revealed that these findings were regulated primarily by volumetric regression and morphometric improvements in cardiomyocytic mitochondria.

Baseline cardiac magnetic resonance imaging versus baseline endomyocardial biopsy for the prediction of left ventricular reverse remodeling and prognosis in response to therapy in patients with idiopathic dilated cardiomyopathy

Endomyocardial biopsy (EMB) and late gadolinium enhancement cardiovascular magnetic resonance (LGE-CMR) imaging performed at baseline are both used to evaluate the extent of myocardial fibrosis. However, no study has directly compared the effectiveness of these diagnostic tools in the prediction of left ventricular reverse remodeling (LVRR) and prognosis in response to therapy in patients with idiopathic dilated cardiomyopathy (IDCM). Seventy-five patients with newly diagnosed IDCM who were undergoing optimal therapy were assessed at baseline using LGE-CMR imaging and EMB; the former measured LGE area and the latter measured collagen volume fraction (CVF) as possible predictive indices of LVRR and cardiac event-free survival. Among all the baseline primary candidate factors with P < 0.2 as per univariate analysis, multivariate analysis indicated that only LGE area was an independent predictor of subsequent LVRR (β = 0.44; 95 % confidence interval (CI) 0.87–2.53; P < 0.001), as indicated by decreasing left ventricular end-systolic volume index over the 1-year follow-up. Kaplan–Meier curves indicated significantly lower cardiac event-free survival rates in patients with LGE at baseline than in patients without (P < 0.01). By contrast, there was no significant difference in prognosis between patients with CVF values above (severe fibrosis) and below (mild fibrosis) the median of 4.9 %. Cox proportional hazard analysis showed that LGE area was an independent predictor of subsequent cardiac events (hazard ratio 1.06; 95 % CI 1.02–1.10; P ≤ 0.01). The degree of myocardial fibrosis estimated by baseline LGE-CMR imaging, but not that estimated by baseline EMB, can predict LVRR and cardiac event-free survival in response to therapy in patients with newly diagnosed IDCM.

End-tidal carbon dioxide concentration can estimate the appropriate timing for weaning off from extracorporeal membrane oxygenation for refractory circulatory failure

Although extracorporeal membrane oxygenation (ECMO) is widely used as temporary circulation support, there are no reports of direct parameters indicating cardiac recovery to determine the timing of weaning off. Twenty-five patients supported by ECMO due to hemodynamic deterioration were divided into 2 groups according to their outcome: weaned ECMO (W: n = 18) or not (NW: n = 7). In the W group, we examined the differences in parameters between the 2 time points, ECMO introduction, and the reduction in ECMO flow to 40% of the initial setting known as the conventional recovery point (C-point). Significant differences were observed in systolic pulmonary artery pressure, the cardiac index measured by the thermodilution method, C-reactive protein, lactate, base excess, and the end-tidal CO(2) concentration (ETCO(2)). Next, by closely examining these 6 parameters measured every 12 hours, we found that only ETCO(2) had always changed steeply, like a 'flexion point' (E-point), in all W cases, but not in NW. The E-point was defined as an initial increase in ETCO(2) of >or= 5 mmHg over the preceding 12 hours with a continued rise over the next 12 hours. E-points appeared as much as 95 +/- 60 hours earlier than C-points and also preceded weaning off of ECMO. ETCO(2) can be a useful continuous parameter for predicting the adequate timing of weaning off of ECMO for circulatory failure at the bedside.

Clinical impact of adherence to guidelines on the outcome of chronic heart failure in Japan

The impact of guideline adherence on clinical outcomes in the management of chronic heart failure (CHF) has never been evaluated in Japan. We investigated outcomes in 92 consecutive CHF patients admitted to Kitasato University Hospital in 2004-2006 for HF exacerbation with a left ventricular ejection fraction < or = 40% by the use of class I drugs for pump-failure, as recommended in the Japanese Circulation Society guideline. Drugs, namely angiotensin-converting enzyme inhibitors (ACEI), beta-blockers (BB), spironolactone, diuretics, and cardiac glycosides were administered to 64.1%, 59.8%, 28.2%, 96.7%, and 68.0% of patients, respectively. Patients for whom adherence to the prescription of ACEI and BB as first-line agents was high had significantly and independently better prognostic outcomes for cardiac events (P = 0.0036) as well as subsequent improvements in clinical surrogate markers for HF status such as NYHA class and BNP. Addition of the 3 latter drugs to the prescription of ACEI and BB did not affect the superiority of ACE plus BB in improving the long-term prognosis. We have demonstrated that adherence to treatment guidelines for CHF is a significant predictor of subsequent cardiac events in actual practice in Japan. An effective means of improving adherence to current guideline standards of care for CHF has yet to be established.

Beta2-Adrenergic agonists suppress rat autoimmune myocarditis: potential role of beta2-adrenergic stimulants as new therapeutic agents for myocarditis

BACKGROUND

The therapeutic potential of beta2-adrenergic receptor (AR) agonists in the treatment of autoimmune diseases has been reported. However, the role of these drugs in the myocardial structure-induced autoimmune process, which is thought to play a crucial role in the progression of myocarditis to subsequent complications, has not been elucidated.

METHODS AND RESULTS

Experimental autoimmune myocarditis (EAM) was induced in rats by immunization with cardiac myosin. On daily administration from day 0 after immunization, the beta2-selective AR agonists formoterol or salbutamol ameliorated EAM on day 21 and increased myocardial interleukin-10/interferon-gamma mRNA levels. Propranolol, a nonselective beta-AR antagonist, aggravated EAM on day 21 and decreased mRNA levels, whereas metoprolol, a beta1-selective AR antagonist, showed no effect. These results were reflected in vivo by the proliferation of cardiac myosin-primed lymph node cells from drug-treated rats. In vitro addition of beta2-selective AR agonists inhibited the activation of cardiac myosin fragment-specific myocarditogenic T lymphocytes, and this effect was reversed by ICI118,551, a beta2-selective AR antagonist. Furthermore, treatment with 2 different beta2-selective AR agonists starting on day 14 also ameliorated EAM on day 21.

CONCLUSIONS

beta2-AR stimulation suppressed the development of EAM by inhibiting cardiac myosin-specific T-lymphocyte activation in lymphoid organs and by shifting the imbalance in Th1/Th2 cytokine toward Th2 cytokine. Furthermore, it also ameliorated established myocardial inflammation. beta2-AR-stimulating agents may represent important immunomodulators of the cardiac myosin-induced autoimmune process and have potential as a new therapy for myocarditis.

Impact of additional pleurodesis in video-assisted thoracoscopic bullectomy for primary spontaneous pneumothorax

BACKGROUND

Bullectomy for primary spontaneous pneumothorax has been associated with high postoperative recurrence rates when video-assisted thoracoscopic surgery (VATS) has been used rather than thoracotomy. The aim of this study was to evaluate the efficacy and identify the disadvantages, if any, of adding pleurodesis to VATS bullectomy to prevent recurrent pneumothorax.

METHODS

Fifty-three patients who underwent VATS bullectomy with additional pleurodesis for pneumothorax after November 1996 and 50 who underwent VATS bullectomy alone before October 1996 were compared retrospectively in terms of intraoperative factors and postoperative chest pain, pulmonary function, and pneumothorax recurrent rates. Pleurodesis was achieved by electrocauterizing the upper surface of the parietal pleura in a patchy fashion.

RESULTS

There were no significant differences between the additional pleurodesis group and the bullectomy alone group in terms of age, sex, operating time, intraoperative bleeding, number of resected bullae, duration of chest drainage, or volume of fluid drained. Postoperative chest pain and pulmonary function were also similar in both groups. A recurrent pneumothorax occurred in one patient (1.9%) in the additional pleurodesis group; this recurrence rate was significantly lower than that for the bullectomy alone group (eight patients, 16%; p = 0.029). Although the mean postoperative follow-up period was considerably shorter in the additional pleurodesis group (38 months [range, 26-49]) than in the bullectomy alone group (63 months [range, 50-72] ), eight (89%) of all nine recurrences occurred within 26 months of surgery-i.e., within the minimum follow-up period for the additional pleurodesis group.

CONCLUSIONS

Pleurodesis is a minimally invasive technique that is effective in preventing postoperative recurrences of pneumothorax when added to VATS bullectomy. Additional pleurodesis has no disadvantages vs bullectomy alone in terms of worsening postoperative chest pain or pulmonary function.

A case of multiple atypical adenomatous hyperplasia of the lung detected by computed tomography

Multiple atypical adenomatous hyperplasia (AAH) of both lungs in a 72-year-old male, detected by computed tomography, is reported. The lesions of the right lung were resected for diagnosis via video-assisted thoracoscopic surgery (VATS). The resected specimen had 22 AAH lesions up to 10 mm in size. For nine of these lesions, the expressions of carcinoembryonic antigen (CEA), c-erbB-2 oncoprotein and p53 gene product were examined by immunohistochemistry and the loss of heterozygosity (LOH) on chromosomes was investigated by polymerase chain reaction analysis. These lesions showed a variety of expressions for CEA, c-erbB-2 and p53 oncoprotein. Three of the nine lesions showed LOH on chromosome 13q, although this was not exhibited in the largest one. These results indicate that each AAH in this case has independent genetic abnormalities and is multicentric.