ver the past 2 decades, many studies have shown that a number of factors contribute to the exercise intolerance of patients with chronic heart failure (CHF). Factors suggested include skeletal muscle underperfusion caused by central hemodynamic alterations such as diminished cardiac output, as well as left ventricular (LV) 1-3 and right ventricular dysfunction, 4 and abnormalities in peripheral mechanisms such as skeletal muscle vasodilation, 5-7 skeletal muscle histology, 8,9 metabolism, 10-14 and muscle oxygen uptake. 15,16 Blunt vasodilation during exercise is also reported in apparently healthy, coronary highrisk subjects. 17 Among these factors, cardiac output and skeletal muscle vasodilation are the important determinants of skeletal muscle blood flow during exercise. Particularly in patients with CHF, impaired skeletal muscle vasodilation plays a key role in their exercise intolerance by reducing muscle blood flow. Therefore, the evaluation of muscle vasodilation during exercise is an important issue; however, until recently, no non-invasive method by which to assess muscle vasodilation during dynamic exercise had been available.Near-infrared spectroscopy (NIRS) is a non-invasive method suitable for the measurement of tissue oxygenated and deoxygenated hemoglobin (Hb) and myoglobin (Mb) content. This technique utilizes the principal that the absorbance of light by oxygenated Hb and Mb (oxy-Hb + Mb) and deoxygenated Hb and Mb (deoxy-Hb + Mb) differs at different near-infrared wavelengths. 18 By using NIRS, oxyHb + Mb, deoxy-Hb + Mb and total-Hb + Mb can be measured. As the amount of Mb does not change over a short period of time, the changes in total-Hb + Mb represent the changes in total Hb, that is, the blood volume, and because blood exists in blood vessels, we hypothesized that changes in working muscle total-Hb + Mb indicate muscle vasodilation, that is, the conductance of the vessel.The present study was designed to investigate whether the changes in total-Hb + Mb obtained by non-invasive measurement using NIRS reflect blood vessel conductance of working muscle during exercise. Methods SubjectsTen male patients without LV systolic dysfunction (normal LV systolic function group) and 6 male patients with cardiac dysfunction (cardiac dysfunction group) participated in this study. The clinical characteristics of the participants are shown in Table 1.The mean age of the normal LV systolic function group was 64±10 years. Clinical diagnoses were angina pectoris in 6 patients, arrhythmia (paroxysmal atrial fibrillation or Background In patients with chronic heart failure, an inadequate increase in muscle blood flow resulting from impaired vasodilation plays a key role in their exercise intolerance. However, no non-invasive methods to assess muscle vasodilation during dynamic exercise were available. We investigated whether the changes in tissue hemoglobin and myoglobin content (total-Hb + Mb) determined by non-invasive measurement using near-infrared spectroscopy (NIRS) reflect vessel conductance of working ...

oil embolization has been recently used for closure of patent ductus arteriosus (PDA), but because large PDA are difficult to close with this technique, it is generally used when the duct diameter is less than 3.5 mm. 1 However, there are some case reports in which large PDA were closed by placing more than 2 coils. 2,3 Serious complications of coil embolization are coil migration and hemolysis caused by a residual shunt, 4,5 the latter being reported as the major complication with approximately 1-2% occurrence. 2,6,7 Although a hemolytic complication usually needs additional coil embolization 4,5 or surgical treatment, medical treatment may be preferable when the residual shunt is minimal and the degree of hemolysis is mild. We report 2 cases of large PDA that were treated by multiple coil embolization, complicated by hemolysis, but successfully managed by medical treatment. Case Reports Case 1A 67-year-old woman was admitted for evaluation of dyspnea on exersion, paroxysmal atrial fibrillation (AF), and a continuous murmur of grade 4/6 in the second left intercostal space. Physical examination revealed blood pressure of 120/60 mmHg under medical treatment. The ECG finding was left ventricular hypertrophy with ST-T abnormality. Chest X-ray (CXR) showed moderate cardiomegaly with increased pulmonary vascular markings. Color Doppler echocardiography showed a shunt flow in the pulmonary artery. Right heart catheterization revealed the pulmonary artery pressure was 30/14 mmHg and there was an oxygen step-up at the level of the main pulmonary artery. The ratio of pulmonary to systemic flow was 2.0. Aortography revealed the shunt flow and a type A PDA 8 with a minimum ductal diameter of 5.3 mm. Left ventriculography showed an increase in ventricular volume, but the ventricular wall motion and coronary angiogram were normal.Because the ductal diameter was relatively large to be closed by embolization with one coil, we planned to deliver multiple Jackson detachable coils (MWCE-8-PDA5; diameter 8 mm and 5 loops, Cook Cardiology, Bjaeverskov, Denmark). Two 7Fr catheters were inserted into the femoral vein and advanced from the pulmonary artery through the Two adult cases of relatively large patent ductus arteriosus (PDA) were treated by coil embolization, but were complicated by hemolysis that was successfully managed by medical treatment. Case 1 was a 67-year-old woman and Case 2 was a 71-year-old woman with a PDA of minimal diameter of 5.3 mm and 5.5 mm, respectively. The approach was via the pulmonary artery and 2 coils were delivered simultaneously into the ductus, known as the 'kissing coil technique'. Although immediately after the procedure only a small residual shunt was revealed by aortogram, hemolysis occurred for several hours after the procedure in both cases. A hemolytic complication usually needs additional coil embolization or surgical treatment, but in these 2 cases it was successfully treated by haptoglobin infusion to prevent nephropathy and by antiplasmin infusion to promote thrombus formation. Hemolyt...

The aim of the present investigation was to compare the hemodynamic and thermal responses to a 30-min aerobic exercise between middle- or old-aged patients with normal left ventricular function and those with left ventricular dysfunction. Constant-load sitting ergometer exercise of approximately 90% of the subject's oxygen uptake (VO2) at the anaerobic threshold for 30 min was conducted in 21 patients with left ventricular dysfunction (61+/-10 years, left ventricular ejection fraction (LVEF) 35+/-7%) and 24 patients with normal left ventricular function (59+/-9 years, LVEF 71+/-7%). Heart rate (HR), blood pressure, deep temperatures in the forehead and thigh, and forearm skin blood flow (SkBF) were measured every minute, and cardiac output (CO) and stroke volume (SV) were determined every 10 min with the dye-dilution technique during the exercise. Patients of both groups exhibited a progressive elevation in each temperature and an increase in SkBF during the exercise. Although the VO2 and CO remained stable, almost the same magnitude of decrease in SV as increase in HR was seen after the 10th min of exercise in both groups. The magnitude of the decrease in SV was greater in old-aged than middle-aged patients with left ventricular dysfunction. Thus, the downward drift in SV during a 30-min constant-load aerobic exercise might not be influenced by left ventricular function, but intensified by aging in patients with left ventricular dysfunction.

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SUMMARYFew previous reports have described a sinus of Valsalva fistula without an aneurysm in Japanese patients. A single origin of the coronary arteries is a rare coronary anomaly. We describe a 75-year-old woman with a single origin of the coronary arteries and a sinus of Valsalva fistula without a typical aneurysm. Echocardiography showed turbulent flow from the right coronary sinus of Valsalva to the right ventricle throughout the cardiac cycle. Aortography confirmed the presence of a right coronary sinus of Valsalva-right ventricle shunt jet. Echocardiography and aortography demonstrated that there was no deformity of the sinus of Valsalva. Cardiac catheterization revealed that the left-to-right shunt rate was 29% and the Qp/Qs was 1.41. Aortography and coronary angiography did not identify a right coronary artery originating from the right sinus of Valsalva. Coronary angiography revealed that the right coronary artery arose from the proximal part of the left anterior descending artery and did not detect significant organic stenosis of the coronary artery. She was diagnosed as having a sinus of Valsalva to right ventricle fistula without an aneurysm, and a single origin of the coronary arteries. ( A sinus of Valsalva fistula without an associated aneurysm is a rare clinical lesion in Japan. [1][2][3][4][5] A single origin of the coronary arteries is a rare coronary anomaly.6,7) We describe an elderly asymptomatic patient with a single origin of the coronary arteries and a sinus of Valsalva fistula without a typical aneurysm. CASE REPORTA 75-year-old Japanese woman consulted a physician for the evaluation of an uncomfortable awareness of her heart beating. She had not had chest pain or From the