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Background After the reports of recalled leads, several technological improvements have been introduced and the durability of implantable cardioverter defibrillator (ICD) leads has improved. The incidence of lead failures is now less than in the previous studies. However, there are few reports that have shown the long-term durability of ICD leads as compared to pacemaker (PM) leads. This study analyzed the medium to long-term performance of transvenous ICD leads as compared to PM leads. Methods We retrospectively studied 1227 cases from April 2007 to December 2017 who underwent an initial transvenous ICD or PM implantation. The number of lead failures and patient background characteristics were analyzed. Results During a median 3-3.5 years follow up period, 1 (0.3%) ICD lead and 18 (2.4%) PM leads failed. The incidence of lead failures was significantly higher in the PM group than ICD group (p = .019). Males were associated with a higher incidence of lead failures in the PM group. Conclusion Since the era of recalled ICD leads, the durability of ICD leads has remarkably improved and the incidence of lead failures with non-recalled ICD leads has been less than that for PM leads.

High-resolution mapping is useful to identify reconnection gaps in the pulmonary vein after pulmonary vein isolation for atrial fibrillation. However, it is sometimes difficult to differentiate pulmonary vein potentials from far-field potentials because of very low amplitudes. Our purpose was to evaluate the usefulness of a novel differential atrial pacing method to differentiate reconnected pulmonary vein potentials from isolated pulmonary vein potentials. This retrospective observational study included 34 patients with atrial fibrillation (22 men; mean age, 64 ± 14 years; 28 with paroxysmal atrial fibrillation) who underwent radiofrequency or cryoballoon ablation. Following pulmonary vein isolation, we created a high-resolution activation map during pacing from both the coronary sinus and left atrial appendage. We compared the characteristics of the pulmonary vein potentials and the pattern of activation between the reconnected and isolated pulmonary veins. We analyzed 131 pulmonary veins and found reconnections in 41 pulmonary veins (R group); 90 pulmonary veins had no reconnection (NR group). The R group had a significantly shorter distance between the earliest pulmonary vein activation sites in both activation maps, compared with the NR group (5.22 ± 0.53 mm versus 17.08 ± 0.36 mm, respectively; P < 0.0001). The amplitude of the pulmonary vein potentials was higher in the R group versus the NR group (0.61 ± 0.05 mV versus 0.04 ± 0.03 mV, respectively; P < 0.0001). Six gaps (14%) in the R group that were unrecognized using a conventional method were identified using our novel method. In conclusion, differential atrial pacing was useful to identify pulmonary vein reconnection gaps during ablation using a novel high-resolution mapping system.

Background Local impedance (LI) has emerged as a new technology that informs on electrical catheter-tissue coupling during radiofrequency (RF) ablation. Recently, IntellaNav StablePoint, a novel LI-enabled catheter that equips contact force (CF) sensing, has been introduced. Although StablePoint and its predecessor IntellaNav MiFi OI share the common technology that reports LI, distinct mechanics for LI sensing between the 2 products raise a concern that the LI-RF lesion formation relationship may differ. Methods In an ex vivo swine cardiac tissue model, we investigated the initial level and range of a reduction in LI during a 60-second RF ablation and the resultant lesion characteristics at 9 combinations of 3 energy power (30, 40, and 50W) and CF (10, 30, and 50g) steps. Correlations and interactions between CF, LI, wattage, and formed lesions were analyzed. Incidence of achieving LI drop plateau and that of a steam pop were also determined. Results Positive correlations existed between CF and initial LI, CF and absolute/relative LI drop, CF and lesion volume, and LI drop and lesion volume. At the same LI drop, wattage-dependent gain in lesion volume was observed. Steam pops occurred in all CF steps and the prevalence was highest at 50W. LI drop predicted a steam pop with a cutoff value at 89Ω. Conclusion In StablePoint, wattage crucially affects LI drop and lesion volume. Because 30W ablation may by underpowered for intramural lesion formation and 50W often resulted in a steam pop, 40W appears to achieve the balance between the safety and efficacy. This article is protected by copyright. All rights reserved.

INTRODUCTION The influence of power (Watt [W]) and total energy (Joule [J]) on lesion size and the optimal overlap ratio remain unclear in laser balloon (LB) ablation for atrial fibrillation. We aimed to evaluate lesion size and visible gaps after LB ablation with various energy settings and different overlap ratios in vitro model. METHODS AND RESULTS Chicken muscles were cauterized using the first-generation LB with single applications of full and a half duration of six energy settings (5.5 W/30 seconds [165 J] to 12 W/20 seconds [240 J]) and varying power (5.5-12 W) at the constant total energy (160 J). Three overlapped ablations with different ratios (25% and 50%) for each energy setting were also performed to evaluate the visible gap degree categorized from 1 (perfect) to 3 (poor). Twenty lesions were evaluated for each energy setting. In single applications of full duration, lesion depth, lesion volume, and maximum lesion diameter increased according to the total energy (all, P

Introduction Detailed three-dimensional (3D) mapping has been useful for effective radiofrequency catheter ablation. The Rhythmia system can create atrio-ventricular dual-chamber mapping, which reveals the atrial and ventricular potentials all at once in the same map. The aim of this study was to investigate the utility of mapping the atrium and ventricle simultaneously with a high-density 3D mapping system for the ablation of accessory pathways (AP). Methods From July 2015 to August 2020, 111 patients underwent ablation of APs. Dual-chamber maps were created in 50 patients (median age 15 [10-54], 32 male [64.0%]), while 61 patients underwent radiofrequency (RF) ablation with conventional single-chamber 3D maps. The background characteristics and procedural details were compared between the dual-chamber mapping group and the conventional single-chamber mapping group. Results The number of RF applications (median [IQR]; 1.0 [1.0-3.0] vs. 3.0 [1.0-6.0], p = .0023), RF time (median [IQR], s; 9.2 [2.0-95.7] vs. 95.6 [4.1-248.7], p = .0107), and RF energy (median [IQR], J; 248.4 [58.7-3328.2] vs. 2867.6 [134.2-7728.4], p = .0115) were significantly lower in the dual-chamber group. The fluoroscopy time (median [IQR], min; 19.9 [14.2-26.1] vs. 26.5 [17.7-43.4], p = .0025) and fluoroscopy dose (median [IQR], mGy; 52.5 [31.3-146.0] vs. 119.0 [43.7-213.5], p = .0249) were also significantly lower in the dual-chamber than single-chamber mapping group. Conclusion The dual-chamber mapping was useful for ablating accessory pathways and reducing the number of RF applications, total RF energy, and radiation exposure as compared with traditional mapping techniques.

Introduction Detail 3D mapping have been useful for effective radiofrequency catheter ablation. Rhythmia system can create the atrio-ventricular dual chamber mapping, which reveals the atrial and ventricular potentials all at once in the same map. The aim of this study was to investigate the utility of Rhythmia system for catheter ablation of accessory pathways (AP). Methods From July 2015 to August 2020, 111 patients underwent ablation of APs. The dual chamber mappings were created in 50 patients [median age 15 (10-54), 32 male(64.0%)], while 61 patients underwent the radiofrequency (RF) ablations with conventional single chamber 3D mappings. The background characteristics and procedure details were compared between the dual chamber mapping group and conventional single chamber mapping group. Results The number of RF application [1 (1-3) vs 3 (1-6), p=0.0023], RF time [9.2 (2.0-95.7) vs 95.6 (4.1-248.7), p=0.0023], RF energy [248.4 (58.7-3328.2) vs 2867.6 (134.2-7728.4), p=0.0115] were significantly lower in dual chamber group. Fluoroscopy time [19.9 (14.2-26.1) vs 26.5 (17.7-43.4), p=0.0025], and fluoroscopy dose [52.5 (31.3-146.0) vs 119.0 (43.7-213.5), p=0.0249] were also significantly lower than in single chamber mapping group. Conclusion The dual chamber mappings were useful for effective ablation with reducing the radiation exposure.

Right ventricular (RV) lead perforations are relatively rare but a potentially life-threatening complication of surgical implantations of cardiac implantable electronic devices (CIEDs). The result of percutaneous simple lead traction after lead perforations in the Japanese population has not been well clarified.We retrospectively studied 1359 patients (pacemakers [PMs], 973 patients; implantable cardioverter defibrillators [ICD], 386 patients) from April 2007 to December 2018 who underwent initial CIED implantation. Fifteen patients (1.1%) were diagnosed with RV lead perforations. The clinical data were evaluated in those patients, and the baseline characteristics and echocardiographic data were compared between the lead perforation group and the non-perforation group. The success and complication rates of the simple traction and repositioning of the RV lead were also assessed.The number of perforated RV leads was seven ICD leads (1.8%) and eight PM leads (0.82%). They were diagnosed on a median seven days (5.5-36.0) after the CIED implantation. Twelve patients were asymptomatic but were detected by an increased capture threshold. Three patients had pericarditis and stimulation of the diaphragm. Only one patient in the ICD lead group who took anticoagulants had a cardiac tamponade and needed an urgent pericardiocentesis (0.07%). No one required a thoracotomy or other devices related to complications after repositioning the RV lead. There was no significant difference in the baseline characteristics and echocardiographic parameters between the groups.RV lead perforations were relatively rare complications of CIED implantations. Percutaneous simple lead traction and repositioning the perforated lead was feasible and effective if the patients did not receive anticoagulants.

Echocardiography plays a pivotal role as an imaging modality in the modern cardiology practice. Information derived from echocardiography is definitely helpful for a patient care. The Japanese Society of Echocardiography has promoted echocardiography for a routine clinical and research use. One of the missions of the Society is to provide information that is useful for high-quality examinations. To ensure it, we believe equipment in good conditions and a comfortable environment are important for both a patient and an examiner. Thus, the Committee for Guideline Writing, the Japanese Society of Echocardiography published brief guidance for the routine use of echocardiography equipment in 2015. Recently, the importance of international standardization has been emphasized in the medical laboratories. Accordingly, the committee has revised and updated our guidance for the routine use of echocardiography equipment.

Aortic regurgitation resulting from blunt chest trauma has been reported only 95 times, to our knowledge. The noncoronary and right coronary cusps are the cardiac structures most often injured. Although the aortic leaflets can appear to be undamaged after nonpenetrating trauma, they can have pathologic abnormalities and insufficient function. Some cases of posttraumatic aortic regurgitation progress slowly. Aortic valve replacement is the optimal treatment. We present the case of a then-62-year-old man who has lived more than 5 years after blunt-trauma aortic regurgitation. His is the only case of long-term survival on medical therapy alone among the 96 cases summarized in this report.

Background An intravenous leiomyomatosis is a special type of uterine leiomyoma characterized by the formation of benign leiomyomatous tissue within the vascular wall. Although histologically benign, intracardiac metastasis can lead to circulatory failure, and death, if untreated. Herein, we report on a case of a uterine intravenous leiomyomatosis with an isolated large adherent metastasis in the right atrium of the heart. Case Presentation A 52-year-old Japanese woman sought medical attention at our hospital for lower abdominal pain. A 27-cm uterine mass was detected on clinical imaging, with a 78 × 47-mm mass in the right atrium detected on preoperative echocardiography. Intracardiac mass resection and tricuspid annuloplasty were performed as the first-stage surgery. The pedicle of the tumor was adherent to the wall of the atrium. On histological examination, the tumor was found to consist of spindle-shaped cells with eosinophilic cytoplasm, without atypia, but with a myxoid change, and rich microvascularization of the pedicle. Total abdominal hysterectomy was performed as the second-stage surgery, with confirmation of the diagnosis as uterine intravenous leiomyomatosis with an isolated metastasic lesion to the right atrium. There has been no evidence of tumor recurrence in the 15 months since surgery. Conclusion We report a unique case in which a large right atrial leiomyoma was identified following a uterine intravenous leiomyomatosis. Our case exemplifies that intravenous leiomyomatosis metastatic tumors have the potential to grow via their vascularization.

Background The ablation index (AI) is reported to be useful for a durable pulmonary vein isolation (PVI). However, there have been no studies investigating the relationship between the power, contact force (CF), AI, and steam pops. Methods Using an in vitro model, ablation energy was delivered until a steam pop occurred and the time to the steam pop and AI when the steam pop occurred were measured. The experiment was performed with a combination of various powers (20, 30, 40, and 50 W) and contact forces (CFs) (10, 30, and 50 g) 20 times for each setting. The analysis consisted of two protocols. The first protocol was a comparison between the ablation power and several parameters under the same CF (10, 30, and 50 g). The second protocol was a comparison between the CF and several parameters under the same power (20, 30, 40, and 50 W). The correlation between the lesion formation and ablation parameters was evaluated. Results The AI value when steam pops occurred varied depending on the ablation settings. All AI median values were

Detailed substrate mapping is important for catheter ablation. However, the influence of the electrode spacing of the mapping catheter on the substrate map has not been well clarified. The aim of this study was to investigate the influence of the electrode spacing of the mapping catheter on the voltage of the substrate map.Protocol 1: We recorded the local atrial potentials of the left atrium (LA) using the ablation catheter during sinus rhythm in six atrial fibrillation (AF) patients. The voltage of each atrial potential was compared between a close-bipolar (1-2 electrode) recording and wide-bipolar (1-4 electrode) recording. Protocol 2: Two voltage-maps of the LA were constructed separately using a 20-pole circular catheter and 10-pole circular catheter during sinus rhythm in 42 AF patients. The low voltage zone (LVZ) (0.5mV) areas obtained by 2 voltage maps using the 10-pole and 20-pole circular catheters were compared.Protocol 1: The close-bipolar voltage of the local potentials was significantly smaller than that of the wide-bipolar voltages (0.76±0.39mV vs. 0.63±0.41mV, p0.0001). Protocol 2: The size of the LVZ areas identified by the 10-pole and 20-pole catheters was 1.12±1.92cmThe voltage of the local atrial potential using the close-bipolar catheter was significantly smaller than that using the wide-bipolar catheter. Care should be given to the electrode spacing of mapping catheters when analyzing the voltage of the atrial myocardial potentials.

Background Hepatosplenic lesion formation is one of the typical clinical symptoms of schistosomiasis japonica. Although it is established that circum-oval granuloma formation mediated by T lymphocytes is the key event triggering the formation of hepatic lesions, the time-course kinetics of disease progression remains to be fully elucidated. Methods The real-time process of the pathophysiology of schistosomiasis japonica from the early to late clinical phase was non-invasively observed in a murine experimental infection model using high-resolution ultrasonography. Together with clinical parameters, including body weight and the levels of serum markers of hepatic damage or fibrosis, ultrasonography was used to assess changes in the liver parenchyma and diameter of the portal vein and portal blood flow velocity. In parallel, parasitological parameters were observed, including egg number in the feces and maturation of parasites. Results Abnormal high-echo spot patterns in the liver parenchyma, reflecting hepatic fibrosis in ultrasonography, appeared in the liver at 4 weeks post-infection and the pattern became more enlarged and severe over time. This finding was concordant with parasite maturation and initial egg excretion. The serum M2BPGi level markedly increased from 8 weeks post-infection, suggesting sharp deterioration of hepatic fibrosis. At the same time, the diameter of the portal vein, reflecting portal hypertension, became enlarged and reached the peak level at 8 weeks post-infection. Ascites were apparent around the spleen at 9 weeks post-infection, and dilatation of the splenic vein was noted at 10 weeks post-infection. Live adult worms seemed to be detected in the portal vein at 4 weeks post-infection by ultrasonography. Conclusions We obtained real-time imaging of the development of hepatosplenic lesions of schistosomiasis japonica in mice. The time-course kinetics of the onset, development, and modulation of each symptom was uncovered. These results are expected to provide new clues for understanding the pathophysiology of human schistosomiasis japonica.

Although left atrial function index is reportedly a possible predictor of hospitalization for heart failure and of stroke irrespective of the presence or not of atrial fibrillation (AF), the effects of catheter ablation on left atrial function index have not yet been reported. We performed catheter ablation on 55 patients (age 56.6 ± 9.6 years; 44 men; 30 with paroxysmal and 25 with persistent, long-standing AF) and evaluated them by transthoracic echocardiography preoperatively and 3 monthly for 12–24 months after catheter ablation. We then compared clinical characteristics and echocardiographic variables before catheter ablation between two groups: the 42 subjects with the most recent left atrial function index

Echocardiography plays a pivotal role as an imaging modality in modern cardiology practice. Information derived from echocardiography is definitely helpful for patient care. The Japanese Society of Echocardiography has promoted echocardiography in routine clinical and research use. One of the missions of the Society is to provide information that is useful for high-quality examinations. To ensure this, we believe that equipment in good condition and a comfortable environment are important for both patient and examiner. Here, the Guideline Preparation Committee of the Japanese Society of Echocardiography has established brief guidance for the routine use of echocardiography equipment.

We present the rare case of a 76-year-old female with infective endocarditis (IE) caused by Candida glabrata. Immediately before developing the present infection, she developed IE with vegetation on the mitral annular calcification, which was caused by Streptococcus mitis and successfully treated with penicillin-G and gentamicin. However, her fever recurred, and she developed disseminated intravascular coagulation. Blood culture revealed C. glabrata, and echocardiography revealed new vegetation on the mitral valve. After 4 weeks of treatment with micafungin, prosthetic valve replacement was performed, followed by additional administration of micafungin for 4 weeks (total of 8 weeks). No relapse at 9 months after surgery has been observed. C. glabrata endocarditis is extremely rare and difficult to manage. Our case and review of past reported cases suggest that early diagnosis and initiation of treatment contribute to good prognosis of C. glabrata endocarditis.

Aims Vagal responses such as marked bradycardia or a rapid blood pressure decrease are often observed during pulmonary vein (PV) isolation of atrial fibrillation (AF) using a cryoballoon (CB). However, the relationship between the marked vagal response and change in the heart rate variability (HRV) as a marker of the autonomic tone is not well understood. Methods and results Fifty-four paroxysmal AF patients underwent CB ablation. The CB ablation was started from the right sided PVs in 25 patients (R group) and left sided PVs in 29 (L group). The HRV and haemodynamic status during the procedure were analysed. A vagal response was observed in 16 L group patients (61.5%) during the ablation of the different PVs (RSPV:1, RIPV:5, LSPV:15, LIPV:5), while it was observed in only 2 R group patients (9.5%) (RSPV:0, RIPV:0, LSPV:1, LIPV:1) (P = 0.0002). The HRV in the L group was significantly higher than that in the R group just after the CB ablation especially for the left sided PVs (L group vs. R group, total power of the HRV, median; RSPV, 11184.7 vs. 4360.0, P = 0.21; RIPV, 9044.3 vs. 2115.1, P = 0.01; LSPV, 21186.0 vs. 1314.2, P = 0.0002; LIPV 10265.9 vs. 1236.2, P = 0.0007). Conclusion A marked increase in the HRV parameters was observed just after the CB ablation. An initial CB ablation of the right PVs decreased the change in the autonomic tone during the right PV ablation and subsequent left PV ablation. It prevented an excessive vagal response during the CB ablation and might be a safe procedure.

Carcinoid heart disease (CHD) commonly occurs in association with primary gastrointestinal tract carcinoid tumors with hepatic metastases. Unlike primary gastrointestinal tract carcinoid tumors, primary ovarian carcinoid tumors may cause CHD without hepatic metastases, accounting for only 0.3 % of all carcinoid tumors. Only 37 cases of CHD from primary ovarian carcinoid tumors have been reported. We present a case of CHD in which tricuspid valve thickening and shortening led to reduced valve mobility with the resulting severe tricuspid regurgitation. Considering these characteristics of an abnormal tricuspid valve, we suspected CHD, but prosthetic valve replacement was performed without sufficient systemic examination before surgery. Two years after valve replacement, the patient underwent excision of a mass in the lower abdomen, which was diagnosed as an ovarian carcinoid tumor by histopathological examination. The patient has been observed for more than 3 years after tricuspid valve replacement. She has not experienced bioprosthetic valve leaflet degeneration or dysfunction, although it has been reported that bioprosthetic valves may degenerate in patients with carcinoid tumors. Sufficient systemic examinations should be performed to explore the cause of disease.

We compared the efficacy of drug-eluting stents (DESs) versus bare-metal stents (BMSs) in de novo and native aorto-ostial lesions (AOLs) guided by intravascular ultrasound (IVUS).Thirty-eight patients underwent DES implantation for 38 AOLs; 35 with sirolimus-eluting stents, and three with paclitaxel-eluting stents (DES group). The control group was composed of 40 AOLs treated by BMS. The incidence of the primary composite end point of all-cause mortality, Q-wave myocardial infarction and target vessel revascularization (TVR) as TVR-major adverse cardiac event (TVR-MACE) was evaluated during a 1-year follow-up. Clinical and IVUS parameters were compared between the DES and BMS groups, and Cox hazards model was used to calculate hazard ratios of several factors for the 1-year TVR-MACE.Although the vessel, plaque, and stent volumes were significantly larger after the procedures in the DES group owing to longer lesions (18.3 ± 5.1 vs. 13.2 ± 5.9 mm, P.001), the stent volume index (10.8 ± 2.6 vs. 12.4 ± 3.3, P=.024) was much smaller than that in the BMS group. During the 1-year follow-up, there were 13 TVR-MACEs in all patients (13% in DES vs. 20% in BMS, P=.4 by Kaplan-Meier analysis). The Cox hazards model did not indicate any specific unfavorable factor for the 1-year TVR-MACE.The present study showed equality between DES and BMS on de novo and native AOLs about the 1-year TVR-MACE rate, even though a DES was used in longer and bulkier lesions as compared to BMS.

The evaluation of left ventricular diastolic function provides important information about hemodynamics and has prognostic implications for various cardiac diseases. In particular, left atrial (LA) volume is an increasingly significant prognostic biomarker for diastolic dysfunction. The aim of this study was to assess left ventricular diastolic function by measuring changes in LA volume using real-time 3-dimensional echocardiography. The 106 subjects were divided into 4 groups (normal, impaired relaxation, pseudonormal, and restrictive) on the basis of diastolic function, as assessed by transmitral flow patterns. LA volume was measured during a heart cycle using real-time 3-dimensional echocardiography. LA stroke volume (maximum LA volume - minimum LA volume) and the LA ejection fraction (LA stroke volume/maximum LA volume x 100) were calculated using Doppler imaging to assess their correlation with other parameters used to evaluate left ventricular diastolic function, including transmitral flow pattern and early diastolic mitral annular velocity (E'). LA volume indexed to body surface area was dilated in subjects with left ventricular diastolic dysfunction, whereas the LA ejection fraction was lower. The maximum LA volume, minimum LA volume, and LA ejection fraction were significantly different between each group, and each was significantly correlated with the ratio of early diastolic transmitral flow velocity (E) to E' (E/E'). The LA ejection fraction correlated best with E/E' (r = -0.68, p

Background/Aims: Mitral regurgitation (MR) is frequently observed in patients with acute myocardial infarction (AMI), and is known to convey an adverse prognosis. We sought to clarify the relationship between MR and left ventricular (LV) remodeling, in association with serum C-reactive protein (CRP) elevation. Methods/Results: A total of 181 patients with first anterior ST-elevation AMI were examined. MR was detected in 68 patients by color Doppler echocardiography 2 weeks after AMI, and the patients with MR were associated with higher incidence of readmission for heart failure. Serum CRP was serially measured, and the peak serum CRP level was markedly increased in patients with MR compared with those without MR. Multiple logistic regression analysis showed that peak CRP tertile was an independent determinant of MR after AMI (p < 0.0001). In the substudy, the increases in LV end-diastolic volume and sphericity index were higher in patients with MR than in those without MR. Conclusions: MR during the early phase of anterior AMI was associated with LV spherical change and late-phase heart failure, in association with increased serum CRP level. These findings suggest an important role of the inflammatory response in the development of ischemic MR and LV remodeling.

Acute aortic dissection (AAD) is sometimes complicated by respiratory failure due to severe lung oxygenation impairment. Systemic activation of inflammatory system after aortic injury may play some roles in the development of this complication. The aim of this study was to determine the significance of serum C-reactive protein (CRP) elevation in the development of oxygenation impairment and clinical outcome with distal type AAD.A total of 61 patients, who were admitted with distal type AAD within 24 h from the onset, were examined. Serum CRP levels, white blood cell (WBC) counts and body temperature were measured serially for at least 4 days. Oxygenation impairment, defined as the lowest PaO2/FIO2 ratioor = 200 mmHg, was noted in 31 patients (51%). In patients with oxygenation impairment, peak CRP levels (20.7+/-7.9 vs. 12.7+/-3.8 mg/dl, P0.001), peak WBC counts (14,600+/-3600 vs. 11,800+/-4300/mm3, P = 0.008) and body temperature (38.4+/-0.5 vs. 38.0+/-0.6 degrees C, P = 0.004) were significantly higher than those without. Peak CRP level was inversely correlated with the lowest PaO2/FIO2 (P0.001). Patients who underwent urgent surgical treatment and/or died in the hospital had higher peak CRP levels (25.1+/-12.3 vs. 16.1+/-7.4 mg/dl, P = 0.010) than those who did not. Multivariate analysis revealed that a peak CRP levelor = 15 mg/dl (relative risk = 12.6, P0.001) was an independent determinant of the development of oxygenation impairment.The greater serum CRP elevation after distal type AAD was associated with a higher incidence of oxygenation impairment and poor clinical outcome. Systemic activation of the inflammatory system after aortic injury may play an important role in the development of oxygenation impairment.

MMPs are implicated in LV remodeling after acute myocardial infarction (MI). To analyze the role of MMP-2, we generated MI by ligating the left coronary artery of MMP-2–KO and WT mice, the latter of which were administered orally an MMP-2–selective inhibitor or vehicle (TISAM). The survival rate was significantly higher in MMP-2–KO and TISAM-treated mice than in control WT mice. The main cause of mortality in control WT mice was cardiac rupture, which was not observed in MMP-2–KO or TISAM-treated mice. Control WT mice, but not MMP-2–KO or TISAM-treated mice, showed activation of the zymogen of MMP-2, strong gelatinolytic activity, and degradation of ECM components, including laminin and fibronectin, in the infarcted myocardium. Although infarcted cardiomyocytes in control WT mice were rapidly removed by macrophages, the removal was suppressed in MMP-2–KO and TISAM-treated mice. Macrophage migration was induced by the infarcted myocardial tissue from control WT mice and was inhibited by treatment of macrophages with laminin or fibronectin peptides prior to migration assay. These data suggest that inhibition of MMP-2 activity improves the survival rate after acute MI by preventing cardiac rupture and delays post-MI remodeling through a reduction in macrophage infiltration.

Plasma brain natriuretic peptide (BNP) levels are useful marker to guide medical treatment in patients with congestive heart failure (CHF). We tested the hypothesis that the plasma BNP concentration would be a useful marker of beta-blocker therapy for CHF.Eighty-four patients with New York Heart Association class II-IV CHF and a left ventricular ejection fraction (LVEF)40% were treated with beta-blockers, including metoprolol and carvedilol, for at least 16 weeks. End-diastolic and end-systolic dimensions decreased, and radionuclide LVEF increased 4 weeks after introduction of beta-blockers (early phase). LV end-diastolic and end-systolic dimensions both decreased, and LVEF increased 16 to 48 weeks after the therapy (late phase). However, the BNP concentration did not change during the observation period. Overall LV function improved in all 4 subgroups divided according to the baseline BNP levels.Plasma BNP concentration is not a sensitive marker of successful beta-blocker therapy for CHF.

This study was designed to apply ECG-gating to stress myocardial perfusion single-photon emission tomography (SPET) for the evaluation of myocardial stunning after exercise. Technetium-99m sestamibi was selected as the perfusion agent and a rest/exercise 1-day protocol was employed. Fourteen patients without coronary stenosis and 33 patients with coronary stenosis were enrolled in the study. We carried out three data acquisitions with ECG-gating: a 15-min data acquisition starting 30 min after the rest injection (AC1), a 5-min acquisition starting 5 min after the stress injection (AC2) and a 15-min acquisition starting 20 min after the stress injection (AC3). Calculation of left ventricular ejection fraction (LVEF) values was performed by means of automatic determination of the endocardial surface for all gating intervals in the cardiac cycle. Measured global EF values in 14 patients without coronary stenosis were 52.3% +/- 7.6% (AC1), 60.6% +/- 8.9% (AC2) and 55.6% +/- 5.6% (AC3), and those in 11 patients with severe ischaemia were 53.6% +/- 8.0% (AC1), 45.6% +/- 12.1% (AC2) and 49.7% +/- 10.7%. The magnitude of the depression of post-stress LVEF relative to the rest LVEF correlated with the severity of ischaemia (r = 0.594, P = 0.002), and segments manifesting post-stress functional depression were associated with ischaemic segments showing reversible perfusion defects. Stress myocardial perfusion SPET with ECG-gating is a feasible method for the evaluation of myocardial stunning as well as exercise-induced ischaemia.

EAT/mcl-1 (EAT), a bcl-2-related immediate early gene, is up-regulated at an early stage of differentiation of human embryonal carcinoma cells. Recent studies have revealed that EAT inhibits apoptosis both in vitro and in vivo. In the present study, we demonstrated that the EAT gene was up-regulated in the early stage of rat myocardial infarction. This pattern of up-regulation was apparently different from that of another immediate early gene, c-fos. EAT, an anti-apoptotic molecule, was strongly up-regulated in the non-ischemic region. In contrast, the expression of c-fos was induced in both ischemic and non-ischemic regions, and was higher in the ischemic region. Apoptosis of cardiomyocytes is currently thought to significantly contribute to acute myocardial infarction. We detected cardiomyocyte apoptosis by gel electrophoresis of genomic DNA and in situ nick end labeling in the ischemic region, but not in the non-ischemic region. As an inhibitor of apoptosis, EAT may play a role in the protection of cardiomyocytes in the early stage of acute myocardial infarction.

The present study investigated whether regional ventricular dyskinesia (ie, systolic bulging) is a direct cause of ST-segment elevation in canine hearts in vivo. Regional ventricular dyskinesia was induced in 33 anesthetized open-chest dogs by injection of negative inotropic agents into the left anterior descending coronary artery (LAD) without disruption of coronary blood flow. Regional myocardial contraction was assessed in terms of the percent systolic shortening (%SS) and percent systolic bulging (%bulging), which were measured using ultrasonic crystals. The ST-segment elevation of the LAD-perfused area was measured with a unipolar electrode. Lidocaine, a sodium channel blocker, nicorandil, a potassium channel opener, propranolol, a beta-adrenergic blocker, or verapamil, a calcium channel blocker, was administered by intracoronary injection during maximal vasodilation induced by adenosine. All drugs induced dose-dependent ST-segment elevation in association with a parallel reduction in %SS and a parallel increase in %bulging. The absence of myocardial ischemia was confirmed by the absence of NADH fluorescence. It was concluded that regional ventricular dyskinesia had an important role in ST-segment elevation not associated with myocardial ischemia.

We examined the effectiveness of Palmaz-Schatz (P-S) stent and directional coronary atherectomy (DCA) in ostial lesions of left anterior descending arteries (LAD). The P-S stent was implanted in 11 cases at LAD ostial lesions, and DCA was performed in 13 cases. Percent stenosis and vessel diameter at the target site and the ostium of the circumflex coronary artery (LCX) were measured before and after the procedure. The initial success rate was 100% in both groups. No major complication occurred. LAD ostial lesions were improved from 81.3+/-3.4% to -8.1+/-5.7% by P-S stent and from 82.8+/-2.6% to -2.7+/-3.9% by DCA. LCX ostial vessel diameter was not changed by DCA (from 3.0+/-0.2 mm to 3.1+/-0.3 mm); however, it was significantly decreased by P-S stent (from 2.9+/-0.2 mm to 2.6+/-0.2 mm, P0.01). When the angle of LAD and LCX wasor = 80 degrees from the view of RAO 30 degrees and Caudal 30 degrees, the LCX ostium was significantly narrowed by stenting at LAD ostium (P0.01). These findings indicate that both the P-S stent and DCA are effective and safe therapies for LAD ostial lesions in cases with LAD-LCX angle80 degrees. In cases with LAD-LCX angleor = 80 degrees, however, DCA is a favored therapy rather than P-S stenting to avoid narrowing of the LCX ostium.

The purpose of this study was to evaluate ST-segment elevation induced by regional myocardial stretch without myocardial ischemia in canine hearts. A strain gauge arch (TH-601T) was sutured to the left ventricular epicardium, parallel to the short axis, to shorten the end-diastolic length of the myocardium beneath the arch (stretch zone; SZ) and to produce regional myocardial stretch in each of 6 dogs. An increase in preload caused by altering the height of a saline-filled reservoir affected prolongation or shortening of the myocardium both in the SZ and outside the arch (normal zone; NZ) to increase myocardial stretch. An epicardial electrocardiogam was recorded in both the SZ and the NZ. After suture of the strain gauge arch, the ST segment was elevated in the SZ. An increase in preload augmented stretch during systole in the SZ, resulting in additional ST-segment elevation. These results suggest that regional myocardial stretch itself plays an important role in ST-segment elevation. (Jpn Circ J 1997; 61: 921 - 926)

complaining of palpitation Yoshiyasu Aizawa ⁎, Seiji Takatsuki , Yuko Suenaga , Takehiro Kimura , Nobuhiro Nishiyama , Kotaro Fukumoto , Yoko Tanimoto , Kojiro Tanimoto , Shun Kohsaka , Yukiko Fukuda , Mitsushige Murata , Shunichiro Miyoshi , Toshiaki Sato , Shiro Iwanaga , Satoshi Ogawa , Keiichi Fukuda a a Keio University School of Medicine, Tokyo, Japan b Kyorin University, Tokyo, Japan c Tokyo Medical University, Tokyo, Japan d International University of Health and Welfare, Mita Hospital, Tokyo, Japan

The elevation of aortic pressure increases myocardial oxygen consumption and increases the blood supply to the myocardium. It is not obvious whether elevated systemic arterial pressure would enhance or diminish myocardial protection during acute myocardial ischemia. This report reviews previously published data on the effects of aortic pressure elevation on the coronary pressure-flow relationship, and on the ischemic myocardium in the dog. The shift of the maximally-dilated coronary pressure-flow line to the right on the pressure-flow diagram is an indication of the deterioration of the oxygen supply/demand ratio caused by aortic pressure elevation. The only maneuver recognized for protecting the ischemic myocardium is early reperfusion. In patients with de novo acute myocardial ischemia, we propose that myocardial protection can be enhanced by reduction of systemic blood pressure until coronary reperfusion therapy is initiated.

Accessory mitral valve tissue is a membranous or tumor-like structure observed in the left ventricular outflow tract. This congenital anomaly has been reported in more than 100 cases since 1842; however, most of them were found in patients with complex cardiac malformations. We report a 72-year-old Asian woman with isolated accessory mitral valve tissue incidentally found during the evaluation of hypertension and arrhythmia. Her left ventricular outflow tract obstruction was mild. Because worsening of the left ventricular outflow tract obstruction was reported in patients without significant obstruction at the time of diagnosis, periodical echocardiographic follow-up is necessary.

We measured the QRS duration during a treadmill exercise test and the QT interval using a 24-hour Holter electrocardiogram at various heart rates to identify use-dependent QRS prolongation and reverse use-dependent QT prolongation of class I and III antiarrhythmic drugs. Use-dependent QRS prolongation was detected in 61%, 53%, and 64% of patients receiving disopyramide, mexiletine, and pilsicainide, respectively. Reverse use-dependent QT prolongation was found in 40% and 70% of patients receiving disopyramide and E4031. Drugs suppressedor = 75% of the total premature ventricular contractions in all patients who had both use-dependent QRS prolongation and reverse use-dependent QT prolongation, in 79% of patients with use-dependent QRS prolongation alone, in 70% with reverse use-dependent QT prolongation alone, and in 11% with neither use-dependent QRS prolongation nor reverse use-dependent QT prolongation. Use-dependent QRS prolongation and reverse use-dependent QT prolongation were identified noninvasively and were useful in evaluating antiarrhythmic efficacy.

Magnetic resonance imaging (MRI) is considered the clinical reference standard for measuring the right ventricular (RV) volume and ejection fraction, although real-time 3-dimensional echocardiography (RT3DE) would be a preferred method owing to its convenience and availability for repetitive examinations. However, the feasibility, accuracy, and reproducibility of RT3DE have not been fully examined. The present study sought to validate the correlation of RT3DE with a 2-dimensional summation method compared to MRI for assessing the function of the right ventricle and to evaluate the RV function in patients with pulmonary hypertension (PH). Thirty patients with PH underwent both RT3DE and MRI. The right ventricle was reconstructed with RT3DE using a 2-dimensional summation method to analyze the MRI measurements. The RV end-diastolic volume, RV end-systolic volume, and RV ejection fraction were measured. Fifteen normal subjects underwent the same echocardiographic protocol for comparison. The RV end-diastolic volume index, RV end-systolic volume index, and RV ejection fraction measured using RT3DE correlated well with those measured using MRI (R = 0.96, p0.001; R = 0.96, p0.001; p = 0.93, and p0.001, respectively). All inter- and intraobserver variability values for the RV end-diastolic volume, RV end-systolic volume, and RV ejection fraction were17%. Both the RV end-diastolic volume index and the RV end-systolic volume index were significantly enlarged in those with PH compared to those in the normal subjects (RVEDVI 123 ± 42 ml/m² vs 74 ± 12 ml/m²; RVESVI 86 ± 33 ml/m² vs 26 ± 5 ml/m² in those with PH and the normal subjects, respectively, p0.0001). In contrast, the RV ejection fraction was significantly reduced in the patients with PH compared to that in the normal subjects (30 ± 12% vs 65 ± 6%, respectively, p0.01). Thus, RT3DE with a 2-dimensional summation method might provide comparable and feasible measurements of the RV volume in patients with PH compared to MRI.

In patients with active infective endocarditis mitral valve repair is better than mitral valve replacement, but it remains a challenge when there has been massive destruction of the rough zone of the anterior leaflet. We report a technical modification of mitral valve repair for advanced active infective endocarditis in which a widely infected rough zone and the chordae were successfully replaced with autologous pericardium and multiple artificial chordae. The procedure described here is capable of improving the prospects of mitral valve repair in advanced infective endocarditis.

Loeffler endocarditis is a serious complication of idiopathic hypereosinophilic syndrome (HES) characterized by a peculiar type of fibrosing endomyocarditis [1]. It results in various cardiac disorders and systemic embolism due to intracardiac thrombus, and these manifestations are the major causes of morbidity and mortality. Although there is still no definite therapy for Loeffler endocarditis and the prognosis is poor with high mortality rates, steroid therapy may be effective if treated at the appropriate period. Echocardiography is a mandatory evaluation in HES patients and useful to detect cardiac manifestations. A 33-year-old man with medical history of pulmonary embolism and hepatitis B was admitted to our institution with activity-induced dyspnea and systemic edema. An abnormal blood eosinophil count (1820 per lL) was also reported. Bone marrow was normocellular on examination. Echocardiography demonstrated the presence of pronounced biventricular apical thrombi, and enlarged atriums with normal LV dimension and ejection fraction (Fig. 1). Transmitral flow pattern was restrictive with increased E/A ratio (4.3) and shortened deceleration time (85 ms). Cardiac catheterization demonstrated markedly elevated biventricular end-diastolic pressure, which differed by 11 mmHg, as well as pulmonary artery pressure of 55 mmHg with a normal LV ejection fraction of 63 % (Fig. 2). These hemodynamics were consistent with restrictive cardiomyopathy. Endomyocardial biopsy remains the diagnostic gold standard, because only biopsy can detect endocardial infiltration. Thus, despite the iatrogenic complications such as embolism, endomyocardial biopsy was performed, revealing infiltration of eosinophils into the myocardium. Together, these findings confirmed a diagnosis of Loeffler endocarditis. Oral anticoagulation with Coumadin and high-dose steroid therapy was promptly initiated, resulting in improvement of clinical symptoms and reduction of E/A ratio (4.3 to 3.0).

[Figure][1] [![Graphic][3] ][3][![Graphic][4] ][4] A 29-year-old asymptomatic man was referred to our hospital for treatment of Crohn's disease. Before commencing treatment, the patient underwent a cardiac assessment. An echocardiogram showed a localized low-echoic cavity with a