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Background Pocket-sized echocardiography may serve as an initial tool to screen for aortic stenosis (AS). The purpose of this study was to evaluate the usefulness of a novel and simple method using pocket-sized echocardiography to screen for AS. Methods Subjects ( n = 130) with systolic ejection murmur or known AS were studied. After physical examination, each aortic cusp's opening was visually scored using pocket-sized echocardiography as follows: 0 = not restricted, 1 = restricted, or 2 = severely restricted. The sum of the scores was defined as the visual AS score. On the basis of high-end echocardiography, an aortic valve area index 2 /m 2 and an aortic valve area index of 0.60 to 0.85 cm 2 /m 2 were considered to indicate severe and moderate AS, respectively. Results For diagnosing severe AS ( n = 27), a visual AS score ≥4 had sensitivity of 85% and specificity of 89%. For diagnosing moderate to severe AS ( n = 57), a visual AS score ≥3 had sensitivity of 84% and specificity of 90%. The areas under the receiver operating characteristic curves for diagnosing severe and moderate to severe AS with a visual AS score (0.946 and 0.936, respectively) were slightly larger than those for a skilled physical examination (0.917 and 0.898, respectively) ( P = NS for both) but were significantly larger than for an aortic valve calcification score also obtained using pocket-sized echocardiography (areas under the curve, 0.816 [ P = .0015] and 0.827 [ P = .0001], respectively). Conclusions A novel and simple method using pocket-sized echocardiography is useful for rapid grading of AS in subjects with systolic ejection murmur.

Yasushi Kono,1 Shota Fukuda,1 Kenei Shimada,2 Koki Nakanishi,2 Kenichiro Otsuka,2 Tomoichiro Kubo,1 Satoshi Jissho,1 Haruyuki Taguchi,1 Junichi Yoshikawa,3 Minoru Yoshiyama21Department of Medicine, Osaka Ekisaikai Hospital, Nishi-ku, Osaka, Japan; 2Department of Internal Medicine and Cardiology, Osaka City University School of Medicine, Abeno-ku, Osaka, Japan; 3Nishinomiya Watanabe Cardiovascular Center, Nishinomiya, JapanBackground: It has been reported that pitavastatin improves endothelial function faster than other statins. Recently introduced reactive hyperemia peripheral arterial tonometry (RH-PAT) provides objective and quantitative assessment of peripheral microvascular function.Purpose: This study aimed to investigate whether peripheral microvascular function improved 2 hours after pitavastatin in subjects with coronary artery disease (CAD) using RH-PAT, and the results were compared with those of rosuvastatin.Methods: This study included 94 subjects with CAD, assigned to a group given 2 mg of pitavastatin (n = 36), a group given 2.5 mg of rosuvastatin (n = 38), and a control group (n = 20). RH-PAT examinations were performed before and 2 hours after statin administration.Results: The RH-PAT index increased 2 hours after pitavastatin administration from 1.82 ± 0.45 to 2.16 ± 0.62 (P = 0.02), whereas there were no differences in the RH-PAT index in the rosuvastatin group (1.79 ± 0.71 to 1.91 ± 0.53, P = 0.09) and the control group (1.68 ± 0.36 to 1.84 ± 0.58, P = 0.4). No significant changes were observed at 2 hours in serum cholesterol levels in each group.Conclusion: The present study demonstrated that peripheral microvascular function improved 2 hours after a single clinical dose of pitavastatin, but not after rosuvastatin.Keywords: coronary artery disease, statin, microvascular function

End-stage renal disease (ESRD) patients undergoing hemodialysis (HD) have a high prevalence of cardiovascular events. Low-density lipoprotein (LDL) in dialysis patients has been shown to be susceptible to in vitro peroxidation; therefore, oxidized-LDL (ox-LDL) could be generated in these patients. Moreover, myeloperoxidase (MPO) released from activated neutrophils may play a role in the induction of LDL oxidation. The purpose of this study was to investigate the relationship between plasma ox-LDL levels, plasma MPO levels, and serum high-sensitivity C-reactive protein (hs-CRP) levels during initial HD in patients with diabetic ESRD. Patients (n=28) had serial venous blood samples drawn before and after HD at the initial, second, and third sessions. Plasma ox-LDL levels were measured using a specific monoclonal antibody (DLH3), and plasma MPO levels were measured using an enzyme-linked immunosorbent assay kit. Plasma ox-LDL levels and MPO levels after a single HD session increased significantly (ox-LDL, P

The accuracy of measurements of the intima-media thickness (IMT) and flow-mediated dilatation (FMD) of the brachial artery made using a new semiautomated ultrasound system and the relationships among those parameters and the Framingham Risk Score (FRS) as a predictor of coronary heart disease (CHD) are unknown. We enrolled 70 subjects, including 47 patients with cardiovascular risk factors and 23 normal healthy volunteers. IMT and FMD were simultaneously measured using a new semiautomated ultrasound system, and the measurements were compared with those obtained manually as a reference standard (study 1). In addition, we enrolled 200 consecutive patients with risk factors but no CHD to examine the relationships among IMT, FMD and the FRS. The optimal cutoff values of FMD and IMT were determined in 200 patients without CHD, and the subjects were classified into four groups. The 10-year Framingham risks for each group were compared (study 2). FMD and IMT measurements made using the new semiautomated ultrasound system showed a good correlation with the measurements determined manually (study 1). Furthermore, FMD and IMT showed a significant correlation with the FRS. The 10-year Framingham risk was markedly higher in group D (FMD5.5% and IMT0.3 mm; 19.0±11.3%; study 2). In conclusion, the measurements made using a new semiautomated ultrasound system provided reliable and simultaneous evaluations of IMT and FMD. The combination of IMT and FMD measurements of the brachial artery may be beneficial for risk stratification of patients with cardiovascular risk factors but no CHD.

Background Coronary artery disease (CAD) often occurs concurrently in patients with severe aortic stenosis (AS). However, the influence of concomitant CAD on the presence of atherosclerotic complex plaques in the aortic arch, which is associated with increased stroke risk, has not been fully assessed in patients with severe AS. Hypothesis We hypothesized that concomitant CAD would be associated with the presence of complex arch plaques in patients with severe AS. Methods The study population consisted of 154 patients with severe AS who had undergone transesophageal echocardiography (TEE) and coronary angiography (71 male; mean age, 72 ± 8 years; mean aortic valve area, 0.67 ± 0.15 cm2). Aortic arch plaques were assessed using TEE, and complex arch plaques were defined as large plaques (≥4 mm), ulcerated plaques, or mobile plaques. Results The prevalence of aortic arch plaques (87% vs 70%; P = 0.03) and complex arch plaques (48% vs 20%; P

Aortic valve stenosis (AS) is a frequent complication contributing to poor prognosis in chronic hemodialysis (CHD) patients. However, little is known regarding the risk factors affecting AS progression. The purpose of this study was to define risk factors affecting AS progression in CHD patients.We retrospectively investigated 34 consecutive CHD patients with asymptomatic AS (mild in 9, moderate in 20, severe in 5; aortic valve area (AVA), 1.31±0.31cm(2); mean age, 69±8years) who underwent followed-up paired transthoracic echocardiography with period of at least six months apart (22±9months). AS progression was evaluated using the absolute reduction in AVA per year.CHD patients were divided into 20 patients with rapid progression (AVA reduction,0.1cm(2) per year) and 14 with slow progression (AVA reduction, ≤ 0.1cm(2) per year). Serum parathyroid hormone (PTH) level was significantly higher in patients with rapid progression than in those with slow progression [343±489pg/ml vs. 76±80pg/ml, P0.05]. In univariate analysis, AS progression by absolute AVA reduction per year was associated with age, PTH level, initial AVA, systolic blood pressure (SBP), diastolic blood pressure, total cholesterol, and left ventricular diameter at end-diastole and end-systole. Multiple regression analysis indicated that serum PTH level and SBP remained independently associated with AS progression.AS progression was accelerated in the presence of high PTH and SBP. Careful monitoring and intensive treatment of these parameters may have a beneficial effect on secondary prevention in CHD patients.

Low high-density lipoprotein (HDL) cholesterol is well-established as a negative risk factor for coronary artery disease (CAD) and its anti-oxidant property has been attributed mainly to the HDL-bound enzyme paraoxonase-1 (PON-1). Recently, myeloperoxidase (MPO), a pro-oxidant enzyme released from activated neutrophils, has been shown to alter the atheroprotective function of HDL to a dysfunctional form. This study investigated the relationship between plasma MPO and serum PON-1 levels in patients with stable (SAP) and unstable angina pectoris (UAP). Plasma MPO levels and serum PON-1 concentration/activity were measured in patients with SAP (n = 226), UAP (n = 151) and in control subjects (n = 99). Plasma MPO levels in UAP patients were significantly higher than those in SAP patients or in control subjects (UAP, 21.6[16.7-44.6]; SAP, 19.3[15.7-29.1]; control, 15.9[14.7-18.7] ng/mL; P < 0.0001). Serum PON-1 concentrations in UAP and SAP patients were significantly lower than those in control subjects (UAP, 55.6[45.9-69.7]; SAP, 55.0[46.9-64.9]; control, 62.5[51.1-78.8] μg/mL; P = 0.0002). Plasma MPO levels showed a weak inverse correlation with serum PON-1 concentrations in all subjects (R = -0.163, P < 0.0005). Moreover, in women, plasma MPO levels showed a significant inverse correlation with serum PON-1 concentrations and PON-arylesterase activity in SAP (concentration: R = -0.537, P < 0.0001; arylesterase-activity: R = -0.469, P < 0.001) and UAP (concentration: R = -0.340, P < 0.05; arylesterase-activity: R = -0.350, P < 0.05) patients, but not in men. This study demonstrates that plasma MPO levels have a significant inverse correlation with PON-1 levels, especially in women, in SAP and UAP patients, and suggests that an imbalance between pro-oxidants and anti-oxidants may contribute to the progression of coronary plaque instability

ObjectivesThis study sought to investigate the association between pathological characteristics of aspirated intracoronary thrombi and the incidence of angiographically visible distal embolization (AVDE) during primary percutaneous coronary intervention (p-PCI) in patients with ST-segment elevation myocardial infarction (STEMI) treated with thrombus aspiration.BackgroundAVDE of atherosclerotic and thrombotic material has been shown to impair myocardial perfusion and contribute to poor clinical outcome in patients with STEMI. Recent studies have shown that thrombus composition and size are associated with the incidence of AVDE.MethodsAspirated thrombi from 164 STEMI patients within 12 h of symptom onset were investigated immunohistochemically using antibodies against platelets, erythrocytes, and inflammatory cells.ResultsThe angiographic results showed that AVDE during p-PCI occurred in 22 (13.4%) patients. Pathological analysis revealed that thrombi from patients with AVDE had a greater erythrocyte-positive area (60 ± 15% vs. 43 ± 21%, p < 0.0005) and more myeloperoxidase-positive cells (943 ± 324 cells/mm2 vs. 592 ± 419 cells/mm2, p < 0.0005) than those from patients without AVDE. Thrombus size, quantified as the thrombus surface area, was positively correlated with the erythrocyte component (r = 0.362, p < 0.0001). Moreover, multivariate logistic analysis demonstrated that erythrocyte-positive area in the thrombi, glucose levels on admission, larger vessel diameter (≥3.5 mm), and pre-balloon dilation were independent predictors of the incidence of AVDE.ConclusionsThis study demonstrated that the erythrocyte-rich component of aspirated thrombi may be associated with the incidence of AVDE during p-PCI in patients with STEMI.

Coronary artery disease (CAD) is a leading cause of mortality and morbidity in developed countries, although percutaneous coronary intervention and coronary artery bypass grafting have developed recently. Appropriate diagnosis will improve the prevention, treatment, and care of all patients. We could diagnose only calcification in the coronary arteries with the past computed tomography. Recently, multislice computed tomography has been already accepted as an efficient non-invasive tool for the detection of coronary artery stenosis. We get to estimate the coronary artery stenosis with cardiac computed tomography. We discuss the usefulness of cardiac computed tomography for the risk stratification of coronary artery atherosclerosis.

Background Sugen5416 (semaxinib) is an inhibitor of the vascular endothelial growth factor (VEGF) receptor. A rat model of Pulmonary Arterial Hypertension (PAH), created with Sugen5416 and chronic hypoxia, is known to have similar histological findings to those of PAH patients. Objective To evaluate the pathophysiological mechanisms of cardiac remodeling due to hypoxic stress with Sugen5416 in vivo. Methods Male Sprague-Dawley rats were exposed to hypoxia (10 ± 1% O2) for 2 weeks after a single injection of Sugen5416 (SU-hypoxia group) or the vehicle (V-hypoxia group). Results Hypoxia elevated right ventricular (RV) systolic pressure and caused RV remodeling on Day 14. By electron microscopy, metamorphosis of capillaries with endothelial cell occlusive degeneration was observed in the RV myocardium of the SU-hypoxia group from Day 3. After reoxygenation, progressive RV remodeling with extensive degeneration of cardiomyocytes was observed in the SUhypoxia group, associated with a significant increase of oxidative stress and TUNEL-positive cells in both RV and left ventricular myocardium on Day 84. The expression of VEGF mRNA in the RV myocardium was significantly suppressed in the SU-hypoxia group on Day 3, whereas delayed activation of VEGF/extracellular signal-regulated kinase (ERK) signaling pathway on Day 14 were observed. Conclusion Capillary degeneration and activation of VEGF/ERK signaling pathway might be crucial to accelerate the cardiac remodeling due to hypoxic stress with Sugen5416.

Background Functional mitral regurgitation (MR) can occur in patients with atrial fibrillation (AF) despite having preserved left ventricular (LV) systolic function. This MR is known as atrial functional MR. The aim of this study was to clarify the mechanism of atrial functional MR using real-time three-dimensional transesophageal echocardiography (3DTEE). Methods Sixty patients underwent transthoracic echocardiography and 3DTEE: 16 patients with AF and significant non-organic MR and preserved LV ejection fraction (>50%) constituted the AF-MR group, 20 patients with AF and no significant MR formed the AF-NSMR group, and 24 normal subjects comprised the control group. Results The left atrial volume index was significantly larger in the AF-MR group (95 ± 41 ml/m2) than in the AF-NSMR group (38 ± 13 ml/m2, p Conclusions In patients with AF and significant functional MR occurring despite their preserved LV systolic function, the left atrium and mitral annulus were dilated and the anterior leaflet was flattened along the mitral annular plane, whereas the posterior leaflet was bent toward the LV cavity.

Aims Left ventricular (LV) diastolic function assessed by tissue Doppler imaging (TDI) is reported to be associated with left atrial (LA) blood stasis in patients with non-valvular atrial fibrillation (AF). This study aimed to evaluate the relationship of diastolic TDI parameters with silent brain infarction (SBI) on brain magnetic resonance imaging (MRI), and in turn the risks of subsequent stroke or dementia, in non-valvular AF patients. Methods and results The study population consisted of 171 neurologically asymptomatic patients with non-valvular AF who underwent transoesophageal echocardiography (TOE) (128 men; mean age, 63 ± 11 years). We measured diastolic TDI parameters by transthoracic echocardiography, and also screened for SBI employing brain MRI. Early transmitral flow velocity ( E ) and mitral annular velocity by TDI ( e ′) were measured, and E / e ′ ratios were calculated. An increased tertile of the E / e ′ ratio was significantly related to high prevalences of LA abnormalities detected by TOE (32% vs. 12% vs. 9%; P =0.002) and SBI on brain MRI (46% vs. 23% vs. 14%; P

Although comprehensive risk factor modification is recommended, a uniform management strategy does not necessarily prevent secondary events in patients with coronary artery disease (CAD). Therefore, identification of high-risk patients who may benefit from more intensive interventions may improve prognosis. Carotid ultrasound can reliably identify systemic atherosclerosis, and carotid plaque and intima-media thickness (IMT) are known independent risk factors for CAD. However, it is unclear whether findings on carotid ultrasound can improve prediction of secondary CAD events.The study population comprised 146 consecutive patients with CAD (mean age, 66 ± 9 years; 126 with angina pectoris, 20 with acute myocardial infarction). IMT, plaque score, plaque area, plaque surface irregularity, and calcification length (calculated by summing the calcified lesions within each plaque accompanied by acoustic shadow) were measured at baseline. Patients were followed for 10 years to ascertain secondary CAD events defined as hard major adverse cardiovascular events (MACE; cardiac death and acute myocardial infarction) and as total MACE (hard MACE and angina pectoris with coronary revascularization).Multiple regression analysis demonstrated that calcification length (p 0.05) and plaque surface irregularity (p 0.01) remained independently associated with total MACE after adjustment for age, sex, diabetes mellitus, dyslipidemia, hypertension, chronic kidney disease, smoking, and multivessel CAD.These findings suggest that the combination of calcification length and plaque surface irregularity has additional value beyond traditional risk classification. Intensive intervention for these high-risk patients may avoid or delay progression of atherosclerosis towards secondary CAD events.

Popliteal venous aneurysms (PVAs) are often reported as a cause of pulmonary embolism. Previous reports documented the association between a single PVA and pulmonary embolism. We experienced a rare case with multiple venous saccular and fusiform aneurysms resulting in a nearly fatal pulmonary embolism. Surgical ligation is usually considered the first-line treatment for PVAs. In our patient, however, we selected inferior vena cava filter implantation and anticoagulant therapy to avoid the phlegmasia cerulea dolens caused by ligation of multiple aneurysms in both legs. We report a patient with multiple venous aneurysms, including PVAs, causing a nearly fatal pulmonary embolism.

Several trials demonstrated that a long detection interval and a high-rate cutoff reduced implantable cardioverter-defibrillator (ICD) therapy in primary prevention patients. However, only a few data are available for secondary prevention (SP) patients. The aim of this study was to evaluate whether these ICD programming would be effective in reducing ICD therapies in SP patients. We enrolled 65 SP patients under ICD or cardiac resynchronization therapy with the defibrillator programmed with the same setting (conventional setting). During follow-up, we changed detection rates in each zone; cycle length (CL) ≤400 to ≤370 ms for ventricular tachycardia (VT) zone, CL ≤350 to ≤320 ms for fast VT zone, CL ≤300 to ≤270 ms for ventricular fibrillation (VF) zone, and number of intervals to detect ventricular tachyarrhythmia in VF zone: 12–24. We retrospectively compared the incidences of ICD therapies, syncope, and hospitalization due to slow VT under the detection rate between both settings. Median follow-up periods were 5.0 (interquartile range 2.5–7.8) and 2.5 years (interquartile range 2.3–2.7) in conventional and strategic settings, respectively. The incidence of appropriate ATP and shock significantly decreased in strategic setting (conventional and strategic settings: 21.2 and 4.8 ATPs per year, respectively, OR 0.18, 95 % CI 0.06–0.54, p = 0.002, 26.1 and 7.8 shocks per year, respectively, OR 0.29, 95 % CI 0.09–0.88, p = 0.03). The incidence of overall inappropriate therapy significantly decreased (conventional and strategic settings: 17.6 and 2.8 therapies per year, respectively, OR 0.14, 95 % CI 0.05–0.44, p = 0.01). The incidence of syncope and slow VT was not significantly different between both settings. In conclusion, ICD programming-combined long detection interval with high-rate cutoff was effective in reducing appropriate shock and inappropriate therapy without increasing the incidence of syncope and slow VT in SP patients.

Background— Arginine vasopressin, which promotes the reabsorption of renal water is increased in chronic heart failure. Here, we compared the effects of tolvaptan, a newly developed nonpeptide V 2 receptor antagonist, with those of furosemide, a loop diuretic, and a combination of these 2 agents in rats with left ventricular dysfunction after myocardial infarction (MI). Methods and Results— After 10 weeks of MI induction, the rats were separated them into the following 6 groups adjusted to the infarct size: a vehicle group, a group treated with 15 mg·kg -1 ·day -1 of furosemide, 2 groups treated with 3 or 10 mg·kg −1 ·day −1 of tolvaptan; and 2 groups treated with 15 mg·kg −1 ·day −1 of furosemide plus 3 or 10 mg·kg −1 ·day −1 tolvaptan. Each treatment agent was administered for 4 weeks, and all groups had similar blood pressure levels and infarct size. The tolvaptan-treated groups were found to have lower levels of left ventricular end-diastolic and systolic cardiac volumes than the vehicle group did. Furthermore, the improvement in the ejection fraction in the tolvaptan-treated groups was significantly greater than those in the vehicle group. ED-1 immunostaining and Sirius red staining revealed that tolvaptan significantly repressed MI-induced macrophage infiltration and interstitial fibrosis in the left ventricle, respectively. Tolvaptan attenuated the MI-induced mRNA expressions of atrial and brain natriuretic peptides, monocyte chemotactic protein-1, transforming growth factor-β1, arginine vasopressin V 1a receptor, and endothelin-1 in the marginal infarct region. Conclusions— Tolvaptan may improve cardiac dysfunction after MI, which is partially mediated by the suppression of V 1a receptor, neurohumoral activation and inflammation.

Background The whole body periodic acceleration (WBPA) system was recently developed as a passive exercise device by providing increased pulsatile shear stress for improvement of endothelial function. This study aimed to investigate the acute effects of WBPA on coronary microcirculation and glucose tolerance in patients with type 2 diabetes (T2D). Methods The study subjects were 8 patients with T2D who underwent transthoracic Doppler echocardiography for the assessment of coronary flow reserve (CFR) before and immediately after a 45-min session of WBPA. The flow velocity in the distal portion of the left anterior descending coronary artery was measured at baseline and during adenosine infusion. The CFR represented the ratio of hyperemic to basal mean diastolic flow velocity. Results WBPA increased CFR from 2.3 ± 0.3 to 2.6 ± 0.4 ( p = 0.02). WBPA decreased serum insulin level from 26 ± 19 μIU/ml to 19 ± 15 μIU/ml ( p = 0.01) and increased total adiponectin from 11.6 ± 7.3 μg/ml to 12.5 ± 8.0 μg/ml ( p = 0.02) and high molecular weight adiponectin from 4.9 ± 3.6 μg/ml to 5.3 ± 3.9 μg/ml ( p = 0.03), whereas the serum glucose level was stable from 207 ± 66 mg/dl to 203 ± 56 mg/dl ( p = 0.8). Conclusions This study demonstrates that a single session of WBPA treatment simultaneously improved coronary microcirculation and glucose tolerance in patients with T2D.

Recently, an aortic valve area (AVA) index (AVAI)0.6 cm(2)/m(2) was proposed as an indicator of severe aortic stenosis. The purpose of the present study was to clarify the prognostic value of the AVAI. We identified 103 consecutive asymptomatic patients (mean age 72 ± 11 years) with severe aortic stenosis, defined by an AVA of1.0 cm(2), who had not undergone aortic valve replacement on initial evaluation. During follow-up (median 36 ± 27 months), 31 aortic valve replacements and 20 cardiac deaths occurred. Multivariate analysis revealed that an AVAI0.6 cm(2)/m(2) (hazard ratio 2.6, 95% confidence interval 1.1 to 6.3; p = 0.03) and peak aortic jet velocity (Vp)4.0 m/s (hazard ratio 2.6, 95% confidence interval 1.2 to 5.8; p = 0.02) were associated with cardiac events but that an AVA0.75 cm(2) was not. The event-free survival of patients with an AVAI of ≥0.6 cm(2)/m(2) was better than that for those with an AVAI0.6 cm(2)/m(2) (86% vs 41% at 3 years, p0.01). Furthermore, patients with an AVAI of ≥0.6 cm(2)/m(2) and Vp of ≤4.0 m/s showed an excellent prognosis, but those without these findings had poorer outcomes. In conclusion, AVAI is a powerful predictor of adverse events in asymptomatic patients with severe aortic stenosis. Furthermore, the combination of AVAI and Vp provides additional prognostic information. Watchful observations are required for timely aortic valve replacement in patients with an AVAI of0.6 cm(2)/m(2) or a Vp4.0 m/s.

Aims Many investigators have speculated that hyperintense plaques (HIPs) of the carotid artery on non-contrast T1-weighted imaging (T1WI) in magnetic resonance indicate the presence of mural or intraplaque haemorrhage containing methemoglobin. Coronary plaque imaging with T1WI is challenging, and the clinical significance of coronary HIP on T1WI remains unknown. The aim of this study was to compare HIPs on T1WI with coronary plaque morphology assessed by optical coherence tomography (OCT), which allows us to identify not only plaque rupture, but also fibrous cap thickness and intracoronary thrombus in vivo, in patients with angina pectoris. Methods and results Twenty-six lesions from 26 patients with either stable or unstable angina pectoris were examined in this study. All patients underwent T1WI within 24 h before the day on which invasive coronary angiography was performed, and pre-interventional OCT was performed on a native atherosclerotic lesion, considered to be the culprit lesion. Of the 26 lesions studied, 16 (62%) were HIPs and 10 (38%) were non-HIPs. The signal intensity of the coronary plaque to cardiac muscle ratio in HIPs was significantly higher than that in non-HIPs. There were no significant differences in the frequency of lipid-rich plaque, thin-cap fibroatheroma, plaque rupture, and calcification between HIPs and non-HIPs. In contrast, the frequency of thrombus was significantly higher in HIPs than in non-HIPs (P = 0.004). Conclusion This study shows that the HIPs on T1WI in angina patients relate to the presence of intracoronary thrombus as detected by OCT imaging.

Background: Atrial fibrillation (AF) is associated with considerable morbidity and mortality in patients with coronary artery disease (CAD). Epicardial adipose tissue (EAT) is recognized as an important inflammatory tissue that may exert deleterious effects on the adjacent left atrial (LA) wall. Multidetector computed tomography (MDCT) can accurately assess EAT’s volume and distribution. This study used MDCT to investigate the effect of peri-atrial EAT on new-onset nonvalvular AF. Methods and Results: The study group consisted of 279 patients (176 men; age, 65±10 years) with no history of AF who underwent MDCT examination for evaluation of CAD. EAT was automatically identified on the basis of threshold attenuation values of −30 to −250 Hounsfield units. EAT volume was calculated as the sum of EAT area and subsequently divided into peri-atrial and peri-ventricular EAT. During follow-up of 3.3±1.0 years, AF occurred in 17 (6.1%) patients. Cox proportional hazards regression analysis indicated that male sex, and the LA and peri-atrial EAT volumes (P=0.03, P

Background: In the absence of obstructive coronary narrowing, impaired coronary flow reserve (CFR) represents coronary microvascular dysfunction. Transthoracic Doppler echocardiography (TTDE) allows non-invasive measurement of CFR in the left anterior descending (LAD) artery. This study aimed to assess the prognostic value of TTDE-derived CFR (as a marker of microvascular function) in predicting long-term cardiovascular events, acute coronary syndrome (ACS) events, and the development of heart failure (HF). Methods and Results: This study consisted of 272 patients with coronary artery disease not involving obstructive narrowing (≥50%) in the LAD. Patients underwent TTDE examination for CFR measurement in the LAD. During the follow-up period of 4.0±1.9 years, 32 patients (12%) had cardiovascular events. Cox proportional hazard analysis identified lower CFR as an independent risk factor of cardiovascular events (P

Background: Carbon dioxide (CO2) baths have been used to treat a variety of diseases, but developing an artificial bath of highly concentrated CO2 is difficult. Here, we tried the efficacy of a novel device instead of a CO2 bath. Methods and Results: Using a device equipped with double fluid nozzles, CO2 gas and H2O were compounded and compressed at 4 barometric pressures. As a result, CO2 gas was dissolved in H2O, which contained a few micrometers of CO2 particles, namely, a CO2 mist. Wistar rats with myocardial infarction (MI) by ligation of the left coronary artery were percutaneously administered CO2 mist or CO2 gas alone or no treatment for 30min daily. With regard to tissue blood flow during treatment, the group treated with CO2 mist had significantly increased tissue oxygenated hemoglobin levels and tissue saturation levels, and significantly decreased deoxygenated hemoglobin levels compared with the group treated with CO2 gas. After 4 weeks treatment, the group treated with CO2 mist had a significantly improved ejection fraction by echocardiography compared with the untreated group. Interestingly, the group treated with CO2 mist had significantly increased nitrate concentrations in serum and vascular endothelial growth factor mRNA expression levels in the myocardium compared with the untreated group. Conclusions: Our new mist production device may be potentially useful for the treatment of heart failure caused by MI. (Circ J 2012; 76: 1203-1212)

Aims The planimetry method using three-dimensional (3D) echocardiography is useful for providing an accurate mitral annulus area (MAA) value. However, this method is relatively unavailable. Therefore, we evaluated the accuracy of conventional methods for MAA measurement compared with that of 3D planimetry. Methods and results Two-dimensional (2D) and 3D transoesophageal echocardiography (TEE) were performed in 70 patients. The mitral annulus diameter (MAD) was measured using four standard TEE imaging planes: four-chamber (4Ch), two-chamber (2Ch), anterior–posterior (LAX), and commissure–commissure (CC). MAA was calculated using a single diameter based on that of a circle and using two diameters based on that of an ellipse. MAA measurements using the single 4Ch MAD method ( r = 0.84, P < 0.001), and two anatomically orthogonal MAD method in 4Ch/2Ch ( r = 0.93, P < 0.001) and LAX/CC ( r = 0.97, P < 0.001) planes correlated with 3D planimetric MAA measurements. Further analysis with Bland–Altman plots revealed that the LAX/CC MAD measurement exhibited the closest limits of agreement with the 3D planimetric MAA measurement. Notably, in patients showing an elliptical annulus shape, only LAX/CC MAD, but not 4Ch or 4Ch/2Ch MAD, provided results comparable with those of 3D planimetric MAA measurements. However, in patients with a circular annulus shape, reliable MAA measurements can be achieved using either single 4Ch MAD or any biplane MAD. Conclusion Conventional LAX/CC MAD can be recommended for MAA measurements in a diverse patient population. This method is applicable as an alternative to the 3D planimetric method, regardless of the mitral annulus shape.

Aortic stenosis (AS) and systemic atherosclerosis have been shown to be closely related. We evaluated the prevalence of aortic arch plaques and their possible association with the risk of cerebral infarction in patients with severe AS. Transesophageal echocardiography was performed in 116 patients with severe AS (55 men, mean age 71 ± 7 years, mean aortic valve area 0.68 ± 0.15 cm(2)) who were scheduled for aortic valve replacement. The presence, thickness, and morphology of the aortic arch plaques were evaluated using transesophageal echocardiography. Cerebral infarcts (chronic cerebral infarction and cerebral infarction after cardiac catheterization and aortic valve replacement) were assessed in all patients. Compared to age- and gender-matched control subjects, the patients with severe AS had a significantly greater prevalence of aortic arch plaques (74% vs 41%; p0.0001) and complex arch plaques such as large plaques (≥4 mm), ulcerated plaques, or mobile plaques (30% vs 10%; p = 0.004). Multivariate logistic analyses showed that the presence of complex arch plaques was independently associated with cerebral infarction in patients with AS after adjusting for traditional atherosclerotic risk factors and coronary artery disease (odds ratio 8.46, 95% confidence interval 2.38 to 30.12; p = 0.001). In conclusion, the results from the present study showed that there is a greater prevalence of aortic arch plaques in patients with AS and that the presence of complex plaques is independently associated with cerebral infarction in these patients. Therefore, the identification of complex arch plaques using transesophageal echocardiography is important for risk stratification of cerebrovascular events in patients with severe AS.

Pirfenidone (5-methyl-1-phenyl-2-[(1)H]-pyridone) is an effective drug for idiopathic interstitial pneumonia that can prevent and reverse tissue fibrosis in several organs. Therefore, we investigated whether pirfenidone has a potential role in preventing angiotensin II (Ang II)-induced cardiac hypertrophy. A cardiac hypertrophic mouse model was created using an Ang II infusion (200 ng kg(-1) min(-1)) in wild-type mice for 2 weeks. Mice were divided into the following three groups: a saline-infused (control) group, an Ang II infusion (vehicle) group and an Ang II infusion+pirfenidone-treated (PFD) group, which received pirfenidone (300 mg kg(-1) per day) by gastric gavage during the Ang II infusion. At 2 weeks, we assessed hemodynamics and cardiac function and investigated tissue fibrosis of the myocardium histologically and genetically. Blood pressure in the vehicle group was significantly increased compared to the control group. Although blood pressure was not different between the vehicle and PFD groups, heart weight was significantly decreased in the PFD group. Echocardiography revealed that left ventricular hypertrophy was significantly increased in the vehicle group vs. the control group. Interestingly, pirfenidone significantly inhibited this effect. Continuous infusion of Ang II increased the perivascular and interstitial tissue fibrosis, and pirfenidone inhibited these fibrotic changes. Pirfenidone also inhibited Ang II-induced hypertrophy. In the vehicle group, the mRNA expressions of atrial natriuretic peptide, brain natriuretic peptide and transforming growth factor-β1 were increased, which was significantly inhibited by pirfenidone. Furthermore, the expression of mineralocorticoid receptors was attenuated by pirfenidone. These results indicate that pirfenidone might be effective as an antifibrotic drug in the treatment of cardiac hypertrophy induced by hypertension.

The aim of this study was to investigate the clinical value of the apex beat and two ECG voltage criteria in the detection of left ventricular hypertrophy (LVH) while considering two distances, from the heart to the inner chest wall and to the chest surface, measured by using multislice CT (MSCT). The study population consisted of 151 patients clinically judged as requiring MSCT angiography. The apex beat was palpated with patients in the supine. Sokolow–Lyon voltage and Cornell voltage to detect LVH were determined. The pattern of sustained or double apical impulse and Cornell voltage had higher specificity as an indicator of LVH than Sokolow–Lyon voltage. Furthermore, the distance to the inner chest wall was negatively correlated with left ventricular end-diastolic volume and mass. Contrarily, the distance to the chest surface was correlated with the body mass index. Multivariate analyses revealed that the pattern of sustained or double apical impulse showed a stronger association with the distance to the inner chest wall than to the chest surface, but Sokolow–Lyon voltage was associated with the distance to the chest surface. Among the screening tests for excluding patients with LVH, Cornell voltage or the apex beat would be better than Sokolow–Lyon voltage because these are less dependent on body size and have higher specificity.

Strain echocardiography has enabled quantification of regional myocardial systolic function objectively and is less influenced by tethering effects and cardiac translational artifact than Doppler tissue imaging. Although strain echocardiography has been applied for the detection of inducible ischemia during dobutamine stress, it has not been fully applied to exercise stress echocardiography (ESE) because of technical difficulties. Prolonged myocardial systolic dysfunction after exercise-induced ischemia has been shown previously. Thus, we designed this study to evaluate whether the myocardial strain analysis can detect myocardial ischemia by the assessment of prolonged regional left ventricular (LV) dysfunction in ESE. We performed ESE with myocardial strain imaging system in 20 consecutive patients who had exercise Tl-201 single photon emission computed tomography (SPECT). Myocardial strain curves were obtained at six segments in mid LV walls from the apical approach before and 5 min after ESE. We measured the duration from the R wave in the electrocardiogram to the timing of peak systolic strain corrected by the square root of the RR interval (TPSc). We finally calculated the differences of TPSc (ΔTPSc) before ESE and 5 min after ESE. The results were compared with SPECT as a reference standard. A receiver operating characteristic curve demonstrated that a ΔTPSc cutoff value of 70 ms had a sensitivity of 80% and a specificity of 84% for the detection of myocardial ischemia. Prolonged regional LV systolic dysfunction assessed by ESE with strain analysis was useful for the detection of myocardial ischemia.

Drug-eluting stents reduce restenosis due to neointimal growth suppression. Considering long-term outcomes, it is both difficult and important to predict drug-eluting stent restenosis. Thus, this study was designed to examine the utility of myocardial fractional flow reserve (FFR) as a predictor of sirolimus-eluting stent (SES) restenosis. Thirty-three patients (35 lesions) were enrolled. Upon completion of SES implantation, FFR was obtained under hyperemia. At 8 months of follow-up, coronary angiography revealed that five lesions had restenosis. Percent diameter stenosis (restenosis 68.7 ± 12.8% vs. non-restenosis 68.7 ± 12.4%, p = 0.78) and lesion length (restenosis 15.8 ± 9.4 mm vs. non-restenosis 14.4 ± 9.2 mm, p = 0.60) were similar. At post-intervention, percent diameter stenosis (restenosis 16.4 ± 6.1% vs. non-restenosis 14.0 ± 7.4%, p = 0.48) and minimum stent area (restenosis 6.01 ± 1.08 mm2 vs. non-restenosis 6.27 ± 1.85 mm2, p = 0.92) were also equivalent. However, proximal edge lumen area was smaller (restenosis 4.24 ± 1.40 mm2 vs. non-restenosis 7.73 ± 2.64 mm2, p = 0.004) and FFR was lower in the restenosis group (restenosis 0.81 ± 0.12 vs. non-restenosis 0.92 ± 0.06, p = 0.029). SES patients with restenosis had a lower FFR post stent deployment, suggesting the decreased FFR may be a useful predictor for SES restenosis.

Background: Although echo Doppler machines have consistently advanced within a quarter of a century, age related prevalence of valvular regurgitation detected by currently available echo machines remains uncertain. The aim of this study was to investigate the prevalence and correlates of valvular regurgitation in healthy individuals. Methods and Results: A total of 1,333 apparently healthy individuals were enrolled in this study. Echocardiographic examinations were performed using a currently available echo machine. Aortic regurgitation (AR) was detected less frequently ( 30 years old. Tricuspid regurgitation (TR) was frequently (>80%) detected in all age groups. In general, prevalence of valvular regurgitation was higher than those reported previously, except for a relatively lower prevalence of AR in the elderly population. Age was an independent correlate of AR and MR, but not of TR. The presence of AR and MR were independent correlates of TR. Conclusions: In healthy subjects, AR, MR or TR are commonly detected by using a current echo machine. These "physiological" valvular regurgitations should not be considered as a "pathological" valvular heart disease. (Circ J 2011; 75: 2699-2704)

The identification and intervention of factors associated with a coronary artery calcification (CAC) score of zero, suggesting the absence of significant coronary artery disease (CAD) with high probability, would be meaningful in the clinical setting. Thus far, the relationship between CAC and left ventricular (LV) hypertrophy has not been documented. We identified factors associated with a CAC score of zero and evaluated the relationship between this score and LV concentric hypertrophy in 309 consecutive patients with suspected CAD who were clinically indicated to undergo multislice computed tomography angiography for coronary artery evaluation. The quantitative CAC score was calculated according to Agatston's method. The total coronary calcium score (TCS) was defined as the sum of the scores for each lesion. Four absolute TCS categories were considered: zero, mild (0-100), moderate (100-400), and severe (400). LV hypertrophy was classified into concentric (LV mass index104 g/m(2) in women or116 g/m(2) in men; LV end-diastolic volume index ≤109.2 mL/m(2)) and eccentric (LV end-diastolic volume index109.2 mL/m(2)) patterns. In the zero-TCS group, the frequency of LV concentric hypertrophy was extremely low (zero 6%, mild 17%, moderate 26%, severe 19%). Multivariate analysis revealed that age, hypercholesterolemia, diabetes mellitus, LV concentric hypertrophy, and LV mass index, but not hypertension, were the independent factors associated with a CAC score of zero. The present study demonstrated that the absence of LV concentric hypertrophy was a prerequisite for a CAC score of zero. That is, the presence of LV concentric hypertrophy, which indicated more severe underlying hypertension, long duration, or poor control of blood pressure, implicates the presence of CAC.

ObjectivesThe aim of this study was to investigate the 2-year prognostic impact of N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels at discharge following transcatheter aortic valve implantation (TAVI).DesignMulticentre prospective observational study.SettingsSeven institutions from multicentre, observational registry of symptomatic patients with severe aortic stenosis who undergo TAVI.ParticipantsWe enrolled 500 consecutive patients who underwent TAVI with measurements of NT-proBNP at discharge between 2013 and 2016. Study patients were stratified into two groups according to survival classification and regression tree (CART) analysis: high versus low NT-proBNP groups.InterventionsThe impact of high NT-proBNP on a 2-year composite endpoint consisting of all-cause mortality and heart failure hospitalisation was evaluated using a multivariable Cox model.ResultsMedian age was 86 years (quartile 82–89), and 24.2% of the study population were men. Median Society of Thoracic Surgeon score was 7.1 (5.1–9.8), and NT-proBNP at discharge was 1381 (653–3136) pg/mL. The composite endpoint incidence was 13.0% (95% CI 9.5% to 16.3%) at 1 year and 22.3% (95% CI 16.1%–27.9%) at 2 years. The survival CART analysis revealed that the NT-proBNP level required to discern the 2-year composite endpoint was 4288 pg/mL. Elevated NT-proBNP had a statistically significant impact on outcomes, with adjusted HR of 2.21 (95% CI 1.21 to 4.04, p=0.010), and with a significant sex difference (Pfor interaction=0.003).ConclusionElevation of NT-proBNP at discharge is associated with higher incidence of the 2-year composite endpoint after TAVI.Trial registration number000020423

Previous studies have shown that oxidative stress and endothelial dysfunction are related to impaired myocardial microcirculation after reperfusion. Moreover, elevated myeloperoxidase (MPO) levels are associated with endothelial dysfunction. Plasma MPO levels were measured in patients with ST-segment elevation acute myocardial infarction (n = 160) who had undergone percutaneous coronary stenting within 12 hours of symptom onset. We investigated whether the plasma MPO level at admission was associated with impaired myocardial microcirculation, as indicated by ST-segment resolution and myocardial blush grade after reperfusion, and left ventricular ejection fraction and remodeling at 6 months. The patients were divided into 2 groups according to the median MPO value for the entire cohort (low-MPO group < or =50 ng/ml, n = 80; high-MPO group >50 ng/ml, n = 80). ST-segment resolution and the myocardial blush grade were significantly lower in the high-MPO than in the low-MPO group (48 +/- 27% vs 61 +/- 24%, p

SummaryObjectivesAlthough physicians frequently perform palpation of the apex beat to evaluate left ventricular (LV) size and hypertrophy, the clinical significance of apex beat palpation is still unclear. The introduction of multislice computed tomography (MSCT) has enabled assessment not only of coronary stenoses but also LV volume, mass, and distance from heart to chest wall. The aim of this study was to evaluate the relationships among presence, location, and sustained or double apical impulse of apex beat and LV function, volume, mass, and distance from heart to chest wall determined by MSCT.Methods and resultsThe study population consisted of 200 consecutive patients clinically indicated for MSCT angiography for coronary artery evaluation. Apex palpation was performed with the patients in the supine and left lateral decubitus positions. Multivariate analysis revealed that LV mass index (p

Summary Objectives The purpose of this study was to explore the possibility of using our novel echocardiographic index of inefficient left ventricular (LV) contraction in patient selection for cardiac resynchronization therapy (CRT). Methods Forty consecutive patients with LV ejection fraction ≤35% were divided into 2 groups, 9 CRT candidates and 31 non-CRT candidates based on conventional criteria. A global LV time–area curve and regional LV time–area curves in 6 radial sectors were obtained using two-dimensional echocardiography in the short-axis view with speckle tracking. Fractional inefficient contraction (FIC, %) was calculated as follows: (1 − global LV area change/sum of regional LV area changes) × 100. LV dyssynergy and dyssynchrony were quantified as the standard deviations of minimal values of circumferential speckle-tracking strain and their timings in the 6 sectors, respectively. Results There was no significant difference in LV dyssynchrony between CRT candidates and non-CRT candidates (79 ± 61 ms vs. 58 ± 26 ms, respectively). In contrast, FIC was significantly larger in CRT candidates than in non-CRT candidates (15.7 ± 11.0% vs. 5.4 ± 3.5%, respectively, p = 0.0018), with less overlap between groups. FIC showed a positive correlation with dyssynchrony (r = 0.64) and a negative correlation with dyssynergy (r = −0.42). Conclusions Our novel echocardiographic index of inefficient LV contraction, which increases with more dyssynchrony or less dyssynergy, may prove more useful in patient selection for CRT than other indices that focus on LV temporal dyssynchrony alone.

Background: Electrocardiographic (ECG) left ventricular hypertrophy (LVH) is a risk factor for cardiovascular events and the incidence of LVH increases with age. However, few studies have assessed risks associated with LVH in elderly hypertensive patients. Methods and Results: The Japanese Trial to Assess Optimal Systolic Blood Pressure in Elderly Hypertensive Patients (JATOS) was conducted to determine optimal blood pressure in elderly patients. At study entry, the sum of the S-wave in lead V1 and the R-wave in lead V5 (SV1+ RV5) could be determined in 3,230 patients, among whom 164 (5.1%) had cardiovascular events. On univariate analysis, the hazard ratio for cardiovascular events was 1.51 for each 10 mm (=1 mV) (95% confidence interval (CI): 1.34–1.69, P

ファブリー病に対して酵素補充療法（ERT）が実用化され，アガルシダーゼアルファ，アガルシダーゼベータの2剤が使用可能である．しかし，透析患者に対してのデータは少ない．特に，アガルシダーゼアルファに関しては血液透析（HD）中投与のデータがないため，HD中投与の可否につき薬物動態の検討を行った．【症例】46歳，男性．26歳時に脳梗塞を発症し，ファブリー病と診断．平成18年7月に血液透析導入，11月よりアガルシダーゼベータによるERTを開始したが，投与関連反応高度のため，平成19年4月よりアガルシダーゼアルファに薬剤を変更．疼痛発作，発汗障害，下痢などの自覚症状はERT開始後1年程度で改善し，心機能の悪化も認めていない．本例に対しHD中，非HD中にERTを行い，薬物動態を検討したが，HD中投与と非HD中投与で，血漿中の酵素活性に差は認めなかった．【まとめ】アガルシダーゼアルファはベータと同様にHD中に投与可能である．また，ERTにより，症状の改善のみならず，心機能維持効果が示唆された．透析患者に対しても，ERTの継続は重要であり，ベータとアルファでの臨床効果の差は認められず，ベータが投与困難な症例に対しアルファへ変更し投与を継続することは効果的であると思われる．

Introduction: Type 1 Brugada ECG is essential for the diagnosis of Brugada syndrome. We aimed to evaluate the usefulness of multichannel Holter ECG recording in the third intercostal space for detecting type 1 Brugada ECG. Methods and Results: We enrolled 60 consecutive individuals with type 1 Brugada ECG and 31 individuals with type 2 or 3 Brugada ECG, in the presence or absence of Na+ channel blockers. All individuals underwent 12-lead ECGs recorded in the standard position and the third intercostal space at least 5 times every 3 months (4L-ECGs, 3L-ECGs, respectively) and multichannel Holter ECG. On multichannel Holter ECG, the precordial electrodes were attached at standard positions (4L-Holter) and the third intercostal space (3L-Holter) for leads V1 and V2. Among the 60 individuals, type 1 Brugada ECG in 4L-ECGs, 3L-ECGs, 4L-Holter, and 3L-Holter was detected in 15 (25%), 26 (43.3%), 23 (38.3%), and 33 individuals (55%), respectively, whereas detected in none of the 31 individuals. The documented duration of type 1 Brugada ECG on 3L-Holter was significantly longer than that on 4L-Holter (700 ± 467 vs 372 ± 422 min; P = 0.01, 3L-Holter vs 4L-Holter, respectively), and type 1 Brugada ECG was most frequently observed between 6 pm and 12 pm. Neither the presence nor the duration of the appearance of type 1 Brugada ECG differed significantly between symptomatic and asymptomatic individuals. Conclusion: Multichannel Holter ECG recording in the third intercostal space is more sensitive and useful for the diagnosis of type 1 Brugada ECG than repeated 12-lead ECGs or multichannel Holter ECG in the standard position.

Objectives: The aim of this study was to clarify whether pioglitazone suppresses in-stent neointimal proliferation and reduces restenosis and target lesion revascularization (TLR) after percutaneou...

Left ventricular (LV) ejection fraction (EF) was known as a conventional predictor of heart failure (HF). However, early transmitral flow velocity (E)/early diastolic velocity of mitral annulus (E') correlated well with LV end-diastolic pressure, and E/E' ratio15 was an excellent predictor of adverse outcomes in patients with HF. This study was designed to determine the prognostic value of a new combined index, E/E' ratio and LVEF, in patients with HF. One hundred twenty-six consecutive patients hospitalized with HF underwent comprehensive echocardiographic-Doppler study when ready for discharge. Patients were divided into the 4 groups of group I (LVEF40% and E/E' ratio15), group II (EF40% and E/E' ratioor=15), group III (EFor=40% and E/E' ratio15), and group IV (EFor=40% and E/E' ratioor=15). The ability of this index to determine the primary end point (rehospitalization for HF or cardiac death) was assessed. Patients with significant valvular disease were excluded. Of 126 patients, 110 met the inclusion criteria. Follow-up was complete for 108 of 110 patients at 351 +/- 252 days after discharge. There were 27, 30, 21, and 30 patients in groups I, II, III, and IV, respectively. There were 52 patients with the primary end point. On univariate analysis, E/E' ratio, group IV, E', and age were significant predictors. In multivariable analysis, the most powerful independent prognostic indicator of events was group IV (hazard ratio 12.6, 95% confidence interval 2.2 to 74.2, p = 0.005). In conclusion, a new index, a combination of LVEF and E/E' ratio, allowed the identification of patients at higher risk of readmission and cardiac death in patients with HF.

Background: Although real-time three-dimensional echocardiography (RT3DE) is useful for delineating the extent and severity of stress-induced wall motion abnormalities during dobutamine stress echocardiography (DSE), it also provides simultaneous multiple two-dimensional cut planes, which may potentially improve the detection of stress-induced wall motion abnormalities. The aim of this study was to determine the comparative diagnostic accuracy of RT3DE in multiplane and multislice modes for the diagnosis of coronary artery disease (CAD) during DSE against coronary angiography reference. Methods: Multiplane and multislice cut planes (3 V, GE Healthcare, Milwaukee, WI) at rest and peak dose of dobutamine were acquired in 71 patients with known or suspected CAD. In multiplane mode, matrix array transducer allowed the simultaneous visualization of parasternal long and short-axis views or apical 4-, 2-, and 3-chamber views. From full-volume datasets, 9 equidistant 2-dimensional short-axis images from LV base to apex were extracted and simultaneously displayed (multislice mode). Visual assessment of regional wall motion was performed. Coronary angiography was performed within 48 hours and used as a reference. Results: Abnormal findings (new or worsened wall motion abnormalities or fixed wall motion abnormalities) were noted in 36 patients by multiplane mode and 28 patients by multislice mode. Coronary angiography showed significant stenosis in 32 of 71 patients in 49 of 213 coronary arteries. On a patient basis, sensitivity was not different, but specificity was significantly higher in multislice mode (95%) compared with multiplane mode (77%, P < .05). Diagnostic accuracy for detecting right CAD was also significantly higher in multislice mode (93% vs 80%, P < .05). Conclusion: Assessment of LV wall motion from multiple short-axis slices extracted from full-volume RT3DE datasets improves the diagnosis of CAD and is thus a useful addition to DSE tools. (J Am Soc Echocardiogr 2009;22:437-442.)

ObjectivesThere is increasing evidence that left atrial (LA) size is an important predictor of adverse cardiovascular outcomes such as atrial fibrillation, stroke, and congestive heart failure. The aim of this study was to determine whether there is a difference in results of quantification of LA volume by the area-length and Simpson's methods using multislice computed tomography (MSCT).Methods and resultsThe study population consisted of 51 patients with sinus rhythm (sinus group) and 20 patients with atrial fibrillation (af group) clinically indicated for MSCT angiography for evaluation of coronary arteries. Maximum LA volume, obtained at end-systole from the phase immediately preceding mitral valve opening, was measured using the area-length and Simpson's methods. In the sinus group, the mean LA volumes, indexed to body surface area, were 48.4±17.9ml/m2 with the area-length method and 48.3±17.0ml/m2 with the Simpson's method. In the af group, the mean indexed LA volumes with the area-length method and the Simposon's method were 91.5±47.5ml/m2 and 90.3±45.9ml/m2, respectively. LA volumes calculated by the area-length method exhibited a strong linear relationship and agreement with those calculated using Simpson's method in both the groups (sinus group: r=0.99, P

Background— Although left ventricular diastolic function has been shown to deteriorate with advancing age, its gender-specific change is unknown. The aim of this study was to investigate age- and gender-specific changes in tissue Doppler–derived left ventricular diastolic index, E′. Methods and Results— A total of 1333 healthy individual without known heart disease or hypertension (mean age, 55 years; range, 10 to 89) were enrolled and studied. Peak early mitral annular velocity (E′) and peak late mitral annular velocity (A′) were recorded and measured. As an index of the left ventricular relaxation, E′ was used. As an index of the left ventricular filling pressure, E/E′ was calculated. Although systolic indices poorly correlated with age, diastolic indices correlated well with age. Among those aged 30 to 39 and 40 to 49 years, E′ was significantly lower in males than in females. In subjects aged 50 to 59 and 60 to 69 years, E′ was similar in both genders. Among those aged 70 to 79 and 80 to 89 years, E′ was significantly lower in females than in males. Predictors of the lowest quartile of E′ among subjects aged >50 years were age ( P 2 =66.11; odds ratio, 1.08; 95% CI, 1.058 to 1.097) and female gender ( P =0.002; χ 2 =9.23; odds ratio, 1.68; 95% CI, 1.202 to 2.343). Conclusion— Age-related changes in diastolic indices were gender specific. In the elderly population, diastolic function deteriorated more significantly in the female gender than in the male gender. These results may explain the relatively higher incidence in elderly females among patients with diastolic heart failure and higher cardiovascular mortality in the female gender.

Using a novel speckle-tracking imaging method, time-left atrial (LA) volume curves (TLAVCs) can be automatically obtained. The aim of this study was to evaluate whether this method can be used for the measurement of LA function with TLAVCs.In 10 normal subjects and 20 patients, apical 4-chamber images were obtained. Maximum volume, reservoir volume, conduit volume, booster pump volume, and minimum volume were measured from TLAVCs. The results were compared with those obtained by the manual tracing method on every frame during 1 cardiac cycle.There was good agreement between the speckle-tracking imaging and manual methods for maximum LA volume (r = 0.98, P.001), reservoir volume (r = 0.82, P.001), conduit volume (r = 0.87, P.001), booster pump volume (r = 0.80, P.001), and minimum volume (r = 0.98, P.001). The time to obtain TLAVCs was significantly shorter with the speckle-tracking imaging method (64 +/- 22 seconds) than with the manual method (22 +/- 4 minutes).TLAVCs obtained using the speckle-tracking imaging method can be used for the rapid and noninvasive automated quantitation of LA function.

Background: Previous studies have shown a correlation between coronary artery cross-sectional diameter and left ventricular (LV) mass. However, no studies have examined the correlation between actual coronary artery volume (CAV) and LV mass. In the present study, measurements of CAV by 64-multislice computed tomography (MSCT) were validated and the relationship between CAV and LV mass was investigated. Methods and Results: First, coronary artery phantoms consisting of syringes filled with solutions of contrast medium moving at simulated heart rates were scanned by 64-MSCT. Display window settings permitting accurate calculation of small volumes were optimized by evaluating volume-rendered images of the segmented contrast medium at different window settings. Next, 61 patients without significant coronary artery stenosis were scanned by 64-MSCT with the same protocol as for the phantoms. Coronary arteries were segmented on a workstation and the same window settings were applied to the volume-rendered images to calculate total CAV. Significant correlations between total CAV and LV mass (r=0.660, P

Background Although multidetector computed tomography (MDCT) allows non-invasive assessment of coronary artery stenosis, the presence of calcified lesions often lead to an overestimation of the stenosis. The present study was an evaluation of whether enhancement of first-pass myocardial data can improve the diagnostic accuracy of 64-MDCT. Methods and Results Data from 70 patients with single-vessel disease who underwent 64-MDCT followed by catheter-based coronary angiography (CAG) were analyzed. Myocardial enhancement was quantified by exaimining the signal densities at diastole. Among a total of 83 plaque segments, 35 calcified plaque segments were detected and 46 segments were found to have more than 50% coronary stenosis on catheter-based CAG. The average diameter stenosis was 75.2±12.8%. Diagnosis by 64-MDCT of significant stenosis (segment-based analysis) had a sensitivity, specificity and accuracy for segments without calcified lesions of 92%, 100% and 99.7%, respectively, and 95.2%, 50%, and 77.1%, respectively, for calcified lesions. Taking into account the myocardial enhancement by calculating the decrease of the standardized signal densities in percent, these parameters could be improved to 95.2%, 85.7% and 91.4%, respectively, for segments with calcified lesions. Conclusions The diagnostic accuracy of 64-MDCT for stenosis with calcified lesions in particular can be improved by taking into account the myocardial enhancement data. (Circ J 2009; 73: 116 - 124)