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Background Long-axis images of the inferior vena cava (IVC) have limitations as surrogates for IVC morphology in grading central venous pressure (CVP) by two-dimensional echocardiography (2DE), because of the various cross-sectional morphologies and the translational motion of the IVC induced by sniffing. On the basis of the relationship between venous pressure and compliance, it was hypothesized that the cross-sectional morphology of the IVC, which was obtained using three-dimensional echocardiography, might estimate CVP more accurately compared with standard grading by 2DE. Methods Sixty consecutive patients who underwent right-heart catheterization studies were prospectively enrolled. Echocardiography was performed

Background Experimental studies have suggested that dipeptidyl peptidase-4 (DPP-4) inhibitors provide cardiovascular protective effects. We performed a randomized study to evaluate the effects of sitagliptin added on to the conventional therapy compared with conventional therapy alone (diet, exercise, and/or drugs, except for incretin-related agents) on the intima-media thickness (IMT) of the carotid artery, a surrogate marker for the evaluation of atherosclerotic cardiovascular disease, in people with type 2 diabetes mellitus (T2DM). Methods and Findings We used a multicenter PROBE (prospective, randomized, open label, blinded endpoint) design. Individuals aged ≥30 y with T2DM (6.2% ≤ HbA1c < 9.4%) were randomly allocated to receive either sitagliptin (25 to 100 mg/d) or conventional therapy. Carotid ultrasound was performed at participating medical centers, and all parameters were measured in a core laboratory. Of the 463 enrolled participants with T2DM, 442 were included in the primary analysis (sitagliptin group, 222; conventional therapy group, 220). Estimated mean (± standard error) common carotid artery IMT at 24 mo of follow-up in the sitagliptin and conventional therapy groups was 0.827 ± 0.007 mm and 0.837 ± 0.007 mm, respectively, with a mean difference of −0.009 mm (97.2% CI −0.028 to 0.011, p = 0.309). HbA1c level at 24 mo was significantly lower with sitagliptin than with conventional therapy (6.56% ± 0.05% versus 6.72% ± 0.05%, p = 0.008; group mean difference −0.159, 95% CI −0.278 to −0.041). Episodes of serious hypoglycemia were recorded only in the conventional therapy group, and the rate of other adverse events was not different between the two groups. As it was not a placebo-controlled trial and carotid IMT was measured as a surrogate marker of atherosclerosis, there were some limitations of interpretation. Conclusions In the PROLOGUE study, there was no evidence that treatment with sitagliptin had an additional effect on the progression of carotid IMT in participants with T2DM beyond that achieved with conventional treatment. Trial Registration University Hospital Medical Information Network Clinical Trials Registry UMIN000004490, In a randomized controlled trial, Koichi Node and colleagues assess the efficacy of sitagliptin in limiting atherosclerosis among patients over 29 years of age living in Japan., Author Summary Why Was This Study Done? Translational research suggests that dipeptidyl peptidase-4 (DPP-4) inhibitors, which are drugs for type 2 diabetes mellitus (T2DM), may prevent cardiovascular disease to a greater extent than other T2DM drugs. However, recently published large clinical trials showed no additional efficacy for DPP-4 inhibitors beyond that expected for the drugs’ glycemic control. Possibly these studies showed no benefit to cardiovascular health because they assessed cardiovascular mortality and other relatively rare outcomes. Change in carotid intima-media thickness (IMT) is a simple, noninvasive method to assess atherosclerosis, an intermediate and more common condition that can precede cardiovascular disease. What Did the Researchers Do and Find? We conducted a trial to evaluate whether DPP-4 inhibitors affect atherosclerosis in people with T2DM. In all, 463 participants recruited at 48 medical centers were randomly divided into two groups and treated with sitagliptin, a DPP-4 inhibitor, or other conventional drugs for two years. Carotid IMT was evaluated with ultrasonography in a blinded manner. We found that annual changes in carotid IMT were not significantly different between the two groups. On the other hand, the decrease in HbA1c and in the incidence of hypoglycemia with sitagliptin were superior to conventional therapy. The rate of other adverse events was not different between the two groups. What Do These Findings Mean? These findings provide no evidence that sitagliptin slows the progression of carotid intima-media thickening in participants with T2DM to a greater extent than conventional drugs. As some of the conventional anti-T2DM drugs have shown anti-atherosclerotic effects in clinical trials, the present findings do not mean that sitagliptin does not possess anti-atherosclerotic properties in participants with T2DM. Importantly, however, sitagliptin is useful for controlling hyperglycemia for clinical setting.

BACKGROUND Speckle-tracking echocardiography (STE)-derived parameters may have better correlation with left ventricular (LV) relaxation and filling pressure than tissue Doppler-derived parameters. However, it has not been elucidated which parameter - strain or strain rate - and which direction of myocardial deformation - longitudinal or circumferential - is the most useful marker of LV relaxation and filling pressure. METHODS AND RESULTS We conducted a prospective multicenter study and compared the correlation of tissue Doppler- and STE-derived parameters with the time constant of LV pressure decay (τ) and LV mean diastolic pressure (MDP) in 77 patients. The correlation of early-diastolic mitral annular velocity (e´) with τ was weak (r=-0.32, P

A fragmented QRS (fQRS) is reported to be associated with a poor prognosis or sudden cardiac death (SCD) in patients with Brugada syndrome or ischemic heart disease. However, no studies have clarified the impact of the presence of an fQRS on SCD or ventricular arrhythmic events in patients receiving cardiac resynchronization therapy (CRT). This study aimed to clarify this point in patients with nonischemic cardiomyopathy.This study included 137 heart failure patients with nonischemic cardiomyopathy who received CRT (NYHA functional class: II/III/IV = 25/84/28). The 12-lead ECGs before and after CRT were analyzed. The presence of an fQRS was decided in accordance with the definition in previous papers. Before the CRT, an fQRS was observed in 67 patients (fQRS-pre; 49%). However, it was masked in 35 (52% of fQRS-pre) patients after the CRT. Inversely, in 70 patients in whom an fQRS was absent before the CRT, it appeared after the CRT in 15 (21%) patients. As a result, 47 patients (34%) had an fQRS after the CRT (fQRS-post), and it was less than that before the CRT (P = 0.014). During 18 months of follow-up, SCD or ventricular arrhythmic events were observed more frequently in patients with an fQRS-post than in those without (36.2% vs. 3.3%, P0.001). A Cox regression analysis revealed that an fQRS-post was significantly associated with those events (hazard ratio = 9.18; 95% confidence interval = 2.45-34.48, P = 0.001).In patients with nonischemic cardiomyopathy who received CRT, an fQRS-post was independently associated with SCD or ventricular arrhythmic events.

The estimation of aortic valve area (AVA) by Doppler echocardiography-derived left ventricular stroke volume (LVSV) remains controversial. We hypothesized that AVA estimated from directly measured LVSV by 3-dimensional echocardiography (3DE) on the continuity equation might be more accurate in classifying aortic stenosis (AS) severity. We retrospectively enrolled 265 patients with moderate-to-severe AS with preserved ejection fraction. Indexed AVA (iAVA) was calculated using LVSV derived by 2D Doppler (iAVADop), Simpson's method (iAVASimp), and 3DE (iAVA3D). During a median follow-up period of 397 days (interquartile range 197 to 706 days), 135 patients experienced the composite end point (cardiac death 9%, aortic valve replacement 24%, and cardiovascular event 27%). Estimated iAVA3D and iAVASimp were significantly smaller than iAVADop and moderately correlated with peak aortic jet velocity. Upper septal hypertrophy was a major cause of discrepancy between iAVADop and iAVA3D methods. Based on the optimal cut-off point of iAVA for predicting peak aortic jet velocity >4.0 m/s, 141 patients (53%) were classified as severe AS and 124 patients (47%) as moderate AS by iAVADop. Indexed AVA3D classified 118 patients (45%) as severe and 147 patients (55%) as moderate AS. Of the 124 patients with moderate AS by iAVADop, 22 patients (18%) were reclassified as severe AS by iAVA3D and showed poor prognosis (hazard ratio 2.7, 95% CI 1.4 to 5.0; p = 0.001). In conclusion, 3DE might be superior in classifying patients with AS compared with Doppler method, particularly in patients with upper septal hypertrophy.

Background— We have developed a noninvasive isochrone activation imaging (AI) system with 3-dimensional (3D) speckle tracking echocardiography (STE), which allows visualization of the wavefront image of mechanical propagation of the accessory pathway (ACP) in Wolff–Parkinson–White syndrome. Methods and Results— Patients with manifest Wolff–Parkinson–White syndrome were imaged in 3D-STE AI mode, which quantified the time from QRS onset to regional endocardial deformation. In 2 patients with left- and right-side ACP, we confirmed that intraoperative contact endocardial electric mapping and the 3D-STE AI system showed comparable images pre- and postablation. In normal heart assessment by 3D-echo AI, the earliest activation sites were found at the attachment of the papillary muscles in the left ventricle and midseptum in the right ventricle, and none showed earliest activation at the peri-atrioventricular valve annuli. An analyzer who was unaware of the clinical information assessed 39 ACP locations in 38 Wolff–Parkinson–White syndrome patients using 3D-STE. All showed abnormal perimitral or tricuspid annular activations, and the location of 34 ACP (87%) showed agreement with the successful ablation sites within a 2-o’clock range. Especially for left free wall ACP, 17/18 (94%) showed consistency with the ablation site within a 2 o’clock range. Among 15 ACP at the ventricular septum, 9 (60%) showed early local activation in both right and left sides of the septum. Conclusions— Isochrone AI with 3D-STE may be a promising noninvasive imaging tool to assess cardiac synchronized activation in normal hearts and detect abnormal breakthrough of mechanical activation from both atrioventricular annuli in Wolff–Parkinson–White syndrome.

Aims Recently developed vector flow mapping (VFM) enables evaluation of local flow dynamics without angle dependency. This study used VFM to evaluate quantitatively the index of intraventricular haemodynamic kinetic energy in patients with left ventricular (LV) diastolic dysfunction and to compare those with normal subjects. Methods and results We studied 25 patients with estimated high left atrial (LA) pressure (pseudonormal: PN group) and 36 normal subjects (control group). Left ventricle was divided into basal, mid, and apical segments. Intraventricular haemodynamic energy was evaluated in the dimension of speed, and it was defined as the kinetic energy index. We calculated this index and created time-energy index curves. The time interval from electrocardiogram (ECG) R wave to peak index was measured, and time differences of the peak index between basal and other segments were defined as ΔT-mid and ΔT-apex. In both groups, early diastolic peak kinetic energy index in mid and apical segments was significantly lower than that in the basal segment. Time to peak index did not differ in apex, mid, and basal segments in the control group but was significantly longer in the apex than that in the basal segment in the PN group. ΔT-mid and ΔT-apex were significantly larger in the PN group than the control group. Multiple regression analysis showed sphericity index, E/E′ to be significant independent variables determining ΔT apex. Conclusion Retarded apical kinetic energy fluid dynamics were detected using VFM and were closely associated with LV spherical remodelling in patients with high LA pressure.

Fabry disease is a genetic disorder caused by deficient activity of lysosomal enzyme α-galactosidase A (GLA) and end-stage renal disease (ESRD) will be present after accumulation of glycosphingolipids within the kidney. Undiagnosed atypical variants of Fabry disease, which are limited to renal involvement, were found in several ESRD patient populations. On the other hand, unexpectedly high frequencies of male subjects having the c.196G>C nucleotide change (p.E66Q) showing low α-GLA activity have been reported on Japanese and Korean screening for Fabry disease. However, several evidences indicate the c.196G>C is not a pathogenic mutation but is a functional polymorphism. In the present study, high-throughput screening of serum GLA could successfully indentify two Fabry disease patients in a cohort consisted of 1080 male hemodialysis patients. Moreover, our serum assay was able to distinguish two patients with disease-causing genetic mutations (p.G195V and p.M296I) from eight functional variants that showed relatively decreased enzyme activity (p.E66Q). In conclusion, high-throughput serum enzyme assay distinctly identified disease-causing mutants and functional variants of GLA gene in Japanese male hemodialysis patients. In addition, our results underscore the high prevalence of not only undiagnosed Fabry patients but functional variants of p.E66Q among the ESRD population.

In patients with chronic aortic regurgitation (AR), systolic wall stress and volume overload affects left ventricular (LV) systolic function and remodeling. The aim of this study was to assess transmural rearrangements of myocardial deformation to preserve LV ejection performances using speckle-tracking echocardiography in patients with chronic AR.Ninety patients with AR were enrolled. On LV short-axis images, total, inner, and outer radial strain and circumferential strain at the inner, mid, and outer layers were calculated. On apical four-chamber images, endocardial longitudinal strain was calculated. End-systolic wall stresses were calculated using previous methods.AR severities were classified as moderate in 31 patients, severe and preserved LV ejection fraction (LVEF) (≥50%) in 42 patients, and severe and reduced LVEF (50%) in 17 patients. Longitudinal strain was decreased even in the moderate AR group, despite normal end-systolic wall stress. Inner radial strain progressively decreased with increasing end-systolic wall stress, whereas outer radial strain in the moderate and severe AR and preserved LVEF groups was higher than in the control group. Consequently, total radial strain was preserved even in the severe AR and preserved LVEF groups with increased end-systolic wall stress. Similarly, despite reduced inner circumferential strain, outer circumferential strain was higher in the severe AR and preserved LVEF group than in the control group. All strain parameters were lower in the severe AR and reduced LVEF group with dramatically increased end-systolic wall stress than in other groups.Transmural strain analysis revealed that subendocardial dysfunction accompanied by increased wall thickening at the subepicardium may be a compensatory mechanism of wall thickening to preserve LVEF in patients with chronic AR.

Objectives The authors used multidetector computed tomography (MDCT) to study the relation between culprit plaque characteristics and cardiac troponin T (cTnT) elevation after percutaneous coronary intervention (PCI). Background Percutaneous coronary intervention is often complicated by post-procedural myocardial necrosis manifested by elevated cardiac biomarkers. Methods Stable angina patients (n = 107) with normal pre-PCI cTnT levels underwent 64-slice MDCT before PCI to evaluate plaque characteristics of culprit lesions. Patients were divided into 2 groups according to presence (group I, n = 36) or absence (group II, n = 71) of post-PCI cTnT elevation ≥3 times the upper limit of normal (0.010 ng/ml) at 24 h after PCI. Results Computed tomography attenuation values were significantly lower in group I than in group II (43.0 [26.5 to 75.7] HU vs. 94.0 [65.0 to 109.0] HU, p 1.05; odds ratio: 4.54; 95% confidence interval: 1.36 to 15.9; p = 0.014) and spotty calcification (odds ratio: 4.27; 95% confidence interval: 1.30 to 14.8; p = 0.016) were statistically significant independent predictors for cTnT elevation. For prediction of cTnT elevation, the presence of all 3 variables (CT attenuation value 1.05, and spotty calcification) showed a high positive predictive value of 94%, and their absence showed a high negative predictive value of 90%. Conclusions MDCT may be useful in detecting which lesions are at high risk for myocardial necrosis after PCI.

FEMAXI-FBR has been developed as the one module of the core disruptive accident analysis code ‘ASTERIA-FBR’ in order to evaluate the mixed oxide (MOX) fuel performance under steady, transient and accident conditions of fast reactors consistently. On the basis of light water reactor (LWR) fuel performance evaluation code ‘FEMAXI-6’, FEMAXI-FBR develops specific models for the fast reactor fuel performance, such as restructuring, material migration during steady state and transient, melting cavity formation and pressure during accident, so that it can evaluate the fuel failure during accident. The analysis of test pin with slow transient over power test of CABRI-2 program was conducted from steady to transient. The test pin was pre-irradiated and tested under transient overpower with several % P 0/s (P 0: steady state power) of the power rate. Analysis results of the gas release ratio, pin failure time, and fuel melt radius were compared to measured values. The analysis results of the steady and transient p...

Flow-mediated vasodilatation of the brachial artery (FMD) is a marker which is related to endothelial nitric oxide bioavailability. Commercially available ultrasound machines equipped with online computer-assisted semi-automatic analysis software to measure FMD have recently become available in Japan. These devices enable more convenient examination, enhanced reproducibility of FMD measurement, and a shortened examination time. Using such devices, in the present multicenter prospective study we propose to: 1) establish standardized FMD values and determine the annual rates of FMD change in healthy subjects; 2) confirm the predictive value of FMD for future cardiovascular events in Japanese subjects; 3) evaluate the potential usefulness of a multimarker strategy, including measurements of FMD, pulse-wave velocity (PWV), ankle-brachial pressure index, biochemical markers, and proteomic biomarkers obtained by mass spectroscopic analysis to assess the prognosis of subjects with coronary artery disease; and 4) clarify the usefulness of FMD measurement to predict the rate of progression of carotid atherosclerosis, arterial stiffness and microalbuminuria in subjects with hypertension or diabetes mellitus. In total, we estimate that approximately 4000 Japanese subjects in 3 different study groups will eventually be enrolled in this prospective observational investigation. We anticipate that the present study will provide important evidence for the usefulness of FMD measurement in the risk stratification for cardiovascular disease.

Background: The aim of this study was to propose modified tissue Doppler imaging (TDI) parameters derived from the first active wall motion and to assess them for the better prediction of cardiac resynchronization therapy (CRT) responders in comparison with to original TDI parameters. Methods and Results: In 61 patients with CRT, time from QRS onset to peak velocities by TDI (Ts), which were derived from active wall motion identified by longitudinal strain rate (LSR) value, were assessed. Time from QRS onset to the negative peak of LSR (TLSR) was also assessed. Modified standard deviation of Ts in 12 left ventricular (LV) segments (Ts-SD), that of TLSR (TLSR-SD), differences of Ts between septum and lateral wall (Ts-SL), and that of TLSR (TLSR-SL) were calculated. Original Ts-SD and Ts-SL were calculated by previously described methods. Responders were defined as patients with LV end-systolic volume reduction (>15%) at 6 months after CRT: 35 patients (57%) were identified as CRT responders. Area under the receiver-operating characteristics curve (AUC) of modified Ts-SD (0.87) was significantly higher than that of Ts-SD (0.65), Ts-SL (0.62), and TLSR-SL (0.69). AUC of modified Ts-SL was significantly higher than those of Ts-SD, and Ts-SL. AUC of TLSR-SD (0.82) also was significantly higher than that of Ts-SD. Conclusions: Modified TDI dyssynchrony parameters derived from the first active wall motion improve the ability to predict responders to CRT. (Circ J 2012; 76: 689-697)

Echocardiography is a powerful noninvasive cardiovascular diagnostic tool. In the emergency room, an outpatient setting, and the intensive care unit, physician-performed point-of-care (POC) echocardiography is particularly important to understand the concurrent pathophysiology of unstable patients. In POC echocardiography, the purpose of examination should be clearly decided in advance by performing careful symptom assessment and physical examination, including heart and lung auscultation. In this article, heart failure, cardiac murmur-, ischemic heart disease, and acute pulmonary artery thromboembolism are selected and overviewed to assess the utility of POC cardiovascular ultrasound. In heart failure, visual assessments of the left ventricular ejection fraction, chamber size ratio, and inferior vena cava diameter are important. An ultrasound lung comet is a very useful finding, suggesting the presence of lung congestion. In patients with a cardiac murmur, the source of the abnormal sound can easily be confirmed by the color Doppler signal in conjunction with chamber size assessment. On the other hand, judgment of the severity of valvular heart disease should be reserved for detailed echocardiography. In acute coronary syndrome, POC echo is extremely important for prompt diagnosis and complication assessment. An understanding of the coronary artery territory and method to detect regional wall motion abnormality in ischemic heart disease is necessary. Papillary muscle rupture and ventricular septal perforation are both fatal complications of myocardial infarction, and they should be kept in mind and pan-systolic murmur should be detected before echocardiography. In acute pulmonary thromboembolism, the right heart size and characteristic wall motion abnormality should be focused on using echocardiography in addition to tricuspid regurgitant flow velocity measurement. Femoral vein ultrasonography with a compression test should be performed for all patients with acute pulmonary thromboembolism to search for potential embolic sources.

The clinical effect of diabetic microangiopathy on left ventricular (LV) function is still uncertain. The purpose of this study was to assess the relation between diabetic microvascular complications and comprehensive myocardial deformation measurements using three-dimensional (3D) speckle tracking echocardiography.Seventy-seven asymptomatic patients with type 2 diabetes mellitus (DM) and 35 age-matched healthy control subjects underwent 3D echocardiography. Patients with coronary artery disease or LV ejection fraction50% were excluded. Presence of proliferative retinopathy, microalbuminuria as nephropathy, and decreased coefficient of variation of R-R intervals (CVRR)3% as cardiac autonomic neuropathy were defined as diabetic microvascular complications.LV ejection fraction, LV mass index, and global radial strain did not differ between control and DM patients. However, global longitudinal and circumferential strain and endocardial area change ratio were lower in patients with DM than in the controls (-12.0±3.0% vs. -16.2±1.9%, -27.7±7.1% vs. 32.2±5.7%, -37.6±7.6% vs. 44.0±6.2%, respectively, p0.001). In DM patients, longitudinal strain is related to CVRR (R=0.58, p0.001), retinopathy stage, and nephropathy stage.Diabetic microangiopathy and its accumulated effects significantly related to subclinical LV dysfunction are characterized by impaired longitudinal shortening.

The advantages of triple-site ventricular pacing (Tri-V) compared to conventional biventricular site pacing (Bi-V) have been reported. We sought to identify the predictors of acute hemodynamic Tri-V responders. Acute hemodynamic studies were performed in 32 patients with advanced heart failure during Tri-V implantation. After the right ventricular (RV) and left ventricular (LV) leads were implanted for a conventional Bi-V system, an additional pacing lead was implanted in the RV outflow tract for Tri-V. The LV peak +dP/dt and tau were measured during AAI, Bi-V, and Tri-V pacing. A Tri-V responder was defined as a patient whose percentage of increase in the peak +dP/dt during Tri-V was >10% compared to of that during Bi-V. The baseline clinical variables and RV outflow tract lead location were analyzed to identify the characteristics of the Tri-V responders. Of the 32 patients, 10 (31%) were classified as Tri-V responders. The LV end-diastolic volume was greater (246 ± 48 vs 173 ± 53 ml, p 212 ml had a sensitivity of 80% and specificity of 77% to distinguish Tri-V responders. In conclusion, Tri-V provides greater hemodynamic effect for patients with a larger LV end-diastolic volume owing to its resynchronization effects on the LV anterior wall.

Biomarkers for detection of acute kidney injury and prediction of mortality will be useful to improve the outcomes of critically ill patients. Although several promising acute kidney injury biomarkers have been reported, evaluation in heterogeneous disease-oriented populations is necessary to confirm their reliability before their translation to clinical use. This study was undertaken to evaluate the reliability of new acute kidney injury biomarkers including urinary L-type fatty acid-binding protein with heterogeneous intensive care unit populations.Prospective observational cohort study.Single-center study, 15-bed medical-surgical mixed intensive care unit at a university hospital.Three hundred thirty-nine adult critically ill patients who had been admitted to the intensive care unit were studied prospectively.None.Five urinary biomarkers (L-type fatty acid-binding protein, neutrophil gelatinase-associated lipocalin, interleukin-18, N-acetyl-β-D-glucosaminidase, and albumin) were measured at intensive care unit admission. By the RIFLE (Risk, Injury, Failure, Loss, End-stage kidney disease) criteria, 131 patients (39%) were diagnosed as acute kidney injury. Urinary L-type fatty acid-binding protein detected acute kidney injury better than the other biomarkers did (the area under the receiver operating characteristic curves for L-type fatty acid-binding protein 0.75, neutrophil gelatinase-associated lipocalin 0.70, interleukin-18 0.69, N-acetyl-β-D-glucosaminidase 0.62, albumin 0.69). Urinary L-type fatty acid-binding protein predicted later-onset acute kidney injury after intensive care unit admission with the highest area under the receiver operating characteristic curve value of 0.70. Furthermore, L-type fatty acid-binding protein, neutrophil gelatinase-associated lipocalin, and interleukin-18 were able to predict 14-day mortality with higher area under the receiver operating characteristic curves than acute kidney injury detection (area under the receiver operating characteristic curve for L-type fatty acid-binding protein 0.90, neutrophil gelatinase-associated lipocalin 0.83, interleukin-18 0.83). The combination of L-type fatty acid-binding protein and neutrophil gelatinase-associated lipocalin improved mortality prediction (area under the receiver operating characteristic curve 0.93).This prospective observational study with a cohort of heterogeneous patients treated in a mixed intensive care unit revealed that new acute kidney injury biomarkers have a significantly and moderately predictive use for acute kidney injury diagnosis and that urinary L-type fatty acid-binding protein and neutrophil gelatinase-associated lipocalin can serve as new biomarkers of mortality prediction in critical care.

Left Atrial Stiffness and Atrial Fibrillation. Introduction: An increased left atrial (LA) stiffness reflects the structural remodeling and deterioration of the LA function. This study was designed to estimate LA stiffness by measuring a combination of the strain and LA pressure in patients undergoing pulmonary vein isolation (PVI) of atrial fibrillation (AF) and to evaluate the influence of the LA stiffness on the cardiac function, serum markers, and recurrence of AF after PVI. Methods: In 155 consecutive patients with AF, the brain natriuretic peptide (BNP) and aminoterminal procollagen type III propeptide (PIIIP) plasma levels were measured before the PVI. The difference between the minimum and maximum LA systolic pressures was directly measured by a transseptal puncture. The ratio of the difference in the LA pressures to the peak systolic LA strain evaluated by speckle-tracking echocardiography was used as an index of the LA stiffness. Results: The calculated LA stiffness index was related to the BNP level (rs= 0.444, P < 0.001), E/E′ ratio (rs= 0.444, P < 0.001), LA volume index (rs= 0.370, P < 0.001), and PIIIP level (rs= 0.305, P = 0.002). During a mean follow-up period of 33.8 ± 12.2 months, 45 patients (29%) presented with AF recurrences. A Cox proportional hazard regression analysis showed the LA stiffness index was an independent predictor of recurrence of AF (HR 2.88; 95% CI 1.75 to 4.73, P < 0.001). Conclusions: In patients with AF, the LA stiffness index is related to left ventricular diastolic dysfunction, LA dilatation, and collagen synthesis and may predict AF recurrences after PVI. (J Cardiovasc Electrophysiol, Vol. 22, pp. 999-1006, September 2011)

Background: The early diagnosis of myocardial ischemia is still challenging. The aim of the present study was to determine whether subendocardial hypokinesis and post-systolic contraction could be early markers of myocardial ischemia. Methods and Results: Thirty-one consecutive patients with flow-limiting severe coronary stenosis but without visually abnormal left ventricular wall motion underwent quantitative echocardiography. Myocardial strain was measured using layer-by-layer analysis in severely hypoperfused segments. Radial strain (RS) was measured in the subendocardial, subepicardial, and total wall (innerRS, outerRS, and totalRS, respectively). Circumferential strain (CS) was also measured as 3 separate layers: subendocardial, mid-layer, and subepicardial layers (innerCS, midCS, and outerCS, respectively). Post-systolic shortening (PSS) was defined as the peak strain after end systole, and post-systolic strain index (PSI) was calculated as PSS divided by end-systolic strain. TotalRS was similar between ischemic and normally perfused segments, but innerRS and inner/outer RS ratio were significantly smaller in the ischemic segments than in corresponding segments in healthy subjects. Receiver operating characteristic analysis identified an optimum cut-off for PSI of 0.6. The combined criteria of inner/outer RS ratio 0.6 achieved 95% specificity for the presence of flow-limiting stenosis. Conclusions: Combined assessment of both subendocardial contractile impairment and PSS is very useful in identifying a severely hypoperfused left ventricular wall even without visual wall motion abnormality. (Circ J 2011; 75: 1934-1941)

This study was designed to determine the ability and reliability of 3-dimensional (3D) transesophageal echocardiography (TEE) to assess the geometry and size of the left atrial appendage (LAA). Three-dimensional TEE may allow more accurate assessment of, and provide additional information on, LAA morphology compared to 2-dimensional TEE. Validation studies for LAA morphology data derived from 3D TEE were performed using 10 isolated porcine LAA specimens. Of 107 enrolled patients, 55 patients were in sinus rhythm (normal sinus rhythm), in whom 3D transesophageal echocardiographic images were obtained from full-volume mode imaging, and in 52 patients with atrial fibrillation, zoom-mode imaging was used. LAA orifice area, depth, and volume and the number of LAA lobes were assessed on reconstructed 3D imaging. Left atrial volume was calculated using 2-dimensional echocardiographic imaging. In experimental studies, excellent correlations (r >0.90, p

The tolerance capability against ATWS for the FBR core with metallic fuel can be improved by employing a fuel with high thermal conductivity (HTC fuel) instead of the conventional metallic fuel, UPu-Zr. To investigate the self-controllability for the HTC-fueled core with U-Pu-Al alloy fuel, having one order of magnitude higher thermal conductivity than that of the U-Pu-Zr, the core employing the U-Pu-Al fuel was evaluated against ULOF and UTOP. Based on the systematic calculation, it was found that the larger temperature margin between the steady state and ULOF/UTOP conditions caused the excellent tolerance capability against ULOF and UTOP for the HTC-fueled core compared with that for the Zralloy-fueled core. Also, the conditions of the core reactivity coefficients required for neither fuel melting nor coolant boiling were investigated by using a “self-controllability map” consisting of effective fuel and coolant reactivities. As a result, the self-controllable region was found to be expanded especially ...

Aims To validate intramural strain measured by a speckle tracking imaging (STI) system against that measured by sonomicrometry crystals. Methods and results In 11 anaesthetized sheep, six sets of three sonomicrometry crystals were implanted in endo-, mid-wall, and epimyocardium on the anterior and lateral walls. Circumferential strain (CS) was calculated at three layers from endo-, mid-wall, and epicardial speckle. Radial strain (RS) was assessed for inner and outer halves of the myocardium. We compared ultrasound-derived strain measurements against those by sonomicrometry at baseline and during pharmacological stress and coronary occlusion. Intraclass correlation coefficients at baseline and during coronary occlusion were as follows: endocardial CS 0.80, 0.97; mid-wall CS 0.58, 0.89; epicardial CS 0.71, 0.81; endocardial RS 0.50, 0.78; epicardial RS 0.35, 0.83; and total RS 0.33, 0.71; respectively. At baseline, endocardial strains were higher than mid-wall and epicardial strains, resulting in an inner/outer wall RS gradient and inner/mid/outer wall CS gradients. Ischaemia caused significant reduction in all strains and disappearance of the strain gradient. Conclusion A newly developed STI system can accurately assess the intramural heterogeneity of CS distribution in normal and ischaemic myocardial segments and has the potential to become a non-invasive bedside tool for characterizing myocardial strain gradient.

Background: Cholesterol crystal embolism (CCE) is a serious complication of vascular procedures and based on the clinical features of patients with CCE, the aim of the present study was to establish screening criteria for aortic complex plaques (ACP) at high-risk of CCE. Methods and Results: For the first study, 10 patients diagnosed as having CCE were recruited. They had prior multiple atherosclerotic disease and a high proportion of complex plaques of the carotid artery and aorta. Elevated levels of high-sensitivity C-reactive protein (hs-CRP), eosinophilia, and renal insufficiency were already recognized before CCE diagnosis. The second study prospectively enrolled 102 patients. ACP is related to CCE and predictive criteria of ACP were established. Among 19 patients with ACP, 2 presented with CCE. Multivariate analysis revealed carotid complex plaque, eosinophilia and multiple atherosclerotic risk factors as independent predictors of ACP. The criteria including these factors (multiple atherosclerotic risk factors, carotid complex plaque, hs-CRP ≥0.2 mg/dl, eGFR ≤60 ml · min-1 · 1.73 m-2, eosinophil count ≥400 /μl) could detect patients with ACP with 95% sensitivity, 94% specificity, and 79% positive predictive value. Conclusions: Multiple atherosclerotic risk factors, elevated hs-CRP, renal insufficiency, eosinophilia before CCE diagnosis and carotid complex plaques were features of patients with CCE. Diagnostic criteria including these characteristics effectively predict ACP patients at high-risk of CCE. (Circ J 2010; 74: 51 - 58)

Background— Three-dimensional speckle tracking imaging (3D-STI) has been introduced to assess regional left ventricular (LV) myocardial function. This study was designed to validate LV strain measurements by 3D-STI against data obtained by sonomicrometry. Methods and Results— In each of 10 anesthetized sheep, sonomicrometry crystals were implanted on the endocardium and epicardium at the LV basal, mid, and apical anterior and lateral walls. LV 3D-STI data sets were obtained from the apical approach at a frame rate of approximately 30 frames/s. Segmental longitudinal (LS), radial (RS), and circumferential strain (CS) measurements by 3D-STI were compared with those by sonomicrometry at baseline and during pharmacological stress tests (dobutamine and propranolol infusion) and acute myocardial ischemia induced by coronary artery occlusion. Data were available from 136 LS, 108 CS, and 175 RS measurements. Good correlations were observed between strain measurements by 3D-STI and those by sonomicrometry (LS: r =0.89, P r =0.84, P r =0.90, P r =0.65 to 0.68, P r =0.59 to 0.70, P r =0.71 to 0.78, P Conclusions— The newly developed 3D-STI technique can estimate LV regional circumferential, longitudinal, and radial strain components with reasonable correlation to sonomicrometry data. This methodology could be applied clinically to assess alteration of myocardial function by accurately measuring strain in basal, mid, and apical LV segments, even during pharmacological and ischemic interventions. Therefore, 3D-STI appears to be a reliable tool to assess LV regional wall function.

A 64-channel Nb-based DC-SQUID magnetocardiography (MCG) system was installed at the University of Tsukuba Hospital (UTH) in March 2007 after obtaining Japanese pharmaceutical approval and insurance reimbursement approval. In the period between 2008 and 2016, the total number of patients was 10 085. The heart diseases diagnosed in fetuses as well as adults are mainly atrial arrhythmia, abnormal repolarization, ventricular arrhythmia, and fetal arrhythmia. In most cases of insufficient diagnostic accuracy with electrocardiography, SQUID MCG precisely revealed these heart diseases as an abnormal electrical current distribution. Based on success in routine examinations, SQUID MCG is now an indispensable clinical instrument with diagnostic software tuned up during routine use at UTH.

Self-controllability and self-terminability are strongly required as passive safety features in future liquid-metal FBR (LMFBR) commercialization. In this study, the self-terminability of the MN-fueled core was focused on. The FBR cores including the MN-fueled core should be designed to eliminate severe recriticality leading to energetics during core disruptive accidents (CDAs) because the cores are not designed to operate in an optimum configuration from a reactivity point of view. In addition, in the case of the MN-fueled core, the nitrogen gas N2 generated by the thermal dissociation, one of the unique phenomena of the nitride fuel, would give another cause of reactor vessel failure. Such a mechanical effect would strongly depend on the magnitude of the void reactivity. In this study, the allowable maximum void reactivity of the MN-fueled core to maintain the mechanical integrity of the reactor vessel was evaluated against an Unprotected Loss-of-Flow (ULOF) accident by using ARGO taking into account th...

Speckle tracking echocardiography (STE) has the potential to detect the heterogeneous initiation of active myocardial contraction, which is the primary cause of left ventricular (LV) systolic dysfunction in patients with mechanical dyssynchrony. This study was designed to assess the ability to predict response to cardiac resynchronization therapy (CRT) of STE-derived dyssynchrony parameters in comparison with invasive hemodynamic assessments. Thirty patients referred for CRT were studied. The time difference of first peak (Td-(first peak)) and the maximum peak (Td-(max peak)) on the radial strain-time curves of the earliest and the latest segments were measured as the dyssynchrony parameter. Peak positive dP/dt (dP/dt(max)) was measured as the indicator of global LV systolic performance. CRT responders were defined as patients with LV end-systolic volume reduction greater than 15% at 3 months after CRT. CRT increased the dP/dt(max) compared with the baseline study (P.001). Percent changes in the dP/dt(max) (dP/dt(max)) were significantly correlated with Td-(first peak) (R = 0.743, P.001), but weakly correlated with Td-(max peak) (R = 0.390, P = .03). Twenty patients (66%) were identified as chronic CRT responders. Receiver operating characteristics analysis revealed that Td-(first peak) shared a similar ability with dP/dt(max) to detect chronic responders (Td-(first peak)167.0 ms, area under the curve [AUC] 0.945; dP/dt(max)16.2%, AUC 0.934) compared with Td-(max peak) (194.5 ms, AUC 0.820). STE-derived Td-(first peak) showed a reliable ability to predict the acute and chronic response to CRT as well as dP/dt(max).

application/pdf, Septal and lateral wall myocardial velocity-time curves from tissue Doppler imaging were analyzed to determine wall motion from whichthe velocity originated in 34 patients with left bundle branch and systolic dysfunction (ejection fraction < 45%). Longitudinal strain rate by speckle tracking imaging was assessed to identify whether corresponding wall motion was active or passive. All lateral peak velocities duringthe ejection period were derived from delayed active movement. However, septal peak velocities were more numerous and complex. Septal peak velocities during pre-ejection were derived fromthe first active movement in 29 patients (85.2%). Septal peak velocities during the ejection period were derived from the second active movement in 20 patients, passive movement in 9 patients, and first active movement in 5 patients. Because septal peak velocities were consistent with various wall motion types, identificationof the origin of septal peak velocities, including during pre-ejection, may be important in identifying LV dyssynchrony based on the propagation of first active myocardial movements.

Background This study evaluated the usefulness of 3-dimensional echocardiography (3-DE) for identifying permanent pacemaker (PPM) or implantable cardioverter defibrillator (ICD) lead-related symptomatic tricuspid regurgitation (TR). Methods and Results Eighty-seven patients underwent 3-DE examination: 50 patients with PPM, 17 with ICD, and 20 with cardiac resynchronization therapy devices. TR severity was classified as trivial/mild, moderate, or severe according to the ratio of TR area to right atrium area. The 3-DE identified the lead route and position at the tricuspid valve in 82 patients (94.2%). In 5 patients, images without lead-induced artifacts could not be obtained. TR severity was trivial/mild in 50 patients, moderate in 20 patients, and severe in 12 patients. In all patients with trivial/mild TR and all but 1 patient with moderate TR, leads were positioned on the annulus side between leaflets. Lead-induced obstruction to tricuspid valve closing was identified in 1 patient with moderate TR and in 7 of 12 patients with severe TR: 4 patients had septal leaflet obstruction, and 4 had posterior leaflet obstruction. Conclusions The 3-DE can identify the lead route and position at the tricuspid valve and lead-related severe TR, so may be a useful technique of diagnosing the cause of severe TR in patients with PPM or ICD. (Circ J 2008; 72: 1465 - 1470)

Given the complex morphologic nature of the right ventricle, three-dimensional (3D) approaches would be more appropriate for assessing right ventricular (RV) function than two-dimensional approaches. Thus, the investigators have developed a novel 3D speckle-tracking echocardiographic (STE) system specialized for the right ventricle. The aim of this study was to assess the characteristics of RV global and regional deformation as well as changes on stress tests using the 3D STE system in experimental studies.In 10 sheep, sonomicrometry crystals were implanted to validate 3D STE data in the RV endocardium of seven RV segments, including the basal and mid anterior, lateral and inferior wall, and outflow free wall. Full-volume 3D STE data sets and sonomicrometric data were acquired at baseline, during pulmonary artery banding (PAB)-induced moderate (peak RV pressure 40 mm Hg) and severe (peak RV pressure 60 mm Hg) RV pressure increases, and during propranolol infusion. The 3D STE area change ratio (ACR), longitudinal strain (LS), and circumferential strain (CS) were measured, and RV global and all segmental deformation data were compared between baseline and stress tests. To assess clinical feasibility, 30 control subjects and 11 patients with pulmonary arterial hypertension were enrolled.All combined 3D STE data were significantly correlated with the sonomicrometric data (ACR, R(2) = 0.88; LS, R(2) = 0.84; CS, R(2) = 0.82; P .001). In all seven segments, the 3D STE data correlated with the sonomicrometric data (R(2) = 0.72-0.90, P .001). Global ACR and LS data showed significant differences among baseline, moderate PAB, and severe PAB; however, CS differed only between baseline and severe PAB. The magnitudes of segmental deformation in the free wall were larger than those in the septum and apex under all conditions (P .05) except LS during severe PAB. Segmental analyses also showed similar responses during stress tests; the ACR in each segment differed significantly between conditions. In all but the apical segments, LS showed significant reductions from moderate PAB; in contrast, CS was significantly reduced with severe PAB in all segments. In this clinical study, the acquisition rate of adequate images for analysis of the RV outflow tract was lower (75.6%) compared with the rate in other segments (from 85.4% to 100%). However, the pulmonary arterial hypertension group had lower RV global deformation values than the control group (ACR and LS, P .001; CS, P = .003), the ACR and LS in basal and middle segments differed significantly between groups, and the outflow and apex did not differ.A novel 3D STE system specialized for the right ventricle is reliable for RV deformation analyses and may provide additional information about RV global and segmental function. The clinical feasibility of this system is acceptable.

Type 2 diabetes mellitus is a leading health issue worldwide. Among cases of diabetes mellitus nephropathy (DN), the major complication of type 2 diabetes mellitus, the nephrotic phenotype is often intractable to clinical intervention and demonstrates the rapid decline of renal function to end-stage renal disease. We recently identified the gene for glypican-5 ( GPC5 ), a cell-surface heparan sulfate proteoglycan, as conferring susceptibility for acquired nephrotic syndrome and additionally identified an association through a genome-wide association study between a variant in GPC5 and DN of type 2 diabetes mellitus. In vivo and in vitro data showed a progressive increase of GPC5 in type 2 DN along with severity; the excess was derived from glomerular mesangial cells. In this study, diabetic kidney showed that accumulation of fibroblast growth factor (Fgf)2 strikingly induced progressive proteinuria that was avoided in Gpc5 knockdown mice. The efficacy of Gpc5 inhibition was exerted through expression of the Fgf receptors 3 and 4 provoked in the diabetic kidney attributively. Extraglomerular Fgf2 was pathogenic in DN, and the deterrence of Gpc5 effectively inhibited the glomerular accumulation of Fgf2, the subsequent increase of mesangial extracellular matrix, and the podocytes' small GTPase activity. These findings elucidate the pivotal role of GPC5 , identified as a susceptible gene in the genome-wide association study, in hyperglycemia-induced glomerulopathy.

The CHADS2 score is considered a reliable predictor of stroke/thromboembolism risk in patients with atrial fibrillation (AF). However, thromboembolism can occasionally occur even in patients with AF with low CHADS2 score (CHADS2 score = 0 or 1). To investigate the incidence and predictors of left atrial appendage (LAA) thrombus (LAAT) formation in patients with AF, we studied consecutive 543 Japanese patients with AF who underwent transesophageal echocardiography before pulmonary vein isolation from 2008 to 2012. All patients were treated with anticoagulation therapy with warfarin, and their clinical and echocardiographic characteristics were evaluated. LAATs were observed in 35 (6.4%) of 543 patients, and the prevalence was clearly correlated with the patient's CHADS2 scores. Of 338 patients with low CHADS2 score, LAATs were observed in 7 patients (2.1%). By multivariate analysis, increased left atrial volume (≥50 ml), decreased ejection fraction (56%), and increased brain natriuretic peptide level (75 pg/ml) were significantly associated with increased prevalence of LAATs, even in patients with low CHADS2 score. Accordingly, we proposed a new scoring system to predict LAAT (left atrial volume ≥50 ml: score 2; ejection fraction56%: score 1; brain natriuretic peptide75 pg/ml: score 1). Patients with a score ≥2 have a greater risk of LAAT, whereas all patients with score ≤1 have no LAATs. Our scoring system is useful for evaluation of the risk of LAAT in patients with AF even with low CHADS2 score.

BACKGROUND We sought to identify the feasibility of speckle tracking echocardiography (STE) to predict cardiac resynchronization therapy (CRT) responders in a prospective multicenter study. METHODS AND RESULTS: Patients who were newly implanted with a CRT device were enrolled. Time (T) from QRS to maximum peak radial and circumferential strain (CS) in 6 segments on the left ventricular (LV) short-axis plane, and to the maximum peak of longitudinal strain in 18 segments on 3 apical LV planes was measured (Tmax). In segments with multiple peaks on the time-strain curves, time to the first peak (Tfirst) was also assessed. Difference in T between the earliest and latest segment and standard deviation (SD) of T in each strain component were assessed. CRT responders were defined as having LV end-systolic volume reduction >15% at 6 months after CRT. Clinical outcomes were assessed with a composite endpoint of death from cardiac causes or unplanned hospitalization for heart failure. Among 180 patients, 109 patients were identified as responders. Tfirst-SD of CS >116 ms was selected as the best independent predictor of CRT responders (P

Background Carotid arterial ultrasound examination may be helpful for screening populations at high risk for acute coronary syndrome (ACS), so the present study was designed to identify the carotid arterial characteristics of patients with ACS. Methods and Results Carotid ultrasound examinations were performed in 172 patients with ACS, 166 patients with stable coronary artery disease (CAD), and 96 control subjects. Common carotid arterial structures were assessed by the intima - media thickness (IMT), interadventitial diameter (IAD), lumen diameter (LD), the IMT to LD ratio (IMT/LD), and the plaque burden based on the plaque score. Plaque morphology was assessed by the echogenecity based on the gray-scale median (GSM). IMT, IAD, IMT/LD, and plaque score did not differ between the ACS and stable CAD groups. The GSM in the ACS group was lower (47.5±25.3, p

Wall motion abnormality in the apical legion of the left ventricle (LV) with stagnant flow alone is not sufficient to identify patients at high risk for LV thrombus formation among those with first anterior acute myocardial infarction (AMI). The aim of this study was to identify the determinants of LV thrombus formation using contrast echocardiography.In 75 patients with first anterior AMI, standard and contrast echocardiography was performed to detect LV thrombus. Although LV thrombus was found in 10 patients (13%) using standard echocardiography, it was found in 15 patients (20%) using contrast echocardiography. Apical stagnant flow was observed in 14 patients (93%) with LV thrombus. In addition, patients with LV thrombus had a higher peak C-reactive protein (CRP) concentration (18.2+/-4.3 vs 7.9+/-5.5 mg/dl, p0.0001). In multivariate analysis, only peak CRP concentration was identified as an independent predictor of LV thrombus (p=0.02, odds ratio: 1.400, confidence interval: 1.040-1.884). The receiver-operating characteristics (ROC) analysis revealed the best cutoff value of a peak CRP concentration10.7 mg/dl to identify patients with LV thrombus (sensivity 0.93, specificity 0.75, area under ROC curve 0.91).The peak CRP concentration is a useful marker of patients with first anterior AMI who are at high risk for LV thrombus.

Background: We conducted a multicenter study in Japan to compare tissue Doppler echocardiography-derived and speckle tracking echocardiography (STE)-derived parameters of left ventricular (LV) diastolic function for the estimation of LV filling pressure. Methods: Seventy-eight patients (age 59±14 years, 59 male) with structural heart diseases including angina pectoris (n=34), old myocardial infarction (n=15), dilated cardiomyopathy (n=13), hypertrophic cardiomyopathy (n=8), and hypertensive heart disease (n=8) were studied according to the same protocol in 5 university hospitals in Japan. LV mean diastolic pressure (MDP) was measured by using a micromanometer-tipped catheter. Early-diastolic mitral annular velocity (e′) was measured at septal and lateral side of the annulus and averaged, and the ratio of early-diastolic transmitral velocity to e′ (E/e′) was calculated. Global longitudinal strain was measured using STE in 3 apical views and averaged on a frame-by-frame basis to construct a time-strain curve as well as a time-strain rate (SR) curve. Then, the absolute value of peak longitudinal strain (LS), early-diastolic peak SR (LSR E ), and that during isovolumic relaxation (IVR) period (LSR IVR ) were measured. Similarly, peak circumferential strain (CS), early-diastolic peak circumferential SR (CSR E ), and that during IVR (CSR IVR ) were measured from 3 short-axis views. Results: E/e′ weakly correlated with MDP (r=0.50, pIVR and E/CSR IVR did not correlate with MDP, whereas there was a significant but weak correlation between E/LSR E and MDP (r=0.50, pE and MDP (r=0.41, p Conclusions: STE-derived longitudinal parameters better correlated with MDP than circumferential parameters. Especially, E/LS was better than E/e′ for estimating LV filling pressure.

Background: Three-dimensional (3D) imaging has the potential to evaluate right ventricular (RV) function accurately because of its complex geometry. We have developed a dedicated 3D-speckle tracking imaging (STI) system for the right ventricle, and performed validation studies to assess the reliability of 3D-STI derived deformation data. Methods: In 9 anesthetized sheep, RV full volume data sets for 3D-STI were obtained using a 3D echocardiography system (Toshiba Medical Systems) simultaneously with sonomicrometry data at the baseline and during pulmonary artery (PA) banding at moderate and severe levels, and propranolol infusion. In 7 RV segments (basal and mid anterior, basal and mid lateral, basal and mid inferior, and outflow), area change ratio (ACR), longitudinal strain (LS), and circumferential strain (CS) were calculated with prototype 3D-STI software (Figures) and compared with those by sonomicrometry. Results: ACR by 3D-STI strongly correlated with sonomicrometry data (Y=0.78X-5.0, R=0.83, p Conclusions: The newly developed 3D-STI system is a reliable modality for RV function analysis.

Left ventricular (LV) dyssynchrony is a key pathophysiology in the era of cardiac resynchronization therapy (CRT). Left bundle branch block (LBBB) is the main substrate for CRT, and understanding the electrical pathophysiology is important in assessing the effects of CRT. Three-dimensional voltage mapping systems clearly demonstrate the typical propagation pattern characterized as propagation from the mid or apical septum to the lateral or posterior wall through the apex, which appears as a U shape. The electrical characteristics in LBBB closely associate with mechanical dyssynchrony, which is visualized as a septal flash motion. This rapid motion can be detected well by M-mode, tissue Doppler, and speckle tracking imaging. However, intraventricular discoordination between the septum and free wall is also a key to the response to CRT. We classified M-mode septum images into 10 patterns and septal strain pattern into two patterns. Through detailed analysis, we found that septal contraction contributes to intraventricular coordination. Therefore, in addition to septal flash, subsequent analysis of wall motion patterns also provides additional information about myocardial contractibility and the severity of electrical dyssynchrony. Recently, 3-dimensional speckle tracking imaging was introduced and used as a novel method to image electromechanical coupling. Because activation imaging by 3-dimensional speckle tracking can visualize similar U-shaped propagation images to those by 3-dimensional voltage mapping systems, it is hoped that this method will contribute to further research. Until now, it has not been fully understood how electrical dyssynchrony is expressed as mechanical abnormalities; therefore, continuous study will be required in the future.

悪性胸膜中皮腫に対する胸膜肺全摘術の周術期の死亡率と合併症の率は非常に高い。悪性胸膜中皮腫6例の術後管理を行い全例退院できた。6例中4例は順調に経過した。しかし,症例1は術中から術後にかけて大量に出血し,重症心不全,呼吸不全を併発した。症例4は重症心不全,呼吸不全に加え,気管支断端が離開し再手術を行った。術後管理が困難な原因は,胸膜,心膜,横隔膜と広範囲に合併切除することによる大量出血と長期にわたる滲出液の喪失であった。循環系の維持のために大量の輸血輸液が必要であった。しかし,肺血管床の減少のために右心不全になりやすく,refillingの時期には容易に両心不全になる。術後心不全を乗り切るためには,完全な止血操作で出血を抑え,適切な前負荷を維持することが最も重要である。

Cardiac resynchronization therapy (CRT) may improve left ventricular (LV) diastolic dysfunction as well as systolic dysfunction. Diastolic dysfunction is a key for prognosis in patients with heart failure; therefore, we aimed to clarify the impact of CRT on diastolic function and prognosis. In 67 patients who underwent CRT, LV diastolic function was assessed by pulsed Doppler transmitral flow pattern at baseline and 1 week after CRT, and classified into restrictive filling pattern (RFP) and non-RFP groups. Volume responders were defined by reduction of LV end-systolic volume >15 % at 6 months after CRT. The clinical endpoint comprised death from any cause or unplanned hospitalization for a major cardiovascular event (MACE). During the follow-up period (479 ± 252 days), 26 patients (38.8 %) had reached the endpoint of MACE. In Cox proportional hazard analyses, RFP at 1 week after CRT was associated with the endpoints independently of age and New York Heart Association (NYHA) class IV at baseline. Thirty (44.8 %) patients were identified as volume responders, who had better prognosis than non-responders. Patients were classified into 4 groups based on their filling pattern at 1 week after CRT and volume responses. The worst prognosis was observed in the RFP and non-responder group, and the best was observed in the non-RFP and responder group. For the remaining 2 groups with intermediate prognosis, the RFP and responder group showed poorer prognosis compared to the non-RFP and non-responder group. Persistent RFP after CRT may be a strong prognostic predictor, which should be treated with more intensive therapy to improve the prognosis of patients following CRT.