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Speckle tracking echocardiography (STE) was popularized in the first decade of this century. Analysis of cardiac mechanics has been the focus of ultrasonics, and the breakthrough came with STE. Beyond analysis solely of left ventricular ejection fraction, STE allows the assessment of various pathophysiologies, including myocardial layer-specific myocardial function, twist and rotation, and dyssynchrony. Recent developments in the technology have resulted in commercially available 3-dimensional (D)-STE systems. Through experimental studies and clinical investigations, the reliability and feasibility of 3D-STE-derived data have been validated, and the advantages of 3D-STE over 2D-STE have been revealed. In addition, because of the 3D nature of the technology, 3D-STE provides novel deformation parameters (ie, 3D-strain and area change ratio) that have the potential for more accurate assessment of overall and regional myocardial function. Recently, various preliminary studies using 3D-STE have reported on myocardial characteristics, novel mechanics in the left ventricle, prediction of therapeutic effects, observations of cardiac function through interventions, and challenges for left atrial and right ventricular functions. In this review, we focus on the features of the methodology, validation, and clinical application of 3D-ST.

Aims To compare the efficacy of Framingham Risk Score (FRS), UK Prospective Diabetes Study (UKPDS) risk engine, a risk score based on the Japanese Atherosclerosis Longitudinal Study-Existing Cohorts Combine (JALS-ECC), the maximum intima-media thickness (max-IMT) determined on coronary computed tomography angiography (CCTA) and their combination in asymptomatic patients with type 2 diabetes. Methods A total of 116 Japanese patients with type 2 diabetes underwent CCTA. The risk of coronary heart disease was calculated according to the FRS, UKPDS and JALS-ECC. We evaluated the reclassification of coronary artery stenosis (CAS) based on the risk score categories after adding each IMT related variable. Results Sixty-eight patients had CAS. The areas under the curves (AUCs) in the receiver operating characteristic curve analyses of FRS, UKPDS and JALS-ECC were 0.763 (95% confidence interval [CI]: 0.674-0.853), 0.785 (95% CI: 0.703-0.868) and 0.767 (95% CI: 0.681-0.853), respectively. The AUCs for FRS, UKPDS and JALS-ECC combined with the max-IMT were 0.788 (95% CI: 0.705-0.872), 0.800 (95% CI: 0.720-0.879) and 0.786 (95% CI: 0.703-0.869), respectively. Combining the max-IMT with the risk scores improved the identification of subjects with stenotic lesions, in particular, those in the first, second and third tertiles of the FRS, first and second tertiles of the UKPDS and first and second tertiles of the JALS-ECC (P=0.054, P=0.056, P=0.015, P=0.082, P=0.060, P=0.007, and P=0.080, respectively). The net reclassification improvement increased following the addition of a max-IMT of ≥ 1.9 mm (32.4% in FRS, 19.9% in UKPDS and 51.7% in JALS-ECC). Conclusions These data suggest that combining a risk score with the max-IMT improves the prediction of CAS in comparison with the risk score alone.

JNES is developing a core disruptive accident analysis code, ASTERIA-FBR, which tightly couples the thermal-hydraulics and the neutronics to simulate the core behavior during core disruptive accidents of fast breeder reactors (FBRs). ASTERIA-FBR consists of the three-dimensional thermal-hydraulics calculation module: CONCORD, the fuel pin behavior calculation module: FEMAXI-FBR, and the space-time neutronics module: Dynamic-GMVP or PARTISN/RKIN. This paper describes a comparison between characteristics of GMVP and PARTISN and summarizes the challenging issues on applying Dynamic-GMVP to the calculation against unprotected loss-of-flow (ULOF) event which is a typical initiator of core disruptive accident of FBR. The statistical error included in the calculation results may affect the super-prompt criticality during ULOF event and thus the amount of released energy.

During the development of Monte-Carlo-based dynamic code system, we have encountered two major Monte-Carlo-specific problems. One is the break down due to “false super-criticality” which is caused by an accidentally large eigenvalue due to statistical error in spite of the fact that the reactor is actually not. The other problem, which is the main topic in this paper, is that the statistical error in power level using the reactivity calculated with Monte Carlo code is not symmetric about its mean but always positively biased. This signifies that the bias is accumulated as the calculation proceeds and consequently results in over-estimation of the final power level. It should be noted that the bias will not eliminated by refining time step as long as the variance is not zero. A preliminary investigation on this matter using the one-group-precursor point kinetic equations was made and it was concluded that the bias in power level is approximately proportional to the product of variance in Monte Carlo calculation and elapsed time. This conclusion was verified with some numerical experiments. This outcome is important in quantifying the required precision of the Monte-Carlo-based reactivity calculations.

With pressure support ventilation (PSV), each PSV breath is flow-cycled, and the breath termination criterion (TC) is usually nonadjustable. When TC does not match the interaction between the patient's inspiratory-expiratory efforts to the opening and closing of the inspiratory and expiratory valves, patient-ventilator asynchrony may occur, and the work of breathing (WOB) may increase. Therefore, we studied the effect of TC on breathing patterns and WOB during PSV in eight patients with acute respiratory distress syndrome or acute lung injury. We studied five levels of TC during PSV-1%, 5%, 20%, 35%, and 45% of the peak inspiratory flow. With increasing levels of TC, the tidal volume decreased and respiratory frequency increased, along with a decrease in duty cycle. WOB markedly increased with increasing levels of TC from 0.31 +/- 0.12 J/L with TC 1% to 0.51 +/- 0.11 J/L with TC 45%. Premature termination with double breathing occurred in one patient with TC 35% and four patients with TC 45%. Delayed termination with a duty cycle of0.5 occurred in two patients with TC 1%. In conclusion, the proper adjustment of TC improves patient-ventilator synchrony and decreases WOB during PSV.Although termination criterion (TC) is usually nonadjustable, it influences the effectiveness of pressure support ventilation for mechanical ventilation. The proper adjustment of TC is crucial to improve patient-ventilator synchrony and decrease work of breathing. TC 5% of the peak inspiratory flow may be the optimal value for patients with acute respiratory distress syndrome or acute lung injury.

Background Speckle tracking echocardiography ( STE ) is reported as a useful method to predict cardiac resynchronization therapy ( CRT ) responders. This study aimed to identify the incremental value of a STE parameter to predict CRT responders. Methods and Results We enrolled 171 patients from the Speckle Tracking imaging for the Assessment of cardiac Resynchronization Therapy ( START ) study. CRT responders were defined as patients with ≥15% reduction of left ventricular ( LV ) end‐systolic volume at 6 months post‐ CRT . Based on multivariable logistic regression analysis, incremental values of STE were assessed by c‐statistics, net reclassification improvement ( NRI )/integrated discrimination improvement ( IDI ), and decision curve analysis. Six parameters (left bundle branch block or right ventricular pacing, use of beta‐blocker, blood urea nitrogen ≤3.0 mg/dL, LV end‐systolic diameter ≤50 mm, mitral regurgitation index ≤40%, and STE parameter standard deviation of time from QRS onset to first peak on the circumferential strain curves [ T SD ] ≥116 ms) were identified as the determinants. Compared to the multivariable logistic regression model without T SD (model 1), that with T SD (model 2) showed significant improvement to predict CRT responders: c‐statistic (0.86 vs 0.77; P NRI =0.19, P IDI =0.17, P START score was constructed. Compared to the Multicenter Automatic Defibrillator Implantation Trial with Cardiac Resynchronization Therapy ( MADIT ‐ CRT ) score, the decision curve of the START score was higher than that of the MADIT ‐ CRT score at threshold probabilities ≥0.2. Conclusions Based on various statistical methods, this study revealed that STE had an incremental value to predict CRT responders.

The staphylococcal scalded skin syndrome (SSSS) is a febrile, self-limited illness. It generally affects infants and children; however a few adults, particularly those with immunosuppression, have developed a similar condition. In adult cases, mortality is high. Here, we report a very rare case of SSSS in an adult without underlying diseases. A 68-year-old man was admitted to our hospital because of spondylitis and arthritis of the right knee joint.The clinical findings and bacteriologic examinations as well as the skin biopsy were consistent with the diagnosis of SSSS. The patient was supported by a mechanical ventilator and successfully treated with antibiotics.

Acute lung injury and acute kidney injury are severe complications in critically ill patients and synergistically increase mortality in intensive care units. Organ cross-talk between the kidney and the lung has been implicated recently as amplifying injury in each organ. Here we sought to identify a possible mechanism of acute kidney injury-induced acute lung injury using a mouse bilateral nephrectomy model. Toll-like receptor 4 (TLR4)-mutant C3H/HeJ mice were more resistant to lung injury including neutrophil infiltration, increased neutrophil elastase activity, and vascular permeability caused by bilateral nephrectomy compared with TLR4-wild-type C3H/HeN mice 6 h after surgery. High-mobility group protein B1 (HMGB1) is one agonist for TLR4. Its blood concentrations were increased significantly by bilateral nephrectomy. Blockade of HMGB1 by neutralizing antibody reduced neutrophil infiltration in TLR4-wild-type C3H/HeN but not in TLR4-mutant C3H/HeJ mice. However, HMGB1 blockade in a renal ischemia reperfusion model reduced pulmonary neutrophil infiltration independent from TLR4. Thus, an enhanced HMGB1-TLR4 pathway contributes to lung injury induced by bilateral nephrectomy and the other HMGB1-dependent pathway exists in pulmonary neutrophil infiltration caused by renal ischemia reperfusion. Targeting the HMGB1-TLR4 pathway might enable development of a new therapeutic strategy to improve the outcomes of severely ill patients with both acute lung and acute kidney injury.

Background: The long-term effects of catheter ablation (CA) on the left atrium and left atrial appendage (LAA) are unknown in persistent atrial fibrillation (AF). This study investigated left atrial (LA) reverse remodeling and evolution of LA/LAA function after successful CA for persistent AF and identified predictors for maintenance of sinus rhythm (SR) and LA reverse remodeling. Methods and Results: CA was performed in 123 patients with persistent AF. LA volumes, LA strain and LAA wall velocity were assessed both at baseline and at 12 months after ablation. Patients who maintained SR were divided into 2 groups according to whether LA volume decreased by ≥15% at follow-up (responders) or not (non-responders). During a follow-up period of 18±2 months, AF recurred in 45 patients (37%). Of the remaining 78 patients (63%) without recurrent AF, 62 patients (79%) were classified as responders. LA/LAA function significantly improved and the prevalence of spontaneous echo contrast decreased only in responders at follow-up. LA systolic strain and LAA wall velocity were independent predictors of both maintenance of SR (odds ratio [OR], 2.57; P=0.003; OR, 3.02; P=0.002, respectively) and LA reverse remodeling (OR, 4.44; P=0.007; OR, 3.52; P=0.01, respectively). Conclusions: Successful CA is associated with LA reverse remodeling and LA/LAA functional recovery in patients with persistent AF. LA systolic strain and LAA wall velocity at baseline predicted both maintenance of SR and LA reverse remodeling. (Circ J 2013; 77: 1695–1704)

Background Type 2 diabetes mellitus is associated strongly with an increased risk of micro- and macro-vascular complications, leading to impaired quality of life and shortened life expectancy. In addition to appropriate glycemic control, multi-factorial intervention for a wide range of risk factors, such as hypertension and dyslipidemia, is crucial for management of diabetes. A recent cardiovascular outcome trial in diabetes patients with higher cardiovascular risk demonstrated that a SGLT2 inhibitor markedly reduced mortality, but not macro-vascular events. However, to date there is no clinical evidence regarding the therapeutic effects of SGLT2 inhibitors on arteriosclerosis. The ongoing PROTECT trial was designed to assess whether the SGLT2 inhibitors, ipragliflozin, prevented progression of carotid intima-media thickness in Japanese patients with type 2 diabetes mellitus. Methods A total of 480 participants with type 2 diabetes mellitus with a HbA1c between 6 and 10 % despite receiving diet/exercise therapy and/or standard anti-diabetic agents for at least 3 months, will be randomized systematically (1:1) into either ipragliflozin or control (continuation of conventional therapy) groups. After randomization, ipragliflozin (50–100 mg once daily) will be added on to the background therapy in participants assigned to the ipragliflozin group. The primary endpoint of the study is the change in mean intima-media thickness of the common carotid artery from baseline to 24 months. Images of carotid intima-media thickness will be analyzed at a central core laboratory in a blinded manner. The key secondary endpoints include the change from baseline in other parameters of carotid intima-media thickness, various metabolic parameters, and renal function. Other cardiovascular functional tests are also planned for several sub-studies. Discussion The PROTECT study is the first to assess the preventive effect of ipragliflozin on progression of carotid atherosclerosis using carotid intima-media thickness as a surrogate marker. The study has potential to clarify the protective effects of ipragliflozin on atherosclerosis. Trial registration Unique Trial Number, UMIN000018440 (https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000021348) Electronic supplementary material The online version of this article (doi:10.1186/s12933-016-0449-7) contains supplementary material, which is available to authorized users.

Introduction: Many pleiotropic effects of dipeptidyl peptidase 4 inhibitor (DPP4I) have been reported and expected to inhibit cardiovascular events. However, better prognostic value of DPP4I has not been proven in many clinical trials. Aim: The aim of this study was to investigate the effect of DPP4I on cardiovascular outcomes in Japanese patients with type 2 diabetes (DM) and heart failure (HF). Methods: Among prospectively enrolled 838 HF patients who were hospitalized for acute decompensated HF, 79 patients with DPP4I were compared with propensity score matched 79 control patients with DM. The primary endpoint was all cause mortality, and the secondary endpoint was a composite of cardiovascular death and hospitalization. Results: During follow up (423 ± 260 days), 8 deaths (10.1%) in DPP4I group and 13 (16.5%) in control group were occurred (log-rank, p=0.283). In patients with HF with preserved ejection fraction (n=75, LVEF ≧ 45%), DPP4I group showed better prognosis compare with control group in the primary endpoint (Figure A, log-rank, p=0.021) and tendency to be better prognosis in the secondary endpoint (log-rank, p=0.119). However, in patients with HF with reduced ejection fraction (n=83, LVEF Conclusion: DPP4I may be beneficial for cardiovascular outcomes in patients with DM and HF with preserved ejection fraction.

Background Xanthine oxidase inhibitors are anti-hyperuricemic drugs that decrease serum uric acid levels by inhibiting its synthesis. Xanthine oxidase is also recognized as a pivotal enzyme in the production of oxidative stress. Excess oxidative stress induces endothelial dysfunction and inflammatory reactions in vascular systems, leading to atherosclerosis. Many experimental studies have suggested that xanthine oxidase inhibitors have anti-atherosclerotic effects by decreasing in vitro and in vivo oxidative stress. However, there is only limited evidence on the clinical implications of xanthine oxidase inhibitors on atherosclerotic cardiovascular disease in patients with hyperuricemia. We designed the PRIZE study to evaluate the effects of febuxostat on a surrogate marker of cardiovascular disease risk, ultrasonography-based intima-media thickness of the carotid artery in patients with hyperuricemia. Methods The study is a multicenter, prospective, randomized, open-label and blinded-endpoint evaluation (PROBE) design. A total of 500 patients with asymptomatic hyperuricemia (uric acid >7.0 mg/dL) and carotid intima-media thickness ≥1.1 mm will be randomized centrally to receive either febuxostat (10–60 mg/day) or non-pharmacological treatment. Randomization is carried out using the dynamic allocation method stratified according to age (

Japan Nuclear Energy Safety Organization, JNES has been studying the methodology to apply the risk informed regulation (RIR) to the safety regulation for Light Water Reactors (LWRs) and Fast Breeder Reactors (FBRs). A best estimate code of plant dynamic analysis is necessary for the RIR application and it must be validated very carefully. To fulfill this requirement, JNES has been developing a FBR plant dynamic analysis code ADYTUM, which has flexible code structure and algorisms for applying to the safety evaluation. ADYTUM is composed of several inherent components of physical model named “module”, based on one-dimensional flow network model which calculates the sodium flow and the heat transfer between sodium and structures in primary and secondary loop systems. In addition, ADYTUM is designed so that variables of each module have no connection with other modules. Therefore, ADYTUM allows us to calculate and validate each module alone [1]. In order to reinforce the precision of the analysis model of ADYTUM, we are trying to quantify the uncertainty of the model parameters by use of the Code Scaling, Applicability, and Uncertainty (CSAU) methodology for the primary pump stick accident in FBRs. The approaches of the CSAU are (1) to define the physical value and the range of time scale which are focused on, (2) to select the input parameters which have a profound effect on the physical value of focus by use of the phenomena identification and ranking table, and finally (3) to provide the uncertainty quantification of the focusing value.

Aim Frequent ventricular premature contractions (VPCs) may cause haemodynamic deterioration and reversible left ventricular (LV) dysfunction. We aimed to clarify this mechanism. Methods and results The haemodynamics, echocardiographic parameters, and plasma brain natriuretic peptide (BNP) level were assessed in 31 patients with idiopathic, frequent VPCs undergoing radiofrequency catheter ablation. The patients were classified into two groups according to the presence (n = 19) or absence (n = 12) of marked augmentation of the pulmonary capillary wedge pressure (PCWP) following VPCs (VPC-induced-PCWP augmentation; VI-PA). The VI-PA(+) group was defined as those with a peak PCWP of >15 mmHg measured after a VPC. Before the ablation, the mean PCWP, right atrial pressure (RAP), left ventricular end-diastolic pressure (LVEDP), and plasma BNP level were significantly greater in the VI-PA(+) group than in the VI-PA(–) group. In the VI-PA(+) group, the mean PCWP, RAP, LVEDP, and cardiac index all improved immediately after a successful ablation. At 7.4 ±0.9 months after the ablation, almost all the echocardiographic parameters and plasma BNP level also significantly improved in the VI-PA(+) group, and the magnitude of the improvement in those parameters measured was greater in the VI-PA(+) group than in the VI-PA(–) group. The left atrial contractions during mitral valve closure during VPCs caused a marked pulmonary venous flow regurgitation and VI-PA. VPC coupling intervals of

Background Recent advances in very high frame rate use of ultrasonography have enabled the application of two-dimensional speckle-tracking echocardiography (STE) to small animal cardiac functional assessments. In this study, two-dimensional STE was applied to a rat model of hypertensive heart failure with preserved ejection fraction to clarify consequences of left ventricular (LV) wall deformation in the progression of heart failure with preserved ejection fraction. Methods STE was performed every 2 weeks in Dahl salt-sensitive rats fed a 0.3% (control group) or 8% (hypertension [HT] group) sodium chloride diet from 6 to 14 weeks of age. Longitudinal, radial, and circumferential global strain and strain rate were measured, and the time courses of these parameters were observed. Results Deterioration of longitudinal strain occurred in the early phase of the progression of LV hypertrophy and continued to worsen until congestive heart failure developed (longitudinal strain in the HT group: 25 ± 3% at 10 weeks, 21 ± 4% at 12 weeks, and 18 ± 2% at 14 weeks; longitudinal strain in controls was preserved during the experimental period). At 12 weeks, radial strain (HT group, 35 ± 7%; controls, 41 ± 10%) had deteriorated at the late stage of manifest diastolic dysfunction. Throughout the experiments, circumferential strain was preserved (HT group, 35 ± 6%; control group, 35 ± 5%), and no significant increase in short-axis function was observed. Conclusions STE is applicable to the small animal heart and detected LV wall long-axis dysfunction preceding short-axis dysfunction or overt congestive heart failure in the progression of hypertensive LV hypertrophy in a rat model.

Peripartum cardiomyopathy is a rare cardiac disorder characterized by the development of heart failure in the last month of pregnancy or up to 5 months postpartum in women without other determinable causes of cardiac failure. Intracardiac thrombi have been found at autopsy in some patients with this condition and have been demonstrated in the left or right ventricles on 2-dimensional echocardiography. A 23-year-old woman presented with peripartum cardiomyopathy and biventricular thrombi on echocardiography. The thrombi were spherical, pedunculate, shaggy and irregular in configuration, and freely mobile, suggesting that they were fresh. She was treated with conventional heart failure therapy and anticoagulants. Four days later, the apical thrombi within both ventricles had disappeared and there was no evidence of embolism on physical examination. The hypercoagulable state of the peripartum period and the severe biventricular dysfunction most likely led to the formation of biventricular thrombi.

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).Percutaneous coronary intervention is often complicated by post-procedural myocardial necrosis manifested by elevated cardiac biomarkers.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.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, p0.001). Remodeling index was significantly greater in group I than in group II (1.20 ± 0.18 vs. 1.04 ± 0.15, p0.001). Spotty calcification was observed significantly more frequently in group I than in group II (50% vs. 11%, p0.001). Multivariate analysis showed presence of positive remodeling (remodeling index1.05; 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 value55 HU; remodeling index1.05, and spotty calcification) showed a high positive predictive value of 94%, and their absence showed a high negative predictive value of 90%.MDCT may be useful in detecting which lesions are at high risk for myocardial necrosis after PCI.

ObjectivesThe aim of this experimental study was to validate area tracking by 3-dimensional (3D) speckle tracking imaging (STI) as a method to measure changes in regional left ventricular (LV) endocardial surface area with sonomicrometry and to assess the usefulness as a wall motion evaluation method compared with 1-dimensional strain parameters.BackgroundA 3D-STI allows for tracking a regional endocardial surface area during a cardiac cycle. Area tracking is a new concept that regional wall motion is quantified through the magnitude of deformation in an endocardial surface area.MethodsIn each of 8 anesthetized sheep, sonomicrometry crystals were implanted on the endocardium at the LV mid and apical anterior walls. Area change ratio (ACR) that was a novel parameter obtained by area tracking was measured as percentage change in a segmental area during systole. Segmental longitudinal (LS) and circumferential strain (CS) also were measured by 3D-STI. The ACR, LS, and CS were compared with those by sonomicrometry at baseline and during pharmacological stress tests (dobutamine and propranolol infusion) and acute myocardial ischemia induced by occlusion of mid-left ascending artery.ResultsThe strong correlation was observed between ACR measurements by 3D-STI and those by sonomicrometry (Y = −4.20 + 0.84X, r = 0.87, p < 0.001). The ACR showed significant relations with both LS and CS (LS: Y = −15.1 + 1.73X, r = 0.73, p < 0.001; CS: Y = −5.85 + 1.06X, r = 0.79, p < 0.001). ACR showed significant differences among baseline, pharmacological stress, and acute myocardial ischemia. In contrast, LS and CS were reduced significantly during acute ischemia studies compared with those during the other studies; no differences were observed among baseline, propranolol infusion, and dobutamine infusion studies.ConclusionsArea tracking by 3D-STI can estimate changes in LV regional area and might be promising for regional wall motion evaluations.

Objective The incremental prognostic impact on cardiovascular outcomes of assessment of carotid plaque ultrasound characteristics in addition to inflammatory biomarkers remains controversial in coronary artery disease (CAD) patients receiving optimal medical treatment. The present study prospectively compared carotid ultrasonic imaging with several biomarkers to stratify cardiovascular risk. Methods One hundred and sixty patients with angiographically confirmed stable CAD underwent carotid ultrasonography and were prospectively followed with optimal medical therapy including statins. Carotid atherosclerotic burden was assessed by mean intima-media thickness (IMT) at the far-wall from the common carotid to proximal internal carotid artery. Carotid plaque echolucency was quantified by measuring gray-scale median value (GSM). Major cardiovascular event was defined as cardiovascular death, newly developed myocardial ischemia, or cerebrovascular infarction. Results Of 154 subjects completing follow-up, 27 experienced a major cardiovascular event during a median 41-month follow-up period. Events comprised cardiovascular death ( n =6), newly developed myocardial ischemia ( n =16), and ischemic stroke ( n =5). Univariate Cox regression analysis showed C-reactive protein (CRP) and several ultrasonic parameters to be significant determinants for cardiovascular events. Multivariate Cox analysis determined CRP and plaque echolucency to be independent variables predicting cardiovascular events after adjustment for classic CAD risk factors. In Kaplan–Meier plots, patients with both high CRP (≥1.0mg/L) and echolucent plaque (GSM≤65) showed higher event rates than did patients with high CRP but without echolucent plaque. Conclusion Ultrasonic findings of echolucent carotid plaque may have incremental prognostic impact on risk assessment by CRP in CAD patients receiving contemporary optimal medical therapy.

A 21-year-old man was admitted to the hospital with exertional dyspnea. At the age of 14, he was diagnosed with Danon disease by genetic analysis (a 2–base-pair deletion at positions 288 and 289 in exon 3 was identified in the lysosome-associated membrane protein-2 [LAMP2] gene of the patient, which led to a frameshift and resulted in a premature stop codon). A chest radiograph demonstrated moderate cardiomegaly (cardiothoracic ratio of 58%). The ECG exhibited normal sinus rhythm, wide and bifid P waves with a duration of 170 ms, complete left bundle-branch block with a QRS duration of 200 ms, and a leftward axis (−2°; Figure 1). Figure 1. Twelve-lead ECGs. Echocardiography revealed left ventricular (LV) dilatation with an end-diastolic internal dimension of 60 mm and diffusely hypokinetic LV wall motion with fractional shortening of 8% (Figure 2; Movie I of the online-only Data Supplement). …

The left atrial volume (LAV) is an important indicator of the severity of certain diseases, and measuring LAV through the cardiac cycle may enable the evaluation of various left atrium (LA) functional parameters. The results of two-dimensional (2D) echocardiographic LAV measurement methods vary, and no technique is accepted as being optimal. This study compared the accuracy of end-systolic and end-diastolic LAV measurements by 2D echocardiography with those obtained by magnetic resonance imaging (MRI). Fifty consecutive patients who underwent both echocardiography and MRI due to clinical reasons with nonselective cardiac disease were studied. LAVs by 2D echocardiography were obtained with the prolate ellipsoid (PE), biplane area-length (AL), and modified Simpson’s (MS) methods. End-systolic and end-diastolic LAVs calculated by each method correlated significantly with MRI results (P

Potential myocardial dysfunction may be present in patients with significant aortic regurgitation (AR) and preserved left ventricular ejection fraction (LVEF). Newly developed software for speckle tracking imaging (STI) allows separate analysis of endo- and epimyocardial strain. The aim of this study was to assess the relationship between endo- and epimyocardial radial strain (RS) distribution and AR severity in identifying the potential myocardial dysfunction in patients with significant AR and LVEF>50%, and its correlation with postoperative LV function. We studied 47 patients with AR and 26 control subjects. Degree of AR was classified according to standard echocardiographic criteria as moderate in 16 and severe in 23 patients. STI was analyzed with the new software (Toshiba Medical Systems, Tokyo, Japan). For STI analysis, an endocardial and epicardial border line were each manually traced at end-systole on a short-axis B-mode image at the mid-ventricular level; peak RS of total, endomyocardium, and epicardium were automatically calculated. Endomyocardial RS was reduced in patients with severe AR compared to control subjects and patients with moderate AR (Figure ). Postoperative changes in LVEF were well correlated with the ratio of baseline endomyocardial RS to epimyocardial RS (n=21, r=−0.69, p

In order to develop a thermal-hydraulic analysis model of the SG (steam-generator) to simulate transient phenomena in the FBR (sodium cooled fast breeder reactor) MONJU, JNES (Japan Nuclear Energy Safety Organization) validated a SG analysis model using the RELAP5/3D code against the results of turbine trip test at a 40% power load. The modeling by using the code was performed to explain main observed behaviors of the pressure and the temperature of the EV (evaporator) steam outlet, and the temperature of water supply distributing piping (near the water supply chamber) until 600 seconds after the turbine trip. The analysis results of these behaviors showed good agreement with the test results on parameter study of the blow efficiency (release coefficient.). It was found that RELAP5/3D with a two-fluid model of water/steam and a sodium fluid model for tube outside predicted well the physical behaviors: the void of steam generated by the depressurization boiling moves upward in the down-comer tubes accompanied by the enthalpy, increases the temperature of the water supply chambers; and that the pressure change of a “shoulder” like shape is induced by the mass balance between the steam mass generated in the down-comer tubes and the steam mass blown from the SG. The applicability of RELAP5/3D to the SG modeling was confirmed by the well simulation of the actual FBR system.Copyright © 2008 by ASME

Methods: We evaluated diastolic functional reserve in 108 patients with normal left ventricular ejection fraction (LVEF) ≥ 50% but abnormal relaxation (ratio of transmitral peak velocity of early and late diastolic flow (E/A)

Aims This study examined the impact of cardiac resynchronization therapy (CRT) by triangle ventricular pacing (Tri-V) on left ventricular (LV) function and dyssynchrony. Methods and results Twenty-one patients with NYHA class III or IV heart failure were studied. For Tri-V, two right ventricular (RV) leads were connected to the CRT device via a Y-connector with one lead anchored at the RV apex and the other at the RV outflow tract. The LV lead was positioned in the posterolateral or lateral cardiac vein. CRT with standard bi-ventricular pacing (Bi-V) was performed with the RV apical and LV leads. LV function was assessed by the measurement of LV positive d p /d t (d P /d t max) and cardiac output (CO). LV dyssynchrony was assessed using the standard deviation of the time to peak myocardial velocity during the systolic phase in 12 LV segments (Ts-SD) derived from tissue Doppler images. In comparison to Bi-V, Tri-V increased d P /d t max (baseline, 746 ± 165; Bi-V, 909 ± 186; Tri-V, 959 ± 195 mmHg/s, P = 0.04) and CO (baseline, 3.1 ± 1.0; Bi-V, 3.4 ± 1.1; Tri-V, 3.8 ± 1.2 L/min, P < 0.001), decreased Ts-SD (baseline, 54.0 ± 35.0; Bi-V, 33.6 ± 15.3; Tri-V, 22.4 ± 8.1 ms, P = 0.02). Conclusion The acute beneficial effects of Tri-V on LV function and dyssynchrony were greater than those of Bi-V.

Background. Pacemaker or implantable cardiovascular-defibrillator (ICD) leads may be a primary cause of symptomatic tricuspid regurgitation (TR). The aim of this study was to evaluate the utility of 3-dimensional echocardiography (3-DE) in identifying intracardiac routes of pacemaker or ICD leads in relation to TR. Methods. 3-DE examinations were performed to evaluate intracardiac lead routes from right atrium to ventricle and positions at the tricuspid valve in 73 patients: 53 patients with pacemaker and 20 patients with ICD. TR severity was assessed by 2-dimensional echocardiography and classified as mild, moderate, or severe based on the ratio of TR area to right atrium area. Results 3-DE identified the lead route and position at the tricuspid valve in 68 patients (93.1%). In the remaining 5 patients, an appropriate image could not be obtained due to artifacts caused by the lead. TR severity was classified as mild in 47 patients, moderate in 18 patients, and severe in 8 patients. In 7 of the 8 patients with severe TR, obstruction to tricuspid valve closing caused by the lead was identified (Figure ): obstruction of septal leaflet in 3 patients, posterior leaflet in 3 patients, and anterior leaflet in 1 patient. However, in all patients with mild to moderate TR, the lead was positioned at the annulus side between leaflets, and no closing obstruction was identified. Conclusion. 3DE can identify pacemaker or ICD lead route and position at the tricuspid valve and the obstruction to closing caused by the lead in patients with severe TR. Therefore, 3DE may be useful to evaluate the cause of severe TR in patients receiving a pacemaker or ICD.

Systemic right ventricular dysfunction is 1 of the late complications of the atrial switch operation for transposition of the great arteries. It has been reported that cardiac resynchronization therapy (CRT) for the failing systemic right ventricle (RV) improves symptoms and systolic function. However, patient selection for CRT in congenital heart disease is still challenging because the clinical standard for CRT in these patients is not established. We describe a case of successful implantation of a CRT device for a failing systemic RV aided by multimodality imaging and cardiac hemodynamic studies.

UNLABELLED Although an intraventricular filling delay has been observed in patients with a psuedonormalized transmitral flow pattern, little is known about the underlying hydrodynamic nature of this phenomenon. METHODS To examine those hydrodynamics, we studied every echocardiographic frame showing ventricular inflow (80 Hz) in the apical long-axis view and M-mode image using contrast echocardiography in 29 patients with a psuedonormalized pattern and in 26 normal controls. The velocity of the filling flow front (Vp), the ratio of Vp to E, and the mean radius of the vortices associated with the filling flow were measured. RESULTS In both groups, vortices were observed at the ridge of the mitral valve during acceleration of the E-wave. The mean radius of the vortices was greater in the pseudonormalized filling group than that in the control group (8 +/- 2 vs 3 +/- 1 mm, P < 0.0001). Vp was smaller in the pseudonormalized group than in the control group (36 +/- 6 vs 47 +/- 6 cm/sec, P = 0.0008). Vp/E was < 1 and smaller in the pseudonormalized group than that in the control group (0.46 +/- 0.13 vs 0.59 +/- 0.07, P = 0.014) and negatively correlated with the mean radius of the vortices (r = 0.54, P < 0.0001). CONCLUSIONS Contrast echocardiography identified uniform flow characteristics with blood in the filling flow front moving in well-developed vortices and resulting in a left ventricular filling delay in the impaired left ventricle in spite of an increased early transmitral flow velocity.

In order to develop a thermal-hydraulic model of the steam-generator (SG) to simulate transient phenomena in the sodium cooled fast breeder reactor (FBR) MONJU, Japan Nuclear Energy Safety Organization (JNES) verified the SG model using the RELAP5/MOD3 code against the results of the turbine trip test at a 40% power load of MONJU. The modeling by using RELAP5 was considered to explain the significant observed behaviors of the pressure and the temperature of the EV steam outlet, and the temperature of water supply distributing piping till 600 seconds after the turbine trip. The analysis results of these behaviors showed good agreement with the test results based on results of parameter study as the blow efficiency (release coef.) and heat transferred from the helical coil region to the down-comer (temperature heating down-comer tubes). It was found that the RELAP5/MOD3 code with a two-fluids model can predict well the physical situation: the gas-phase of steam generated by the decompression boiling moves upward in the down-comer tubes accompanied by the enthalpy increase of the water supply chambers; and that the pressure change of a “shoulder” like shape is induced by the mass balance between the steam mass generated in the down-comer tubes and the steam mass blown from the SG. The applicability of RELAP5/MOD3 to SG modeling was confirmed by simulating the actual FBR system.Copyright © 2006 by ASME

Many studies have reported the association between mitral annular calcification (MAC) and stroke. MAC has been speculated to be a direct embolic source of stroke. Recently, the association between MAC and atherosclerosis in the coronary artery, aorta, and carotid artery has been reported. This prospective study investigated the association between MAC and severity of carotid atherosclerosis in patients with symptomatic ischemic cerebral disease to evaluate the association between MAC and atherosclerosis as a cause of stroke.We studied 377 patients with ischemic cerebral disease (253 men, 124 women, mean age 68 +/- 11 years) who underwent echocardiography to determine the presence of MAC and carotid ultrasonography to determine the severity of carotid atherosclerosis. Plaque score was the sum of the maximum intimamedia thickness in the common carotid region, the bifurcation bulb region, and the internal carotid artery region, including both right and left arteries.MAC was found in 86 patients, and was more frequent in women, the elderly, and patients with diabetes or hyperlipidemia (p0.05). Plaque score was higher in patients with than without MAC (8.3 +/- 5.8 vs 5.2 +/- 5.2 mm, p0.001). Multivariate regression analysis identified MAC (r = 0.26, p0.0001), female sex (r = -0.12, p = 0.03), and age (r = 0.23, p0.0001) as independently associated with plaque score.MAC is independently associated with severity of carotid atherosclerosis in patients with symptomatic ischemic cerebral disease. This association suggests MAC may be indirectly related to cerebrovascular disease as a marker of the presence of progressive arteriosclerosis for thromboemboli causing stroke.

Few previous reports have described a sinus of Valsalva fistula without an aneurysm in Japanese patients. A single origin of the coronary arteries is a rare coronary anomaly. We describe a 75-year-old woman with a single origin of the coronary arteries and a sinus of Valsalva fistula without a typical aneurysm. Echocardiography showed turbulent flow from the right coronary sinus of Valsalva to the right ventricle throughout the cardiac cycle. Aortography confirmed the presence of a right coronary sinus of Valsalva-right ventricle shunt jet. Echocardiography and aortography demonstrated that there was no deformity of the sinus of Valsalva. Cardiac catheterization revealed that the left-to-right shunt rate was 29% and the Qp/Qs was 1.41. Aortography and coronary angiography did not identify a right coronary artery originating from the right sinus of Valsalva. Coronary angiography revealed that the right coronary artery arose from the proximal part of the left anterior descending artery and did not detect significant organic stenosis of the coronary artery. She was diagnosed as having a sinus of Valsalva to right ventricle fistula without an aneurysm, and a single origin of the coronary arteries.

Color Doppler propagation velocity (Vp) (color-Vp) has not yet been standardized, although it should be able to specifically reflect the intraventricular movements of left ventricular (LV) inflow. Because contrast echocardiography can depict a specified flow, we used this modality to standardize measurements of color-Vp of LV inflow.We performed contrast echocardiographic examinations in 100 patients (70 men, 30 women; age 53 +/- 12 years). Four types of color-Vp were measured: by the flow wave front method and by aliasing method using 3 aliasing velocity levels based on the peak velocity of early diastolic flow of transmitral flow. We also determined contrast echocardiographic Vp by M-mode imaging of LV inflow (contrast-Vp).Contrast-Vp and all 4 types of color-Vp could be compared in 86 patients. Contrast-Vp was significantly lower than color-Vp ( P.01), except for color-Vp measured at the aliasing level 50%peak velocity of early diastolic flow/= 40% (color-Vp 40). A close relationship was observed between contrast-Vp and color-Vp 40 ( r = 0.801, P.0001). Contrast-Vp and color-Vp 40 showed high ability to detect abnormal transmitral flow patterns according to receiver operating characteristics curves (area under curve for contrast-Vp, 0.94; for color-Vp 40, 0.90).Our results should be useful in standardization of color-Vp measurement to specifically reflect propagation of the fluid elements derived from LV inflow, with ability to distinguish LV filling abnormalities.

From Jan 2001 to Nov 2003, 12 patients receiving home oxygen therapy (HOT) underwent surgery under spinal anesthesia at Okayama Rosai Hospital. The basic diseases for HOT were emphysema (n=8), interstitial pneumonia (n=1), asthma (n=1) and lung cancer (n=1). Mean FEV1.0 and FVC were 0.85 l and 1.97 l, respectively. Mean PaO2 and PaCO2 were 76.5 mmHg and 45.5 mmHg, respectively, under nasal oxygen of 1.67 l x min(-1). Perioperative complications occured in 3 cases. In case 5, postoperative heart failure occured and was easily treated with diuretics. In case 8, intraoperative hypotension (systemic blood pressure less than 80 mmHg) occured. In case 12, the patient developed dyspnea because of high spinal anesthetic level of T1. She was not intubated because PaO2, PaCO2 and pH were not deteriorated. Perioperative PaO2, PaCO2 and pH were stable and there were no pulmonary or morbid complications in all cases. It is important to assess not only pulmonary function but also cardiovascular status by echocardiography and general physical status by Hugh-Jones classification in order to avoid severe complications.

We report a case of epidural hematoma after a single epidural block. The patient was a 67-year-old woman with sciatica and osteoarthritis of the spine. She had no coagulopathy. She underwent a single epidural block without difficulty 3 times in 5 days. She had a lumbar MRI for an examination of the spine 4 days after the final epidural block. Subacute epidural hematoma of 0.8 x 1.5 x 3.0 cm was revealed on MRI at L 3-4. She had no new neurological symptoms. MRI 1 month later revealed a resolution of the hematoma. Epidural hematoma after an epidural block might occur in an outpatient with no bleeding tendency.

Although color Doppler M-mode propagation velocity (Vp) is preload-independent, the variation in Vp with the temporal variation of preload in the clinical setting has not been evaluated. Because left ventricular filling pressure changes dramatically with treatment of congestive heart failure (CHF), we hypothesized that preload-dependent variations in Vp occur with treatment of CHF.We performed Doppler echocardiographic and hemodynamic evaluation in 24 patients with CHF (15 men, 62 +/- 10 years) at initial presentation (baseline study) and after CHF had improved with therapy (second study).The interval between the baseline and the second study was 48.6 +/- 21.5 hours. Vp decreased between the baseline study (41 +/- 5 cm/s) and the second study (28 +/- 5 cm/s, P.0001). Only the change in pulmonary capillary wedge pressure (-8.3 +/- 3.3 mm Hg) between the baseline and second study was an independent predictor of the change in Vp (-12.5 +/- 5.9 cm/s) by stepwise linear regression (r = 0.68, P =.0002).Vp decreases significantly with decreases in pulmonary capillary wedge pressure with the treatment of CHF. The preload-dependent variation should be taken into account in the assessment of Vp in patients with CHF.