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Recently, due to increases in the number of cardiac device implantations, especially implantable cardioverter-defibrillators and cardiac resynchronization therapy, device complications have been experienced more frequently. Myocardial perforation of an implanted lead is one of the most severe complications. We report a case of ventricular lead perforation clearly visualized by 3-dimensional echocardiography, which was not identified by 2-dimensional echocardiography.

"Takotsubo" cardiomyopathy is characterized by transient left ventricular dysfunction. We have reported a case of "Takotsubo" cardiomyopathy unrecognized during anesthesia because of no ischemic changes in monitored electrocardiogram (ECG). The patient was an 80-year-old woman undergoing open reduction surgery for fractures of the left tibia and ulna. Anesthesia was maintained with O2, N2O, sevoflurane and fentanyl. Sinus tachycardia was noted throughout anesthesia which was unresponsive to fluid loading and blood transfusion. ECG of limb leads showed no ST-T changes or abnormal Q waves and the blood pressure was stable during anesthesia. Postoperative echocardiography showed extensively decreased left ventricular wall motion with akinesis of the anterior wall and anterior septum from the mid-papillary level to apex. ECG showed negative T waves in V2-V6 without abnormal Q waves or ST changes. The increase in CPK-MB was very little. The abnormal left ventricular wall motion was completely recovered on the third postoperative day. Her perioperative cardiac event was diagnosed as "Takotsubo" cardiomyopathy by reversible ampulla-shaped ventricular dysfunction. She had no symptoms throughout the perioperative period and recovered without any sequela.

To investigate relationships between carotid arterial intima-media thickness (IMT) and age in childhood, we performed high-resolution carotid arterial ultrasonography in 60 healthy children (27 boys, 33 girls; age range, 5-14 years) determined by screening to have no dyslipidemia or hypertension. No plaque formation was found, and irregularity of IMT (root mean square roughness of IMT) did not correlate with age. Mean IMT increased in a linear manner with age [IMT in millimeters = (0.009 x age in years) + 0.35] ( r = 0.39, P = 0.002). This correlation remained significant after adjustment for gender, parental smoking, systolic and diastolic blood pressure, body mass index, and serum concentrations of low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, and triglycerides. None of these known cardiovascular disease risk factors in adults had a significant relationship with age-adjusted IMT in children. While circumferential wall stress and diastolic blood pressure were not correlated with age, mean IMT and lumen diameter showed significant positive relationships with circulating blood volume, which was calculated as the function of height and weight. These data suggested that age-dependent physiologic thickening of arterial walls begins in childhood.

Noninvasive ultrasonographic assessment of carotid artery intima-media thickness (IMT) can improve risk stratification for coronary artery disease (CAD) in certain patients. Several measurements have been used to evaluate carotid atherosclerosis by ultrasonography. Although it has been reported that angiographic arterial irregularities correlate with pathologic changes of atherosclerosis and the occurrence of cardiovascular events, only a few studies have assessed carotid arterial wall irregularity by ultrasonography. The purpose of this study was to evaluate the irregularity of IMT quantitatively, and its association with the presence or absence of CAD. The correlation of maximum and mean IMT values, and IMT irregularity with the presence or absence of CAD, was investigated in 90 patients who had undergone coronary angiography. IMT was measured by manual tracking of the far wall of the common carotid arteries, carotid bulbs, and internal carotid arteries. The IMT irregularity was defined as the root mean square (RMS) difference between each IMT and averaged IMT. Multiple logistic regression analysis, after adjustment for coronary risk factors, indicated that the RMS difference was a more accurate predictor of CAD than were the mean or maximum IMT values. These results indicate that the evaluation of IMT irregularity by ultrasonography is a useful predictor for the presence of coronary atherosclerosis.

We gave propofol anesthesia to a patient with limb-girdle type of progressive muscular dystrophy. A 42 year-old male was to have skin graft for third degree burn. His respiratory function test showed %VC of 73.6% and %FEV1.0 of 107.6%. Arterial blood gas data were within normal ranges. He was anesthetized with propofol, fentanyl, vecuronium and nitrous oxide. During position change, Wenckebach type of second degree AV block occurred. AV block returned to sinus rhythm easily by injection of ephedrine hydrochloride and atropine sulfate, and reduction of propofol infusion rate. There were no perioperative respiratory complications and no clinical manifestations of malignant hyperthermia. Propofol anesthesia is suitable for limb-girdle type of progressive muscular dystrophy, because of very little possibility of triggering malignant hyperthermia, rapid awaking, minimal residual effects of the respiratory system, and easiness in controlling anesthetic depth.

The present study was performed to determine whether a multilineal regression model based on the early diastolic transmitral flow peak velocity (E) and the propagation velocity of early diastolic inflow (PV) could estimate the pulmonary capillary wedge pressure (PCWP). PCWP and Doppler variables were simultaneously recorded in 30 patients. PCWP was estimated by multilinear regression analysis using E and PV. The predictive accuracy of the equation obtained from the analysis was tested prospectively in a separate group of 65 patients divided into 3 groups: left ventricular (LV) systolic dysfunction (Group A), LV hypertrophy (Group B), and preserved systolic function without hypertrophy (Group C). The initial results obtained in groups B and C, respectively, were: r=0.77; r=0.81. These results indicate that a multilinear regression model based on E and PV is a noninvasive method of accurately estimating PCWP in a variety of cardiac disease states. (Jpn Circ J 2001; 65: 33 - 39)

Purpose: Controversy exists regarding prognosis in Paradoxical Low Flow Low Pressure Gradient (PLFLPG) severe Aortic Stenosis (AS) despite normal Left Ventricular Ejection Fraction (LVEF). Little is known about conversion rate from low Pressure Gradient (PG) to high PG during longitudinal study and its impact on prognosis. Methods: Among 220 patients with severe PLFLPG AS (indexed aortic valve area 50%), we selected 86 patients who had received more than 2 echo examinations at least 6 months apart. Patients were followed up, and Cardiac Death (CD) and Major Cardiovascular Events (MACEs), including CD, aortic valve replacement, non-fatal myocardial infarction and congestive heart failure were determined. Results: During a follow up for a median of 720 days from the first echo study, 2 patients died due to CD, and 14 patients developed MACEs. After a mean of 419 days from the first to the second echo examinations, 67 patients (78%) still remained low PG status and other 19 patients (22%) converted from low PG to high PG AS. Although no significant difference of CD was noted between the two groups, MACE was significantly higher in high PG group compared to low PG group. ![Figure][1] MACE-free survival of HPG/LPG group Conclusions: Overall, prognosis in Japanese patients with PLFLPG severe AS seems to be better compared to Western patients. However, conversion from low PG to high PG status occurred in 1/4 of patients during follow up, and this was associated with poorer prognosis. [1]: pending:yes

Left ventricular (LV) systolic wall strain is one of the new candidates for the prognostic indicator for the hypertensive heart failure. However, it is still unclear what underlying transmural structural remodeling corresponds strain abnormality in progression of hypertensive heart failure. Objective and methods: To investigate the relationship between the structural change and myocardial strain, 60 Dahl salt-sensitive rats fed a high-salt (HF-group) or a low-salt diet (Control-group) from 6-weeks age. Pressure-volume relationship was analyzed and lung weight was measured at 10, 14, and 18 weeks of age and assessed the heart failure stage. In each stage, transmural distribution of LV myocardial fiber angle, fibrosis, and myocyte hypertrophy were evaluated pathologically and related mRNA quantification were performed. LV global longitudinal (GLS) and circumferential strain (GCS) were measured using 2D speckle tracking echocardiography. Results: While, Emax was preserved throughout the study period, tau and EDPVR indicated progressive deterioration from 14 weeks (diastolic dysfunction stage). And lung weight was significantly increased at 18 weeks (decompensated stage). Myocardial fiber orientation did not change as disease progress. Fibrosis-area% in histology and collagen type I/ type III mRNA ratio were significantly elevated in subendocardial-layer at 14 weeks and propagated into mid-layer at 18 weeks. Myocyte hypertrophy and mRNA of embryonic type -myosin heavy chain increased in subendocardial-layer at 14 weeks and progress into mid-layer at 18 weeks. In compared to control-group, HT-group showed progressively deteriorated GLS at 14 weeks (-27±4% in control, -17±3% in HT-group, p

Purpose: Left Atrial Volume (LAV) is a robust index for predicting future prognosis in various clinical scenarios. However, its prognostic value in Aortic Stenosis (AS) has not been determined in a large patient population. Methods: To address this, 509 severe AS (indexed aortic valve area 50%) were enrolled from 4 Japanese cardiovascular centers. LAV at end-systole was determined by 2D biplane Simpson's method. Values were indexed to body surface area (LAVImax). All patients were followed up to determine cardiovascular death, aortic valve replacement (AVR) and Major Cardiovascular Events (MACEs). Results: Mean value of LAVImax was 45.8±18.3ml/m2. During a median of 364 days of follow up, 29 cardiac death, 217 MACEs and 175 AVR were developed. Using receiver-operating characteristic analysis, LAVImax≥52.3ml/m2 had 69% sensitivity and 72% specificity for predicting cardiac death (AUC=0.71, p

Purpose: In patients with repaired tetralogy of Fallot (ToF), right ventricular (RV) dilation and dysfunction caused by residual pulmonary regurgitation are associated with their prognosis. In contrast, left ventricular (LV) function has been focused as a novel determinant of prognosis in patients with repaired ToF. Although RV-LV interaction may cause LV dysfunction in patients with repaired ToF, the mechanism of LV dysfunction has been poorly understood. Then, we aimed to assess LV regional myocardial function through consideration of interaction with RV properties. Methods: Subclinical 32 patients with rToF (17male, 17.5yrs, range 13.5-21yrs) and 20 control subjects (9male, 11.5 yrs, range 9-13yrs) were enrolled. We examined an echocardiographic examination at the time of scheduled outpatients clinic appointment and were in sinus rhythm at the presentation. All cases were Japanese, and QRS durations were measured from the standard 12-lead electrocardiogram. RV and LV volume index (ml/m2) were measured with 3-dimensional echocardiographic system. Pulmonary regurgitation fraction (PRF) was calculated by volumetric method (RV stroke volume – LV stroke volume/RV stroke volume). Left atrium area (LA) and velocity ratio of early mitral flow to mitral ring (MV E/E') were measured for evaluation of LV diastolic function. LV longitudinal strain (LS), radial strain (RS), circumferential strain (CS) and RV-LS were assessed by 2-dimmensinal speckle tracking echocardiography. Results: QRS duration was significantly longer (114±29.7 vs 85.3±12.2, p

Tachycardia induced cardiomyopathy is a well-known form of reversible cardiac dysfunction; however, the effect of maintaining sinus rhythm by a radiofrequency catheter ablation (RFCA) in patients with impaired cardiac function and adequately rate-controlled atrial fibrillation (AF) is unclear. Six patients (54±9 years old, 5 men) with drug-resistant persistent AF (lasting 21±14 months) combined with dilated cardiomyopathy (DCM) had suffered from heart failure for more than one year in spite of an adequate ventricular rate control (

BackgroundWhether the prognosis of paradoxical low-gradient severe aortic stenosis (PLG-SAS), especially due to paradoxical low-flow low-gradient SAS (PLFLG-SAS), is malignant in any specific ethnicity, including Japanese, remains unclear.MethodsWe retrospectively enrolled 385 consecutive Japanese patients (age, 76±8 years; 148 men) with moderate AS [MAS: 0.6≤indexed aortic valve area (iAVA)

Background To determine an appropriate M-mode method in assessing left ventricular (LV) dyssynchrony in left bundle branch block (LBBB), and to assess feasibility of the method to predict cardiac resynchronization therapy (CRT) responses. Methods and results Fifty-one patients with LBBB were enrolled. Among them 31 patients underwent CRT. In addition to original septal to posterior wall motion delay (SPWMD), first peak-SPWMD was proposed as time of difference between the first septal displacement and the maximum displacement of the posterior. If an early septal point was not present, anatomical M-mode was used to visualize an early septal displacement spreading scan-area until inferoseptal wall. CRT responders were defined as LV end-systolic volume reduction (>15%) at 6 months after CRT. Twenty patients (65%) were identified as CRT responders. First peak-SPWMD in responders was significantly higher than those in nonresponders, although SPWMD did not differ between groups. Strong predicting ability of first peak-SPWMD was revealed (first peak-SPWMD: 80/90/83%; SPWMD: 35/100/58%), and area under the curve in receiver operating characteristic analysis of first peak-SPWMD (0.88) was significantly higher than that of SPWMD (0.61) ( p Conclusion In patients with LBBB, time differences between early septal and delayed displacement of posterolateral wall on M-mode images were the appropriate dyssynchrony parameter, and could improve the predictive ability for CRT responses.