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Objective Our aim was to investigate the impact of the sodium glucose cotransporter type 2 (SGLT2) inhibitor on the left ventricular (LV) diastolic function in type 2 diabetes mellitus (T2DM) patients with chronic heart failure (HF) complicating cardiovascular risk factors. Methods We analyzed data from our previous prospective multicenter study, in which we investigated the effect of dapagliflozin on the LV diastolic function of T2DM patients with stable HF at five institutions in Japan. Patients who had been taking at least 1 antidiabetic drug other than SGLT2 inhibitors started treatment with dapagliflozin. Echocardiography was performed at baseline and six months after the administration of dapagliflozin. Cardiovascular risk factors other than T2DM were age, gender, hypertension, dyslipidemia, history of cardiovascular events and overweight. Results The LV diastolic function, defined as the ratio of the mitral inflow E to the mitral e' annular velocities (E/e'), significantly decreased from 9.3 to 8.5 by six months after the administration of dapagliflozin (p=0.020) as previously reported. A multivariate logistic regression analysis showed that dyslipidemia was the only independent determinant of improvement in the E/e' after the administration of dapagliflozin among cardiovascular risk factors. Furthermore, the relative change in the E/e' from baseline to six months after the administration of dapagliflozin for HF patients with preserved ejection fraction (HFpEF) and dyslipidemia was significantly larger than that for HFpEF patients without dyslipidemia (-15.2% vs. 29.6%, p=0.014), but no such finding was observed in non-HFpEF patients. Conclusion SGLT2 inhibitors may exert a more beneficial effect on the LV diastolic function for T2DM patients with stable HF, especially those with complicating dyslipidemia, than existing treatments.

The aim of this study was to investigate the association of type 2 diabetes mellitus (T2DM) with the development of new-onset atrial fibrillation (AF) for non-ischemic dilated cardiomyopathy (DCM) patients. We also tested the hypothesis that sodium glucose cotransporter type 2 (SGLT2) inhibitors reduce the risk of development of new-onset AF for non-ischemic DCM patients. We retrospectively studied 210 patients with non-ischemic DCM and sinus rhythm, mean age of 59.0 ± 16.7 years and left ventricular ejection fraction of 31.0 ± 8.2% (all

This study aimed to test the hypothesis that left ventricular dyssynchrony may negatively affect left atrial (LA) dyssynchrony and reservoir function, and cardiac resynchronization therapy (CRT) may improve LA function. It also assessed, whether residual LA dyssynchrony affects the prognosis in patients with heart failure with reduced ejection fraction (HFrEF). Ninety subjects were included: 40 HFrEF patients with a wide-QRS complex (≧130 ms), 28 HFrEF patients with a narrow-QRS, and 22 normal controls. LA global longitudinal strain (LA-GLS) and LA dyssynchrony were quantified by speckle-tracking strain analysis. LA dyssynchrony was defined as the maximal difference of time-to-peak strain (LA time-diff). All patients with a wide-QRS underwent CRT, and event-free survival was tracked for 24 months. At baseline, LA dyssynchrony was significantly more pronounced in patients with a wide-QRS HFrEF (342 ± 126 ms) than that in patients with a narrow-QRS (236 ± 127 ms, P < 0.001) and controls (186 ± 78 ms, P < 0.001). Six months after CRT, LA-GLS significantly improved from 11.9 ± 4.7 to 19.6 ± 10.1% (P < 0.05) and LA time-diff was reduced from 338 ± 123 to 245 ± 141 ms (P < 0.05) in responders only. Patients with an LA time-diff < 202 ms and those with an LA-GLS ≧14.6% six months after CRT showed significantly better outcomes than the others (P < 0.05, respectively). Among the responders, those with an LA time-diff < 202 ms after CRT showed a better prognosis than others (P < 0.05). CRT improved LA dyssynchrony and reservoir function through the improved left ventricular coordination. Reduced LA dyssynchrony and improved LA reservoir function after CRT lead to better outcomes.

Funding Acknowledgements Type of funding sources: None. Background Type 2 diabetes mellitus (T2DM) is a well-known risk factor for heart failure (HF), even in patients without a structural heart disease or a symptom of HF. Diabetes-related cardiomyopathy is presented as an left ventricular (LV) diastolic dysfunction, which, like cardiovascular disease, is a contributor of the development of HF in both patients with reduced ejection fraction (HFrEF) and with preserved ejection fraction (HFpEF). Furthermore, comorbid factors other than T2DM also have been identified as high risk factors for of progression to HF. Dapagliflozin is a sodium glucose cotransporter type 2 (SGLT2) inhibitor, and represents a new class of anti-hyperglycemic agents for T2DM. A result from a recent large clinical trial showed that dapagliflozin reduced risk of worsening HF or death from cardiovascular causes for patients with HFrEF compared to those who received a placebo, regardless of the presence or absence of T2DM. However, the effect of SGLT2 inhibitors on LV diastolic function in T2DM patients with HF who had cardiovascular risk factors other than T2DM remains uncertain. Purpose Our purpose was to investigate the impact of dapagliflozin on LV diastolic function in T2DM patients with stable HF complicating cardiovascular risk factors. Methods We analyzed data from our previous prospective multicenter study, which investigate the effect of dapagliflozin on LV diastolic function of 53 T2DM patients with stable HF at five institutions in Japan. Patients who had been taking at least one antidiabetic drugs other than SGLT2 inhibitor started the administration of dapagliflozin. Cardiovascular risk factors other than T2DM was determined as age, gender, hypertension, dyslipidemia, history of cardiovascular events and overweight. Results E/e′ significantly decreased from 9.3 to 8.5 cm/s 6 months after administration of dapagliflozin (p = 0.020) as previously described. Multivariate logistic regression analysis showed that dyslipidemia was the only independent determinant of an improvement of E/e’ among cardiovascular risk factors. Furthermore, relative changes in E/e’ from baseline to 6 months after administration of dapagliflozin seen in HFpEF patients with dyslipidemia were significantly larger than those in HFpEF patients without dyslipidemia (-15.2% vs. 29.6%, p = 0.014), but such a difference was not observed in non-HFpEF patients. In addition, relative changes in high-density lipoprotein cholesterol (HDL-C) from baseline to 6 months after administration of dapagliflozin had significant correlation with those in E/e’ (r=-0.300, p = 0.038). However, such correlations were not observed in low-density lipoprotein cholesterol (LDL-C) and triglyceride (r = 0.05, p = 0.72 and r = 0.05, p = 0.73). Conclusion: Dapagliflozin was more beneficial effect on LV diastolic function for T2DM patients with stable HF, especially those with complicating dyslipidemia. Our findings may thus offer a new insight into the management of T2DM patients with HF. Abstract Figure.

Funding Acknowledgements Type of funding sources: None. Background The structural remodeling of the left atrium (LA) has been proposed as an important determinant of adverse outcomes in patients with heart failure (HF). However, little is known about the potential impact of LA mechanical dyssynchrony on its reservoir function and the prognosis of patients with HF. In addition, it has not been fully investigated whether cardiac resynchronization therapy (CRT) is also beneficial to LA function. Purposes The purposes of this study were to test whether left ventricular (LV) dyssynchrony may negatively affect LA synchronicity and reservoir function, and to assess whether residual LA dyssynchrony after CRT affects the prognosis in patients with HF with reduced ejection fraction (HFrEF). Methods This study included total of 90 subjects: 40 HFrEF with a wide-QRS complex (≧130 ms), 28 HFrEF with a narrow-QRS, and 22 age- and sex-matched normal controls. LA global longitudinal strain (LA-GLS) and LA dyssynchrony were quantified using speckle-tracking strain analysis. LA dyssynchrony was defined as the maximal difference of time-to-peak strain (LA time-diff). All wide-QRS HFrEF received CRT, and event-free survival was tracked for 24 months. Results At baseline, HFrEF patients showed significant LA remodeling coupled with the reduced LA reservoir function, as evidenced by larger LA volume index (LAVi: 46 ± 16 vs. 30 ± 14 mL/m², P 14.6% after CRT exhibited significantly favorable event-free survival than the others (P Conclusions The improved LV coordination by CRT also resulted in resynchronization of discoordinated LA wall motion and a consecutive improvement of LA reservoir function, which ultimately lead to the favorable outcome for HFrEF patients with wide-QRS complex. Abstract Figure.

BACKGROUND Left ventricular end-systolic volume (LVESV) changes at 6 months and clinical status are useful for assessing responses to cardiac resynchronization therapy (CRT). Regression of the LVESV following CRT has not been described beyond 6 months. This study aimed to assess the proportion, predictors, and clinical outcomes of responders whose LVESVs had regressed. METHODS We retrospectively analyzed 104 consecutive CRT patients. A responder was defined as a patient with a relative reduction in the LVESV ≥15% at 6 months after CRT. Fifty-six responders participated in this study. A transient responder was defined as a responder without a relative reduction in the LVESV ≥15% at 2 years after CRT or who died of cardiac events during the 24-month follow-up period. RESULTS Of the 56 responders, 16 (29%) were transient responders. Multivariable logistic regression analysis showed that chronic atrial fibrillation (odds ratio [OR] = 19.2, 95% confidence interval [CI] [1.93, 190], P = 0.012) and amiodarone usage (OR = 60.9, 95% CI [4.18, 886], P = 0.003) were independent predictors of transient responses. Hospitalizations for heart failure were significantly higher among the transient responders than among the lasting responders during a mean follow-up period of 7.6 years (log-rank P < 0.001), and all-cause mortality tended to be higher among the transient responders (log-rank P = 0.093). CONCLUSIONS One-third of the responders were transient responders at 2 years after CRT, and their long-term prognoses were poor. Careful attention should be paid to maintain the reduction in LVESV especially in patients with chronic AF.

The coronary sinus is located within the inferior pyramidal space, which is the part of the epicardial visceral fibroadipose tissue wedging between the four cardiac chambers from the bottom of the heart. Therefore, this region is susceptible to the morphological changes of the cardiac chambers. We present a case of slit-like deformation of the coronary sinus orifice due to compression of the inferior pyramidal space by the severely dilated left ventricle, which has not been previously described.

Background Current guidelines recommend the routine use of tricuspid annular plane systolic excursion (TAPSE) as a simple method for estimating right ventricular (RV) function. However, when ventricular apical longitudinal rotation (apical-LR) occurs in pulmonary hypertension (PH) patients, it may result in overestimated TAPSE. Methods We studied 105 patients with PH defined as mean pulmonary artery pressure >25 mmHg at rest measured by right heart cardiac catheterization. TAPSE was defined as the maximum displacement during systole in the RV-focused apical four-chamber view. RV free-wall longitudinal speckle tracking strain (RV-free) was calculated by averaging 3 regional peak systolic strains. The apical-LR was measured at the peak rotation in the apical region including both left and right ventricle. The eccentricity index (EI) was defined as the ratio of the length of 2 perpendicular minor-axis diameters, one of which bisected and was perpendicular to the interventricular septum, and was obtained at end-systole (EI-sys) and end-diastole (EI-dia). Twenty age-, gender-, and left ventricular ejection fraction-matched normal controls were studied for comparison. Results The apical-LR in PH patients was significantly lower than that in normal controls (−3.4 ± 2.7° vs. −1.3 ± 1.9°, P = 0.001). Simple linear regression analysis showed that gender, TAPSE, EI-sys, and EI-dia/EI-sys were associated with apical-LR, but RV-free was not. Multiple regression analysis demonstrated that gender, EI-dia/EI-sys, and TAPSE were independent determinants of apical-LR. Conclusions TAPSE may be overestimated in PH patients with clockwise rotation resulting from left ventricular compression. TAPSE should thus be evaluated carefully in PH patients with marked apical rotation.

Background Type 2 diabetes mellitus (T2DM) has come to be considered an independent predictor of mortality, and also a contributor to the development of heart failure (HF) with reduced ejection fraction (HFrEF) and with preserved ejection fraction (HFpEF). Left ventricular (LV) longitudinal myocardial dysfunction as assessed in terms of lower global longitudinal strain (GLS), has been identified even in T2DM patients with preserved LV ejection fraction (LVEF), and should be considered the first marker of a preclinical form of DM-related cardiac dysfunction, leading to HFpEF. Sodium glucose cotransporter type 2 (SGLT2) inhibitors represent a new class of anti-hyperglycemic agents for T2DM, but the effect of SGLT2 inhibitors on LV longitudinal myocardial function in T2DM patients with HF remains uncertain. To examine this effect, as well as the association of LV longitudinal myocardial function with LV diastolic function after administration of SGLT2 inhibitor in T2DM patients with stable HF, we analyzed data from our previous prospective multicenter study, in which we investigated the effect of SGLT2 inhibitor on LV diastolic functional parameters of T2DM patients with stable HF at five institutions in Japan. Methods Our previous trial was a prospective multicenter study of 58 T2DM patients with stable HF at five institutions in Japan. Patients who had been taking at least one antidiabetic drugs other than SGLT2 inhibitors started the administration of 5 mg/day of dapagliflozin. Echocardiography was performed at baseline and 6 months after administration of dapagliflozin. LV diastolic function was defined as the ratio of mitral inflow E to mitral e' annular velocities (E/e'). LV longitudinal myocardial function was assessed as GLS based on the current guidelines. Results E/e' significantly decreased from 9.3 to 8.5 cm/s 6 months after administration of dapagliflozin (p=0.020) as previously described, while GLS showed significant improvement from 15.5±3.5% to 16.9±4.1% (p Conclusion Dapagliflozin was found to be associated with improvement of LV longitudinal myocardial function, which led to further improvement of LV diastolic function of T2DM patients with stable HF. GLS-guided management may thus lead to improved management of T2DM patients with stable HF. Representative case Funding Acknowledgement Type of funding source: None

Background The objective of this study was to investigate the impact of sodium glucose cotransporter type 2 (SGLT2) inhibitors on left ventricular (LV) diastolic function of type 2 diabetes mellitus (T2DM) patients with heart failure (HF). Methods This trial was a prospective multicenter study of 58 T2DM patients with stable HF at five institutions in Japan. Patients who had been taking at least one antidiabetic drugs other than SGLT2 inhibitors started the administration of 5 mg/day of dapagliflozin. The physical examinations, blood tests, and echocardiography were performed at baseline and 6 months after administration of dapagliflozin. The primary endpoint was defined as a change in mitral inflow E and mitral e′ annular velocities (E/e′) between baseline and 6 months after the administration of dapagliflozin. The secondary end points consisted of a change in brain natriuretic peptide (BNP), LV mass index (LVMI) and left atrial volume index (LAVI). Results E/e′ significantly decreased from 9.3 to 8.5 cm/s (p = 0.020) 6 months after administration of dapagliflozin. LAVI and LVMI significantly decreased from 31 to 26 mL/m2 (p = 0.001), and from 75.0 to 67.0 g/m2 (p Conclusion This prospective multicenter trial showed the beneficial effect of SGLT2 inhibitors on LV diastolic functional parameters for T2DM patients with HF. Our findings may thus offer a new insight into the management of T2DM patients. Trial registration UMIN000019789, Registered 28 September 2014, Date of registration: 11/14/2015, Date of enrolment of the first participant to the trial: 6/15/2016, Date of enrolment of the last participant to the trial: 12/9/2017

Background: The leg-positive pressure maneuver can safely and noninvasively apply preload stress without increase in total body fluid volume. The purpose of this study was to determine whether preload stress could be useful for risk stratification of patients with heart failure with reduced ejection fraction. Methods and Results: For this study, 120 consecutive patients with heart failure with reduced ejection fraction were prospectively recruited. The stroke work index was estimated as product of stroke volume index and mean blood pressure, and the E/e′ ratio was calculated to estimate ventricular filling pressure. The echocardiographic parameters were obtained both at rest and during leg-positive pressure stress. During the median follow-up period of 20 months, 30 patients developed adverse cardiovascular events. During preload stress, stroke work index increased significantly (from 3280±1371 to 3857±1581 mm Hg·mL/m 2 ; P P 2 ; P =0.70) and a serious increase in E/e′ ratio (from 19±11 to 25±14; P P 2 increase; P =0.001) and in E/e′ (hazard ratio: 2.58 per 5-U increase; P Conclusion: Contractile reserve and diastolic reserve during leg-positive pressure stress are important determinants of cardiovascular outcomes for patients with heart failure with reduced ejection fraction.

The use of β-blockers has improved the prognosis of dilated cardiomyopathy (DCM) and the appearance of left ventricular (LV) reverse remodeling is generally thought to result in a more favorable prognosis. While there are many prognostic predictors, not all of them are applicable to individual patients. Global circumferential strain (GCS) was identified as a powerful prognostic marker, which appears to be a better parameter than LV global function for patients with depressed left ventricular (LV) ejection fraction. Seventy consecutive patients with newly-diagnosed DCM with LVEF of 28 ± 8 % (all

Background:Left ventricular (LV) dyssynchrony has emerged as an important mechanism contributing to the patient’s response to cardiac resynchronization therapy (CRT), but other potential factors, especially LV myocardial viability, are also influential.Methods and Results:We studied 132 patients undergoing CRT. LV dyssynchrony was determined by anteroseptal-to-posterior wall delay on the mid-LV short-axis view using 2-dimensional speckle-tracking radial strain (≥130 ms as significant). Global circumferential strain (GCS), considered as a parameter of LV intrinsic myocardial function, was also determined as the peak GCS from the same view. Long-term follow-up was tracked over 40 months. Kaplan-Meier analysis indicated that patients with GCS >3.9% experienced fewer cardiovascular events overall (log-rank P=0.034). Similarly, patients with GCS >3.9% and ≥6.6% experienced fewer cardiovascular events than those with GCS ≤3.9% and

The objective of this study was to investigate the impact of sodium glucose cotransporter type 2 (SGLT2) inhibitors on left ventricular (LV) diastolic function of type 2 diabetes mellitus (T2DM) patients with heart failure (HF). This trial was a prospective multicenter study of 58 T2DM patients

Postoperative atrial fibrillation (POAF) is associated with increased risk of embolic events and heart failure, but its associated factors remains unknown. Left atrial (LA) subclinical mechanical dysfunction caused by the acute stress of surgery may be clinically manifested as POAF. The purpose of our study was therefore to test the hypothesis that preoperative LA subclinical myocardial dysfunction is a potential predictor of development of POAF in patients with aortic stenosis (AS). We studied 27 patients with severe AS undergoing aortic valve replacement (AVR) with left ventricular (LV) ejection fraction of 63 ± 11 %. All patients were in sinus rhythm and had no history of atrial fibrillation (AF). LA reservoir (SR-LAs), conduit (SR-LAe), and booster-pump (SR-LAa) functions were determined as the averaged global LA speckle-tracking longitudinal strain rates from apical four- and two-chamber views. POAF, defined as any episode of AF within 30-day after AVR, was observed in 15 patients (56 %). There were no differences in clinical characteristics, LA and LV volumes, and global LV function between patients with and without POAF. Multivariate logistic regression analysis identified SR-LAa as the only independent predictor of POAF. Furthermore, SR-LAa >0.79 s−1 predicted POAF with 60 % sensitivity, 92 % specificity, and area under the curve of 0.828 (p < 0.0001). Of the 15 patients with POAF, one developed paroxysmal AF during long-term follow-up. In conclusions, SR-LAa helped to detect subtle LA booster-pump dysfunction and was associated with new-onset POAF in patients with severe AS. These findings may be useful for risk stratification and management of such patients.

Left ventricular end-systolic volume (LVESV) changes at 6 months and clinical status are useful for assessing responses to cardiac resynchronization therapy (CRT). Regression of the LVESV following CRT has not been described beyond 6 months. This study aimed to assess the proportion, predictors, and clinical outcomes of responders whose LVESVs had regressed.We retrospectively analyzed 104 consecutive CRT patients. A responder was defined as a patient with a relative reduction in the LVESV ≥15% at 6 months after CRT. Fifty-six responders participated in this study. A transient responder was defined as a responder without a relative reduction in the LVESV ≥15% at 2 years after CRT or who died of cardiac events during the 24-month follow-up period.Of the 56 responders, 16 (29%) were transient responders. Multivariable logistic regression analysis showed that chronic atrial fibrillation (odds ratio [OR] = 19.2, 95% confidence interval [CI] [1.93, 190], P = 0.012) and amiodarone usage (OR = 60.9, 95% CI [4.18, 886], P = 0.003) were independent predictors of transient responses. Hospitalizations for heart failure were significantly higher among the transient responders than among the lasting responders during a mean follow-up period of 7.6 years (log-rank P0.001), and all-cause mortality tended to be higher among the transient responders (log-rank P = 0.093).One-third of the responders were transient responders at 2 years after CRT, and their long-term prognoses were poor. Careful attention should be paid to maintain the reduction in LVESV especially in patients with chronic AF.

The coronary sinus is located within the inferior pyramidal space, which is the part of the epicardial visceral fibroadipose tissue wedging between the four cardiac chambers from the bottom of the heart. Therefore, this region is susceptible to the morphological changes of the cardiac chambers. We present a case of slit-like deformation of the coronary sinus orifice due to compression of the inferior pyramidal space by the severely dilated left ventricle, which has not been previously described.

Since cardiac sarcoidosis (CS) leads to substantial morbidity and sudden death, early diagnosis and appropriate management are crucial for patients with CS. Echocardiography used to be considered a useful diagnostic tool for patients with CS, but CS may clinically present as dilated cardiomyopathy (DCM). Our objective was to investigate whether a novel three-dimensional (3-D) speckle-tracking strain can identify patients with CS more accurately. We studied 23 CS patients with an ejection fraction (EF) of 46 ± 10 %, and 16 EF-matched patients with DCM (EF 45 ± 11 %). Global radial (GRS), circumferential (GCS) and longitudinal (GLS) strain was assessed using 3-D speckle-tracking system. GRS of patients with CS was significantly lower than that of patients with DCM (18.5 ± 8.4 vs. 28.5 ± 8.3 %, p < 0.01), but GCS and GLS in patients with CS and DCM were similar. GRS ≦ 21.1 could differentiate CS from DCM with a sensitivity of 70 %, specificity of 88 % and area under the curve of 0.79. An additional noteworthy findings was that, patients with CS showed more negative radial strain curves than did those with DCM (1.7 ± 2.3 vs. 0.1 ± 0.5, p < 0.01). In conclusion, 3-D speckle-tracking radial strain shows good potential to distinguish CS from DCM. Our observations can thus be expected to have clinical implications for management of CS patients.

Tissue Doppler imaging-obtained isovolumetric myocardial acceleration (IVA) is load independent, reportedly predicts systolic functions, and correlates with exercise capacity in patients with reduced ejection fraction (EF). We hypothesized that IVA correlates with the pulmonary capillary wedge pressure (PCWP) in patients with reduced EF.Of 113 patients, correlations between PCWP and IVA were done for all patients, 48 patients with EF ≥55%, and 65 patients with EF55%. Results were compared to the correlation between PCWP and other echocardiographic predictors. IVA correlated moderately with PCWP in all patients (r=0.54, P0.0001) and was comparable to the E/A and E/e' ratios. In patients with EF ≥55%, IVA lost correlation and the only predictor was the E/e' ratio (r=0.08, 0.58, P=0.58,0.0001). In patients with EF55%, IVA was better than E/A and E/e' (r=0.72, 0.61, 0.51, P0.0001), especially for atrial fibrillation or when E/e' fell between 8 and 15. Furthermore, IVA1.60 m/s(2) can predict PCWP ≥15 mmHg, with a sensitivity of 95%, specificity of 73%, and an area under the curve of 0.867 (P0.0001).IVA can predict PCWP in patients with reduced EF, and can be considered an alternative to the E/e' ratio for patients with atrial fibrillation or E/e' ratio between 8 and 15.

Background: The purpose of this study was to investigate whether patients with severe aortic stenosis (AS) and preserved ejection fraction (EF) have dyssynchrony and whether it improves after aortic valve replacement (AVR). Methods and Results: We studied 30 consecutive patients with severe AS and preserved EF undergoing AVR. For baseline comparison, we studied 17 EF-matched patients with mild-to-moderate AS, and 18 EF-matched normal volunteers. Longitudinal dyssynchrony was determined as the standard deviation for time-to-peak speckle-tracking strain in apical 4- and 2-chamber views at the basal- and mid-levels. Radial and circumferential dyssynchrony was determined as the difference for time-to-peak strain between the anteroseptum and posterior wall from the mid-left ventricular (LV) short-axis view. Each of the myocardial functions was also evaluated by averaging each peak systolic strain. Longitudinal dyssynchrony and function in patients with severe AS was significantly worse than in the patients with mild-to-moderate AS and the controls (94±46 vs. 66±18ms* and 52±17ms*, and 12.5±3.7% vs. 16±3.5%* and 18.7±3.7%*, respectively, *P

Background: Dyssynchrony has various detrimental effects on cardiac function, but its effect on cardiac sympathetic activity is not fully understood. Methods and Results: We studied 50 heart failure patients who underwent cardiac resynchronization therapy (CRT). Cardiac sympathetic activity was assessed by 123I-metaiodobenzylguanidine (123I-MIBG) scintigraphy as the delayed heart-to-mediastinum ratio (H/M ratio). Echocardiography was performed before and 7 months after CRT, and response was defined as a ≥15% decrease in end-systolic volume. Dyssynchrony was determined by the time difference between the anteroseptal-to-posterior wall using speckle-tracking radial strain (≥130ms predefined as significant). H/M ratio in patients with dyssynchrony was less than that in patients without dyssynchrony (1.62±0.31 vs. 1.82±0.36, P

The aim of this study was to test the hypothesis that, unlike calculation of the mitral valve area (MVA) with the pressure half-time method (PHT), the proximal isovelocity surface area method (PISA) is not affected by changes in net atrioventricular compliance (Cn). Methods and results We studied 51 patients with mitral stenosis (MS) from two centres. MVA was assessed with the PISA (MVAPISA), PHT (MVAPHT), and planimetry (MVAPLN, serving as the gold standard) method. Cn was calculated with a previously vali- dated equation using 2D echocardiography. MVAPISA closely correlated with MVAPLN (r ¼ 0.96, P , 0.0001), while MVAPHT and MVAPLN showed a weaker but still good correlation (r ¼ 0.69, P , 0.0001). The correlation between MVAPHT and MVAPLN for patients with Cn between 4 and 6 mL/mmHg (considered to be normal) was excellent (r ¼ 0.93, P , 0.0001), but that for patients with Cn of less than 4 or more than 6 mL/mmHg was not as good (r ¼ 0.64, P , 0.0001). Importantly, a significant inverse correlation was detected between the percentage difference among MVAPHT ,M VAPLN, and Cn (r ¼ 20.77, P , 0.0001), but the line of fit was nearly flat for the percentage differ- ence among MVAPISA ,M VAPLN, and Cn (r ¼ 0.1, P ¼ 0.388). Conclusion MVA calculated with both the PISA and PHT methods correlated well with MVA calculated with the planimetry method. However, the PISA rather than PHT is recommended for patients with MS and extreme Cn values because PISA, unlike PHT, is not affected by changes in Cn.

The aim of this study was to test the impact of posterolateral myocardial systolic function on response to cardiac resynchronization therapy (CRT).Forty patients were studied before and 4 +/- 2 months after CRT. Dyssynchrony was defined as anteroseptal wall-to-posterior wall delay (or = 130 ms) caused by speckle-tracking radial strain. The average longitudinal strain in 4 posterior and lateral segments (epsilon-pl) in which the left ventricular pacing lead was positioned was calculated by automated functional imaging. Response to CRT was defined as aor = 15% decrease in end-systolic volume.The negative value of epsilon-pl in responders was significantly higher than that in nonresponders at baseline (-7.8 +/- 6.9% vs -2.1 +/- 4.9%, P.01). Combining dyssynchrony with epsilon-pl-7.8% was more effective for predicting response to CRT than dyssynchrony parameters alone (92% vs 75%).The addition of posterolateral myocardial systolic function to the measurement of dyssynchrony appears to be of value for predicting response to CRT.

1967年、校友の佐伯義男氏から同志社大学に寄贈された考古資料中に、ながく学会から行方知れずとなっていた馬ノ山4号墳(鳥取県東伯郡湯梨浜町)採集の人物画を線刻した円筒埴輪片があった。本論は当該埴輪資料に関する発見以来の来歴と、馬ノ山4号墳の概要を述べつつ、線刻人物画の図像表現について検討するものである。とくに人物画がなぜ円筒埴輪に描かれたか、またその所作がいかなる意味をもつものであるかを古墳時代の絵画資料のなかに渉猟し、それが辟邪の綬作をなす人物像であることを明らかにする。, 調査・研究報告

An 84-year-old man with non-ischaemic cardiomyopathy underwent cardiac resynchronization therapy (CRT) based on the presence of drug-refractory heart failure, depressed left ventricular ejection fraction (25%), and wide QRS complex (160 ms). Longitudinal tissue velocity revealed no significant dyssynchrony (23 ms in Yu index and 35 ms in opposing wall delay). However, longitudinal tissue Doppler strain revealed unique appearances in apical four-chamber and long-axis views. The anterior and inferior septum at basal and mid-levels had reversed strain (becoming positive), indicating paradoxical systolic expansion. Ejection fraction dramatically improved from 26 to 50% the day following CRT, and this beneficial effect of CRT was sustained 12 months following CRT. The presence of the segmental reversed strain might have a potential to predict a large response to CRT in the assessment of longitudinal dyssynchrony.

Background The relationship between regional and global left ventricular function has not been evaluated. The present study aimed to assess whether regional myocardial contraction and relaxation reflect global left ventricular systolic and early diastolic function, respectively. Methods and Results The study involved 45 patients with coronary artery disease (CAD). Conventional echocardiography was performed, and segmental peak strain rate (SR) in the systole (SSR) and early diastole (ESR) were obtained from tissue Doppler imaging in each of 18 segments of the left ventricular myocardium from the apical views. The ESR was significantly correlated with SSR in all studied segments (r=0.55, p

The purpose of this study was to investigate the prognostic impact of the changes in ventriculo-arterial (VA) coupling during dobutamine stress on the cardiovascular events for patients with dilated cardiomyopathy (DCM).For this study, 89 DCM patients with ejection fractions of 32 ± 10% and 30 normal controls were recruited. Ees was estimated with the non-invasive single-beat method using three-dimensional echocardiography at rest and during dobutamine stress (20 μg/kg/min). Effective arterial elastance (Ea) was calculated as left ventricular (LV) end-systolic pressure divided by stroke volume, and VA coupling was calculated as Ea/Ees. Event-free survival was then tracked for 32 months. At baseline, VA coupling was far from optimal in patients with DCM compared with controls (Ea/Ees: 2.49 ± 1.02 vs. 1.04 ± 0.21, P0.001). During the follow-up period, 22 patients developed adverse cardiovascular events. During dobutamine stress, VA coupling was significantly improved in patients without cardiovascular events (from 2.47 ± 1.09 to 1.59 ± 0.68, P0.001), but remained unchanged in those with cardiovascular events. A multivariate Cox proportional-hazards analysis revealed that age, NYHA functional class (II), and the change in VA coupling during dobutamine stress were the independent determinants of cardiovascular events (P0.05,0.01, and0.001, respectively). When patients were divided into two subgroups based on the finding of receiver operating characteristic curve analysis, patients with good VA coupling reserve (cut-off: change in VA coupling0.29) showed significantly favourable event-free survival than those with poor VA coupling reserve (P0.001).Improvement in VA coupling during dobutamine stress is an important determinant of cardiovascular outcome for patients with DCM.

Although impaired right ventricular (RV) performance has been associated with adverse outcomes for pulmonary hypertension (PH) patients, the relationship between bi-ventricular interdependence and outcomes is not fully understood. We studied 96 PH patients. RV systolic function was assessed by RV

Aims Right ventricular (RV) as well as left ventricular (LV) function has been recognized as an important prognostic factor for heart failure patients. Our objective was thus to investigate the prognostic significance of combined assessment of bi-ventricular functional reserve for patients with dilated cardiomyopathy (DCM). Methods and results We studied 104 DCM patients with ejection fractions (EF) of 32 ± 9%, and speckle-tracking echocardiography was used to assess both RV and LV contractile reserve under dobutamine stress (20 µg/kg/min). RV contractile function was measured as peak global longitudinal strain (GLS) from the RV free wall (RV-free), and LV function as global circumferential strain (GCS) and GLS, respectively. Event-free survival was then tracked for 17 months. Twenty-one patients (20%) developed cardiovascular events. A multivariate Cox proportional-hazards analysis revealed that the baseline EF, E / A , and the relative change in EF (ΔEF), in GCS (ΔGCS), and in RV-free (ΔRV-free) during dobutamine stress were the independent predictors of cardiovascular events ( P < 0.001

新島襄は1888年に人物・馬形埴輪を写生し、それは「新島先生筆埴輪見取図」として、同志社大学社史資料センターに保管されている。これら資料について現状での実測図・写真を掲載。また、それらについて、諸文献への掲載の来歴を調査して報告した。1920年代以前に多くの考古学者が研究誌上に掲載し議論の対象とした埴輪であることが判明した。現在は京都大学総合博物館に所蔵されている資料であることを明らかにした。, 調査・研究報告

We encountered complications of septic shock and retroperitoneal hemorrhage which occurred after implantation of a retrievable Günther Tulip filter. A 79-year-old woman was diagnosed as right femoral vein thrombosis, and a retrievable Günther Tulip filter was deployed prior to a total knee replacement surgery. However, the patient developed septicemia due to Citrobacter freundii, followed by thrombocytopenia and retroperitoneal hemorrhage. A large hematoma was formed along the lateral side of the filter struts. We considered that the filter should be removed to control retroperitoneal hemorrhage and prevent secondary infection of the hematoma. Removal of the retrievable filter was effective in managing these complications.

Background: Since survival of patients with pulmonary hypertension (PH) is closely related to right ventricular (RV) function, assessment of RV function is important for patients with PH. Right atrial (RA) area and/or RA pressure have also been reported to serve as prognostic predictors for adverse outcomes for in PH patient. Accordingly, we tested the hypothesis that the addition of RA remodeling to RV function enhances the capability of the latter to predict long-term outcome for PH patients. Methods: We studied 82 PH patients, all of whom underwent echocardiography and right heart catheterization. RV function was calculated by averaging the three regional peak speckle-tracking longitudinal strains from RV free wall (RV-free). RA remodeling was assessed as the RA area traced planimetrically at end-systole. Pre-defined cutoffs for RV dysfunction and RA remodeling were RV-free≤19.4% and RA area of >18cm2, respectively. Long-term unfavorable outcome events were tracked for 2.0 years. Results: RA area correlated with mean RA pressure (r=0.62, p19.4% (log-rank p=0.01), as did patients with RA area>18cm2 compared with those with RA area ≤18cm2 (log-rank p Conclusions: The combined assessment of RV function and RA remodeling results in more accurate prediction of long-term outcome, and may well have clinical implications for better management of PH patients.

Background: The development of right ventricular (RV) dysfunction in patients with pulmonary hypertension (PH) has been associated with adverse outcomes. Right atrial (RA) function could be a prognostic factors as well as RV function, but non-invasive evaluation of RA function is limited. Our objective was thus to test the hypothesis that RA function was associated with hemodynamic parameters of RV performance in PH patients. Methods: Eighty PH patients with mean pulmonary artery pressure (PAP) of 40±11mmHg (all≥25mmHg) were recruited in this study. RA function was assessed by using two-dimensional speckle-tracking strain from RV-focused apical 4-chamber view. RA strain was calculated with the reference point set at the P wave, which enabled the recognition of peak negative (RAneg), positive strain (RAposi), and the sum of those values (RAtotal), corresponding to RA contractile, conduit, and reservoir function, respectively. All patients underwent right-heart catheterization for measurement of mean PAP and pulmonary vascular resistance (PVR). Results: RAneg (r=0.24 and p=0.03), RAposi (r=0.31 and p=0.01) and RAtotal (r=0.35 and p=0.001) were significantly correlated with mean PAP. In addition, RAposi (r=0.41 and p Conclusions: Non-invasively assessed RA strains were associated with mean PAP and PVR. RA strain may be of a valuable additive factor for the management of PH patients, and thus have potential clinical applications.

Background: Right ventricular (RV) dysfunction plays an important role in disease progression and prognosis of patients with pulmonary hypertension (PH). However, the association of RV reverse remodeling with long-term outcomes remains unclear. Our objective was thus to test the hypothesis that mid-term RV reverse remodeling after adding PH-specific drugs was linked to long-term outcomes in patients with PH. Methods: We studied 45 PH patients with resting mean pulmonary artery pressure (mPAP) of 35±10mmHg. PH patients with chronic thromboembolic pulmonary hypertension and left-sided heart failure including pulmonary capillary wedge pressure of >15mmHg were excluded. Echocardiography was performed at enrollment and mid-term of 5.7±4.1 months after adding PH-specific drugs. RV function was calculated by averaging the three regional peak speckle-tracking longitudinal strains from RV free-wall (RV-free). RV remodeling was assessed in terms of the RV area, which was traced planimetrically at the end-systole (RVESA) from RV-focused apical 4-chamber views. Mid-term RV reverse remodeling was defined as a relative decrease in RVESA of at least 15%. Long-term event-free survival was then tracked for 5 years. Results: Patients with mid-term RV reverse remodeling experienced favorable long-term outcomes than those without mid-term RV reverse remodeling (log-rank p Conclusion: Mid-term RV reverse remodeling after adding PH-specific drugs was associated with long-term outcomes, and this combined approach may well have clinical implications for better management of PH patients.

Background: The occurrence of cardiopulmonary exercise testing-derived exercise oscillatory breathing (EOB) is a predictor of survival in heart failure (HF) patients. Whereas, it was recently reported that global circumferential strain (GCS) as assessed by two-dimensional speckle-tracking imaging reflects intrinsic left ventricular (LV) myocardial function and is a powerful predictor of cardiovascular events, and thus appears to be a better predictive parameter than global LV function, including LV ejection fraction (EF). The objectives of our study were to test the hypothesis that a combined assessment of EOB and GCS can further enhance the ability of the method to predict cardiac events in HF patients. Methods: A total of 86 HF patients with LVEF of 44±11% underwent cardiopulmonary exercise testing and echocardiography. GCS was determined as the peak global speckle-tracking strain from mid-LV short-axis view, and GCS of Results: Overall, patients with EOB (n=35) were associates with unfavorable clinical events compared with those without EOB (n=49) (2% vs. 18%, p=0.04). Of 35 patients with EOB, there were 10 patients with EOB and GCS10.7%. The prevalence of unfavorable clinical events of patients with EOB and GCS10.7% (70% vs. 4%, p Conclusions: The combined approach of EOB and GCS leads to more accurate prediction of unfavorable cardiac events than using individual parameters in HF patients. The study presented here offers new insights into management of HF patients.

Background Identification of heart failure (HF) symptoms in patients with severe aortic stenosis (AS) and preserved left ventricular (LV) ejection fraction (EF) is clinically important, but assessment of HF symptoms is challenging. It was recently reported that resting left atrium (LA) functions are related to exercise performance and are also important prognostic markers for patients with HF. The aim of this study was to assess the association of the HF symptoms with LA function in patients with severe AS and preserved LVEF. Methods We retrospectively studied 40 patients with severe AS and preserved LVEF (all ≥50%) who were referred for aortic valve replacement (AVR). LA reservoir (SR-LAs), conduit (SR-LAe), and booster-pump (SR-LAa) functions were determined as the averaged global LA speckle tracking longitudinal strain rate from apical four- and two-chamber views. Twenty patients were symptomatic and 20 asymptomatic. Results Aortic stenosis severity was similar for the 2 groups. Symptomatic status was associated with age, LV mass index, hemoglobin, B-type natriuretic peptide, LV end-systolic volume index, LVEF, LA volume index, SR-LAs, SR-LAe, and SR-LAa. Importantly, multivariate logistic regression analysis revealed that SR-LAa was the only independent determinant of symptomatic status (OR = 0.242, P = 0.002). Furthermore, significant improvement of SR-LAa was observed along with the reduction in LA volume index and LV mass index after AVR. Conclusions SR-LAa was found to be associated with the HF symptoms. Characterization of LA booster-pump function may be useful for the assessment of the symptomatic status in patients with severe AS patients and limited physical activity.

Early diastolic mitral inflow and annulus velocities ratio (E/e') is the parameter used to estimate left ventricular (LV) filling pressure, but their use for patients with reduced ejection fraction (EF) (50 %) is controversial. LV endocardial area change rate with 3-dimensional (3-D) speckle-tracking can be used to evaluate the entire LV diastolic function, we tested the hypothesis that the early diastolic area change rate (E-ACR) represents LV relaxation, and E and E-ACR ratio (E/E-ACR) can accurately predict LV filling pressure in patients with reduced and preserved EF (≥50 %). We studied 125 patients with EF of 40 ± 17 %. E-ACR of all patients was measured using the global area change rate, and LV relaxation time constant (τ, n = 53) and pulmonary capillary wedge pressure (PCWP, n = 125) were measured by cardiac catheterization. E-ACR significantly correlated with τ (r = -0.60, p0.001). In the retrospective group (n = 101), E/E-ACR correlated with PCWP for patients with reduced EF as well as those with preserved EF (n = 79 and 22, r = 0.62 and 0.81, both p0.001). In overall patients, E/E-ACR ≥94 cm was a better predictor of elevated mean PCWP (12 mmHg) (sensitivity: 69 %, specificity: 87 %, areas under the curves = 0.82; p0.001) and was a more accurate predictor than E/e' (p = 0.001) for the retrospective group. For the validation group (n = 24), E/E-ACR ≥94 cm was similarly predictive for elevated mean PCWP (sensitivity: 60 %, specificity: 100 %, positive predictive value: 100 %, negative predictive value: 78 %). In conclusions, global E-ACR by 3-D speckle-tracking proved to be dependent on LV relaxation. Moreover, E/E-ACR was found to be a powerful predictor of LV filling pressure regardless of EF.

We tested the hypothesis that the addition of right atrial (RA) remodeling to right ventricular (RV) function enhances the capability of the latter to predict long-term outcome for pulmonary hypertension (PH) patients. We studied 82 PH patients, all of whom underwent echocardiography and right heart catheterization. RV function was calculated by averaging the three regional peak speckle-tracking longitudinal strains from RV free wall (RV-free). RA remodeling was assessed as the RA area traced planimetrically at end-systole. Pre-defined cutoffs for RV dysfunction and RA remodeling were RV-free ≤19.4 % and RA area of18 cm(2), respectively. Long-term unfavorable outcome events were tracked for 2.0 years. RA area correlated with mean RA pressure (r = 0.62, p0.001), as well as with tricuspid E/E' (r = 0.38, p = 0.001). Moreover, RA area in patients with RV restrictive filling was significantly larger than that in patients with others (all p0.05). Kaplan-Meier analysis revealed that patients with RV-free ≤19.4 % had worse long-term outcomes than those with RV-free19.4 % (log-rank p = 0.01), as did patients with RA area18 cm(2) compared with those with RA area ≤18 cm(2) (log-rank p0.05). For sequential Cox models, a model based on hemodynamic parameters of RV performance (χ2 = 3.11) was improved by addition of brain natriuretic peptide, World Health Organization functional class (χ2 = 9.24; p0.05), and RV-free (χ2 = 17.11; p = 0.005), and further improved by addition of RA area (χ2 = 21.36, p0.05). In conclusion, the combined assessment of RV function and RA area results in more accurate prediction of long-term outcome, and may well have clinical implications for better management of PH patients.

Background Anthracycline chemotherapy generates progressive dose-dependent left ventricular (LV) dysfunction associated with a poor prognosis. Early detection of minor LV myocardial dysfunction caused by the cardiotoxicity of anthracycline is thus important for predicting global LV dysfunction. Methods Fifty patients with preserved ejection fraction (all ≥55%) after receiving anthracycline chemotherapy were recruited for this study. Two-dimensional speckle tracking was used to assess global radial and circumferential strains from mid-LV short-axis views and global longitudinal strain from the apical four- and two-chamber view as peak global strain curves. Three-dimensional (3D) radial, circumferential, and longitudinal myocardial function was quantified as a peak global strain curve using 3D speckle tracking from all 16 LV segments. 3D speckle tracking imaging was used to evaluate LV endocardial area change ratio (area strain) quantified as peak global area strain curve (3D-GAS) to determine LV endocardial function. Twenty age-, gender-, and EF-matched normal volunteers were studied for comparisons. Results Only 3D-GAS and peak 3D global circumferential strains of the anthracycline group were significantly worse than those of the control group (−43.3 ± 3.1 vs. −45.8 ± 4.3% and −31.6 ± 3.5% vs. −34.4 ± 4.2%, respectively; P = 0.008, P = 0.004) even though global LV systolic and diastolic functions were similar. 3D-GAS correlated significantly with the cumulative doxorubicin dose (r = 0.316, P = 0.026). It was noteworthy that multivariate analysis showed only 3D-GAS (β = 0.323, P = 0.025) was independently associated with cumulative doxorubicin dose. Conclusions Three-dimensional speckle tracking area strain was found useful for early detection of minor LV endocardial dysfunction associated with the use of anthracycline, and may thus prove to be clinically useful for predicting global LV dysfunction.

A 45-year-old woman was admitted to our hospital because of exertional dyspnea. At the age of 26, she was diagnosed with corrected transposition of the great arteries (CTGA) and mild left atrioventricular valve (LAVV) regurgitation. On admission, transthoracic echocardiography revealed severe LAVV regurgitation related to CTGA. The appropriate timing of LAVV replacement in CTGA patients remains unclear. In this case, severe LAVV regurgitation was demonstrated; the anatomic right ventricle had gradually enlarged; systolic function of the anatomic right ventricle was slightly reduced; and sinus rhythm was still maintained, so we opted for valve replacement.

The objective of this study was to test the hypothesis that combining assessment of baseline radial strain dyssynchrony index (SDI), that expressed both left ventricular (LV) dyssynchrony and residual myocardial contractility, and of acute changes in this index can yield more accurate prediction of mid-term responders and long-term outcome after cardiac resynchronization therapy (CRT). Radial SDI for 75 CRT patients was calculated as the average difference between peak and end-systolic speckle tracking strain from 6 segments of the mid-LV short-axis view before and 8 ± 2 days after CRT. Mid-term responder was defined as ≥ 15% decrease in LV end-systolic volume 6 ± 2 months after CRT. Long-term outcome was tracked over 5 years. Baseline radial SDI ≥ 6.5% is considered predictive of responder and favorable outcome, as previously reported. Acute reduction in radial SDI ≥ 1.5% was found to be the best predictor of mid-term responders with CRT. Furthermore, patients with acute reductions in radial SDI ≥1.5% were associated with a significantly more favorable long-term outcome after CRT than those with radial SDI

A case was 53-year-old female with dilated-phase hypertrophic cardiomyopathy. She was classified as New York Heart Association functional class III heart failure despite receiving optimal medical therapy. The electrocardiogram taken showed intraventricular conduction delay with a QRS width of 194 msec. The left ventricular (LV) end-diastolic and systolic volumes, and ejection fraction (EF) were 101 mL, 68 mL, and 32%, respectively. The patient showed no significant mechanical LV dyssynchrony as evidenced by two-dimensional (2D) speckle tracking radial strain, which is defined as the time difference between anterior-septum and posterior wall, of 105 msec (

The importance of left atrial (LA) functional reserve in patients with depressed left ventricular function remains unclear. Thus, the aim of this study was to test the hypothesis that diminished augmentation of LA function during dobutamine stress might be associated with cardiovascular events in patients with dilated cardiomyopathy.Eighty-four patients with dilated cardiomyopathy with a mean ejection fraction of 34 ± 9% were retrospectively recruited, and LA strain was determined as the averaged global speckle-tracking longitudinal strain from apical four-chamber and two-chamber views during dobutamine stress (20 μg/kg/min). The systolic component of LA strain was considered to reflect reservoir function, whereas the passive and active emptying components were considered to reflect passive and active emptying function, respectively. Event-free survival was tracked for 17 months.Multivariate Cox proportional-hazards analysis identified LA volume index (hazard ratio [HR], 1.060; P.001) and β-blocker use (HR, 0.048; P.05) as the independent variables associated with cardiovascular events among the baseline parameters and changes in systolic LA strain (HR, 0.971; P = .02), in passive emptying LA strain (HR, 0.942; P.001), and in left ventricular early diastolic strain rate (HR, 0.986; P = .03) under dobutamine as the variables among the functional reserve parameters. In sequential Cox models, a model based on clinical variables (χ(2) = 9.3) was improved by conventional echocardiographic parameters (χ(2) = 19.2, P = .012) and LA strain parameters at rest (χ(2) = 40.1, P = .005) and further improved by the addition of changes in LA strain parameters under dobutamine (χ(2) = 61.6, P.001).The assessment of LA reservoir and passive emptying function during dobutamine stress provides important incremental prognostic value in patients with dilated cardiomyopathy.

BACKGROUND Left ventricular (LV) dyssynchrony is not a stable phenomenon, but rather, changes dynamically. Given that the prognostic impact of dynamic dyssynchrony has not yet been elucidated, the objective was to investigate the clinical impact of dynamic dyssynchrony on patients with dilated cardiomyopathy (DCM). METHODS AND RESULTS Seventy DCM patients with ejection fraction 32±9% were retrospectively recruited, and 3-dimensional speckle-tracking area strain was used to measure both contractile reserve and changes in dyssynchrony during dobutamine stress. The standard deviation of time-to-peak area strain was adopted as the systolic dyssynchrony index. Event-free survival was then tracked over a 13-month period. A ≥7.55% increase in systolic dyssynchrony index during dobutamine stress (Δsystolic dyssynchrony index) was the best predictor of cardiovascular events with 77% sensitivity and 88% specificity. Multivariate Cox analysis indicated that not only the absence of contractile reserve (Δglobal area strain ≤21.1%: hazard ratio [HR], 15.29; P=0.01), but the presence of dynamic dyssynchrony (ΔLV dyssynchrony ≥7.55%: HR: 7.591; P=0.003) was an independent predictor of cardiovascular events. Importantly, absence of dynamic dyssynchrony and presence of contractile reserve were associated with the most favorable outcome (98%), whereas the reverse condition was associated with the worst outcome (20%, P