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Background: Various issues, such as gender diversity and overwork, need to be considered in cardiovascular workplaces. Here, we report the results of 2 questionnaire surveys conducted among members of the Chugoku branch of the Japanese Circulation Society. Methods and Results: The first questionnaire was posted to all 194 female members in 2018. Of the 73 respondents, 61.6% reported feeling that it would be difficult to continue in cardiovascular care. The second questionnaire was completed by participants of the Chugoku Regional Meeting in 2019. Of the 133 respondents, 42.4% reported difficulties continuing in cardiovascular care. Respondents reporting difficulties had a significantly lower mean age, a higher frequency of day and night shifts, and a higher rate of working >80 h/week than respondents who did not report such difficulties. In logistic regression analysis, working >80 h/week was the only independent factor associated with difficulties continuing in cardiovascular care (odds ratio 4.16; 95% confidence interval 1.46–11.9; P=0.008). Although 47.4% of respondents worked >960 h overtime per year (considered a risk factor for death from overwork), 59.6% of these respondents reported being satisfied with their current situation. Conclusions: In the Chugoku region, the work-life balance of medical personnel engaged in cardiovascular care has not been sufficiently secured. In order to promote diverse human resources, we need to recognize the current situation and continue to take countermeasures.

The proximal optimizing technique (POT) -proximal balloon edge dilation (PBED) sequence for side branch (SB) dilatation with cross-over single-stent implantation decreases both strut obstruction at the SB ostium and stent deformation at the main branch (MB).The purpose of this experimental bench test was to assess the impact of stent design on stent deformation, obstruction by stent struts at a jailed SB ostium, and stent strut malapposition in the POT-PBED sequence.Fractal coronary bifurcation bench models (60- and 80-degree angles) were used, and crossover single-stent implantation (3-link stent: XIENCE Sierra, Abbott Vascular, Santa Clara, CA, n = 10; 2-link stent: Synergy, Boston Scientific, Marlborough, MA, n = 10) was performed from the MB using the POT-PBED sequence. Jailing rates at the SB ostium, stent deformation, and stent strut malapposition of the bifurcation segment were assessed using videoscopy and optical coherence tomography.After SB dilatation using the PBED technique, jailing rates at the SB ostium and stent deformation did not differ significantly between the two types of stents. Conversely, the rate of malapposed struts of the bifurcation segment after the PBED procedure was significantly lower with 3-link stents than with 2-link stents for both 60- and 80-degree angles (60-degree angle: 4.3% ± 4.4% versus 22.0% ± 11.1%, P = 0.044; 80-degree angle: 20.8% ± 15.1% versus 57.2% ± 17.0%, P < 0.001, respectively).In the POT-PBED sequence, 3-link stents might be a preferable coronary bifurcation stent, maintaining a jailed SB ostium while significantly reducing stent strut malapposition of the bifurcation segment when compared with 2-link stents.

Guidelines recommend shorter duration (1–12 months) for dual antiplatelet therapy (DAPT) in the second-generation drug-eluting stent (DES) era. However, whether shorter DAPT duration affects stent strut conditions and neointimal characteristics at mid-term follow-up remains uncertain. Therefore, we studied the relation between DAPT duration and vascular healing response as assessed by optical coherence tomography (OCT). This study was retrospective observational study. Participants comprised 64 patients who underwent serial OCT at both 9 and 18 months after DES implantation. All patients received DAPT until the 9-month follow-up then were divided into two groups: 49 patients who continued DAPT (longer DAPT group); and 15 patients who stopped taking the P2Y12 inhibitor and were treated with aspirin alone (shorter DAPT group) at the 18-month follow-up. Using OCT, we evaluated and compared stent strut conditions and neointimal characteristics between groups at both 9 and 18 months after stent implantation. Baseline clinical and procedural parameters were mostly similar between groups. At the 18-month follow-up, no in-stent thrombus assessed by OCT was observed in either group. No significant differences in OCT characteristics or measurements of neointima were seen between groups at 9- or 18-month follow-ups. Neointimal volume increased from 9 to 18 months in both groups, with a similar degree of neointimal proliferation in both groups (shorter DAPT group, 0.23 ± 0.29 mm3/mm; longer DAPT group, 0.19 ± 0.27 mm3/mm; P = 0.56). In conclusion, interrupting DAPT 9 months after second-generation DES implantation did not affect the development of in-stent thrombus, neointimal proliferation or stent strut coverage at 18-month follow-up compared with continuing DAPT.

Background: Patients with acute coronary syndrome (ACS) still have high rates of recurrent adverse cardiovascular events. The purpose of this study was to evaluate the effects of changes in the Japan Atherosclerosis Society Guidelines for Prevention of Atherosclerotic Cardiovascular Diseases for intensive lipid-lowering therapy on the prescription status, lipid profile and clinical outcomes among Japanese patients with ACS. Methods: Data were retrospectively analysed for 283 consecutive patients with de novo ACS who underwent primary percutaneous coronary intervention and received follow-up coronary angiography between January 2012 and September 2019. Patients were divided into two groups according to the to onset of ACS relative to the guideline update – before (Group 1; n=182) and after (Group 2; n=101). Changes in prescription status, lipid profile and clinical outcomes (composite of cardiac death and non-fatal MI, coronary events from culprit and non-culprit lesions) were evaluated. Results: Post-treatment LDL concentrations were significantly lower in Group 2, but target LDL concentrations of

Objective The purpose of this experimental bench test was to compare stent deformation, obstruction of stent struts at a jailed side branch (SB) ostium, and stent strut malapposition between SB inflation using proximal balloon edge dilation (PBED) technique and SB inflation using conventional balloon dilation in repetitive-proximal optimizing technique (re-POT) sequence. Background The second proximal optimizing technique (POT) procedure in the re-POT sequence might increase obstruction of stent struts at a jailed SB ostium, because deformation of stent cells at the main branch (MB) occurred during SB inflation for opening the SB ostium. Methods A fractal coronary bifurcation bench model made of flexible urethane was used, and crossover single-stent implantation (Xience Sierra, Abbott Vascular, Santa Clara, CA, n = 12) was performed from the MB with the re-POT sequence. During the re-POT sequence, the jailing rate at the SB ostium assessed by videoscopy was compared between SB inflation using PBED technique (PBED group, n = 6) and SB inflation using conventional balloon dilation (conventional group, n = 6). Results The jailing rate after the second POT procedure tended to be lower in the PBED group than in the conventional group (26 ± 12% vs. 34 ± 8%, p = .211), and the change in the jailing rate during the second POT procedure was significantly smaller in the PBED group than in the conventional group (4.8 ± 5.3% vs. 11.6 ± 3.5%, p = .026). Conclusions In the re-POT sequence, the PBED technique with a short balloon for SB inflation might minimize worsening of the jailing rate at the SB ostium during the second POT procedure.

Disease-causing mutations in a linkage-specific deubiquitylase provide insights into chromatin remodeling during embryogenesis., Reversible modification of proteins with linkage-specific ubiquitin chains is critical for intracellular signaling. Information on physiological roles and underlying mechanisms of particular ubiquitin linkages during human development are limited. Here, relying on genomic constraint scores, we identify 10 patients with multiple congenital anomalies caused by hemizygous variants in OTUD5, encoding a K48/K63 linkage–specific deubiquitylase. By studying these mutations, we find that OTUD5 controls neuroectodermal differentiation through cleaving K48-linked ubiquitin chains to counteract degradation of select chromatin regulators (e.g., ARID1A/B, histone deacetylase 2, and HCF1), mutations of which underlie diseases that exhibit phenotypic overlap with OTUD5 patients. Loss of OTUD5 during differentiation leads to less accessible chromatin at neuroectodermal enhancers and aberrant gene expression. Our study describes a previously unidentified disorder we name LINKED (LINKage-specific deubiquitylation deficiency–induced Embryonic Defects) syndrome and reveals linkage-specific ubiquitin cleavage from chromatin remodelers as an essential signaling mode that coordinates chromatin remodeling during embryogenesis.

BACKGROUND: The purpose of this study was to investigate the clinical significance of elevated plasma high-sensitivity troponin T (hs-TnT) in the chronic phase in patients with stable angina pectoris (SAP) who underwent a successful percutaneous coronary intervention (PCI). METHODS: This study enrolled 158 consecutive SAP patients who underwent routine follow-up coronary angiography 9 months after a successful PCI with the implantation of a second-generation drug-eluting stent. Patients with previous coronary artery bypass graft and renal dysfunction were excluded. Patients were divided into two groups according to hs-TnT plasma level at follow-up: elevated hs-TnT (≥ 0.015 ng/ml) group and non-elevated hs-TnT group. RESULTS: Among the 158 subjects, 42 had an elevated hs-TnT level at follow-up. The elevated hs-TnT group had a significantly higher rate of any coronary lesion (in-stent restenosis and de novo lesions) in follow-up CAG (coronary angiography) than the non-elevated group (28.6% vs. 10.3%, p < 0.05). Multivariate analysis also showed that hs-TnT elevation was independently associated with the presence of significant coronary stenosis in the chronic phase (odds ratio: 3.99, 95% confidence interval: 1.38 to 11.53). The best cut-off value of the hs-TnT level at 9 months after a successful PCI to predict the presence of significant coronary stenosis was 0.016 ng/ml (sensitivity: 50.0%; specificity: 82.1%; area under the receiver operating characteristic curve: 0.67). CONCLUSIONS: hs-TnT elevation was independently associated with the presence of coronary stenosis in the chronic phase in SAP patients with successful PCI. Routine measurement of hs-TnT in the chronic phase may be useful to refine the risk of patients after PCI.

Objectives The jailed strut at the side-branch (SB) orifice may be a cause of delayed neointimal coverage and SB flow disturbance after single stenting to bifurcation. The aim of this study was to characterize the exact relationship between the jailed strut pattern at the SB orifice immediately after stent implantation and neointimal coverage of the jailed SB orifice in the chronic phase. Patients and methods A total of 29 bifurcation (left anterior descending coronary artery and diagonal branch) lesions treated by optical coherence tomography-guide single-stent implantation and followed at 18 months after a percutaneous coronary intervention were included in this study. Results Using three-dimensional optical coherence tomography images, the jailed stent strut pattern was classified into two groups on the basis of the presence of a stent strut link at the SB orifice (link group: n=11, and no-link group: n=18). SB orifice obstruction by neointima was significantly greater in the link group than in the no-link group during the 18-month follow-up period (26.8±21.9 vs. 9.5±22.1%, P=0.049). Conclusion This single-center observational study with a small sample size showed that a jailed strut pattern at the SB orifice might be related to neointimal coverage of the SB orifice in bifurcation lesions treated with single-stent implantation. Further large-scale studies with long-term follow-up will be necessary to determine the exact relationship between the jailed strut pattern at the SB orifice and SB flow disturbance because of delayed neointimal coverage as well as clinical outcome.

Background Previous studies have suggested that vasa vasorum (VV) neovascularization plays an important role in the progression and vulnerability of coronary atherosclerotic plaque. Methods A total of 130 patients with coronary artery disease including 75 acute coronary syndrome (ACS) cases and 55 stable angina pectoris (SAP) cases were studied. By using intravascular ultrasound (IVUS), VV was defined as a small (

Background Various unfavorable echocardiographic findings other than apical ballooning, such as right ventricular involvement, mitral regurgitation, left ventricular outflow tract obstruction, and left ventricular thrombus, occur in takotsubo cardiomyopathy. Occasionally, these findings are observed simultaneously in a single patient. This study was performed to investigate the prevalence and characteristics of patients with multiple unfavorable echocardiographic findings in takotsubo cardiomyopathy and their associations with adverse outcomes. Methods The echocardiographic images of 113 patients with takotsubo cardiomyopathy (mean age, 72.7 ± 11.4 years; 29 men) were retrospectively reviewed. According to the number of unfavorable echocardiographic findings, patients were classified into a low-risk group (zero or one finding), an intermediate-risk group (two findings), and a high-risk group (three or more findings). In-hospital events were defined as a composite of acute heart failure, shock, ventricular tachyarrhythmia, and in-hospital death. Results Apical ballooning, right ventricular involvement, mitral regurgitation, left ventricular outflow tract obstruction, and left ventricular thrombus were observed in 92 (81.4%), 21 (18.6%), 17 (15.0%), 11 (9.7%), and three (2.7%) patients, respectively. There were 77 (68.1%), 25 (22.1%), and 11 (9.7%) patients in the low-, intermediate-, and high-risk groups, respectively. Logistic regression analysis indicated that being in the high-risk group had a significant association with in-hospital events (odds ratio, 8.74, P = .003) and death (odds ratio, 16.9; P = .027) compared with being in the low-risk group. Net reclassification improvement indicated that adding this risk group classification to known clinical factors that are associated with adverse outcomes could yield incremental information regarding patients with takotsubo cardiomyopathy with in-hospital events (net reclassification improvement, 0.59; P = .002). Conclusions Multiple unfavorable echocardiographic findings in takotsubo cardiomyopathy are not uncommon and are associated with increased in-hospital events and mortality.

BACKGROUND Healed plaques are identified as a layered pattern with optical coherence tomography (OCT) imaging, but the exact relationship between healed plaques and the development of significant coronary stenosis in stable angina pectoris (SAP) is not fully understood.Methods and Results:A retrospective clinincal study investigated the OCT characteristics of culprit lesions of SAP patients (n=205), and a prospective study examined the histopathological characteristics of layered plaque in directional coronary atherectomy (DCA) samples (42 samples from 18 SAP patients). In the retrospective study, layered plaque was observed in 36.6% of the SAP culprit lesions. Compared with patients with non-layered plaque, male sex and smoking were more frequent, and HbA1c level was significantly higher in the patients with layered plaque (81.3% vs. 65.9%, P

Re-proximal optimizing technique (re-POT) sequence comprising an initial POT, side branch (SB) inflation, and second POT has become a popular technique in bifurcation PCI. However, the second POT increased struts jailing at a SB ostium. We hypothesized that SB inflation using proximal balloon edge

OBJECTIVES The purpose of this study was to compare the stent deformation, obstruction of stent struts at a jailed side branch (SB) ostium, and stent strut malapposition after a repetitive proximal optimizing technique (re-POT) sequence between bifurcation lesions with and without stent links at SB ostia in ex vivo experimental setting. METHODS A flexible urethane coronary bifurcation bench model was used, and crossover single stent implantation was performed from main branch (MB) with re-POT sequence. Under videoscope observation, presence (link group, n = 12) or absence (no-link group, n = 12) of stent link at distal semicircle of SB ostium was intentionally set, and rewiring was performed through distal cell in four different stent platforms. RESULTS There were no significant differences in the rate of malapposed struts and in SB jailing ratio after the re-POT sequence between the link and no-link groups. SB jailing ratio increased significantly from 8.0% to 9.6% during the second POT procedure (P

Background Previous studies showed that patients with takotsubo cardiomyopathy had a higher long-term mortality rate than the general population and the incidence of in-hospital complications was higher in takotsubo cardiomyopathy with than without right ventricular (RV) involvement. This study was performed to investigate the long-term prognostic impact of RV involvement in takotsubo cardiomyopathy. Methods and results The clinical data of 113 patients (72.7 ± 11.4 years old, 84 females) with takotsubo cardiomyopathy were studied retrospectively. The patients were divided into two groups according to the presence (biventricular group, n = 21, 18.6%) or absence (classical group, n = 92, 81.4%) of RV involvement assessed by initial echocardiography. The end point was a composite of all-cause death, re-hospitalization due to heart failure, and recurrence of takotsubo cardiomyopathy. The in-hospital mortality rate was significantly higher in the biventricular group than the classical group (14.3 vs. 1.1%, respectively, P = 0.02). Kaplan–Meier analysis indicated a significantly lower event-free survival rate in the biventricular group than the classical group (log-rank, P < 0.001). On multivariate analysis, RV involvement was the only independent predictor of the end point (HR: 2.73, P = 0.026). Conclusion The rates of in-hospital and long-term events were significantly higher in takotsubo cardiomyopathy with than without RV involvement, and RV involvement was the independent predictor of the poor prognosis.

Atrial fibrillation (AF) is a risk factor for ischemic stroke and congestive heart failure. AF may cause left atrial (LA) dyssynchrony as well as electrical and mechanical remodeling. The aim of this study was to investigate LA dyssynchrony in patients with paroxysmal AF (PAF) and its recovery after pulmonary vein isolation (PVI), using a three-dimensional strain method.Thirty patients with PAF who underwent PVI were enrolled. Three-dimensional echocardiography was performed before and 3 months after PVI. Twenty subjects in whom AF had never been detected served as controls. LA dyssynchrony was quantified by the standard deviation of time to peak strain (TP-SD) from end-diastole by area tracking. Serial changes in TP-SD, LA volume, and global strain in three-dimensional echocardiography were investigated.In the PAF group, TP-SD was significantly higher (9.19 ± 4.98% vs 4.80 ± 2.30% in controls, P .02) and global strain significantly lower (48.2 ± 20.2% vs 84.4 ± 32.9% in controls, P = .0003) than in the control group. TP-SD, global strain, and LA volume all improved significantly from before to after PVI (TP-SD, from 9.19 ± 4.98% to 6.31 ± 2.94%, P = .005; global strain, from 48.2 ± 20.2% to 58.1 ± 21.2%, P = .018; LA volume index, 29.5 ± 10.6 to 25.8 ± 7.1 mL/m(2), P = .04). Despite the improvement after PVI, TP-SD was still significantly higher and global strain lower than in controls.In patients with PAF, impaired LA function was documented by three-dimensional echocardiography. Despite early LA structural reverse remodeling, LA dyssynchrony was still observed 3 months after PVI. These results may affect medical therapy after successful PVI.

A 62-year-old man with a family history of coronary artery disease and a history of smoking, diabetes and dyslipidemia was admitted to our hospital with chest pain from acute myocardial infarction. Emergent coronary angiography was performed with intervention to a mid-right coronary occlusion with drug-eluting stent implantation. Optical coherence tomography (OCT) visualized well-apposed stent struts and no remarkable tissue protrusion, stent underexpansion, malapposition, edge dissection, and hematoma. Immediately after OCT imaging, a coronary angiogram showed a filling defect surrounded by contrast medium at the site of the stented lesion. OCT imaging was performed again and a low backscattering protrusion suggestive of white thrombus in the coronary lumen was clearly visualized in OCT imaging. We performed thrombus aspiration immediately after OCT imaging. Aspirated thrombi were off-white in color. We made a diagnosis of early-onset heparin-induced-thrombocytopenia (HIT) due to thrombus formation within the stent and positive HIT antibodies. OCT in the acute phase of stent thrombosis allowed us to promptly identify the main causative mechanisms of early stent thrombosis.

Background: The clinical impact of stent edge dissection, tissue protrusion, and incomplete stent apposition (ISA) after stent implantation, detectable only on optical coherence tomography (OCT), is still unknown because the natural course has not been investigated. Methods and Results: All consecutive patients with angina pectoris in whom both intravascular ultrasound (IVUS) and OCT were performed immediately after stenting and at follow-up were included in the present study. The natural history of OCT-detected stent edge dissection, tissue protrusion, and ISA during follow-up was investigated. A total of 36 patients with 39 lesions was analyzed. At baseline, OCT showed 12 stent edge dissections, 25 tissue protrusions, and 8 ISAs, whereas IVUS demonstrated 6 stent edge dissections, 5 tissue protrusions, and 3 ISAs. All IVUS findings were clearly visualized on OCT. The maximum length of dissection flap and depth of ISA visualized on OCT were significantly shorter than those visualized on IVUS. Maximum length of tissue protrusion tended to be smaller on OCT than on IVUS. At follow-up (median 188 days), all findings noted on OCT were healed or resolved without any restenosis or thrombus formation. Conclusions: Acute findings after stenting, such as edge dissection, tissue protrusion, and ISA, detectable only on OCT, tended to be smaller than those seen on both OCT and IVUS. The majority of OCT-detected acute findings resolved completely at follow-up. (Circ J 2012; 76: 698-703)

Coronary plaque component in vivo could be obtained by Directional Coronary Atherectomy (DCA) and evaluated in histological examination. The purpose of this study was to evaluate the relationship between histological characteristics obtained by DCA and optical coherence tomography (OCT) findings in

血液試料に含まれる微量のアルミニウムの分析では，多量かつ複雑な組成で共存する有機及び無機物質による干渉が深刻である．このため，既存の方法のほとんどは比較的共存物の少ない血清，血しょう試料を対象としたものであり，有機物や鉄をより多く含む全血試料を定量した例は少ない．本研究では，血清，全血試料中の有機物をマイクロ波加熱法により分解し，更に溶媒抽出により鉄などの妨害無機元素を除去した後，ルモガリオン蛍光光度法によりアルミニウムを定量した．本法は，血中の共存成分による干渉を軽減したことによって，血清試料のみならず，測定が困難な全血試料を同様の操作で定量できた．本法により測定したヒト健常者血清，全血中のアルミニウム濃度から，血球中の濃度を算出し，血清-血球間のアルミニウムの分布を調べた．

Objective Patients with atrial fibrillation (AF) have an increased risk of congestive heart failure (CHF) as well as ischemic stroke. The aim of this study was to investigate the clinical predictors of CHF in patients with non-valvular AF (NVAF). Methods Three hundred and forty-seven patients (derivation cohort) with NVAF were retrospectively evaluated between 2004 and 2005. The associations between potential risk factors and CHF were tested using a Cox proportional hazards analysis, and a risk score for predicting CHF was created. The model was then validated in 161 patients (validation cohort) enrolled between 2008 and 2010. During the follow-up period, 41 patients in the derivation cohort developed CHF requiring hospitalization due to New York Heart Association (NYHA) class III or IV disease. Four independent risk factors were identified, each of which was assigned a number of points as follows: Age ≥72 years (1 point), heart rate ≥80 bpm (1 point), hypertension (1 point), and a previous history of congestive heart failure (2 points). The patients were grouped into one of three risk categories according to the calculated risk score (ARC2H score): low risk (0 points), intermediate risk (1-3 points) and high risk (4-5 points). Result In the derivation cohort, the annual rates of CHF in these risk categories were 0%, 2.5% and 18% per year respectively. In the validation cohort, the corresponding rates were 0.8%, 8% and 35% per year respectively. Conclusion A simple clinical risk score, the ARC2H score, was developed to predict CHF in patients with NVAF and validated in an independent cohort.

Liquid chromatographic separation and detection with catalytic analysis was investigated for highly sensitive and automated fractional determination of vanadium(IV) and -(V). Chromatographic separation between these species was performed with a mixture (pH 3.0) of ethylenediamine and tartaric acid as the eluent and a separation column containing sulphonate groups. The eluent was introduced to an air-segmented continuous flow analysis system based on the catalytic reaction with Bindschedler’s green leuco base. The detection limit of this method was 0.2 nmol dm−3 for both vanadium(IV) and -(V).

To evaluate the effects of nongenetic factors, aging, and salt-loading on the quantitative trait loci (QTLs) for blood pressure (BP), we conducted a genome-wide linkage analysis using multiple sets of BP measurements in 125 male F2 generation cross derived from stroke-prone spontaneously hypertensive rats and normotensive Wistar-Kyoto rats. The experiment was arranged in two stages. In the first stage, corresponding to the developing period of the rats, BP was measured repeatedly without loading of salt; this continued until the rats were 5 months of age. In the second stage, after the baseline BP leveled off, 1% salt water was given to the rats and BP was monitored for the subsequent 7 months. Genome scanning was performed using 201 markers. In the developing period, three QTLs were identified on chromosomes 1, 3, and 4 (logarithmic odds [LOD] scores of 5.6, 3.1, and 3.2, respectively), which had peaks at 8 or 10 weeks of age. In the latter salt-loading stage, QTLs for BP were detected on chromosomes 1 and 10 (LOD scores 4.6 and 4.5, respectively). When the BP increase during salt-loading was analyzed as a phenotype, however, only the region on chromosome 10 showed linkage at a suggestive level (LOD score 3.2). The present study provides experimental evidence that QTLs for BP could be modulated by nongenetic factors, such as aging and salt-loading.

Received October 8, 2014; accepted October 22, 2014; released online November 20, 2014 Time for primary review: 13 days Division of Cardiology, Kawasaki Medical School, Kurashiki (T.T., H.O.); Division of Cardiology, Sakakibara Heart Institute of Okayama, Okayama (K.Y.), Japan Mailing address: Hiroyuki Okura, MD, Division of Cardiology, Kawasaki Medical School, 577 Matsushima, Kurashiki 701-0192, Japan. E-mail: hokura@fides.dti.ne.jp ISSN-1346-9843 doi: 10.1253/circj.CJ-14-1103 All rights are reserved to the Japanese Circulation Society. For permissions, please e-mail: cj@j-circ.or.jp New Echo Window to Quantify Eccentric Mitral Regurgitation Using a Transgastric Approach on Transesophageal Echocardiography

Objective The conventional mid-esophageal observation by three-dimensional transesophageal echocardiography (3DTEE) sometimes fails to visualize the subvalvular apparatus. In this study, we compared the effectiveness of the transgastric approach by 3DTEE in visualizing the mitral valve complex with the conventional mid-esophageal approach. Methods We studied 10 consecutive patients who underwent mitral valve surgery for functional mitral regurgitation. The anatomy of the mitral complex was interpreted from the 3DTEE data acquired by both the mid-esophageal and the transgastric approach preoperatively. The interpretations of the image of the mid-esophageal approach and the transgastric approach were compared with surgical observations. Results In the concordance rate for surgical observation, the interpretation of the number of papillary heads and chordal distribution for the transgastric observation were superior to those for the mid-esophageal observation both for anterior papillary muscle (P

To detect genetic loci responsible for stroke susceptibility, we produced 107 male F2 progenies crossed between stroke-prone spontaneously hypertensive rats (SHRSP/Izm) and normotensive Wistar Kyoto rats (WKY/Izm) and followed them up until they developed cerebral stroke. One hundred and twenty-five simple sequence repeat (SSR) markers were analyzed in these F2 rats. Nine of 107 F2 rats suffered from macroscopically overt stroke. In these 9 rats, the segregation ratio of 3 genotypes at 6 SSR marker loci on chromosomes 2, 4, 9, and 10 was highly distorted from the expected value (the observed sp/sp:sp/wky:wky/wky ratio was either 6:3:0 or 6:2:1, while the expected was 1:2:1, p < 0.01 by χ2test). Further, the brain weight was significantly heavier (p < 0.001) in the F2 rats suffering from stroke, suggesting that the brain weight was a parameter for stroke. The brain weight of F2 rats cosegregated with D4Mit19, D4Mgh7, and D4Mgh8 (p = 0.0015, 0.0014, and 0.0040 by ANOVA, respectively) on chromosome 4 supporting genetic effects of this genetic loci on the pathogenesis of cerebral stroke. Blood pressure did not cosegregate with these markers on chromosome 4. These results suggest that a region on chromosome 4, independently of hypertension, determines genetic susceptibility to cerebral stroke.

A 75-year-old man with atrial fibrillation was hospitalized because of shortness of breath triggered by upper respiratory infection and tachycardia. His symptoms were improved by bed rest and administration of diuretics. Pretreatment echocardiogram reported dilatation of the right ventricle (RV). Follow-up study was performed before discharge. Apical four-chamber view still demonstrated remarkable dilatation of RV (Fig. 1A). In one of the apical four-chamber views, the tricuspid valve showed a bridge-like appearance in systole without valve opening (Fig. 1B and C, Supplementary movie 1). The RV inflow view (Fig. 1D, E, and F, Supplementary movie 2) revealed localized small leaflet defect at posterior septum (Fig. 1D) with the opposing leaflet tip coapting against the RV wall (Fig. 1D). At the anterior side of the "bridge", another valve orifice was observed in RV inflow view as well as parasternal short-axis views (Fig. 1G, H, and I, Supplementary movie 3). Color Doppler images in these views showed flow from the RV to right atrium across two orifices (Fig. 1F and I), suggesting double-orifice tricuspid valve.1),2) There was no pressure gradient across both orifices in diastole. Tricuspid regurgitation jet velocity of less than 3 m/s was observed from both orifices in systole. Three-dimensional transthoracic echocardiography clearly visualized double orifices (Fig. 2, Supplementary movie 4) and confirmed the diagnosis.

ObjectivesThe purposes of this study were to examine whether tethering of the mitral leaflets affects coaptation in patients with functional mitral regurgitation (FMR) and to assess the interaction between the mitral coaptation and mitral regurgitation severity.BackgroundFunctional mitral regurgitation causes restriction of leaflet closure as a result of enhanced tethering of the mitral leaflets and papillary muscle (PM) displacement.MethodsThree-dimensional transesophageal echocardiography was performed in 44 patients with FMR related to the bilateral PM displacement and in 56 controls. The distance between the tip of the anterior or posterior PM and the intervalvular fibrosa were measured as the lateral or medial tethering length (TL) in midsystole. To evaluate the degree of coaptation, coaptation length (CL) at medial, middle, and lateral sites of mitral valve and an estimate of coaptation area (CA) were measured.ResultsThe FMR group showed the significantly decreased CA (1.3 ± 0.4 cm2 vs. 1.6 ± 0.4 cm2, p = 0.005) and CL (medial 3.2 ± 0.9 mm vs. 4.8 ± 0.6 mm, middle 3.8 ± 1.3 mm vs. 5.8 ± 0.7 mm, lateral 3.3 ± 0.9 mm vs. 4.8 ± 0.6 mm; all p < 0.0001) compared with the controls. Each CL correlated negatively and significantly with both medial and lateral TL (all p < 0.0001). Annular area (p = 0.004) was significantly smaller and leaflet-to-annular area ratio (p < 0.0001) was significantly larger in patients with nonsignificant FMR than in the patients with significant (moderate to severe) FMR. Significant correlations were found between effective regurgitant orifice area and CA or each CL (all p < 0.0001).ConclusionsCoaptation decreased significantly in patients with FMR. The CL at each region was related to PM displacement and the indexes of coaptation were associated with mitral regurgitation severity.

Two commercial software systems have become available for quantitation of mitral leaflet and annulus geometry based on three-dimensional (3D) transesophageal echocardiographic (3DTEE) images. The aim of this study is to investigate the accuracy and compatibility of the three-dimensional (3D) measurements by Real View(®) and MVQ(®).3DTEE images were obtained from phantom models with saddle-shaped annulus of mitral valve prolapse and mitral valve tenting. From reconstructed 3D data, prolapse and tenting volume were calculated by both Real View(®) and MVQ(®) and compared with the actual volume.The volume of the phantom models with saddle-shaped annulus measured by Real View(®) (tenting r = 0.99, prolapse r = 0.99) and MVQ(®) (tenting r = 0.99, prolapse r = 0.99) showed good agreement with the actual volume. However, significant difference between Real View(®) and MVQ(®) was observed in the result of quantification (tenting 2.27 ± 1.5 ml versus 2.53 ± 1.6 ml, prolapse 2.55 ± 1.7 ml versus 2.31 ± 1.6 ml, both P 0.05).Although the 2 commercially available systems allow accurate quantitative measurements of the 3D volume, discrepancy in the quantified value as a result of differences in the estimation of annular level is observed. Therefore, we should take into account the characteristics of each software when interpreting analytical results.

1. Linkage analysis is performed between basal or salt-sensitive high blood pressure and several loci on chromosomes in F2 progenies obtained from crossing stroke-prone spontaneously hypertensive rats (SHR) and normotensive Wistar-Kyoto rats. 2. Basal hypertensive genes are mapped to a region near the D1Mit2 locus on chromosome 1 and near the D3Mgh8 locus on chromosome 3 in the male and female F2 progenies. 3. Salt-sensitive hypertensive gene is mapped to a region near RR1023 locus on chromosome 10 in the male F2 progenies. 4. Salt-sensitive hypertensive gene is mapped to a region near D3Mgh12 locus on chromosome 3 in the female F2 progenies.

Abstract —The stroke-prone spontaneously hypertensive rat (SHRSP) has been reported to show significantly lower levels of serum total cholesterol than the normotensive control strain Wistar-Kyoto rat (WKY). Because selective inbreeding was conducted for stroke proneness, this concomitantly inherited characteristic of SHRSP may play some pathophysiological role in stroke. We evaluated the genetic determinants of the cholesterol trait by estimating heritability and subsequently by undertaking a genome-wide screen with 161 genetic markers in F 2 progeny involving SHRSP and WKY (104 male and 106 female rats). Three quantitative trait loci (QTLs) were detected on rat chromosomes 5, 7, and 15. Markers from the linked region on chromosome 15 indicated significant evidence of linkage with a maximal log of the odds (LOD) score of 7.7, whereas those on chromosomes 5 and 7 cosegregated with the trait in a sex-specific manner (the QTL close to genetic marker D5 Mit5 reached an LOD score of 7.3 in males, and that close to D7 Mit10 reached an LOD score of 3.2 in females). The male-specific QTL on chromosome 5 appeared to overlap with previously reported QTLs for stroke-associated phenotypes, but an identical gene (or genes) appeared unlikely to control these and the cholesterol traits simultaneously. In the present study, serum cholesterol levels were shown to be highly genetically determined in SHRSP (the heritability estimates are 76% in males and 83% in females), and 3 QTLs with substantial effects were identified. Further work, however, is required to clarify whether the cholesterol trait is related to the etiology of stroke or has been retained by chance through the inbreeding process in SHRSP.

Takotsubo cardiomyopathy (TC) is characterized by acute and transient left ventricular (LV) wall motion abnormalities triggered by emotional and/or physical stress. Although, it was named after the unique “Takotsubo like” wall motion, recent studies have shown possible variants of TC such as “

Background Two commercial software systems have become available for quantitation of mitral leaflet and annulus geometry based on three-dimensional (3D) transesophageal echocardiographic (3DTEE) images. The aim of this study is to investigate the accuracy and compatibility of the three-dimensional (3D) measurements by Real View® and MVQ®.