Cardiac tamponade due to rupture of coronary artery fistula to the coronary sinus with giant aneurysm of coronary artery: usefulness of transthoracic echocardiography.

A 68-year-old woman was admitted to our hospital because of back pain and syncope. Transthoracic echocardiography revealed pericardial effusion, a collapsed right ventricle, a giant aneurysm connected to the coronary sinus, a dilated left main trunk coronary artery, and a dilated left circumflex artery (LCx). Furthermore, there was a coronary artery fistula arising from the LCx that drained into the coronary sinus. We diagnosed cardiac tamponade due to rupture of the coronary artery fistula or giant aneurysm, and successful emergency surgery was performed. Rupture of coronary artery aneurysm or coronary artery fistula is very rare. Transthoracic two-dimensional echocardiography was very useful in our case for the diagnosis of cardiac tamponade, giant coronary aneurysm, and coronary artery fistula.

Effects of valsartan on fibrinolysis in hypertensive patients with metabolic syndrome.

BACKGROUND: The purpose of this study was to analyze the effect of valsartan on abnormal adipocyte metabolism and prothrombotic state in hypertensive patients with metabolic syndrome (MetS). METHODS AND RESULTS: We conducted a multicenter, prospective, randomized, parallel-group controlled trial in 150 hypertensive patients with MetS. They were randomly assigned to receive either 80-160 mg valsartan per day (valsartan group, n=79) or other conventional treatment without a renin-angiotensin system (RAS) inhibitor (non-RAS inhibitor group, n=71). After 1 year, there were no significant differences between the 2 groups in the changes in systolic and diastolic blood pressures (valsartan: 153±15/86±15 to 138±16/77±12 mmHg; non-RAS inhibitor: 150±14/82±15 to 137±15/76±10 mmHg). There was a significant difference in the change in the levels of plasminogen activator inhibitor-1 (PAI-1) between the 2 groups after 1 year (valsartan: 3.7±3.2 ng/ml; non-RAS inhibitor: 5.8±3.3 ng/ml, P=0.04). There was no significant difference between groups in the change in the concentration of adiponectin after 1 year (valsartan: 0.3±0.4 µg/ml; non-RAS inhibitor: 0.9±0.4 µg/ml, P=0.22). The animal study showed aortic PAI-1 protein expression was reduced in double knockout mice of angiotensin II type 1a receptor and apolipoprotein E (apoE) compared with the apoE knockout mice. CONCLUSIONS: Valsartan reduced plasma PAI-1 levels compared to non-RAS inhibitor in hypertensive patients with MetS, which suggests it may be useful for improving fibrinolytic function.

Gender differences in age-related changes in left and right ventricular geometries and functions. Echocardiography of a healthy subject group.

BACKGROUND: The purpose of the present study was to investigate gender differences in age-related changes of left ventricular (LV) and right ventricular (RV) geometries and functions throughout the entire adult age range using the Japanese Normal Values for Echocardiographic Measurements Project (JAMP) study database. METHODS AND RESULTS: Seven hundred healthy volunteers (aged 20-79 years) underwent 2-dimensional and Doppler echocardiography. The subjects were stratified into 6 different age groups and then stratified by gender in each age group. LV diastolic function was assessed from pulsed wave Doppler measurements of mitral early (E) and late (A) inflow velocities and tissue Doppler measurements of mitral early (e') and late (a') annular velocities. LV volume decreased and LV mass increased with age to a similar extent in both men and women. Furthermore, for subjects <50 years, women had significantly greater E, E/A ratio and e' than men, but these parameters were similar between genders in subjects >50 years. In addition, there was a significant interaction between age and gender that affected the differences in E, e' and E/e' among the groups (P<0.03, P<0.01, and P<0.03, respectively; ANOVA). There were no gender differences in age-related changes in RV parameters. CONCLUSIONS: Gender differences were found in age-related changes in LV diastolic function in a healthy population. Gender differences should be considered for optimal diagnosis and management of cardiovascular disease.

Nimura lecture: "Three EBMs".

The three EBMs in the title refer to the following concepts: evidence-based medicine, experience-based medicine, and echo-based medicine. Evidence-based medicine: I have carried out the following clinical research using transthoracic Doppler echocardiography: (1) noninvasive pulsed-wave Doppler echocardiographic detection of the direction of shunt flow in patients with atrial septal defect: usefulness of the right parasternal approach (1985), (2) significance of laminar systolic regurgitant flow in patients with tricuspid regurgitation: a combined pulsed-wave, continuous-wave, and two-dimensional echocardiography (1990), (3) obstruction of the inferior vena caval orifice by the giant left atrium in patients with mitral stenosis: a Doppler echocardiographic study from the right parasternal approach (1992), and (4) demonstration of a localized acceleration flow signal in the transmural penetrating coronary artery using transthoracic color and pulsed-wave Doppler echocardiography in patients with hypertrophic cardiomyopathy (1996-2017). Experience-based medicine: Dr. Eugene Braunwald says "The best book of cardiology is the patient itself." I have conducted my modest research activities gleaning hints through day-to-day routine work and sometimes investigating experimentally using the Doppler echocardiographic method. I have also learned from the Japanese Society of Echocardiography that a physician should stand between evidence-based medicine and experience-based medicine. Echo-based medicine: This term is intended to express my personal determination. I believe that echocardiography is the stethoscope of the 21st century. It is a safe, painless, low-cost, and repeatable tool at the bedside. I expect that echocardiography can reduce unnecessary healthcare costs and appropriately select reasonable examinations for patients. I would like to devote the time left in my career to the study of cardiovascular medicine, believing in the power of echocardiography and the Doppler method to provide a link between evidence-based medicine and experience-based medicine.

Significance of asymmetric basal posterior wall thinning in patients with cardiac Fabry's disease.

Although classic Fabry's disease results in multiple causes of death, the cardiac variant of Fabry's disease affects only the cardiac system and results in initial symmetric left ventricular (LV) hypertrophy and later LV dysfunction, asymmetric basal posterior LV wall thinning, restrictive mitral flow, and functional mitral regurgitation with end-stage chronic heart failure (CHF), leading to death. The purpose of this study was to investigate whether these findings predict prognoses in patients with cardiac Fabry's disease. In 13 consecutive men with cardiac Fabry's disease, LV wall thickness, the ejection fraction, mitral E-wave deceleration time, the LV Tei index, and functional mitral regurgitation were measured by echocardiography. Patients were followed for 5 to 96 months (mean 41 +/- 9). Eight patients developed New York Heart Association class III CHF, and 6 experienced cardiac death. A LV Tei index >0.60 and basal posterior LV wall thinning with a ratio of ventricular septal to posterior wall thickness >1.3 significantly preceded CHF and death (Tei index: 4.4 and 5.1 years; posterior wall thinning: 4.0 and 4.7 years), respectively (p <0.05). In conclusion, an increased LV Tei index and asymmetric basal posterior LV wall thinning are important echocardiographic findings that precede CHF and cardiac death in patients with cardiac Fabry's disease.

Mechanism of persistent ischemic mitral regurgitation after annuloplasty: importance of augmented posterior mitral leaflet tethering.

BACKGROUND: We hypothesized that surgical annuloplasty for ischemic mitral regurgitation (MR) that displaces the posterior annulus anteriorly can potentially augment posterior leaflet (PML) tethering, leading to persistent MR. Relationships between leaflet configurations and persistent ischemic MR after the annuloplasty were investigated. METHODS AND RESULTS: In 31 patients with surgical annuloplasty for ischemic MR and 20 controls, posterior and apical displacement of the leaflet coaptation, the anterior leaflet (AML) and PML tethering angles relative to the line connecting annuli, coaptation length (CL), and the MR grade were quantified before and early after surgery in echocardiographic left ventricular long-axis views. Six of the 31 patients showed persistent MR despite annuloplasty. Compared with patients without persistent MR, those with MR showed no improvement in the left ventricular ejection fraction and systolic volume, similar reduction in the annular area, significant increase in posterior displacement of the coaptation (P<0.01), no improvement in AML tethering, greater worsening in PML tethering (P<0.01), and no increase in the CL. All tethering variables were significantly correlated with both preoperative and postoperative MR in univariate analysis, and reduced CL was the primary independent determinant of both preoperative and postoperative MR. Although increased AML tethering was the primary determinant of the preoperative CL (r2=0.46, P<0.0001), increased PML tethering was the primary determinant afterward (r2=0.60, P<0.0001). CONCLUSIONS: Although tethering of both leaflets is the major determinant of ischemic MR before surgical annuloplasty, both leaflets tethering but with predominant and augmented PML tethering is related to persistent ischemic MR after the annnuloplasty.

Papillary muscle dysfunction attenuates ischemic mitral regurgitation in patients with localized basal inferior left ventricular remodeling: insights from tissue Doppler strain imaging.

OBJECTIVES: The purpose of this research was to test whether papillary muscle (PM) dysfunction attenuates ischemic mitral regurgitation (MR) in patients with left ventricular (LV) remodeling of a similar location and extent. BACKGROUND: Papillary muscle dysfunction could attenuate tethering and MR because of PM elongation. However, variability in the associated LV remodeling, which exaggerates tethering, can influence the relationship between PM dysfunction and MR. METHODS: In 40 patients with a previous inferior myocardial infarction but without other lesions, the LV volume, sphericity, PM tethering distance, PM longitudinal systolic strain, and MR fraction were quantified by echocardiography. The patients were divided into two groups: group 1 with significant basal inferoposterior LV bulging but without advanced LV bulging involving other territories, therefore with a similar location and extent of LV remodeling, and group 2 without significant LV bulging. RESULTS: The medial PM tethering distance was significantly correlated with the %MR fraction (r2 = 0.64, p < 0.01), and multiple regression analysis identified an increase in the tethering distance as the only independent determinant of the MR fraction in all subjects and also in group 1. The PM longitudinal systolic strain had no significant relationships with MR fraction in all subjects with variable degrees of LV remodeling, but it had a significant inverse correlation with the MR fraction (r2 = 0.33, p < 0.01) in group 1 with LV remodeling of a similar location and extent, indicating that PM dysfunction is associated with less MR. CONCLUSIONS: Papillary muscle dysfunction, reducing its longitudinal contraction to induce leaflet tethering, attenuates ischemic MR in patients with basal inferior LV remodeling.

Noninvasive evaluation of coronary reperfusion by transthoracic Doppler echocardiography in patients with anterior acute myocardial infarction before coronary intervention.

BACKGROUND: Transthoracic Doppler echocardiography (TTDE) enables evaluation of distal left anterior descending coronary artery (LAD) flow. The purpose of this study was to test whether TTDE can differentiate coronary reperfusion with Thrombolysis in Myocardial Infarction (TIMI) grade 3 from TIMI grade < or =2 in patients with anterior acute myocardial infarction (AMI). METHODS AND RESULTS: In 46 consecutive patients with a first anterior AMI in the acute phase before emergent coronary intervention, the presence of antegrade distal LAD flow and its diastolic peak velocity were evaluated by color and pulsed TTDE and compared with TIMI grades by subsequent coronary angiography performed 29+/-12 minutes later. Nineteen patients had TIMI 0 reperfusion, 4 had TIMI 1, 10 had TIMI 2, and 13 had TIMI 3. Visual antegrade distal LAD flow was present in 22 of the 46 patients. TIMI 2 and 3 reperfusions were both generally visualized by color TTDE. However, peak distal LAD flow velocity by pulsed TTDE was significantly greater in patients with TIMI 3 compared with those with TIMI 2 (40+/-10 vs 20+/-6 cm/s, P<0.0001). The diagnosis of TIMI 3 based on diastolic peak distal LAD flow velocity > or =25 cm/s by TTDE had a sensitivity, specificity, and accuracy of 77%, 94%, and 89%, respectively. CONCLUSIONS: TTDE enables noninvasive differentiation of TIMI 3 from TIMI < or =2 coronary reperfusion in patients with AMI in the acute phase before emergent coronary intervention.

Repeated sauna treatment improves vascular endothelial and cardiac function in patients with chronic heart failure.

OBJECTIVES: The purpose of this study was to determine the mechanism by which 60 degrees C sauna treatment improves cardiac function in patients with chronic heart failure (CHF). BACKGROUND: We have previously reported that repeated 60 degrees C sauna treatment improves hemodynamic data and clinical symptoms in patients with CHF. We hypothesized that the sauna restores endothelial function and then improves cardiac function. METHODS: Twenty patients (62 plus minus 15 years) in New York Heart Association (NYHA) functional class II or III CHF were treated in a dry sauna at 60 degrees C for 15 min and then kept on bed rest with a blanket for 30 min, daily for two weeks. Ten patients with CHF, matched for age, gender and NYHA functional class, were placed on a bed in a temperature-controlled (24 degrees C) room for 45 min as the nontreated group. Using high-resolution ultrasound, we measured the diameter of the brachial artery at rest and during reactive hyperemia (percent flow-mediated dilation, %FMD: endothelium-dependent dilation), as well as after sublingual administration of nitroglycerin (%NTG: endothelium-independent dilation). Cardiac function was evaluated by measuring the concentrations of plasma brain natriuretic peptide (BNP). RESULTS: Clinical symptoms were improved in 17 of 20 patients after two weeks of sauna therapy. The %FMD after two-week sauna treatment significantly increased from the baseline value, whereas the %NTG-induced dilation did not. Concentrations of BNP after the two-week sauna treatment decreased significantly. In addition, there was a significant correlation between the change in %FMD and the percent improvement in BNP concentrations in the sauna-treated group. In contrast, none of the variables changed at the two-week interval in the nontreated group. CONCLUSIONS: Repeated sauna treatment improves vascular endothelial function, resulting in an improvement in cardiac function and clinical symptoms.

Isolated annular dilation does not usually cause important functional mitral regurgitation: comparison between patients with lone atrial fibrillation and those with idiopathic or ischemic cardiomyopathy.

OBJECTIVES: We sought to test whether isolated mitral annular (MA) dilation can cause important functional mitral regurgitation (MR). BACKGROUND: Mitral annular dilation has been considered a primary cause of functional MR. Patients with functional MR, however, usually have both MA dilation and left ventricular (LV) dilation and dysfunction. Lone atrial fibrillation (AF) can potentially cause isolated MA dilation, offering a unique opportunity to relate MA dilation to leaflet function. METHODS: Mid-systolic MA area, MR fraction, LV volumes and papillary muscle (PM) leaflet tethering length were compared by echocardiography among 18 control subjects, 25 patients with lone AF and 24 patients with idiopathic or ischemic cardiomyopathy (ICM). RESULTS: Patients with lone AF had a normal LV size and function but MA dilation (isolated MA dialtion) significant and comparable to that of patients with ICM (MA AREA: 8.0 +/- 1.2 vs. 11.6 +/- 2.3 vs. 12.5 +/- 2.9 cm(2) [control vs. lone AF vs. ICM]; p < 0.001 for both lone AF and ICM). However, patients with lone AF had only modest MR, compared with that of patients with ICM (MR fraction: -3 +/- 8% vs. 3 +/- 9% vs. 36 +/- 25%; p < 0.001 for patients with ICM). Multivariate analysis identified PM tethering length, not MA dilation, as an independent primary contributor to MR. CONCLUSIONS: Isolated annular dilation does not usually cause moderate or severe MR. Important functional MR also depends on LV dilation and dysfunction, leading to an altered force balance on the leaflets, which impairs coaptation.

Relation of aneurysmectomy in patients with advanced left ventricular remodeling to postoperative left ventricular filling pressure, redilatation with ischemic mitral regurgitation.

Left ventricular (LV) volume, mitral E deceleration time, and mitral regurgitation (MR) fraction were measured by echocardiography in 14 patients with surgical LV aneurysmectomy. Late MR developed 3 to 6 months after surgery in 5 of the 14 patients (36%). Compared with patients without late MR, those with late MR had a significantly greater preoperative LV end-diastolic volume index (LVEDVI) (134 +/- 21 vs 93 +/- 19 ml/m(2), p <0.01), surgical reduction in LVEDVI (-51 +/- 14 vs -20 +/- 16 ml/m(2), p <0.01), early postoperative LV diastolic dysfunction with shortened mitral E deceleration time (106 +/- 23 vs 141 +/- 24 ms, p <0.01), and a late postoperative reincrease in LVEDVI (+28 +/- 4 vs +3 +/- 8 ml/m(2), p <0.01), suggesting that surgical LV aneurysmectomy in patients with advanced preoperative LV remodeling may result in postoperative LV diastolic dysfunction, promoting later LV redilation with ischemic MR.

Repeated thermal therapy diminishes appetite loss and subjective complaints in mildly depressed patients.

OBJECTIVE: We observed that repeated thermal therapy improved appetite loss and general well-being in patients with chronic heart failure. The purpose of this study is to clarify the effects of repeated thermal therapy in mildly depressed patients with appetite loss and subjective complaints. METHODS: Twenty-eight mildly depressed inpatients with general fatigue, appetite loss, and somatic and mental complaints were randomly assigned to thermal therapy group (n = 14) or nonthermal therapy group (n = 14). Patients in the thermal therapy group were treated with 60 degrees C far-infrared ray dry sauna for 15 minutes and were then kept at bed rest with a blanket for 30 minutes once a day, 5 days a week for a total of 20 sessions in 4 weeks. RESULTS: Four weeks after admission, somatic complaints, hunger, and relaxation scores significantly improved (p < .001, p < .0001, p < .0001, respectively) and mental complaints slightly improved (p = .054) in the thermal therapy group compared with the nonthermal therapy group. Furthermore, the plasma ghrelin concentrations and daily caloric intake in the thermal therapy group significantly increased compared with the nonthermal therapy group (p < .05). CONCLUSIONS: These findings suggest that repeated thermal therapy may be useful for mildly depressed patients with appetite loss and subjective complaints.

Noninvasive prediction of complications with anteroseptal acute myocardial infarction by left ventricular Tei index.

BACKGROUND: Tei index has been proposed as a noninvasive and simple index that enables the evaluation of global left ventricular (LV) function and prediction of patient prognosis. However, its use to predict complications with acute myocardial infarction (AMI) is not fully investigated. Therefore, the purpose of this study was to investigate whether or not LV Tei index allows noninvasive prediction of complications with AMI. METHODS: In all, 80 consecutive patients with anteroseptal AMI were enrolled. LV Tei index was measured at the time of admission as (a - b)/ b , where a is the interval between cessation and onset of mitral filling flow and interval b is the aortic flow ejection time. Subsequent complications including cardiac death, shock, congestive heart failure, ventricular tachycardia/fibrillation, paroxysmal atrial fibrillation/flutter, advanced atrioventricular block requiring pacing, pericardial effusion, and LV aneurysm during the 30 days after the onset of AMI were prospectively evaluated and compared with the initial Tei index at admission. RESULTS: Complications developed in 31 of 80 (39%) patients with AMI. The Tei index was significantly increased for patients with complications compared with those without them (0.69 +/- 0.16 vs 0.50 +/- 0.11, P < .0001). When Tei index > or = 0.59 was used for the criteria, the sensitivity, specificity, and overall accuracy to predict subsequent complications were 77%, 86%, and 85%, respectively. CONCLUSION: In patients with anteroseptal AMI, LV Tei index at arrival to the hospital in the acute phase allows noninvasive prediction of subsequent complications.

The effects of repeated thermal therapy for two patients with chronic fatigue syndrome.

OBJECTIVE: This paper describes the successful treatment of two patients with chronic fatigue syndrome (CFS) using repeated thermal therapy. METHODS: Two patients with CFS underwent treatment with prednisolone (PSL), with no satisfactory effect. They were subjected to thermal therapy that consisted of a far-infrared ray dry sauna at 60 degrees C and postsauna warming. The therapy was performed once a day, for a total of 35 sessions. After discharge, these subjects continued the therapy once or twice a week on an outpatient basis for 1 year. RESULTS: Symptoms such as fatigue, pain, sleep disturbance, and low-grade fever were dramatically improved after 15 to 25 sessions of thermal therapy. Although PSL administration was discontinued, the subjects showed no relapse or exacerbation of symptoms during the first year after discharge. The patients became socially rehabilitated 6 months after discharge. CONCLUSIONS: These results suggest that repeated thermal therapy might be a promising method for the treatment of CFS.

Soluble fibrin, C-reactive protein, fibrinogen, factor VII, antithrombin, proteins C and S, tissue factor, D-dimer, and prothrombin fragment 1 + 2 in men with acute myocardial infarction

To evaluate the contribution of hematologic factors and long-term inflammation to the development of myocardial infarction at a young age, we measured hematologic variables, including soluble fibrin and high-sensitivity C-reactive protein, in 90 patients who had myocardial infarction and 138 controls

Contribution of increased minimal coronary resistance and attenuated vascular adaptive remodeling to myocardial ischemia in patients with systemic hypertension and ventricular hypertrophy.

This study assessed the impact of coronary vascular adaptive remodeling and coronary vascular reactivity on myocardial ischemia in patients with hypertension and left ventricular hypertrophy. Myocardial ischemia is associated with impaired endothelium-independent vasodilation of resistance coronary arteries and increased minimal coronary resistance. These changes may occur in association with lumen reduction caused by attenuated adaptive remodeling in response to plaque accumulation.

Pseudonormalized Doppler total ejection isovolume (Tei) index in patients with right ventricular acute myocardial infarction.

The Doppler total ejection isovolume (Tei) index is useful for estimating global cardiac function. However, the relation between the right ventricular (RV) Tei index and RV infarction has not been investigated. The relation between the RV Tei index and severity of RV infarction was evaluated in 25 patients with inferior wall acute myocardial infarction (13 with and 12 without RV infarction). RV infarction was diagnosed when right atrial pressure was > or = 10 mm Hg or when right atrial pressure/pulmonary capillary wedge pressure was >0.8 by catheterization. The RV Tei index was significantly increased in patients with RV infarction compared with those without (0.53 +/- 0.15 vs 0.38 +/- 0.14, p <0.05). The RV Tei index in patients with severe RV infarction (right atrial pressure > or = 15 mm Hg) was significantly smaller compared with those with mild/moderate RV infarction (right atrial pressure <15 mm Hg) and showed no significant difference in patients with myocardial infarction but without RV infarction (0.44 +/- 0.09 vs 0.61 +/- 0.16 vs 0.38 +/- 0.14, severe RV infarction vs mild/moderate RV infarction vs no RV infarction, p <0.01). The RV Tei index is generally increased in patients with RV infarction; however, severe RV infarction can be manifested with limited or no increase in the Tei index (pseudonormalization).

Evaluation of left ventricular ejection fraction by tissue locus imaging.

The newly developed echocardiographic technique called "tissue locus imaging" (TLI) can visualize temporal series of images in a single picture by maintaining the display of previous images with a shading function; therefore, it can display the whole systolic shift of the mitral leaflets toward the apex in a single picture and can potentially offer useful information on left ventricular (LV) function. In 36 consecutive patients with varying degrees of LV dysfunction (15 with coronary artery disease, 9 with cardiomyopathy, 3 with hypertension, 2 with aortic stenosis, 1 with aortic regurgitation, and 6 controls), the systolic shift of the mitral leaflets (X) by TLI showed a significant correlation with the LV ejection fraction (Y) by 2-dimensional echocardiography (Y = 7.2 x+13, r(2) = 0.83, p <0.01). TLI enables the evaluation and visualization of LV systolic function by displaying the whole systolic shift of the mitral leaflets toward the apex.

Mechanism of higher incidence of ischemic mitral regurgitation in patients with inferior myocardial infarction: quantitative analysis of left ventricular and mitral valve geometry in 103 patients with prior myocardial infarction.

OBJECTIVE: The mechanism of higher incidence of ischemic mitral regurgitation in patients with inferior compared with anterior myocardial infarction despite less global left ventricular remodeling and dysfunction is controversial. We hypothesized that inferior myocardial infarction causes left ventricular remodeling, which displaces posterior papillary muscle away from its normal position, leading to ischemic mitral regurgitation. METHODS: In 103 patients with prior myocardial infarction (61 anterior and 42 inferior) and 20 normal control subjects, we evaluated the grade of ischemic mitral regurgitation on the basis of the percentage of Doppler jet area, left ventricular end-diastolic and end-systolic volumes, midsystolic mitral annular area, and midsystolic leaflet-tethering distance between papillary muscle tips and the contralateral anterior mitral annulus, which were determined by means of quantitative echocardiography. RESULTS: Global left ventricular dilatation and dysfunction were significantly less pronounced in patients with inferior myocardial infarction (left ventricular end-systolic volume: 52 +/- 18 vs 60 +/- 24 mL, inferior vs anterior infarction, P<.05; left ventricular ejection fraction: 51% +/- 9% vs 42% +/- 7%, P <.0001). However, the percentage of mitral regurgitation jet area and the incidence of significant regurgitation (percentage of jet area of 10% or greater) was greater in inferior infarction (percentage of jet area: 10.1% +/- 7.5% vs 4.4% +/- 7.0%, P =.0002; incidence: 16/42 (38%) vs 6/61 (10%), P <.0001). The mitral annulus (area = 8.2 +/- 1.2 cm2 in control subjects) was similarly dilated in both inferior and anterior myocardial infarction (9.7 +/- 1.7 vs. 9.5 +/- 2.3 cm2, no significant difference), and the anterior papillary muscle-tethering distance (33.8 +/- 2.6 mm in control subjects) was also similarly and mildly increased in both groups (35.2 +/- 2.4 vs 35.2 +/- 2.8 mm, no significant difference). However, the posterior papillary muscle-tethering distance (33.3 +/- 2.3 mm in control subjects) was significantly greater in inferior compared with anterior myocardial infarction (38.3 +/- 4.1 vs 34.7 +/- 2.9 mm, P =.0001). Multiple stepwise regression analysis identified the increase in posterior papillary muscle-tethering distance divided by body surface area as an independent contributing factor to the percentage of mitral regurgitation jet area (r2 = 0.70, P <.0001). CONCLUSIONS: It is suggested that the higher incidence and greater severity of ischemic mitral regurgitation in patients with inferior compared with anterior myocardial infarction can be related to more severe geometric changes in the mitral valve apparatus with greater displacement of posterior papillary muscle caused by localized inferior basal left ventricular remodeling, which results in therapeutic implications for potential benefit of procedures, such as infarct plication and leaflet or chordal elongation, to reduce leaflet tethering.

A simple oscillometric technique for determining new indices of arterial distensibility.

Recently, oscillometric devices have been developed that can measure blood pressure in the extremities and analyze pulse volume record. On the basis of the extremity pulse volume record, these devices can automatically determine three types of simply measured pulse wave velocity (PWV) (brachial PWV: heart to right upper arm; R-PWV: right upper arm-right ankle; and L-PWV: right upper arm-left ankle). The percent mean pulse volume record (%MPVR=the height that bisects the area of the pulse volume record/pulse pressure X100), a quantitative index of right brachial pulse volume record, can also be determined. To evaluate the usefulness of these new indices, we studied 1,067 consecutive subjects undergoing health checkups (648 men, 419 women; mean age, 50 +/- 9 years). In both sexes, age correlated positively with simply measured PWVs (men, brachial PWV: r=0.46, p<0.0001; R-PWV: r=0.46, p<0.0001; L-PWV: r=0.47, p<0.0001; women, brachial PWV: r=0.37, p<0.0001; R-PWV: r=0.47, p<0.0001; L-PWV: r=0.48, p<0.0001) and correlated negatively with %MPVR (men: r=-0.40, p<0.0001; women: r=-0.45, p<0.0001). Simply measured PWVs and %MPVR were significantly correlated with mean blood pressure. In a separate group of 60 patients, simply measured PWVs correlated positively with carotid PWV (heart to carotid) derived from an elastic vessel (brachial PWV: r=0.76, p<0.0001; R-PWV: r=0.43, p<0.01; L-PWV: r=0.43, p<0.01). %MPVR correlated negatively with carotid PWV (r=-0.35, p<0.01). In conclusion, simply measured PWVs and %MPVR are easier to determine than conventional PWV and may be useful as new indices of age-related changes in arterial distensibility.