Echocardiographic Estimates of Left Ventricular Diastolic Dysfunction Do Not Predict the Clinical Course in Elderly Patients Undergoing Transcatheter Atrial Septal Defect Closure: Impact of Early Diastolic Mitral Annular Velocity.

OBJECTIVE: This study evaluated the effect of echocardiographic left ventricular (LV) diastolic dysfunction on acute congestive heart failure after transcatheter atrial septal defect (ASD) closure in elderly patients. BACKGROUND: Although there is concern that LV diastolic dysfunction develops acute congestive heart failure after ASD closure, limited information is available regarding the influence, especially in elderly patients with severe LV diastolic dysfunction. METHODS: Two hundred consecutive patients older than 60 years were divided into 3 groups according to echocardiographic LV diastolic dysfunction: severe (early diastolic mitral annular velocity [e'] <5.0 cm/s), mild (5.0≤ e' <8.0 cm/s), and normal (e' ≥ 8.0 cm/s). Changes in plasma B-type natriuretic peptide (BNP) levels were evaluated. RESULTS: No patients with severe LV diastolic dysfunction developed acute congestive heart failure immediately after the procedure. BNP levels unchanged after the procedure in patients with severe LV diastolic dysfunction (126 ± 181 to 131 ± 148 pg/ml, P = 0.885), and this increase in BNP levels was not different from that between the diagnosis of ASD and the procedure. The change in BNP levels in patients with severe LV diastolic dysfunction, who were frequently treated with diuretics before the procedure, was equivalent to that in patients with mild LV diastolic dysfunction and normal LV diastolic function (5 ± 119 vs. 16 ± 101 vs. 9 ± 131 pg/ml, P = 0.724). CONCLUSIONS: Our findings suggest that transcatheter ASD closure under volume management is safe and valuable in elderly patients with echocardiographic severe LV diastolic dysfunction.

Reverse Right Ventricular Remodeling After Lung Transplantation in Patients With Pulmonary Arterial Hypertension Under Combination Therapy of Targeted Medical Drugs.

BACKGROUND: Patients with pulmonary arterial hypertension (PAH) are currently treated with combination therapy of PAH-targeted drugs. Reverse right ventricular (RV) remodeling after lung transplantation (LTx) in patients with end-stage PAH despite combination therapy of PAH-targeted drugs has not been fully elucidated.Methods and Results:A total of 136 patients, including 32 with PAH, underwent LTx from 1998 to 2014. We enrolled 12 consecutive patients with PAH treated with combination therapy of PAH-targeted drugs who underwent LTx and retrospectively analyzed the temporal and serial changes in hemodynamics and echocardiography before LTx and at 3 and 12 months after LTx. Before LTx, the RV was markedly dilated with substantially reduced RV fractional area change (RVFAC). At 3 months after LTx, pulmonary artery pressure, pulmonary vascular resistance and RV stroke work index were significantly decreased, while left ventricular stroke work index was increased. RV size assessed by echocardiography also significantly decreased and RVFAC improved. At 12 months after LTx, RVFAC was further increased and RV wall thickness was decreased significantly. CONCLUSIONS: Although severe RV dysfunction and dilation were observed in patients with end-stage PAH despite combination therapy of PAH-targeted drugs, RV function and morphology were improved after reduction of RV pressure load by LTx.

Association between coronary artery calcification and left ventricular diastolic dysfunction in elderly people.

Coronary artery calcification (CAC) is associated with the incidence of congestive heart failure. We evaluated the association between CAC and left ventricular diastolic dysfunction (LVDD) in elderly patients without coronary artery disease. Coronary computed tomography was performed in 1,021 consecutive patients >55 years of age who were suspected of having coronary artery disease. A total of 530 patients (age, 70 ± 8 years; 56 % men) with a LV ejection fraction >50 % and without obstructive coronary artery disease and a history of coronary artery disease were included in the analysis. LVDD was defined according to a standard algorithm by echocardiography (septal e' <8, lateral e' <10, and left atrial volume index ≥34 mL/m(2)). A total of 224 of 530 patients had LVDD. CAC scores in patients with LVDD were higher than those in patients without LVDD (p < 0.01). The prevalence of LVDD in patients with CAC scores ≥400 was greater than that in patients with CAC scores of 0-9 (58 vs. 34 %, p < 0.01). After adjustment for confounding factors, the CAC score was associated with LVDD, with an odds ratio of 1.96 (95 % confidence interval: 1.11-3.43, p = 0.02) for a CAC score ≥400 compared with a CAC score of 0-9. A CAC score ≥400 was associated with LVDD in elderly patients without CAD in this population. Further prospective studies are needed to evaluate the clinical relevance of CAC as a risk of heart failure with preserved ejection fraction.

Measurement of epicardial fat thickness by transthoracic echocardiography for predicting high-risk coronary artery plaques.

Epicardial adipose tissue (EAT) volume is reported to be associated with coronary plaques. We evaluated whether non-invasive measurement of EAT thickness by echocardiography can predict high-risk coronary plaque characteristics determined independently by coronary computed tomography (CT) angiography. We enrolled 406 patients (mean age 63 years, 57 % male) referred for 64-slice CT. EAT was measured on the right ventricle free wall from a parasternal long-axis view at the end of systole. High-risk coronary plaques were defined as low-density plaques (<30 Hounsfield units) with positive remodeling (remodeling index >1.05). Patients were divided into thin or thick EAT groups using a cutoff value derived from receiver operator characteristic curve analysis for discriminating high-risk plaques. The receiver operator characteristic cutoff value was 5.8 mm with a sensitivity of 83 % and specificity of 64 % (area under the curve 0.77, 95 % confidence interval 0.70-0.83, p < 0.01). Compared with the thin EAT group, the thick EAT group had a high prevalence of low-density plaques (4 vs. 24 %, p < 0.01), positive remodeling (39 vs. 60 %, p < 0.01), and high-risk plaques (3 vs. 17 %, p < 0.01). Multiple logistic analysis revealed that thick EAT was a significant predictor of high-risk plaques (odds ratio 7.98, 95 % confidence interval 2.77-22.98, p < 0.01) after adjustment for covariates, including conventional risk factors, visceral adipose tissue area, and medications. The measurement of EAT thickness by echocardiography may provide a non-invasive option for predicting high-risk coronary plaques.

Comparison of effects of sitagliptin and voglibose on left ventricular diastolic dysfunction in patients with type 2 diabetes: results of the 3D trial.

BACKGROUND: Left ventricular (LV) diastolic dysfunction is frequently observed in patients with type 2 diabetes. Dipeptidyl peptidase-4 inhibitor (DPP-4i) attenuates postprandial hyperglycemia (PPH) and may have cardio-protective effects. It remains unclear whether DPP-4i improves LV diastolic function in patients with type 2 diabetes, and, if so, it is attributable to the attenuation of PPH or to a direct cardiac effect of DPP-4i. We compared the effects of the DPP-4i, sitagliptin, and the alpha-glucosidase inhibitor, voglibose, on LV diastolic function in patients with type 2 diabetes. METHODS: We conducted a prospective, randomized, open-label, multicenter study of 100 diabetic patients with LV diastolic dysfunction. Patients received sitagliptin (50 mg/day) or voglibose (0.6 mg/day). The primary endpoints were changes in the e' velocity and E/e' ratio from baseline to 24 weeks later. The secondary efficacy measures included HbA1c, GLP-1, lipid profiles, oxidative stress markers and inflammatory markers. RESULTS: The study was completed with 40 patients in the sitagliptin group and 40 patients in the voglibose group. There were no significant changes in the e' velocity and E/e' ratio from baseline to 24 weeks later in both groups. However, analysis of covariance demonstrated that pioglitazone use is an independent factor associated with changes in the e' and E/e' ratio. Among patients not using pioglitazone, e' increased and the E/e' ratio decreased in both the sitagliptin and voglibose groups. GLP-1 level increased from baseline to 24 weeks later only in the sitagliptin group (4.8 ± 4.7 vs. 7.3 ± 5.5 pmol/L, p < 0.05). The reductions in HbA1c and body weight were significantly greater in the sitagliptin group than in the voglibose group (-0.7 ± 0.6 % vs. -0.3 ± 0.4, p < 0.005; -1.3 ± 3.2 kg vs. 0.4 ± 2.8 kg, p < 0.05, respectively). There were no changes in lipid profiles and inflammatory markers in both groups. CONCLUSIONS: Our trial showed that sitagliptin reduces HbA1c levels more greatly than voglibose does, but that neither was associated with improvement in the echocardiographic parameters of LV diastolic function in patients with diabetes. TRIAL REGISTRATION: Registered at http://www.umin.ac.jp under UMIN000003784.

Prognostic significance of endothelial dysfunction in patients undergoing percutaneous coronary intervention in the era of drug-eluting stents.

BACKGROUND: Endothelial function is a prognostic predictor in patients undergoing percutaneous coronary intervention (PCI). However, in an era with widespread use of drug-eluting stents, the clinical relevance of endothelial dysfunction on restenosis in patients undergoing PCI has not been fully evaluated. METHODS: This study included 80 patients with stable angina pectoris. Flow-mediated dilation (FMD) of the brachial artery was examined 1 week after PCI. Patients were retrospectively followed-up for an average of 21 months after PCI. The primary endpoints included cardiac death, nonfatal myocardial infarction, stroke, coronary revascularization, and critical limb ischemia. RESULTS: A drug-eluting stent was used in 58 patients and a cardiovascular event was recorded in 34 patients during follow-up. The incidence of all cardiovascular diseases was significantly greater in the low FMD (median FMD <4.2%) than the high FMD (median FMD ≥4.2%) group (60% vs. 25%, p <0.01). Furthermore, the incidence of coronary revascularization was significantly higher in the low than the high FMD group (p = 0.02), while the incidence of in-stent restenosis did not differ between the two groups. Cox regression analysis showed that low FMD was an independent predictor of cardiovascular events (hazard ratio: 2.77, 95% confidence interval: 1.23 to 6.19, p = 0.01). CONCLUSIONS: Impaired brachial artery FMD independently predicts long-term cardiovascular events after PCI in the era of drug-eluting stents.

[Echocardiography and Respiratory Function Testing for Pulmonary Arterial Hypertension].

Pulmonary hypertension (PH) is a hemodynamic and pathophysiologic condition characterized by elevated pulmonary artery pressure (PAP) and pulmonary vascular resistance (PVR), defined as an increase in the mean PAP of more than 20 mmHg at rest. PH can be a progressive and fatal disease if not treated appropriately. In the advanced stage of PH, the right ventricular (RV) function may be impaired, and it is associated with poor outcomes in PH. PH, however, can be easily misdiagnosed until the disease is at an advanced stage, because of its nonspecific and subtle symptoms in the early stages. PH is also a multi-factorial disease, it can be due to a primary elevation of pressure in the pulmonary arterial system alone (pulmonary arterial hypertension), or secondary to elevations of pressure in the pulmonary venous and pulmonary capillary systems (pulmonary venous hypertension). Establishing its etiology is also important for the early diagnosis of PH. Echocardiography is an important modality to assess the presence or absence of PH and its etiology, and it has been used to screen for this disease, determine the left and right heart structure and function, and assess the response to therapy in persons with PH. The pulmonary function test is also useful in PH, especially PH in chronic lung disorders. PH patients may also display mild to moderate ventilatory impairment in the absence of any evidence of lung airway or parenchymal disease, mainly in the form of airway obstruction. In this review, we discuss the diagnostic and prognostic role of clinical echocardiography and pulmonary function testing in clinical practice for pulmonary hypertension in this modern era.

Effect of vildagliptin, a dipeptidyl peptidase 4 inhibitor, on cardiac hypertrophy induced by chronic beta-adrenergic stimulation in rats.

BACKGROUND: Heart failure with left ventricular (LV) hypertrophy is often associated with insulin resistance and inflammation. Recent studies have shown that dipeptidyl peptidase 4 (DPP4) inhibitors improve glucose metabolism and inflammatory status. We therefore evaluated whether vildagliptin, a DPP4 inhibitor, prevents LV hypertrophy and improves diastolic function in isoproterenol-treated rats. METHODS: Male Wistar rats received vehicle (n = 20), subcutaneous isoproterenol (2.4 mg/kg/day, n = 20) (ISO), subcutaneous isoproterenol (2.4 mg/kg/day + oral vildagliptin (30 mg/kg/day, n = 20) (ISO-VL), or vehicle + oral vildagliptin (30 mg/kg/day, n = 20) (vehicle-VL) for 7 days. RESULTS: Blood pressure was similar among the four groups, whereas LV hypertrophy was significantly decreased in the ISO-VL group compared with the ISO group (heart weight/body weight, vehicle: 3.2 ± 0.40, ISO: 4.43 ± 0.39, ISO-VL: 4.14 ± 0.29, vehicle-VL: 3.16 ± 0.16, p < 0.05). Cardiac catheterization revealed that vildagliptin lowered the elevated LV end-diastolic pressure observed in the ISO group, but other parameters regarding LV diastolic function such as the decreased minimum dp/dt were not ameliorated in the ISO-VL group. Histological analysis showed that vildagliptin attenuated the increased cardiomyocyte hypertrophy and perivascular fibrosis, but it did not affect angiogenesis in cardiac tissue. In the ISO-VL group, quantitative PCR showed attenuation of increased mRNA expression of tumor necrosis factor-α, interleukin-6, insulin-like growth factor-l, and restoration of decreased mRNA expression of glucose transporter type 4. CONCLUSIONS: Vildagliptin may prevent LV hypertrophy caused by continuous exposure to isoproterenol in rats.

DPP-4 inhibitor and alpha-glucosidase inhibitor equally improve endothelial function in patients with type 2 diabetes: EDGE study.

BACKGROUND: Alpha glucosidase inhibitor (GI) attenuates postprandial hyperglycemia (PPH) and reduces the risk of cardiovascular events in patients with impaired glucose tolerance or type 2 diabetes. Dipeptidyl peptidase 4 (DPP-4) inhibitors also attenuate PPH. PPH is one of the factors leading to endothelial dysfunction which is an early event in the pathogenesis of atherosclerosis. Furthermore, DPP-4 inhibitors protect endothelial function through a GLP-1-dependent mechanism. However, the impact of these two types of drugs on endothelial dysfunction in patients with type 2 diabetes has not been fully elucidated. We compared the effects of sitagliptin, a DPP-4 inhibitor, and voglibose, an alpha GI, on endothelial function in patients with diabetes. METHODS: We conducted a randomized prospective multicenter study in 66 patients with type 2 diabetes who did not achieve the treatment goal with sulfonylurea, metformin or pioglitazone treatment; 31 patients received sitagliptin treatment and 35 patients, voglibose treatment. The flow-mediated dilatation (FMD) of the brachial artery was measured in the fasting state at baseline and after 12 weeks of treatment. The primary endpoint was a change in FMD (ΔFMD) from the baseline to the end of follow-up. The effects of sitagliptin and voglibose on FMD were assessed by ANCOVA after adjustment for the baseline FMD, age, sex, current smoking, diabetes duration and body mass index. Secondary efficacy measures included changes in HbA1c, GIP, GLP-1, C-peptide, CD34, lipid profile, oxidative stress markers, inflammatory markers and eGFR and any adverse events. RESULTS: ΔFMD was significantly improved after 12 weeks of treatment in both groups, and there was no significant difference in ΔFMD between the two groups. There were no significant differences in changes in HbA1c, GIP, GLP-1, C-peptide, lipid profile, oxidative stress marker, inflammatory marker and eGFR between the two groups. Compared with voglibose, sitagliptin significantly increased the circulating CD34, a marker of endothelial progenitor cells. Adverse events were observed in 5 patients in only the voglibose group (diarrhea 1, nausea 1, edema 2 and abdominal fullness 1). CONCLUSIONS: Sitagliptin improved endothelial dysfunction just as well as voglibose in patients with type 2 diabetes. Sitagliptin had protective effects on endothelial function without adverse events. TRIAL REGISTRATION: registered at http://www.umin.ac.jp/ctrj/ under UMIN000003951.

Bezafibrate improves postprandial hypertriglyceridemia and associated endothelial dysfunction in patients with metabolic syndrome: a randomized crossover study.

BACKGROUND: Postprandial elevation of triglyceride-rich lipoproteins impairs endothelial function, which can initiate atherosclerosis. We investigated the effects of bezafibrate on postprandial endothelial dysfunction and lipid profiles in patients with metabolic syndrome. METHODS: Ten patients with metabolic syndrome were treated with 400 mg/day bezafibrate or untreated for 4 weeks in a randomized crossover study. Brachial artery flow-mediated dilation (FMD) and lipid profiles were assessed during fasting and after consumption of a standardized snack. Serum triglyceride and cholesterol contents of lipoprotein fractions were analyzed by high-performance liquid chromatography. RESULTS: Postprandial FMD decreased significantly and reached its lowest value 4 h after the cookie test in both the bezafibrate and control groups, but the relative change in FMD from baseline to minimum in the bezafibrate group was significantly smaller than that in the control group (-29.0 ± 5.9 vs. -42.9 ± 6.2%, p = 0.04). Bezafibrate significantly suppressed postprandial elevation of triglyceride (incremental area under the curve (AUC): 544 ± 65 vs. 1158 ± 283 mg h/dl, p = 0.02) and remnant lipoprotein cholesterol (incremental AUC: 27.9 ± 3.5 vs. 72.3 ± 14.1 mg h/dl, p < 0.01). High-performance liquid chromatography analysis revealed that postprandial triglyceride content of the chylomicron and very low-density lipoprotein fractions was significantly lower in the bezafibrate group than in the control group (p < 0.05). CONCLUSION: Bezafibrate significantly decreased postprandial endothelial dysfunction, and elevations of both exogenous and endogenous triglycerides in patients with metabolic syndrome, suggesting that bezafibrate may have vascular protective effects in these patients. CLINICAL TRIAL REGISTRATION: Unique Identifiers: UMIN000012557.

Pioglitazone prevents the endothelial dysfunction induced by ischemia and reperfusion in healthy subjects.

BACKGROUND: No study has investigated whether pioglitazone (an agonist of peroxisome proliferator-activated receptor gamma) protects against ischemia and reperfusion (IR)-induced endothelial dysfunction in humans. METHODS AND RESULTS: In the first crossover study, 20 volunteers were randomized to 1 week of pioglitazone (30 mg/d, postoperatively) or control (no treatment). In the second single-arm study, 15 volunteers received pioglitazone and the cyclooxygenase-2 inhibitor meloxicam for 1 week. On day 7, endothelium-dependent flow-mediated dilation (FMD) of the distal brachial artery was measured before and after IR (15 minutes of ischemia followed by 15 minutes of reperfusion in the proximal upper arm). Pre-IR brachial-artery diameter and FMD were similar across the 2 sessions (control, pioglitazone) in protocol 1 and between the 2 protocols. IR significantly blunted FMD after no treatment (pre-IR FMD: 10.2% ± 2.6%; post-IR FMD: 3.5% ± 1.9%, P < 0.01) but not after pioglitazone administration (pre-IR FMD: 9.7% ± 2.5%; post-IR FMD: 8.8% ± 2.9%, P = 0.11). This protective effect was accompanied by an increase in serum levels of the antioxidant enzyme extracellular superoxide dismutase and was not affected by concomitant administration of the cyclooxygenase-2 inhibitor meloxicam (P = 0.10). CONCLUSIONS: In humans, pioglitazone provides potent protection against IR-induced endothelial dysfunction.

Three-dimensional echocardiography guided closure of complex multiple atrial septal defects.

Transcatheter closure of complex multiple atrial septal defects (ASDs) remains a challenge. We describe our clinical experience with staged device deployment in a patient with multiple ASDs using four Amplatzer septal occluder devices. Three-dimensional transesophageal echocardiography imaging contributed not only to the therapeutic guidance of successful device deployment but also to the decision making for the staged device delivery approach in a case of morphologically complex multiple ASDs.

Alogliptin ameliorates postprandial lipemia and postprandial endothelial dysfunction in non-diabetic subjects: a preliminary report.

BACKGROUND: Postprandial hyperlipidemia impairs endothelial function and participates in the development of atherosclerosis. We investigated the postprandial effects of a dipeptidyl peptidase IV inhibitor, alogliptin, on endothelial dysfunction and the lipid profile. METHODS: A randomized cross-over trial design in 10 healthy volunteers (8 males and 2 females, 35 ± 10 years) was performed. The postprandial effects before and after a 1-week treatment of 25 mg/day alogliptin on endothelial function were assessed with brachial artery flow-mediated dilation (FMD) and changing levels of lipids, apolipoprotein B48 (apoB-48), glucose, glucagon, insulin, and glucagon-like peptide-1 (GLP-1) during fasting and at 2, 4, 6, and 8 h after a standard meal loading test. RESULTS: Alogliptin treatment significantly suppressed the postprandial elevation in serum triglyceride (incremental area under the curve [AUC]; 279 ± 31 vs. 182 ± 32 mg h/dl, p = 0.01), apoB-48 (incremental AUC; 15.4 ± 1.7 vs. 11.7 ± 1.1 µg h/ml, p = 0.04), and remnant lipoprotein cholesterol (RLP-C) (incremental AUC: 29.3 ± 3.2 vs. 17.6 ± 3.3 mg h/dl, p = 0.01). GLP-1 secretion was significantly increased after alogliptin treatment. Postprandial endothelial dysfunction (maximum decrease in%FMD, from -4.2 ± 0.5% to -2.6 ± 0.4%, p = 0.03) was significantly associated with the maximum change in apoB-48 (r = -0.46, p = 0.03) and RLP-C (r = -0.45, p = 0.04). CONCLUSION: Alogliptin significantly improved postprandial endothelial dysfunction and postprandial lipemia, suggesting that alogliptin may be a promising anti-atherogenic agent.

Inadequate increase in the volume of major epicardial coronary arteries compared with that in left ventricular mass. Novel concept for characterization of coronary arteries using 64-slice computed tomography.

BACKGROUND: Previous studies have shown a correlation between coronary artery cross-sectional diameter and left ventricular (LV) mass. However, no studies have examined the correlation between actual coronary artery volume (CAV) and LV mass. In the present study, measurements of CAV by 64-multislice computed tomography (MSCT) were validated and the relationship between CAV and LV mass was investigated. METHODS AND RESULTS: First, coronary artery phantoms consisting of syringes filled with solutions of contrast medium moving at simulated heart rates were scanned by 64-MSCT. Display window settings permitting accurate calculation of small volumes were optimized by evaluating volume-rendered images of the segmented contrast medium at different window settings. Next, 61 patients without significant coronary artery stenosis were scanned by 64-MSCT with the same protocol as for the phantoms. Coronary arteries were segmented on a workstation and the same window settings were applied to the volume-rendered images to calculate total CAV. Significant correlations between total CAV and LV mass (r=0.660, P<0.0001) were found, whereas an inverse relation was present between total CAV per 100 g of LV mass and LV mass. CONCLUSIONS: The novel concept of "CAV" for the characterization of coronary arteries may prove useful for future research, particularly on the causes of LV hypertrophy.

Prognostic significance of residual functional mitral regurgitation in hospitalized heart failure patients with chronic atrial fibrillation and preserved ejection fraction after medical therapies.

BACKGROUND: Functional mitral regurgitation (MR) can be seen in patients with atrial fibrillation (AF), even without left-ventricular (LV) systolic dysfunction, as a result of left atrial enlargement. The purpose of this study was to evaluate the prognostic significance of residual functional MR in hospitalized heart failure patients with chronic AF and preserved LV ejection fraction (pEF) after medical therapies. METHODS: In this retrospective multi-center study, the determinants of post-discharge prognosis (cardiac death and re-hospitalization for worsening heart failure) were examined in 54 hospitalized heart failure patients with chronic AF and pEF at discharge. RESULTS: Of the 54 patients, 53 (98%) had mild or higher degrees of functional MR at hospitalization.At discharge, 47 (87%) still had functional MR, even after medical therapies [mild in 27 (50%), moderate in 16 (30%), and severe in 4 (7%)]. During the follow-up period (20 ± 16 months) after discharge, 16 (30%) patients met the composite end points. The grading of residual functional MR at discharge was the significant predictor of the end point (hazard ratio per one grade increase: 2.4, 95% confidence interval 1.1-5.5, p = 0.035). The greater the residual functional MR was, the lower the event-free rate from the end point was in the Kaplan-Meier curve analysis (p = 0.0069 for trend). CONCLUSIONS: A substantial proportion of patients hospitalized due to heart failure with chronic AF have residual functional MR at discharge, even with pEF after medical therapies, and the MR is related to future heart failure events.

Morphological but not functional changes of the carotid artery are associated with the extent of coronary artery disease in patients with preserved left ventricular function.

BACKGROUND AND PURPOSE: The atherosclerotic process is associated with both morphological and functional changes in the carotid artery. We evaluated the relationship between these parameters of the carotid artery and the extent of coronary artery disease (CAD) in patients with preserved left ventricular function. METHODS: The study population consisted of 104 stable patients with CAD who had preserved left ventricular function (left ventricular ejection fraction >or=45%). All patients underwent carotid ultrasound for evaluation of carotid artery plaque score defined by the sum of plaque thickness, maximum percent area stenosis, and carotid arterial stiffness index beta calculated by a combination of changes in carotid arterial diameter and blood pressure. RESULTS: Plaque score and percent area stenosis correlated with the extent of CAD defined as the number of diseased coronary vessels (P<0.001 and 0.002, respectively), but arterial stiffness beta did not (P=0.39). Using logistic regression analyses adjusting for confounding coronary risk factors and arterial stiffness beta, plaque score and percent area stenosis were independently correlated with multivessel CAD (P=0.001 and 0.004, respectively). CONCLUSIONS: Carotid artery plaque burden, but not arterial stiffness, is associated with the extent of CAD, suggesting morphological rather than functional changes in the carotid artery may be a more accurate predictor of the extent of CAD and multivessel CAD independent of left ventricular function.

Potential benefit of a simultaneous, side-by-side display of contrast MDCT and echocardiography over routine sequential imaging for assessment of adult congenital heart disease: A preliminary study.

BACKGROUND: Management of adult congenital heart disease (ACHD) patients requires understanding of its complex morphology and functional features. An innovative imaging technique has been developed to display a virtual multi-planar reconstruction obtained from contrast-enhanced multidetector-computed tomography (MDCT) corresponding to the same cross-sectional image from transthoracic echocardiography (TTE). The aim of this study is to assess the usefulness of this imaging technology in ACHD patients. METHODS: This study consisted of 46 consecutive patients (30 women; mean age, 52±18 years old) with ACHD who had undergone contrast MDCT. All patients underwent TTE within a week of MDCT. An experienced sonographer who did not know the results of MDCT conducted a diagnosis using TTE and, then, using the new imaging technology. We studied whether this imaging technology provided additional or unexpected findings or makes more accurate diagnosis. RESULTS: In this imaging technology, MDCT cross-section provides higher-resolution image to the deep compared to corresponding TTE image. Depending on the MDCT section which can be arbitrarily set under the echo guide, we can diagnose unexpected or incremental lesions or more accurately assess the severity of the lesion in 27 patients (59%) compared to TTE study alone. This imaging technology was useful in the following situations: CONCLUSIONS: This integrated imaging technology provides incremental role over TTE in complex anatomy, and allows functional information in ACHD patients.

Reduced variability of visual left ventricular ejection fraction assessment with reference images: The Japanese Association of Young Echocardiography Fellows multicenter study.

BACKGROUND: Visual estimation of left ventricular ejection fraction (LVEF) is widely applied to confirm quantitative EF. However, visual assessment is subjective, and variability may be influenced by observer experience. We hypothesized that a learning session might reduce the misclassification rate. METHODS: Protocol 1: Visual LVEFs for 30 cases were measured by 79 readers from 13 cardiovascular tertiary care centers. Readers were divided into 3 groups by their experience: limited (1-5 years, n=28), intermediate (6-11 years, n=26), and highly experienced (12-years, n=25). Protocol 2: All readers were randomized to assess the effect of a learning session with reference images only or feedback plus reference images. After the session, 20 new cases were shown to all readers following the same methodology. To assess the concordance and accuracy pre- and post-intervention, each visual LVEF measurement was compared to overall average values as a reference. RESULTS: Experience affected the concordance in visual EF values among the readers. Groups with intermediate and high experience showed significantly better mean difference (MD), standard deviation (SD), and coefficient of variation (CV) than those with limited experience at baseline. The learning session with reference image reduced the MD, SD, and CV in readers with limited experience. The learning session with reference images plus feedback also reduced proportional bias. Importantly, the misclassification rate for mid-range EF cases was reduced regardless of experience. CONCLUSION: This large multicenter study suggested that a simple learning session with reference images can successfully reduce the misclassification rate for LVEF assessment.