Diagnostic Accuracy of Pre-Transcatheter Aortic Valve Replacement Nitroglycerin-Free Fractional Flow Reserve-Computed Tomography-Based Physiological Assessment in Patients With Severe Aortic Stenosis for Predicting Post-Transcatheter Aortic Valve Replacement Ischemia.

BACKGROUND: Fractional flow reserve-computed tomography (FFRCT) has not been validated in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR) for coronary artery disease due to theoretical difficulties in using nitroglycerin for such patients.Methods and Results: In this single-center study, we prospectively enrolled 21 patients (34 vessels) and performed pre-TAVR FFRCTwithout nitroglycerin, pre-TAVR invasive instantaneous wave-free ratio (iFR) measurements, and post-TAVR FFR measurements using a pressure wire. The diagnostic accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of pre-TAVR FFRCT≤0.80 to predict post-TAVR invasive FFR ≤0.80 were 82%, 83%, 82%, 71%, and 90%, respectively. A receiver operating characteristic analysis demonstrated an optimal cutoff of 0.78 for pre-TAVR FFRCTto indicate post-TAVR FFR ≤0.80, with an area under the curve (AUC) of 0.84, and the counterpart cutoff of pre-TAVR iFR was 0.89 with an AUC of 0.86. CONCLUSIONS: FFRCTwithout nitroglycerin could be a useful non-invasive imaging modality for assessing the severity of coronary artery lesions in patients with severe AS.

Hospital-associated disability and hospitalization costs for acute heart failure stratified by body mass index- insight from the JROAD/JROAD-DPC database.

BACKGROUND: The impact of body mass index (BMI) on hospital mortality in patients with acute heart failure has been well documented in Asian populations. However, the relationship between BMI, hospital-associated disability (HAD), and hospitalization costs in patients with heart failure is poorly understood. This study aimed to explore the impact of BMI on HAD and hospitalization costs for acute heart failure in Japan. METHODS: From April 2012 to March 2020, the Japanese Registry of All Cardiac and Vascular Disease Diagnosis Procedure Combination (JROAD-DPC) database was used to identify patients with acute heart failure. All patients were categorized into five groups according to the World Health Organization Asian BMI criteria. The hospitalization costs and HAD were evaluated. RESULTS: Among the 238,160 eligible patients, 15.7% were underweight, 42.2% were normal, 16.7% were overweight, 19.3% were obese I, and 6.0% were obese II, according to BMI. The prevalence of HAD was 7.43% in the total cohort, and the risk of HAD increased with a lower BMI. Restricted cubic spline analysis showed a U-shaped relationship between BMI and hospitalization costs for all ages. Furthermore, developing HAD was associated with greater costs compared with non-HAD, regardless of BMI category. CONCLUSIONS: We found that the lower the BMI, the higher the incidence of HAD. A U-shaped association was confirmed between BMI and hospitalization costs, indicating that hospitalization costs increased for both lower and higher BMI regardless of age. BMI could be an important and informative risk stratification tool for functional outcomes and economic burdens.

Successful catheter ablation of postoperative atrial tachycardia with conduction disturbances: Assessment by late-gadolinium enhancement magnetic resonance imaging and high-resolution electro-anatomical mapping.

Atrial tachycardia (AT) in the right atrium often occurs following open-heart surgery. Catheter ablation for these AT is challenging and can lead to unintended conduction block. We performed late-gadolinium enhancement magnetic resonance imaging (LGE-MRI) prior to catheter ablation and predicted wavefront propagation during SR as well as the slow conduction zone during tachycardia. LGE-MRI may assist predicting the conduction disturbance and reducing the risk of unexpected sinus exit block.

Prognostic Impact of Myocardial Extracellular Volume Fraction Assessment Using Dual-Energy Computed Tomography in Patients Treated With Aortic Valve Replacement for Severe Aortic Stenosis.

Background Myocardial extracellular volume fraction (ECV), measured by cardiac magnetic resonance imaging, is a useful prognostic marker for patients who have undergone aortic valve replacement (AVR) for aortic stenosis. However, the prognostic significance of ECV measurements based on computed tomography (CT) is unclear. This study evaluated the association between ECV measured with dual-energy CT and clinical outcomes in patients with aortic stenosis who underwent transcatheter or surgical AVR. Methods and Results We retrospectively enrolled 95 consecutive patients (age, 84.0±5.0 years; 75% women) with severe aortic stenosis who underwent preprocedural CT for transcatheter AVR planning. ECV was measured using iodine density images obtained by delayed enhancement dual-energy CT. The primary end point was a composite outcome of all-cause death and hospitalization for heart failure after AVR. The mean ECV measured with CT was 28.1±3.8%. During a median follow-up of 2.6 years, 22 composite outcomes were observed, including 15 all-cause deaths and 11 hospitalizations for heart failure. In Kaplan-Meier analysis, the high ECV group (≥27.8% [median value]) had significantly higher rates of composite outcomes than the low ECV group (<27.8%) (log-rank test, P=0.012). ECV was the only independent predictor of adverse outcomes on multivariable Cox regression analysis (hazards ratio, 1.25; 95% CI, 1.10‒1.41; P<0.001). Conclusions Myocardial ECV measured with dual-energy CT in patients who underwent aortic valve intervention was an independent predictor of adverse outcomes after AVR.

Successful catheter ablation approach above the aortic sinus cusp eliminating a ventricular arrhythmia arising from the myocardial crescent beneath the interleaflet triangle: Late gadolinium enhancement magnetic resonance imaging assessment.

A 61-year-old female with 50 000 ventricular premature contractions and a reduced left ventricular ejection fraction of 35% was referred to our center. Although the origin was considered to originate from the junction between the left and right coronary cusp, a single radiofrequency application above the aortic sinus cusp could eliminate it. LGE-MRI was able to reveal the exact location of the single RF lesion.

Feasibility of morphological assessment of coronary artery calcification with electrocardiography-gated non-contrast computed tomography: a comparative study with optical coherence tomography.

To investigate the feasibility of pre-procedural morphological assessment of coronary artery calcification in severely calcified lesions with electrocardiography (ECG)-gated non-contrast computed tomography (CT). Severely calcified coronary arteries in patients who underwent ECG-gated non-contrast CT prior to optical coherence tomography (OCT)-guided percutaneous coronary intervention (PCI) were studied retrospectively. CT and OCT data were co-registered by marking landmark structures such as side branches and reviewed side by side with cross-sectional images. The maximum calcium angle (MCA) and presence of nodular calcification (NC) were evaluated. A total of 496 cross-sections in 16 lesions were included in this analysis. The Pearson correlation coefficient between CT- and OCT-derived MCA was 0.92 (p < 0.001). Bland-Altman plots of OCT-derived MCA in relation to CT-derived MCA showed a mean bias of 4.8 degrees with 95% limits of agreement of - 69.7 to 79.4 degrees. Sensitivity, specificity, and positive and negative predictive values of CT in identifying MCA > 270 degrees were 90.3%, 79.7%, 92.1%, and 97.4%, respectively. Sensitivity, specificity, and positive and negative predictive values of CT in identifying NC were 73.3%, 97.5%, 47.8%, and 99.2%, respectively. ECG-gated non-contrast coronary CT might be helpful to obtain detailed information of severe coronary artery calcification before PCI.

Lesion characteristics between cryoballoon ablation and radiofrequency ablation with a contact force-sensing catheter: Late-gadolinium enhancement magnetic resonance imaging assessment.

BACKGROUND: Pulmonary vein isolation (PVI) lesions after cryoballoon ablation (CBA) are characterized as a wider and more continuous than that after conventional radiofrequency catheter ablation (RFCA) without the contact force (CF)-sensing technology. However, the impact on the lesion characteristics of ablation with a CF-sensing catheter has not been well discussed. We sought to assess the lesions using late-gadolinium enhancement magnetic resonance imaging (LGE-MRI) and to compare the differences between the two groups (CB group vs. RF group). METHODS: A total of 30 consecutive patients who underwent PVI were enrolled (CB group, 18; RF group, 12). The RF applications were delivered with a target lesion size index (LSI) of 5. The PVI lesions were assessed by LGE-MRI 3 months after the PVI. The region around the PV was divided into eight segments: roof, anterior-superior, anterior carina, anterior inferior, bottom, posterior inferior, posterior carina, and posterior superior segment. The lesion width and visual gap of each segment were compared between the two groups. The visual gaps were defined as no-enhancement site of >4 mm. RESULTS: The mean LSI was 4.7 ± 0.7. The lesion width was significantly wider but the visual gaps were more frequently documented at the bottom segment of right PV in the CBA group (lesion width: 8.1 ± 2.2 vs. 6.3 ± 2.2 mm; p = .032; visual gap at the bottom segment or right PV: 39% vs. 0%; p = .016). CONCLUSIONS: The PVI lesion was wider after CBA, while the visual gaps were fewer after RFCA with a CF-sensing catheter.

Acute Adrenal Insufficiency Precipitated by the Discontinuation of a Betamethasone and Dextrochlorpheniramine Combination: The Diagnostic Utility of an Echocardiographic Assessment of Systemic Vascular Resistance.

A 72-year-old woman with primary biliary cholangitis was admitted to our hospital with heart failure with a preserved ejection fraction. An accidental right ventricular perforation that occurred during an endomyocardial biopsy precipitated cardiogenic shock. Despite successful surgical treatment, she demonstrated progressive hemodynamic deterioration, which was resistant to the administration of high-dose catecholamines. She was diagnosed with acute adrenal insufficiency, which was attributed to the discontinuation of Celestamine® (betamethasone/dextrochlorpheniramine combination) just after the perforation. Prompt intravenous administration of hydrocortisone (150 mg/day) led to hemodynamic stabilization. The serial noninvasive assessment of systemic vascular resistance using transthoracic echocardiography was instrumental in detecting acute adrenal insufficiency in this case.

Combined assessment of left atrial volume parameters for predicting recurrence of atrial fibrillation following pulmonary vein isolation in patients with paroxysmal atrial fibrillation.

OBJECTIVES: Our aim was to test the hypothesis that comprehensive simplified left atrial (LA) assessment derived from routine echocardiography may be more useful than assessment of LA volume alone for predicting atrial fibrillation (AF) recurrence after pulmonary vein isolation (PVI). METHODS: We studied 156 patients with paroxysmal AF (PAF) who had undergone PVI. Echocardiography was performed within two days before PVI. Maximum (Max-LAVi) and minimum LA volume index (Min-LAVi) were calculated with the biplane modified Simpson's method, and then normalized to the body surface area. On the basis of previous findings, the predefined cutoff value of Max-LAVi for AF recurrence was set at Max-LAVi ≥ 34 mL/m2 . ΔLA volume index (ΔLAVi) was also calculated as Max-LAVi minus Min-LAVi. The follow-up period after PVI was 24 months. RESULTS: AF recurrence was observed in 35 patients. Multivariate logistic regression analysis showed that ΔLAVi (odds ratio [OR]: 1.131; 95% confidence interval [CI]: 1.057-1.221; P < 0.001) was an independent predictor of AF recurrence. Sequential logistic regression models for predicting AF recurrence revealed that a model based on clinical variables including age, gender and AF duration (χ2  = 1.65) was improved by the addition of Max-LAVi ≥ 34 mL/m2 (χ2  = 13.8; P < 0.001), and further improved by the addition of ΔLAVi (χ2  = 18.2; P = 0.036). Of note is that only 1.02 ± 0.10 minutes per patient was needed to obtain a comprehensive LA assessment that included Max-LAVi, Min-LAVi, and ΔLAVi. CONCLUSION: This easy-to-use comprehensive simplified LA approach from routine echocardiography may well have clinical implications for better management of PAF patients.

Noninvasive Assessment of Preload Reserve Enhances Risk Stratification of Patients With Heart Failure With Reduced Ejection Fraction.

BACKGROUND: The leg-positive pressure maneuver can safely and noninvasively apply preload stress without increase in total body fluid volume. The purpose of this study was to determine whether preload stress could be useful for risk stratification of patients with heart failure with reduced ejection fraction. METHODS AND RESULTS: For this study, 120 consecutive patients with heart failure with reduced ejection fraction were prospectively recruited. The stroke work index was estimated as product of stroke volume index and mean blood pressure, and the E/e' ratio was calculated to estimate ventricular filling pressure. The echocardiographic parameters were obtained both at rest and during leg-positive pressure stress. During the median follow-up period of 20 months, 30 patients developed adverse cardiovascular events. During preload stress, stroke work index increased significantly (from 3280±1371 to 3857±1581 mm Hg·mL/m2; P<0.001) along with minimal changes in ventricular filling pressure (E/e', from 16±10 to 17±9; P<0.05) in patients without cardiovascular events. However, patients with cardiovascular events showed impairment of Frank-Starling mechanism (stroke work index, from 2863±969 to 2903±1084 mm Hg·mL/m2; P=0.70) and a serious increase in E/e' ratio (from 19±11 to 25±14; P<0.001). Both the patients without contractile reserve and those without diastolic reserve exhibited worse event-free survival than the others (P<0.001). In a Cox proportional-hazards analysis, the changes in stroke work index (hazard ratio: 0.44 per 500 mm Hg·mL/m2 increase; P=0.001) and in E/e' (hazard ratio: 2.58 per 5-U increase; P<0.001) were predictors of cardiovascular events. CONCLUSION: Contractile reserve and diastolic reserve during leg-positive pressure stress are important determinants of cardiovascular outcomes for patients with heart failure with reduced ejection fraction.

The impact of serum trans fatty acids concentration on plaque vulnerability in patients with coronary artery disease: Assessment via optical coherence tomography.

BACKGROUND AND AIMS: Recent epidemiological studies have showed that excessive intake of trans fatty acids (TFA) can be a residual risk for the development of coronary artery disease (CAD) even under medical management, including statins. This study aimed at investigating the association between lipid profile, including serum TFA concentration, and plaque vulnerability using optical coherence tomography (OCT). METHODS: The level of serum elaidic acid, a major TFA component, was measured using gas chromatography in 161 consecutively enrolled patients with CAD under guideline-directed risk factor management. OCT was performed to evaluate morphological features of angiographic intermediate stenosis (30% < diameter of stenosis <70%). OCT data were also used to measure lipid index (LI), defined as mean lipid arc multiplied by lipid length, and determine the presence of thin-cap fibroatheroma (TCFA), defined as a lipid-rich plaque with the smallest fibrous cap thickness <65 µm and the maximal arc >90°. RESULTS: Among 190 lesions assessed using OCT, 49 TCFAs were detected. In patients with at least one TCFA lesion, levels of elaidic acid (12.9 ± 4.9 vs. 10.3 ± 4.3 µmol/L, p = 0.001), triglycerides (169 ± 81 vs. 130 ± 60 mg/dL, p = 0.005), and remnant-like particle cholesterol (10.4 ± 6.5 vs. 7.7 ± 4.7 mg/dL, p = 0.005) were higher than in those without TCFAs. Generalized estimating equations identified elaidic acid level as the independent risk factor of TCFA. LI had a positive correlation with elaidic acid level (r = 0.173, p = 0.025). CONCLUSIONS: TFA may affect plaque vulnerability in patients with CAD. Serum TFA concentration may represent another cardiovascular risk factor during conventional risk factor management.

Cholesterol Uptake Capacity: A New Measure of HDL Functionality for Coronary Risk Assessment.

BACKGROUND: Recent studies have shown that the cholesterol efflux capacity of HDL is a better predictor of cardiovascular disease (CVD) than HDL cholesterol. However, the standard procedures used for measuring cholesterol efflux capacity involve radioisotope-labeled cholesterol and cultured macrophages. Thus, a simpler method to measure HDL functionality is needed for clinical application. METHODS: We established a cell-free assay system to evaluate the capacity of HDL to accept additional cholesterol, which we named cholesterol "uptake capacity," using fluorescently labeled cholesterol and an anti-apolipoprotein A1 antibody. We quantified cholesterol uptake capacity of apolipoprotein B (apoB)-depleted serum samples from patients with coronary artery disease who had previously undergone revascularization. RESULTS: This assay system exhibited high reproducibility (CV <10%) and a short processing time (<6 h). The myeloperoxidase-mediated oxidation of apoB-depleted serum impaired cholesterol uptake capacity. Cholesterol uptake capacity correlated significantly with cholesterol efflux capacity (r2 = 0.47, n = 30). Furthermore, cholesterol uptake capacity correlated inversely with the requirement for revascularization because of recurrence of coronary lesions in patients with optimal control of LDL cholesterol (P < 0.01, n = 156). A multivariate analysis adjusted for traditional coronary risk factors showed that only cholesterol uptake capacity remained significant (odds ratio, 0.48; 95% CI, 0.29-0.80; P = 0.0048). CONCLUSIONS: Cholesterol uptake capacity assay evaluates the functionality of HDL in a sensitive and high-throughput manner without using radioisotope label and cells. This assay system could be used for the assessment of CVD risk in the clinical settings.

Comprehensive Functional Assessment of Right-Sided Heart Using Speckle Tracking Strain for Patients with Pulmonary Hypertension.

BACKGROUND: Right ventricular (RV) systolic function is one of the most important determinants of outcome for pulmonary hypertension (PH) patients, but the factors influencing prognosis vary widely. Elevated right atrial (RA) pressure is reported to be one of these prognostic factors, but its functional importance has scarcely been assessed. METHODS: Eighty-two PH patients, all of whom underwent echocardiography and right heart catheterization, were recruited. RV function was assessed by two-dimensional speckle tracking longitudinal strain from RV-focused apical four-chamber view and calculated by averaging the three regional peak strains from the RV free wall (RV-free). RA function was determined as the sum of three peak strain values comprising reservoir, conduit, and contractile function (sum of RA strain). RESULTS: Sum of RA strain correlated significantly with hemodynamic parameters such as mean right atrial pressure (r = -0.35, P = 0.002) and end-diastolic RV pressure (r = -0.29, P = 0.008). Patients with sum of RA strain ≥30.2% experienced more favorable outcomes than those with sum of RA strain <30.2% (log-rank P = 0.001). Furthermore, patients with impaired RV systolic function (RV-free <20%) and RA function (sum of RA strain <30.2%) showed the worst outcome (P = 0.001). A sequential Cox model based on clinical variables (χ(2) = 5.8) was improved by addition of RV-free (χ(2) = 8.7; P < 0.05) and further improved by addition of sum of RA strain (χ(2) = 12.0; P < 0.01). CONCLUSION: Right atrial strain appears to be a valuable additive factor for predicting outcomes for PH patients, and comprehensive functional assessment of right-sided heart using speckle tracking strain may have potential clinical implications for better management of PH patients.

Two-year vessel healing after everolimus-eluting stent implantation: serial assessment by optical coherence tomography.

BACKGROUND: Previous reports have suggested the importance of delayed arterial healing and the development of neoatherosclerosis as major contributors to stent thrombosis and delayed restenosis. The difference of in vivo assessment of long-term vessel healing between first-generation drug-eluting stents and current generation everolimus-eluting stents (EESs) is limited. The aim of this study was to evaluate long-term arterial healing in EES in comparison with the first generation sirolimus-eluting stents (SES). METHODS: We evaluated 31 EES (23 patients) and 8 SES (7 patients) by serial optical coherence tomography at 12 months (mid-phase) and 24 months (late-phase) after stenting and evaluated the change in neointimal thickness (NIT), the percentages of uncovered struts, peri-strut low intensity area (PLIA; region around stent struts homogenously lower-intensity appearance than surrounding tissue), and thrombus. RESULTS: Although the average NIT showed no significant changes from the mid- to the late-phase follow-up in both EES and SES groups, the change in NIT and minimum lumen area was significantly larger in SES than EES (5.2±29.4 vs. 37.2±48.9; p=0.02, -0.06±0.36 vs. -0.45±0.74; p=0.04, respectively). The incidence of uncovered struts and struts with PLIA of EES was lower than those of SES, at both phases. Stents with in-stent thrombus of EES tended to be lower than that of SES at both phase follow-ups. CONCLUSION: Although both SES and EES showed progressive luminal narrowing from the mid- to the late-phase follow-up, the extent of delayed lumen narrowing and delayed neointimal proliferation was significantly less in the second generation EES than the first generation SES. EESs seem to offer sustained stability in efficacy, without sacrificing safety, up to 2 years after implantation.

Optical coherence tomography and histopathology assessment after implantation of first- and second-generation drug-eluting stents in a porcine coronary model.

BACKGROUND: This study directly compared optical coherence tomography (OCT) and histopathology for the assessment of vascular response to first- and second-generation drug-eluting stents. METHODS AND RESULTS: Sirolimus-, everolimus-, and biolimus-eluting stents (SES, EES, and BES, respectively) were randomly implanted into the coronary arteries of 12 porcine. OCT was conducted after implantation: at 1, 3, and 6 months; histopathology was assessed at 3 and 6 months. At 1-month OCT, EES had the highest neointimal area (NA) and lowest neointimal unevenness score (NUS). At 6 months, NA and NUS were equivalent among the stent types. ∆NA from 1 to 6 months was lowest for EES, and ∆NA correlated with the histopathological inflammation score at 6 months, which was highest for SES (P<0.001). The mean signal intensity (MSI) and the attenuation were different for the stent types at 3 months, and were associated with inflammation score. Moderate diagnostic efficiency for measuring MSI was found, with an optimal cut-off of 6.88 predicting a high (≥grade 3) inflammation score. CONCLUSIONS: EES had the greatest uniformity and the least neointimal proliferation and were associated with less persistent inflammation. OCT provides accurate morphometric data; furthermore, quantitative measurement of the optical properties may help assess histological inflammation, which was more predominantly associated with SES than with EES and BES.

Global endocardial area change rate for the assessment of left ventricular relaxation and filling pressure: using 3-dimensional speckle-tracking study.

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

Utility of combining assessment of right ventricular function and right atrial remodeling as a prognostic factor for patients with pulmonary hypertension.

We tested the hypothesis that the addition of right atrial (RA) remodeling to right ventricular (RV) function enhances the capability of the latter to predict long-term outcome for pulmonary hypertension (PH) patients. We studied 82 PH patients, all of whom underwent echocardiography and right heart catheterization. RV function was calculated by averaging the three regional peak speckle-tracking longitudinal strains from RV free wall (RV-free). RA remodeling was assessed as the RA area traced planimetrically at end-systole. Pre-defined cutoffs for RV dysfunction and RA remodeling were RV-free ≤19.4 % and RA area of >18 cm(2), respectively. Long-term unfavorable outcome events were tracked for 2.0 years. RA area correlated with mean RA pressure (r = 0.62, p < 0.001), as well as with tricuspid E/E' (r = 0.38, p = 0.001). Moreover, RA area in patients with RV restrictive filling was significantly larger than that in patients with others (all p < 0.05). Kaplan-Meier analysis revealed that patients with RV-free ≤19.4 % had worse long-term outcomes than those with RV-free >19.4 % (log-rank p = 0.01), as did patients with RA area >18 cm(2) compared with those with RA area ≤18 cm(2) (log-rank p < 0.05). For sequential Cox models, a model based on hemodynamic parameters of RV performance (χ2 = 3.11) was improved by addition of brain natriuretic peptide, World Health Organization functional class (χ2 = 9.24; p < 0.05), and RV-free (χ2 = 17.11; p = 0.005), and further improved by addition of RA area (χ2 = 21.36, p < 0.05). In conclusion, the combined assessment of RV function and RA area results in more accurate prediction of long-term outcome, and may well have clinical implications for better management of PH patients.

Noninvasive and simple assessment of cardiac output and pulmonary vascular resistance with whole-body impedance cardiography is useful for monitoring patients with pulmonary hypertension.

BACKGROUND: Right heart catheterization (RHC) is the gold standard for the diagnosis of pulmonary hypertension (PH) and a useful tool for monitoring PH. However, there are some disadvantages in the regular use of RHC because it is invasive. Noninvasive methods for monitoring hemodynamics are needed to manage patients with PH. In this study, we aimed to evaluate the reliability of noninvasive hemodynamic assessment with whole-body impedance cardiography (Non-Invasive Cardiac System [NICaS]) for PH. METHODS AND RESULTS: We investigated 65 consecutive patients undergoing RHC. Two-thirds of them had pulmonary arterial hypertension and one-third had chronic thromboembolic PH; 25% of the patients were receiving medical therapy. Cardiac output (CO) was estimated by NICaS (NI-CO), thermodilution (TD-CO), and the Fick method (Fick-CO). There was a strong correlation between NI-CO and TD-CO (r=0.715, P<0.0001) and Fick-CO (r=0.653, P<0.0001). Noninvasive pulmonary vascular resistance (PVR) was estimated using a conventional invasive equation with NI-CO, mean pulmonary arterial pressure was calculated by echocardiographic measurement, and pulmonary capillary wedge pressure was estimated at 10mmHg in all cases. NICaS-derived PVR was very strongly correlated with invasive PVR (TD-PVR: r=0.704, P<0.0001; Fick-PVR: r=0.702, P<0.0001). CONCLUSIONS: Noninvasive measurement of CO and PVR using NICaS and echocardiography is a useful tool for the assessment of PH.

Qualitative and quantitative assessment of stent restenosis by optical coherence tomography: comparison between drug-eluting and bare-metal stents.

BACKGROUND: We hypothesized that the tissue components of in-stent restenosis (ISR) might differ between drug-eluting stents (DES) and bare-metal stents (BMS) and that these differences could be distinguished by qualitative and quantitative optical coherence tomography (OCT) analyses. METHODS AND RESULTS: One-hundred and twenty-two initial ISR lesions (sirolimus-eluting stents: n=28; paclitaxel-eluting stents: n=51; BMS: n=43) were evaluated with OCT. Based on their OCT appearance, the lesions were classified as homogeneous, layered or heterogeneous. The optical properties of backscatter, attenuation and signal intensity of the neointimal tissue (NIT) were quantified. To evaluate the vascular response after balloon angioplasty (BA), the rate of reduction of the NIT area (NITA) was calculated (NITA before - after BA/NITA before BA at the minimum lumen cross-sectional area). Among the morphologic OCT patterns, the layered type was predominant with DES, whereas lesions were homogeneous with BMS (P<0.001). Backscatter and signal intensity were significantly higher with BMS (P<0.05 and P<0.001 respectively). The NITA reduction rate was significantly greater in the layered and heterogeneous groups than in the homogeneous group (P<0.01). CONCLUSIONS: The morphologic OCT patterns of the NIT in ISR differed significantly between DES and BMS, probably reflecting pathologic differences. Layered and heterogeneous tissues might respond better than homogeneous tissue to simple balloon dilatation, suggesting a possible direction for OCT-based ISR treatment strategies.

Utility of combined assessment of baseline dyssynchrony and its acute improvement to predict long-term outcomes after cardiac resynchronization therapy.

Although left ventricular (LV) mechanical dyssynchrony can predict the response to cardiac resynchronization therapy (CRT), the presence of baseline LV dyssynchrony might not be the only determinant of the response to CRT. The objectives of the present study were to test the hypothesis that a combined assessment of baseline LV dyssynchrony and its acute improvement can produce a more accurate prediction of the long-term outcomes after CRT. We studied 121 patients with heart failure undergoing CRT. LV dyssynchrony was determined by measuring the anteroseptal-to-posterior wall time delay using the speckle-tracking radial strain (≥130 ms was predefined as significant) and was assessed at baseline and 7 ± 3 days after CRT. Long-term unfavorable outcome events were tracked for 5 years. Acute improvement in LV dyssynchrony of ≥33% was predictive of the long-term outcome with an area under the curve of 0.67 (p = 0.0024). Using this cutoff value, the Kaplan-Meier curve showed that patients with acute improvement in LV dyssynchrony experienced fewer cardiovascular events than those without (log-rank p = 0.0002). The event-free survival of patients whose baseline LV dyssynchrony was ≥130 ms and whose acute improvement in LV dyssynchrony was ≥33% was greater than that of the patients with baseline LV dyssynchrony of ≥130 ms but with acute improvement in LV dyssynchrony of <33% (88% vs 65%, p = 0.012). In conclusion, the combined assessment of baseline LV dyssynchrony and its acute improvement after CRT produced a more accurate prediction of long-term outcomes after CRT.