[Mid-ventricular Hypertrophic Obstructive Cardiomyopathy in a Patient Whose Hemodynamics Were Exacerbated by Forward Shift of the Posterior Leaflet Caused by Mitral Annular Calcification].

A 82-year-old woman came to our hospital because of orthopnea and cardiac cachexia. Echocardiography revealed a pressure gradient of 50 mmHg at the left ventricular outflow tract and that of 78 mmHg at the mid-ventricle. Systolic anterior motion of the mitral leaflet caused by mitral annular calcification and severe mitral regurgitation( MR) were observed. On the basis of the patient's age and poor general conditions, we resected abnormal myocardium on the septum from the outflow tract down to the apex via aortic valve and we left the mitral annular calcification. The pressure gradient in the left ventricle, systolic anterior motion and mitral regurgitation were relieved, and her postoperative course was uneventful. Two years after the surgery, she remains in New York Heart Association( NYHA) class Ⅰ and is well.

[Dual Repair for Ischemic/Functional Mitral Regurgitation].

In the era of M-clip, surgery for ischemic/functional mitral regurgitation( FMR) which is a ventricular disease remains a challenge. We try to do ventricular treatment as much as possible. We reviewed 11 patients( 9 males, 63±12 years old) who had "dual repair" surgery which consists of anterior relocation of both papillary heads/muscles and simplified ventricular restoration (frozen-apex restoration). There was 1 hospital death of mesenteric ischemia in a 80 years old patient with sarcoidosis and chronic kidney disease(CKD). FMR changed from 2.7±0.9 preoperatively to 0.9±0.5( p<0.001) postoperatively. Similarly, New York Heart Association (NYHA) class from 3.7±0.8 to 1.8±0.6 (p<0.001), left ventricular end-diastolic dimension (LVDd) from 72±12 to 67±12 mm (p<0.01), end-systolic dimension (Ds) from 65±12 to 59±14 mm (p<0.01), ejection fraction (EF) from 23±8 to 28±10 (p=0.04), and right ventricular pressure( RVP) from 38±13 to 31±8 mmHg. There was no late death with the follow-up of 20±15 months (range 2∼42 months). In conclusion, ventricular treatment by "dual repair" surgery helps patients with FMR. Surgery may be a good compensatory treatment for catheter intervention.

[Surgery for Functional Mitral Regurgitation or Dilated Cardiomyopathy in Patients with Non-transplant Candidates].

Surgery for functional mitral regurgitation (FMR) and dilated cardiomyopathy (DCM) remains a challenge. We reviewed our efforts;anterior (i.e. physiological) relocation of papillary heads and muscles(PHO) in 54 patients with FMR and simplified ventricular restoration of uni-directional Dor or Frozen-Apex restoration in 22 patients with DCM. Actuarial survival 4 years after the PHO was 92±6% with improved left ventricular (LV) function and well controlled FMR. Results of the simplified restoration was also promising with no hospital death and just 1 cardiac death late postoperatively, with good symptom relieve and maintained LV function. Surgical outcome for FMR or DCM may be further improved.

Visualization of submitral structure by three-dimensional transesophageal echocardiography.

OBJECTIVE: The conventional mid-esophageal observation by three-dimensional transesophageal echocardiography (3DTEE) sometimes fails to visualize the subvalvular apparatus. In this study, we compared the effectiveness of the transgastric approach by 3DTEE in visualizing the mitral valve complex with the conventional mid-esophageal approach. METHODS: We studied 10 consecutive patients who underwent mitral valve surgery for functional mitral regurgitation. The anatomy of the mitral complex was interpreted from the 3DTEE data acquired by both the mid-esophageal and the transgastric approach preoperatively. The interpretations of the image of the mid-esophageal approach and the transgastric approach were compared with surgical observations. RESULTS: In the concordance rate for surgical observation, the interpretation of the number of papillary heads and chordal distribution for the transgastric observation were superior to those for the mid-esophageal observation both for anterior papillary muscle (P < 0.01 and 0.005, respectively) and posterior papillary muscle (P < 0.001 and 0.0005, respectively). CONCLUSION: The accuracy of transgastric observations of submitral structure using 3DTEE was superior to that provided by the conventional mid-esophageal approach. Transgastric approach offers a ventricular view and complementary information to conventional mid-esophageal approach in patient with functional mitral regurgitation.

Protective effect of cardioplegia with poly (ADP-ribose) polymerase-1 inhibitor against myocardial ischemia-reperfusion injury: in vitro study of isolated rat heart model.

Poly(ADP-ribose) polymerase (PARP)-1 inhibitor has been suggested to attenuate the ischemia-reperfusion injury. We investigated the protective effect of the cardioplegia with a PARP-1 inhibitor, 4-hydoxyquinazoline (4-HQ), against myocardial ischemia-reperfusion injury. Isolated rat hearts were perfused on a Langendorff apparatus and cardioplegically arrested for 90 min by perfusion with St. Thomas' Hospital solution (ST-solution). In the Group ST (n = 8), the hearts were arrested with the ST-solution alone. The Group HQ (n = 8) were treated with the ST-solution containing 4-HQ (10 µM) for cardioplegia. During reperfusion, the Group HQ showed significantly greater functional recovery of +dp/dt(max) (p = 0.005) and lower enzymatic leakage (p < 0.01). NAD(+) levels were also preserved higher in the Group HQ (p < 0.01). Immunohistochemical study revealed lesser extents of oxidative stress and apoptosis, in the Group HQ. Thus, addition of 4-HQ in the cardioplegia may provide a new intervention for myocardial protection against ischemia-reperfusion injury by decreasing NAD(+) consumption and suppressing oxidative stress.

The dietary compound curcumin inhibits p300 histone acetyltransferase activity and prevents heart failure in rats.

Hemodynamic overload in the heart can trigger maladaptive hypertrophy of cardiomyocytes. A key signaling event in this process is nuclear acetylation by histone deacetylases and p300, an intrinsic histone acetyltransferase (HAT). It has been previously shown that curcumin, a polyphenol responsible for the yellow color of the spice turmeric, possesses HAT inhibitory activity with specificity for the p300/CREB-binding protein. We found that curcumin inhibited the hypertrophy-induced acetylation and DNA-binding abilities of GATA4, a hypertrophy-responsive transcription factor, in rat cardiomyocytes. Curcumin also disrupted the p300/GATA4 complex and repressed agonist- and p300-induced hypertrophic responses in these cells. Both the acetylated form of GATA4 and the relative levels of the p300/GATA4 complex markedly increased in rat hypertensive hearts in vivo. The effects of curcumin were examined in vivo in 2 different heart failure models: hypertensive heart disease in salt-sensitive Dahl rats and surgically induced myocardial infarction in rats. In both models, curcumin prevented deterioration of systolic function and heart failure-induced increases in both myocardial wall thickness and diameter. From these results, we conclude that inhibition of p300 HAT activity by the nontoxic dietary compound curcumin may provide a novel therapeutic strategy for heart failure in humans.

Therapeutic treatment with sustained-release platelet-rich plasma restores blood perfusion by augmenting ischemia-induced angiogenesis and arteriogenesis in diabetic mice.

OBJECTIVE: The objective of this investigation was to establish the effectiveness of sustained-release platelet-rich plasma (PRP) on perfusion and neovascularization in diabetic murine hind limb ischemia. METHODS: After surgery in streptozotocin-induced diabetic mice, the mice were randomly assigned to the following 4 experimental groups: control (C), 100 µl of the sustained-release form of platelet-poor plasma (PPP), 100 µl of the solution form of PRP (PRP-sol), and 100 µl of the sustained-release form of PRP (PRP-sr). Endpoint evaluations were: blood perfusion by laser Doppler perfusion imaging (LDPI), vascular density by anti-vWF, and mature vessel density by anti-smooth muscle actin antibody. RESULTS: This study demonstrated that a sustained release of PRP increases the perfusion of ischemic tissue as measured by LDPI (57 ± 12; 56 ± 9; 72 ± 7, and 98 ± 4 for the C, PPP, PRP-sol, and PRP-sr groups, respectively; p < 0.05), capillary density (151 ± 16; 158 ± 12; 189 ± 39, and 276 ± 39 for groups C, PPP, PRP-sol, and PRP-sr, respectively; p < 0.05), and mature vessel density (28 ± 2; 31 ± 3; 52 ± 10, and 85 ± 13 for the C, PPP, PRP-sol, and PRP-sr groups, respectively; p < 0.05). CONCLUSION: A sustained release of PRP containing potent angiogenic growth factors restores blood perfusion by stimulating angiogenesis and arteriogenesis.

The fate of bioprostheses in middle-aged patients: the Japanese experience.

BACKGROUND AND AIM OF THE STUDY: Although the trend of bioprosthesis use has been evaluated extensively, the durability of currently available bioprostheses has not been determined in middle-aged patients. The study aim was to determine the long-term fate of bioprostheses implanted in patients aged < 60 years. METHODS: Valve implantation data were collected from 43 centers in Japan. The data included patient age at implantation, type of valve, implant position, follow up period, and cause of reoperation including structural valve deterioration (SVD) and non-SVD. Between 1975 and 2005, a total of 697 bioprostheses was implanted in the mitral position, and 247 in the aortic position. The mean follow up period was 9.2 years. Rates of freedom from SVD and reoperation were determined using an actuarial method. RESULTS: The mean age at implantation was 45 +/- 10.9 years. The 15-year freedom from SVD was 39% for those with valves implanted in the aortic position, and 27% in the mitral position (p = 0.004). For the same period, the actuarial freedom from reoperation was 31% for valves in the aortic position, and 24% in the mitral position (p = 0.178). The difference in actuarial freedom from SVD was not significant between age groups in the mitral position. However, there were differences in actuarial freedom from SVD in the aortic position for patients aged < 10 years when compared to the other age groups (p < 0.001). New-generation valves showed better long-term durability than older valves (p = 0.05). CONCLUSION: The long-term freedom from SVD in middle-aged patients was unfavorable for bioprostheses implanted in the aortic and mitral positions. Middle-aged patients must be made aware that reoperation will be necessary; consequently, the choice of bioprosthesis should be dictated by patient-surgeon preference.

Cyclosporin-A potently induces highly cardiogenic progenitors from embryonic stem cells.

Though cardiac progenitor cells should be a suitable material for cardiac regeneration, efficient ways to induce cardiac progenitors from embryonic stem (ES) cells have not been established. Extending our systematic cardiovascular differentiation method of ES cells, here we show efficient and specific expansion of cardiomyocytes and highly cardiogenic progenitors from ES cells. An immunosuppressant, cyclosporin-A (CSA), showed a novel effect specifically acting on mesoderm cells to drastically increase cardiac progenitors as well as cardiomyocytes by 10-20 times. Approximately 200 cardiomyocytes could be induced from one mouse ES cell using this method. Expanded progenitors successfully integrated into scar tissue of infracted heart as cardiomyocytes after cell transplantation to rat myocardial infarction model. CSA elicited specific induction of cardiac lineage from mesoderm in a novel mesoderm-specific, NFAT independent fashion. This simple but efficient differentiation technology would be extended to induce pluripotent stem (iPS) cells and broadly contribute to cardiac regeneration.

Surgical treatment for functional mitral regurgitation.

Surgery for functional mitral regurgitation (FMR) was reviewed. As the mechanism of FMR is still being elucidated, surgery for FMR, especially ischemic mitral regurgitation evolved from coronary bypass surgery (CABG) with/without mitral valve replacement, to repair mitral leaflet/chordate/papillary muscles and the left ventricle is required. Currently, the best efforts are made regarding the treatment of mitral leaflet tethering or tenting including that of the posterior leaflet and the treatment of ventricular disease. Although the understanding of FMR is increased and the surgical repair technique becomes more sophisticated, prognosis of the patient is not necessarily satisfactory when the amount of residual myocardium is limited. Further investigation is necessary to solve the problem of ventricular disease.

Controlled release of matrix metalloproteinase-1 plasmid DNA prevents left ventricular remodeling in chronic myocardial infarction of rats.

BACKGROUND: The present study investigated whether administration of controlled release matrix metalloproteinase-1 (MMP-1) plasmid DNA prevents left ventricular (LV) remodeling in a rat chronic myocardial infarction (MI) model. METHODS AND RESULTS: Rats with a moderate-sized MI were randomized to 2 groups: injection of phosphate buffered saline (PBS) containing microspheres into the peri-infarct area (MI group, n=14) and injection of cationized gelatin microspheres incorporating MMP-1 plasmid DNA (MI+MMP-1 group, 50 microg MMP-1/20 microl; n=14). As a control group (n=14), rats received neither the coronary artery ligation nor the injection of PBS. Echocardiography, cardiac catheterization and histological studies were performed. At 2 and 4 weeks after the treatment, the MI+MMP-1 group had smaller LV end-diastolic and end-systolic dimensions, better fractional area change and smaller akinetic areas than the MI group. The LV end-systolic elastance and time constant of isovolumic relaxation were also better in the MI+MMP-1 group compared with the MI group 4 weeks after the treatment. Fibrosis evaluated with Masson's trichrome staining was less in the MI+MMP-1 group than the MI group. CONCLUSIONS: Gelatin microspheres for the controlled release of MMP-1 plasmid DNA are promising for improving cardiac remodeling and function when they are administered during the chronic phase of MI.

Chordal translocation: secondary chordal cutting in conjunction with artificial chordae for preserving valvular-ventricular interaction in the treatment of functional mitral regurgitation.

BACKGROUND AND AIM OF THE STUDY: Functional mitral regurgitation (FMR) with leaflet tethering is a serious complication related to dilated cardiomyopathy. Although FMR with mitral leaflet tethering can be improved by secondary chordal cutting, the technique may compromise valvular-ventricular interaction. The aim of chordal translocation (CT) is to maintain valvular-ventricular interaction. METHODS: An initial successful mitral valve repair with CT was performed on a 55-year-old patient with FMR. Following secondary chordal cutting, artificial chordae were sutured to the tip of each papillary muscle, from where the secondary chordae originated. The artificial chordae were passed through the mid-septal annulus and fixed on the side of the left atrium. The force direction generated by the artificial chordae was very similar to the natural stress line on the anterior mitral leaflet. In a subsequent clinical series, CT was performed on 13 FMR patients. RESULTS AND CONCLUSION: The study results indicated that CT, in conjunction with secondary chordal cutting, might represent a promising treatment for preserving valvular-ventricular interaction in FMR patients.

Effect of edaravone, a novel free radical scavenger, supplemented to cardioplegia on myocardial function after cardioplegic arrest: in vitro study of isolated rat heart.

Cardioplegic arrest has been the main mechanism of myocardial protection during open-heart surgery; however, it causes myocardial injury during ischemia-reperfusion. Free radical scavengers are widely known to attenuate ischemia-reperfusion injury in various settings. We investigated the effects of edaravone, a novel free radical scavenger that was originally used for cerebral protection, on myocardial function during ischemia-reperfusion after cardioplegic arrest. Rat hearts were excised and perfused using Langendorff apparatus. The hearts were cardioplegically arrested for 90 min using St. Thomas' Hospital cardioplegic solution (ST solution) at 4 degrees C every 45 min and then reperfused for 20 min. The hearts were divided into 4 groups (n = 13 in each group). In Group ST, the hearts were arrested using the ST solution alone. In Groups L, M, and H, the hearts were arrested using the ST solution supplemented with a low-dose (1 microM), moderate dose (10 microM), and high dose (100 microM) of edaravone, respectively. Left ventricular function (+dp/dt (max)) and the levels of the cardiac enzymes released were measured before and after cardioplegic arrest. At the end of the study, the water content and the tissue oxidative stress (8-hydroxy-2'-deoxyguanosine) of the heart were measured. During reperfusion, the edaravone-treated groups showed a greater functional recovery with regard to the +dp/dt (max) (P < 0.05). The lactate level was the lowest (P < 0.01) in Group M. The water content of the hearts in the edaravone-treated groups was significantly lower (P < 0.05) than that in Group ST. Oxidative stress was significantly lower (P < 0.01) in the edaravone-treated hearts than in Group ST, and it was the lowest in Group M. The addition of edaravone to the cardioplegic solution ameliorates the impairment in myocardial function by reducing the oxidative stress after cardioplegic arrest. In this study, the maximum improvement in the myocardial function was achieved by addition of a moderate dose (10 microM) of edaravone.

Impact of apex-sparing partial left ventriculectomy on left ventricular geometry, function, and long-term survival of patients with end-stage dilated cardiomyopathy.

BACKGROUND AND AIM: Currently, partial left ventriculectomy (PLV) has not been widely accepted as a treatment option for dilated cardiomyopathy (DCM) because its results thus far have been inconsistent. In an animal study, apex-sparing PLV (AS-PLV) was shown to produce greater improvement in left ventricle (LV) function than conventional PLV in which the apex was removed. The aim of this study is to investigate the effectiveness of AS-PLV in a clinical setting. PATIENTS AND METHODS: From September 1999 to December 2007, 13 patients with DCM underwent AS-PLV. Left ventriculotomy was made in the thinnest portion of the lateral wall without injuring the apex, the papillary muscles, and the circumflex coronary artery, which supplies the neighboring myocardium. RESULTS: All patients were discharged from the hospital, except for one patient who developed refractory ventricular fibrillation on postoperative day 35. After AS-PLV, the LV diastolic dimension decreased from 71 +/- 10 mm to 55 +/- 9 mm; LV ejection fraction (EF) from 28%+/- 8% to 39%+/- 11%; and New York Heart Association (NYHA) class from 3 +/- 1.7 to 1.5 +/- 0.6; the differences were significant (p < 0.01). LV function and geometry remained unchanged 2 years after AS-PLV with LVDD of 60 +/- 7 mm, LVEF of 34%+/- 8%, and NYHA class of 1.7 +/- 0.6, respectively (N.S vs. at discharge). CONCLUSIONS: Regardless of the etiology of LV dilatation, AS-PLV restored the ellipsoidal shape of the LV and improved LV function. AS-PLV is a feasible option for treating diseased LVs with lateral wall lesions.

Left ventricular functional analysis using 64-slice multidetector row computed tomography: comparison with left ventriculography and cardiovascular magnetic resonance.

OBJECTIVE: The progress in computed tomography (CT) has improved temporal resolution and shortened the acquisition time. We compared cardiac function using 64-slice CT with left ventriculography (LVG) and cardiovascular magnetic resonance (CMR). METHODS: A head-to-head comparison between CT, LVG and CMR was performed in 41 patients. In global LV function, CMR served as the reference. Regional wall motion was compared in a 5-point scoring system. RESULTS: CT had excellent intra- and interobserver reproducibility. Ejection fraction, end-diastolic and end-systolic volumes by CT were closely correlated with CMR (r = 0.95, 0.96 and 0.98, respectively), while LVG underestimated LV volumes (p < 0.01). The standard deviation of ejection fraction difference between CT and CMR was significantly lower than that between LVG and CMR (p = 0.0015). In regional function, there were good agreements of 94.8% (kappa = 0.82) between CT and LVG and 94.5% (kappa = 0.84) between CT and CMR. The intermethod agreements in mild hypokinesis using CT tended to be lower. CONCLUSION: An excellent correlation was observed between CT and CMR in the LV function over a wide range of heart rates. However, even though 64-slice CT tended to be less sensitive in detecting mild hypokinesis, it still showed excellent concordance in advanced regional abnormalities.

Chronic chymase inhibition preserves cardiac function after left ventricular repair in rats.

OBJECTIVE: Although left ventricular repair (LVR) has been widely performed, the initial improvement of LV function does not last because of LV remodeling. Recent studies have demonstrated that chymase, a local enzyme in the heart, promotes angiotensin II formation as well as activation of transforming growth factor (TGF)-beta, both of which facilitate myocardial fibrosis. Therefore, chymase blockade may play an important role in the prevention of cardiac remodeling after LVR. In this study, the effects of chronic chymase inhibition (Chy-I) after LVR were evaluated in a rat LV aneurysm model. METHODS: Rats that developed LV aneurysms 4 weeks after coronary artery ligation underwent LVR by plicating the LV aneurysm, and were randomized into two groups, the LVR group and the LVR + Chy-I group that received an oral chymase inhibitor (10 mg/kg/day) for 4 weeks. RESULTS: Echocardiography revealed better LV function in the LVR + Chy-I group than in the LVR group at 4 weeks. Four weeks after LVR, LV end-diastolic pressure and the time constant of LV isovolumic pressure decay, were significantly lower in the LVR+Chy-I group. The end-systolic pressure-volume relationship was higher in the LVR+Chy-I group. In the LVR+Chy-I group, mRNA expressions of TGF-beta1 and BNP significantly decreased in the LV myocardium. Histology showed reduced interstitial fibrosis in the LVR+Chy-I group. CONCLUSIONS: Chronic chymase inhibition prevented myocardial fibrosis and preserved cardiac function after LVR. A chymase inhibition could be an important strategy for management after LV repair surgery.

Flk1(+) cardiac stem/progenitor cells derived from embryonic stem cells improve cardiac function in a dilated cardiomyopathy mouse model.

OBJECTIVES: Flk1(+) cells derived from embryonic stem (ES) cells are known to differentiate into mesodermal lineages such as hematopoietic and endothelial cells. Here we demonstrate that they can develop into cardiomyocytes that support functional recovery in a dilated cardiomyopathy (DCM) C57/BL6 mouse model. METHODS: Flk1(+) and Flk1(-) cells were sorted at day 4 of differentiation, and cardiomyogenesis was assessed in vitro. Next, we transplanted these cells into the hearts of cardiomyopathy mice to assess improvement in cardiac function. RESULTS: Flk1(+) cells, but not Flk1(-) cells, isolated on day 4 after differentiation were efficiently converted into contractile cardiomyocytes. RT-PCR analysis and immunohistological assays demonstrated that contractile cells derived from Flk1(+) cells in vitro expressed mature cardiac markers on day 10 after differentiation. Transplantation of sorted Flk1(+) cells into DCM model mouse hearts improved cardiac function, as determined by echocardiography and cardiac catheterization. The in vivo differentiated Flk1(+) cells expressed cardiac markers and had gap junctions, as demonstrated by immunohistochemistry. Furthermore, these cells generated ventricular type action potentials similar to those of adult ventricle. CONCLUSION: These results indicate that Flk1 is a good marker for sorting cardiac stem/progenitor cells which can differentiate into mature cardiomyocytes both in vitro and in vivo.

"Frozen Apex" Repair of a Dilated Cardiomyopathy.

We try to make surgical ventricular restoration simpler and more adjustable to safely enhance ventricular function. In eight patients with DiDonato type III dilated cardiomyopathy, we applied a few short-axis purse-string sutures to the endocardial side of the left ventricular apex ("Frozen-Apex" restoration) to make a smaller, cone-shaped apex, based on the concept that the left ventricular apex is important in its existence, but not in its function. The procedure took less than 15 minutes in all the patients. There was no hospital or late death with the follow-up of 549 ± 389 days. Mid-late postoperatively, New York Heart Association functional class changed from 3.5 ± 0.8 (preoperative) to 1.6 ± 0.6 (P = 0.000 vs preoperative), left ventricular diastolic diameter from 64 ± 16 to 61 ± 15 mm, systolic diameter from 57 ± 15 to 50 ± 17mm (P = 0.070), ejection fraction from 27 ± 10 to 40 ± 16% (P = 0.014). Diastolic function as assessed by the ratio of the early to late ventricular filling velocities, the ratio of mitral annular early diastolic velocity to early mitral inflow velocity, and estimated right ventricular pressure remained at the similar level to preoperative one. The new ventricular restoration was associated with better systolic left ventricular function without deteriorating diastolic one. It may improve the outcome of the treatment of selected patients with dilated cardiomyopathy.

The impact of carbohydrate intake and its sources on hemoglobin A1c levels in Japanese patients with type 2 diabetes not taking anti-diabetic medication.

BACKGROUND: Although postprandial glucose levels largely depend on carbohydrate intake, the impact of carbohydrate and its sources on hemoglobin A1c (HbA1c) levels has not been demonstrated in patients with type 2 diabetes (T2DM) probably because, in previous studies, more than 50% of patients were taking anti-diabetic medication, and the researchers used energy percent of carbohydrate as an indicator of carbohydrate intake. PATIENTS AND METHODS: We recruited 125 Japanese men (mean age 58±12 years) and 104 women (mean age 62±10 years) with T2DM who were not taking anti-diabetic medication and dietary therapy. We used 3-day dietary records to assess total carbohydrate intake and its sources, computed Spearman's correlation coefficients, and conducted multiple regression analyses for associations of carbohydrate sources with HbA1c by sex. RESULTS: Mean HbA1c and total carbohydrate intake were 8.2%±1.9% and 272.0±84.6 g/day in men and 7.6%±1.3% and 226.7±61.5 g/day in women, respectively. We observed positive correlation of total carbohydrate intake (g/day) with HbA1c in men (rs=0.384) and women (rs=0.251), but no correlation for % carbohydrate in either sex. Regarding carbohydrate sources, we found positive correlations of carbohydrate from noodles (rs=0.231) and drinks (rs=0.325), but not from rice, with HbA1c in men. In women, carbohydrate from rice had a positive correlation (rs=0.317), but there were no correlations for carbohydrate from noodles and drinks. The association of total carbohydrate intake (g/day) and carbohydrate from soft drinks with HbA1c in men remained significant even after adjustment for total energy by multiple regression analyses. CONCLUSION: Our findings warrant interventional studies for moderate low-carbohydrate diets that focus on carbohydrate sources and sex differences in order to efficiently decrease HbA1c in patients with T2DM.

Epicardial 15-MHz Echocardiography for Effective Repair of Coronary Arteriovenous Fistula.

In the era of catheter intervention, the surgical repair of coronary arteriovenous fistula needs to be free from residual shunt. Intraoperative epicardial 15-MHz echocardiography helps to find the residual shunt after ligation or obliteration of anomalous vessels. Here we report our method of the echo-assisted surgical repair of coronary arteriovenous fistula in 7 adult patients. The method made the operation for coronary arteriovenous fistula free from residual shunt, but care should be taken to the development of new vessels after the operation.