Kawasaki disease: Epidemiological differences between past and recent periods, and implications of distribution dynamism.

BACKGROUND: Epidemiological findings suggest that Kawasaki disease (KD) is mediated by infection, which triggers its onset. Although the mechanism of onset seems to involve preconditioning factors and triggering factors, the details remain unclarified. METHODS: Data for 330 662 patients reported in KD nationwide surveys in Japan implemented between 1961 and 2014 were chronologically compared in terms of patient age distribution, estimated mean onset age, and male-to-female ratio during four periods: pre-epidemic (P1), epidemic (P2), stable (P3), and recent (P4): 1961-1978, 1979-1986, 1987-1997, and 1998-2014, respectively. RESULTS: During P2, the number of patients aged 6 months-2 years increased, and the mean onset age was younger; during P4, however, the number of patients aged ≤1 year decreased, but the number of patients ≥2 years increased, with a flat onset age distribution chart, and the mean onset age was older. During P2, increases in the number of patients were accompanied by younger mean onset age, whereas during P4, increases in the number of patients were conversely accompanied by older mean onset ages. The male: female ratio tended to decrease during P2, but this tendency was not seen in P4. No outbreak occurred during a recent 28 year period (P3, P4). Specific preconditioning factors might have been present during the 8 years (P2) of the past three outbreaks. CONCLUSION: P2 and P4 were significantly different in epidemiological features. It is likely that they do not share the same mechanism of onset (preconditioning and/or trigger factors).

Implications of hepatic dysfunction in Kawasaki disease: Time-related changes in aspartate aminotransferase, alanine aminotransferase, total bilirubin, and C-reactive protein levels.

IMPORTANCE: The cause of the hepatic dysfunction that commonly accompanies Kawasaki disease (KD) remains unclear. OBJECTIVE: We tried to clarify the cause of the hepatic dysfunction. METHODS: A total of 381 consecutive patients with acute KD, who had undergone inpatient treatment with intravenous immunoglobulin until the 7th day of illness, were divided into a group of 199 patients with an alanine aminotransferase (ALT) level ≥ 40 IU/L on admission (group I), a group of 52 patients with an ALT level ≥ 40 IU/L at some point after admission (group II), and a group of 130 patients with ALT levels consistently < 40 IU/L throughout hospitalization (group III). Aspartate aminotransferase (AST), ALT, total bilirubin (T-Bil), and C-reactive protein (CRP) levels were analyzed over time, and time-courses were compared. RESULTS: In the initial stage of illness, in group I, AST, ALT, T-Bil peaked on days 1-3, and AST tended to improve significantly on the 4th day (P < 0.001). T-Bil improved on day 5 (P < 0.01), and ALT improved significantly on day 6 (P < 0.001). CRP increased every day up to day 6 (P < 0.001). In group II, AST and ALT increased after admission, and thereafter CRP increased, then decreased. The frequency of use of aspirin and aspirin doses did not differ significantly in the three groups. INTERPRETATION: Recovery from liver dysfunction occurred in the initial stage of illness in group I-within the period of CRP exacerbation, which is an indicator of systemic inflammation.

Impact of Cumulative Smoking Exposure on Subclinical Degenerative Aortic Valve Disease in Apparently Healthy Male Workers.

BACKGROUND: Little is known regarding the impact of cumulative smoking exposure and smoking cessation on subclinical degenerative aortic valve (DAV) disease. METHODS: We examined associations of smoking status, cigarette-years of smoking, and years since quitting smoking with subclinical DAV disease defined by echocardiography. RESULTS: Of 756 apparently healthy male workers, 154 had DAV including 63 with DAV with ≥2 leaflets calcification (DAV ≥2 cal). Compared with never smokers, ever smokers had higher risk of DAV and DAV ≥2 cal; odds ratios (95% CI) were 2.883 (1.800-4.618) (p<0.001) and 5.281 (2.297-12.138) (p<0.001), respectively. Both current and former smokers had dose-dependent relationships of cigarette-years on DAV and DAV ≥2 cal (P for trend, <0.001 for both DAV, in both smokers). In current smokers with >400-≤800 and with >800 cigarette-years, odds ratios (95%CIs) were 3.201 (1.690-6.063) (p<0.001) and 5.326 (2.800-10.053) (p<0.001) for DAV, 7.460 (2.828-19.680) (p<0.001) and 8.397 (3.146-22.414) (p<0.001) for DAV ≥2 cal, respectively. In former smokers with >800 cigarette-years, odds ratios (95%CI) were 3.780 (1.970-7.254) (p<0.001) for DAV, 10.035 (3.801-26.496) (p<0.001) for DAV ≥2 cal. Compared with current smokers, former smokers with quitting smoking >10 years had significantly lower risk of DAV and DAV ≥2 cal. CONCLUSIONS: In apparently healthy male workers, DAV disease was strongly associated with smoking. Cumulative smoking exposure was associated with dose-dependent relationship on subclinical DAV disease both in current smokers and former smokers.

Mitral annulus flattens in ischemic mitral regurgitation: geometric differences between inferior and anterior myocardial infarction: a real-time 3-dimensional echocardiographic study.

BACKGROUND: New surgical strategies to restore the saddle shape of the mitral annulus are expected to increase annuloplasty effectiveness. Preoperative and postoperative configuration of the curved annulus, however, is difficult to quantify with 2-dimensional echocardiography. We sought to investigate the geometric deformity in the mitral annulus in ischemic mitral regurgitation (MR), comparing inferior and anterior myocardial infarction (MI) with the use of a custom quantitation software system with transthoracic 3-dimensional echocardiography. METHODS AND RESULTS: We performed real-time 3-dimensional echocardiography in 23 patients with ischemic MR attributable to inferior MI or anterior MI and in 10 controls. Three-dimensional data were cropped into 18 radial planes, and we manually marked the annulus in mid systole. Three-dimensional annular images were reconstructed, and annular circumferences, areas, and heights were quantified. Annulus was significantly more dilated and flattened in ischemic MR than in controls and was further deformed in anterior MI as compared with inferior MI (control: circumference 9.9+/-0.7 cm, area 9.6+/-0.5 cm2, height 5.0+/-0.7 mm; inferior MI: circumference 11.5+/-1.2 cm [P<0.01 compared with control], area 11.4+/-2.0 cm2 [P<0.05 compared with control], height 3.5+/-1.6 mm [P<0.05 compared with control]; anterior MI: circumference 14.2+/-2.4 cm [P<0.0001 compared with control, P<0.05 compared with inferior MI], area 13.7+/-2.8 cm2 [P<0.01 compared with control, P<0.05 compared with inferior MI], height 1.7+/-1.5 mm [P<0.0001 compared with control, P<0.05 compared with inferior MI]). CONCLUSIONS: Mitral annulus flattens in ischemic MR. Deformity of the mitral annulus was greater in anterior MI group than in the inferior MI group.

Quantitation of mitral valve tenting in ischemic mitral regurgitation by transthoracic real-time three-dimensional echocardiography.

OBJECTIVES: We sought to investigate the geometric changes of the mitral leaflets and annulus, clarify the maximum tenting site of the leaflets, and quantify the valve tenting in ischemic mitral regurgitation (MR) using three-dimensional (3D) echocardiography. BACKGROUND: Although the understanding of the mechanisms of ischemic MR has advanced recently, the geometric changes of the mitral leaflets and annulus have been assessed by two-dimensional echocardiography in the clinical setting, despite the unique configuration of the leaflets and annulus. METHODS: Utilizing real-time 3D echocardiography, we obtained transthoracic volumetric images in 12 patients with ischemic MR presenting with global left ventricular dysfunction and in 10 controls. Original software was used to crop the 3D data into 18 radial planes, and we marked the mitral annulus and leaflets in each plane in mid-systole. The 3D images of the leaflets and annulus were reconstructed for the quantitative measurements. RESULTS: In ischemic MR, the annulus flattened with apparent tenting of the leaflets. Maximum and mean tenting length were longer and tenting volume was larger in ischemic MR than control subjects (maximum tenting length: 9.8 +/- 2.0 mm vs. 3.1 +/- 1.2 mm, p < 0.0001, mean tenting length: 3.7 +/- 0.9 mm vs. 0.7 +/- 0.5 mm, p < 0.0001, tenting volume: 4.09 +/- 1.22 ml vs. 0.45 +/- 0.29 ml, p < 0.0001). The maximum tenting site was located in anterior leaflet in all patients. CONCLUSIONS: We clearly demonstrated 3D geometric deformity of the mitral leaflets and annulus in ischemic MR using novel software for creating images by 3D echocardiography. This technique will be helpful in making a proper decision for the surgical strategy in each patient.

Comparison of high-frequency two-dimensional transthoracic echocardiography versus intravascular ultrasound for evaluation of the left anterior descending coronary artery.

The purpose of this study was to evaluate the feasibility of high-frequency transthoracic echocardiography for measuring the wall thickness and luminal area of the left anterior descending coronary artery (LAD). Fifteen patients underwent simultaneous high-frequency transthoracic echocardiography and intravascular ultrasound (IVUS) examinations. There were good agreements for wall thickness (0.38 +/- 0.05 vs 0.38 +/- 0.06 mm, p = 0.0004) and luminal area (3.24 +/- 1.05 vs 3.32 +/- 1.34 mm2, p <0.0001) between high-frequency transthoracic echocardiography and IVUS measurements. High-frequency transthoracic echocardiography was reliable in the measurement of the wall thickness and luminal area of the LAD.

Geometric deformity of the mitral annulus in patients with ischemic mitral regurgitation: a real-time three-dimensional echocardiographic study.

BACKGROUND AND AIM OF THE STUDY: Saddle-shaped non-planarity of the mitral annulus has been investigated previously. The study aim was to further clarify the configuration of the mitral annulus in ischemic mitral regurgitation (MR) by using transthoracic real-time three-dimensional (3-D) echocardiography. METHODS: Twenty-five patients with previous myocardial infarction and left ventricular dysfunction (ejection fraction < 50%), and 10 healthy control subjects, were examined using real-time 3-D transthoracic echocardiography. The patients were allocated to either a non-MR group or an MR group. By using real-time 3-D echocardiography, the configuration of the mitral annulus was reconstructed in end-systole, and the height of the saddle-shaped mitral annulus calibrated (non-planar index). RESULTS: In controls, the mitral annulus appeared as non-planar 'saddle shape', with a non-planar index of 5.5 +/- 1.7 mm. The mitral annulus was flattened in both the non-MR and MR groups. The non-planar index was significantly smaller in the MR group than in the non-MR group (1.7 +/- 1.8 mm versus 3.8 +/- 1.2 mm, p < 0.05). The systolic annular area was significantly larger in the MR group than the non-MR group. CONCLUSION: The 'saddle shape' of the mitral annulus was deformed in patients with ischemic MR. Mitral annulus deformation may play a role in ischemic MR in conjunction with mitral valve tenting. These results suggest that a non-planar saddle-shaped annuloplasty ring would contribute to successful mitral valve repair durability in patients with ischemic MR.

Relation of aortic valve sclerosis to carotid artery intima-media thickening in healthy subjects.

We studied 252 healthy adults by echocardiography and carotid ultrasonography to determine the relation between early subclinical aortic valve sclerosis (AVS) and carotid intima-media thickness (IMT). Carotid IMT was significantly greater in subjects with AVS than in those without AVS. There was a significant correlation between the grade of AVS and carotid IMT.

Noninvasive assessment of great cardiac vein flow by Doppler echocardiography: a validation study.

The objectives of this study were (1) to compare great cardiac vein (GCV) flow velocity detected by pulsed Doppler echocardiography (PDE) with Doppler guide wire (DGW) in the experimental setting and (2) to clarify whether transthoracic Doppler echocardiography (TTDE) can detect GCV flow in humans. Using opened-chest dogs, we detected GCV flow by PDE under the guidance of color flow Doppler mapping. GCV flow velocity was recorded by PDE and DGW, simultaneously. In 23 volunteers, GCV flow velocity was measured by TTDE. In the experimental setting, the prominent systolic flow wave of the GCV was obtained in PDE and DGW. There were good agreements between PDE and DGW for the measurements of GCV flow velocity (peak velocity: r = 0.98, y = 1.12chi-5.9; time velocity integral: r = 0.97, y = 1.10chi-0.71). In the human subjects, clear envelopes of GCV flow velocity were obtained in 21 (91%) of 23 subjects with the use of TTDE.

A rare case of impending paradoxical embolism with a complex patent foramen ovale.

A 68-year-old woman, who presented with pulmonary embolism, was diagnosed as having an impending paradoxical thromboembolism by transthoracic and transesophageal echocardiography, which revealed an entrapped thrombus in the atrial septum. The patient underwent surgery for thromboembolectomy. A patent foramen ovale (PFO) appeared as a tunnel with three openings into the left atrium; one opening located close to the antero-superior left atrial wall and two small atrial septal defects of a septum primum. A thrombus was trapped at two small atrial septal defects. This was a rare case of impending paradoxical embolism with complex morphology of PFO.

Relation between progression of aortic valve sclerosis and carotid intima-media thickening in asymptomatic subjects with cardiovascular risk factors.

BACKGROUND: Aortic valve sclerosis (AVS) is the early lesion of calcific aortic valve disease and may subsequently progress toward valvular stenosis. Histopathological and clinical evidence has suggested that AVS and atherosclerosis share similar mechanisms. However, little is known regarding the relation between the early AVS progression and the early atherosclerosis progression. The carotid intima-media thickness (IMT) by carotid ultrasonography has been established as the surrogate marker of the early atherosclerosis. The aim of this study was to examine the association between progression of early AVS and increase of carotid IMT. METHODS: We retrospectively analyzed the data of 127 asymptomatic subjects (49 ± 8 years, 114 men) with ≥1 cardiovascular (CV) risk factors, without history of CV disease, who underwent echocardiographic and carotid ultrasonographic examinations twice ≥6 months apart. We evaluated aortic valve morphology and function and carotid IMT at the baseline and at follow-up examinations. RESULTS: During a follow-up of 25 ± 15 months, the number of subjects with AVS was significantly increased (34 vs. 47%, P < 0.0001) and the mean value of carotid IMT was significantly increased (1.16 ± 0.33 vs. 1.29 ± 0.41 mm, P < 0.0001). The progression of AVS was observed in 26 subjects. By logistic regression analysis, the baseline carotid IMT value was an independent predictor of AVS progression (odds ratio = 4.07, P = 0.026). CONCLUSION: In asymptomatic subjects with CV risk factors, progression of AVS and increase of carotid IMT were observed during a mean follow-up period of 25 months. Progression of AVS in asymptomatic subjects with CV risk factors was associated with carotid intima-media thickening.

Three-dimensional quantitation of mitral valve coaptation by a novel software system with transthoracic real-time three-dimensional echocardiography.

We investigated the degree of mitral valve coaptation with a custom quantitation software system using transthoracic three-dimensional (3D) echocardiography. With real-time 3D echocardiography, we obtained transthoracic volumetric images in 20 healthy subjects and 20 patients with dilated cardiomyopathy. With our novel software system, the surface area of mitral valve tenting in the onset of mitral leaflet closure [O] and the timing of maximum closure of mitral leaflet [M] were reconstructed for quantitative measurement. The coaptation index was calculated by the following formula: [(3D tenting surface area in O-3D tenting surface area in M)/3D tenting surface area in O]. The coaptation index in patients with dilated cardiomyopathy was significantly smaller than that in healthy subjects (11% +/- 4.1% vs. 18% +/- 8.0%, P = .004). The custom quantitation software system with 3D echocardiography allowed us to assess the degree of mitral valve coaptation.

Geometric changes of tricuspid valve tenting in tricuspid regurgitation secondary to pulmonary hypertension quantified by novel system with transthoracic real-time 3-dimensional echocardiography.

Geometric changes of tricuspid valve, particularly leaflets configuration, in functional tricuspid regurgitation (TR) remain to be defined. We sought to investigate geometric changes of tricuspid valve tenting in functional TR secondary to pulmonary hypertension by transthoracic real-time 3-dimensional echocardiography (3DE). Real-time 3DE was performed in 30 individuals (17 patients with TR and 13 control subjects). We used a novel software system with 3DE to reconstruct tricuspid geometry at midsystole. In patients with TR, tricuspid leaflets were tethered into right ventricle with apparent tenting showing a mountain-like bulging. Maximum tenting site was mostly located at the center of the tenting. Tenting volume was larger (4.2 +/- 2.4 vs 1.1 +/- 0.6 cm(3), P < .001), and the maximum and mean tenting lengths were longer, than in control subjects. Annular area was also larger (11.3 +/- 2.3 vs 8.7 +/- 1.8 cm(2), P = .003) than in control subjects. Geometric changes in functional TR secondary to pulmonary hypertension were characterized by enlargement of tricuspid tenting volume and dilatation of annulus. This study suggested usefulness of the novel system with 3DE in evaluation of tricuspid valve geometry.

Geometric differences of the mitral valve tenting between anterior and inferior myocardial infarction with significant ischemic mitral regurgitation: quantitation by novel software system with transthoracic real-time three-dimensional echocardiography.

We sought to investigate the 3-dimensional geometric differences of mitral leaflet tenting in ischemic mitral regurgitation, comparing inferior and anterior myocardial infarction (MI). Using real-time 3-dimensional echocardiography, we obtained transthoracic volumetric images for patients with significant ischemic mitral regurgitation (9 inferior and 7 anterior). With our novel software system, 3-dimensional images of the leaflets were reconstructed for quantitation. Mitral leaflet configuration was then represented in contour in which the degree of the tenting could be observed. Calculated percent of tethered leaflet area (>5-mm tenting from the annular level) was compared in inferior and anterior MI. Percent of tethered leaflet area was significantly smaller in inferior than anterior MI, reflecting the localized leaflet tenting in inferior MI (16.7 +/- 18.8% vs 38.9 +/- 9.7%, P = .01). In anterior MI, mitral valve leaflets were widely tethered toward the left ventricle, in contrast with inferior MI showing localized tenting of the leaflet.