Characteristics and prognosis of patients with cryptogenic stroke and suggestive of patent foramen ovale.

AIMS: The purpose of this study were to identify the usefulness of screening for PFO using agitated saline echocardiography (ASE) and characteristics and prognosis of patients with suggestive of patent foramen ovale (PFO). METHODS: Three hundred three patients (mean age, 53 ± 9 years; 199 [66%] men) admitted with acute stroke or suspicion of stroke were included. Patients were classified into those with and without right-to-left shunt (RLS) according to the ASE results (positive ASE [n = 92] vs. negative ASE [n = 211]). Fifty-one out of ninety-two patients with positive ASE and twenty-one out of two hundred eleven patients with negative ASE underwent TEE with ASE to confirm PFO. RESULTS: Ninety-two were positive for ASE and thirty-six of the fifty-one patients who underwent TEE were confirmed as having PFO. Of the patients with RLS grade 1, 50% were diagnosed with PFO and all patients with RLS grade ≥ 2 were diagnosed with PFO. All patients with negative ASE had no PFO (sensitivity of 100% and specificity of 58%). Patients with positive ASE were younger, had a lower body mass, and a lower prevalence of hypertension. The positive ASE patients had a higher mean S' velocity and better diastolic function. Four of ninety-one patients with positive ASE and thirteen of one hundred seventy-seven showed recurrence of stroke and suspicion of stroke. CONCLUSION: Transthoracic ASE is a good method to screen for PFO. Patients with suggestive of PFO had lower risk factors, less atherosclerosis, and better cardiac performance.

Factors associated with abnormal left ventricular ejection fraction (decreased or increased) in patients with sepsis in the intensive care unit.

BACKGROUND: Sepsis-induced cardiomyopathy (SIC) is known to show cardiac dysfunction in patients with sepsis. Both a decrease or an increase in ejection fraction (EF), an indicator of cardiac function, can occur. The purpose of this study was to identify factors associated with abnormal left ventricular (LV) function measured by EF in patients with sepsis in the intensive care unit (ICU). METHODS: This was a retrospective study performed from November 2016 to December 2018. Three-hundred and sixty-six patients (mean age, 73 ± 13 years; 191 [52%] men) admitted to the ICU with sepsis were included. Patients were classified into three categories according to LV EF (group 1 -[EF<50%, n = 36], group 2 -[50≤EF<70%, n = 252], and group 3 -[EF≥70%, n = 78]). Echocardiographic assessment was performed within 48 hours of diagnosis of sepsis. We analyzed clinical factors including mortality, echocardiographic findings, and laboratory parameters. RESULTS: Decreased LV EF occurred in 36 (10%) patients and hyper-dynamic EF developed in 78 (21%) patients. Of 366 patients, 103 (28%) patients died. Baseline characteristics were similar in the three groups, except female sex an indicator of abnormal EF. Mortality rates were also similar in the three groups; however, mortality rates were significantly higher in patients with abnormal EF (decreased or increased vs. normal). Echocardiographic parameters were significantly different in the three groups, in terms of LV systolic parameters and chamber size. Small left atrium (LA) and small LV were significantly associated with abnormal EF (especially in patients with increased EF). High brain natriuretic peptide was associated with decreased EF. Among these factors, female sex and small LA were significantly associated with abnormal EF in the multiple regression analysis. CONCLUSION: Our findings highlight that female sex and small cardiac size are associated with abnormal EF, and therefore, death. Therefore, female patients and patients with small LA should be monitored closely when they present with sepsis.

Lower diastolic wall strain is associated with coronary revascularization in patients with stable angina.

BACKGROUND: Left ventricular (LV) diastolic dysfunction occurs earlier in the ischemic cascade than LV systolic dysfunction and electrocardiographic changes. Diastolic wall strain (DWS) has been proposed as a marker of LV diastolic stiffness. Therefore, the objectives of this study were to define the relationship between DWS and coronary revascularization and to evaluate other echocardiographic parameters in patients with stable angina who were undergoing coronary angiography (CAG). METHODS: Four hundred forty patients [mean age: 61 ± 10; 249 (57%) men] undergoing CAG and with normal left ventricular systolic function without regional wall motion abnormalities were enrolled. Among them, 128 (29%) patients underwent revascularization (percutaneous intervention: 117, bypass surgery: 11). All patients underwent echocardiography before CAG and the DWS was defined using posterior wall thickness (PWT) measurements from standard echocardiographic images [DWS = PWT(systole)-PWT(diastole)/PWT(systole)]. RESULTS: Patients who underwent revascularization had a significantly lower DWS than those who did not (0.26 ± 0.08 vs. 0.38 ± 0.09, p < 0.001). Age was comparable between the two groups (61 ± 9 vs. 60 ± 11, p = 0.337), but the proportion of males was significantly higher among patients who underwent revascularization (69 vs. 52%, p = 0.001). The LV ejection fraction was similar but slightly decreased (60.9 ± 5.7 vs. 62.4 ± 6.2%, p = 0.019) and the E/E' ratio was elevated (10.3 ± 4.0 vs. 9.0 ± 3.1, p < 0.001) among patients who underwent revascularization. In multiple regression analysis, lower DWS was an independent predictor of revascularization (cut-off value: 0.34; sensitivity: 89%; AUC: 0.870; SE: 0.025; p < 0.001). CONCLUSION: DWS, a simple parameter that can be calculated from routine 2D echocardiography, is inversely associated with the presence of coronary artery disease and the need for revascularization.

Association of female sex and heart rate with increased arterial stiffness in patients with type 2 diabetes mellitus.

OBJECTIVE: This study aimed to evaluate the factors associated with increased arterial stiffness (IAS) measured by pulse wave velocity (PWV) and its clinical implications in patients with type 2 diabetes mellitus (DM). METHODS: This was an observational, cross-sectional study. The ankle-brachial PWV was used to measure arterial stiffness, and 310 patients (mean age, 49±9 years; 180 men) with type 2 DM were divided into two groups according to the results of PWV: Group 1 (IAS; n=214) and Group 2 (normal arterial stiffness; n=96). RESULTS: Patients in Group 1 were predominantly females (48% vs. 28%, p=0.001) and showed higher blood pressure and faster heart rate (HR). The glomerular filtration rate was lower and the urine microalbumin level was higher in patients with IAS. In multiple regression analysis, female sex and faster HR were independently associated with IAS. In subgroup analysis among female patients, prior stroke was more common in patients with IAS, and faster HR and increased postprandial 2-h C-peptide level were independently associated with IAS. CONCLUSION: Female sex and faster HR were independently associated with IAS in patients with type 2 DM. In a subgroup analysis among female patients, prior stroke was more common in patients with IAS, and faster HR and elevated postprandial 2-h C-peptide level were found to be independently associated with IAS.

A Method for Enhancing the Sensing Distance of a Fingerprint Sensor.

In this paper, we describe a method for improving the quality of fingerprint images at long sensing distances by reducing the fringe capacitance formed between a pixel and surrounding fingerprint patterns. Air-walls were applied to the glass attached to a fingerprint sensor for reducing the edge capacitance. Fingerprints and air-wall structures were modeled using a three-dimensional capacitance analysis tool. A prototype was fabricated by stacking glass layers with air-walls with a depth of 50 µm and a pitch of 50 µm on a silicon-type capacitive sensor. Using the results of simulations and prototype experiments, we confirmed that the proposed air-wall structure achieved high enough resolution to distinguish 2.5-lp/mm fingerprint patterns at a sensing distance of 300 µm or longer, and its contrast improved from 0.59 to 0.98.

Factors associated with stroke in patients with paroxysmal atrial fibrillation beyond CHADS2 score.

BACKGROUND: This study was conducted to investigate factors associated with stroke in pa-tients with paroxysmal atrial fibrillation (PAF) beyond CHADS2 score in terms of left ventricular (LV) diastolic function or left atrial (LA) function. METHODS: One hundred and sixty-one patients with PAF and age less than 75 (mean age 61 ± 10; 69 male) who underwent transthoracic echocardiography were investigated. Patients were divided into two groups according to the stroke status (group 1 - no stroke vs. group 2 - presence of stroke). Baseline echocardiographic parameters and LA segmental (4 segments: basal septal, lateral, inferior, and anterior) strain rate (SR) during normal sinus rhythm were analyzed. RESULTS: CHAD score (except S2) was similar between the two groups (0.6 ± 0.7 vs. 0.9 ± 0.7, p = 0.125). Patients with stroke had slightly lower body mass index (24.5 ± 2.7 vs. 23.4 ± ± 2.4, p = 0.052). Echocardiographic parameters did not show any differences in both systolic and diastolic functions between the two groups, however elevated E/E' ratio was noted (9.5 ± ± 3.8 vs. 11.6 ± 3.9, p = 0.010) due to higher E velocity (63.5 ± 15.9 vs. 70.9 ± 16.0 cm/s, p = 0.046). In the analysis of LA SR, there are no differences of SR among the 4 segments. However, standard deviations (SD) of time to peak SR (SD of tA-SR) of the 4 segments were higher in patients with stroke (10.9 ± 9.9 vs. 22.1 ± 18.1 ms, p = 0.009) which indicates dyssynchronous contraction of LA. In multivariate analysis, SD of tA-SR (OR 1.074, CI 1.024-1.128, p = 0.004) and elevated E/E' (OR 1.189, CI 1.006-1.406, p = 0.048) were independently associated with stroke in patients with PAF. CONCLUSIONS: Elevated E velocity, E/E' and SD of tA-SR were associated with occurrence of stroke in patients with PAF even with similar CHAD scores. Increased SD of tA-SR and E/E' were independently associated with stroke in patients with PAF. (.

Automatic quantification of aortic regurgitation using 3D full volume color doppler echocardiography: a validation study with cardiac magnetic resonance imaging.

Recent advances in real-time three-dimensional (3D) echocardiography provide the automated measurement of mitral inflow and aortic stroke volume without the need to assume the geometry of the heart. The aim of this study is to explore the ability of 3D full volume color Doppler echocardiography (FVCDE) to quantify aortic regurgitation (AR). Thirty-two patients with more than a moderate degree of AR were enrolled. AR volume was measured by (1) two-dimensional-CDE, using the proximal isovelocity surface area (PISA) and (2) real-time 3D-FVCDE with (3) phase-contrast cardiac magnetic resonance imaging (PC-CMR) as the reference method. Automated AR quantification using 3D-FVCDE was feasible in 30 of the 32 patients. 2D-PISA underestimated the AR volume compared to 3D-FVCDE and PC-CMR (38.6 ± 9.9 mL by 2D-PISA; 49.5 ± 10.2 mL by 3D-FVCDE; 52.3 ± 12.6 mL by PC-CMR). The AR volume assessed by 3D-FVCDE showed better correlation and agreement with PC-CMR (r = 0.93, p < 0.001, 2SD: 9.5 mL) than did 2D-PISA (r = 0.76, p < 0.001, 2SD: 15.7 mL). When used to classify AR severity, 3D-FVCDE agreed better with PC-CMR (k = 0.94) than did 2D-PISA (k = 0.53). In patients with eccentric jets, only 30% were correctly graded by 2D-PISA. Conversely, almost all patients with eccentric jets (86.7%) were correctly graded by 3D-FVCDE. In patients with multiple jets, only 3 out of 10 were correctly graded by 2D-PISA, while 3D-FVCDE correctly graded 9 out of 10 of these patients. Automated quantification of AR using the 3D-FVCDE method is clinically feasible and more accurate than the current 2D-based method. AR quantification by 2D-PISA significantly misclassified AR grade in patients with eccentric or multiple jets. This study demonstrates that 3D-FVCDE is a valuable tool to accurately measure AR volume regardless of AR characteristics.

Differential effect of 3-dimensional color Doppler echocardiography for the quantification of mitral regurgitation according to the severity and characteristics.

BACKGROUND: The aim of this study is to explore the differential effect of 3-dimensional color Doppler echocardiography for the quantification of mitral regurgitation (MR). Two-dimensional color Doppler echocardiography-based MR quantification has well-documented limitations. METHODS AND RESULTS: We consecutively enrolled 221 patients with MR. Adequate image quality was obtained by 2D- and 3D-color Doppler echocardiography in 211 (95.5%) patients. The quantitative differences between the MR volumes obtained by 2D- and 3D-proximal isovelocity surface area (PISA) were analyzed in various MR subgroups. In the validation cohort (n=52), MR volume obtained by 3D-PISA showed a better agreement with phase-contrast cardiac MRI than 2D-PISA (r=0.97 versus 0.84). In all 211 patients, 2D-PISA underestimated the MR volume when compared with 3D-PISA (52.4±19.6 versus 59.5±25.6 mL; P=0.005). A total of 33.3% with severe MR based on 3D-PISA were incorrectly assessed by 2D-PISA as having nonsevere MR. In the subgroup analysis, the MR severity (odds ratio, 6.96; 95% confidence interval, 3.04-15.94; P<0.001) and having an asymmetrical orifice (odds ratio, 11.48; 95% confidence interval, 3.72-35.4; P<0.001), and an eccentric jet (odds ratio, 3.82; 95% confidence interval, 1.27-11.48; P=0.017) were predictors of significant difference in MR volume (>15 mL) between 2D- and 3D-PISA methods. CONCLUSIONS: Quantification of MR by 3D-PISA method is clinically feasible and more accurate than the current 2D-PISA method. MR quantification by 2D-PISA significantly underestimated MR volume with severe, eccentric MR with an asymmetrical orifice. This article demonstrates that 3D-color Doppler echocardiography could be used as a valuable tool to confirm treatment strategy in patients with significant MR.

A case of sheathless transradial coronary intervention for complex coronary lesions with a standard guiding catheter.

One of the major limitations of transradial coronary intervention is the inability to use large guiding system, which leads to the development of dedicated sheathless guide catheter system. However, these devices are not available in the Republic of Korea. We present a case in which conventional guiding catheter was used for sheathless transradial coronary intervention in the treatment of complex coronary anatomy.

The Effect of Metabolic Syndrome on Myocardial Contractile Reserve during Exercise in Non-Diabetic Hypertensive Subjects.

BACKGROUND: Metabolic syndrome (MS) is associated with increased left ventricular (LV) mass and diastolic dysfunction. This study uses relatively load-independent Doppler tissue echocardiography to examine whether MS is associated with decreased longitudinal contractile reserve during dynamic exercise. METHODS: A total of 112 patients with relatively well-controlled, treated hypertension who complained of exertional dyspnea were enrolled (average age: 56.7 ± 10.5 years). Fifty-six were non-diabetic patients with MS (Group 1), and 56 were age-sex matched hypertensive patients without MS (Group 2). Exercise stress echo was performed using a symptom-limited, multistage, supine bicycle exercise test. Multiple Doppler parameters were obtained at baseline, at each stage of exercise, and during recovery. RESULTS: There was no significant difference between the two groups in terms of age, gender, and hemodynamic variables. E/E', an index of LV filling pressure, was significantly higher in the MS group at rest and during exercise. The longitudinal contractile reserve, the change in S' (longitudinal tissue velocity) from baseline to peak exercise, was significantly lower in the MS group (2.00 ± 1.65 vs. 2.90 ± 1.66, p = 0.015). Multiple regression analysis showed independent association of MS with longitudinal contractile reserve when controlled for confounding factors, such as LV mass index, gender, blood pressure, and age (ß = -0.235, p = 0.035). CONCLUSION: Longitudinal contractile reserve was reduced in MS patients compared to others, although both groups demonstrated similar longitudinal contractile function at rest. We present the first demonstration that metabolic syndrome is independently associated with LV systolic dysfunction during exercise in hypertensive patients.