Clinical implication of LAVI over A' ratio in patients with acute coronary syndrome.

PURPOSE: The ratio of the left atrial volume index (LAVI) and late diastolic mitral annular velocity (A') is a useful echocardiographic index for identifying advanced left ventricular (LV) diastolic dysfunction in patients with dyspnoea. We investigated the clinical implications and prognostic value of the aforementioned ratio (LAVI/A') in patients with ST elevation (STE) or non-STE (NSTE) acute coronary syndrome (ACS). METHODS: We studied 212 patients with ACS. All patients underwent electrocardiography, echocardiography and measurement of plasma B-type natriuretic peptide (BNP) level on admission. The study endpoints were hospitalisation and mortality because of heart failure (HF). RESULTS: There was a significant, moderate positive correlation between LAVI/A' and natural logarithm (Ln) BNP level among the participants (r=0.48, p<0.0001). During a mean follow-up of 17 months, eight patients died and nine patients were hospitalised because of HF. The receiver operating characteristics curve indicated that LAVI/A'≥3.0 predicted these events (log-rank, p=0.0021). A significant and moderate positive correlation existed between LAVI/A' and Ln BNP level in the NSTE-ACS group (n=128; r=0.58, p<0.0001). However, the correlation between LAVI/A' and Ln BNP level was weaker in the STE-ACS group (n=84; r=0.33, p=0.0017). CONCLUSION: LAVI/A' was related to plasma BNP levels in patients with ACS, particularly in those with NSTE-ACS. This index was useful for predicting cardiac events in patients with ACS.

Altitude-Induced Pulmonary Hypertension on One-Day Rapid Ascent of Mount Fuji: Incidence and Therapeutic Effects of Sildenafil.

AIMS: Exposure to high altitudes especially with rapid ascent may induce hypoxic pulmonary vasoconstriction (HPV) and pulmonary hypertension (PH) possibly leading to life-threatening high-altitude pulmonary edema (HAPE). The aim of the study was to evaluate the incidence of PH on a 1-day rapid ascent up Mount Fuji (3775 m) in recreational climbers and also to determine the effectiveness of sildenafil for this rapid ascent-induced PH as measured by echocardiography. METHODS AND RESULTS: Twenty-five subjects who climbed Mount Fuji showed significantly increased pulmonary artery systolic pressure (PASP) from 22.3 ± 5.3 mmHg at sea level to 29.4 ± 8.7 mmHg at 3775 m. Five subjects showed PASP >35 mmHg (35.6-46.2 mmHg, average 42.0 ± 3.9 mmHg) and took oral sildenafil 50 mg after which PASP decreased significantly to 24.5 ± 4.6 mmHg (18.7-31.0 mmHg) after 30 minutes. CONCLUSIONS: One-day rapid ascent of Mount Fuji may induce mild-to-moderate PH and intervention with sildenafil can reduce this PH, suggesting that the therapeutic use of sildenafil would be more reasonable for the relatively infrequent occurrence of altitude-induced PH than its prophylactic use.

Usefulness of right ventricular basal free wall strain by two-dimensional speckle tracking echocardiography in patients with chronic thromboembolic pulmonary hypertension.

Recently two-dimensional (2D) speckle tracking echocardiography (STE) derived from right ventricular (RV) free wall has been shown to be a very useful tool for the estimation of RV performance. The purpose of this study was to examine whether RV basal free wall strain can detect increased mean pulmonary arterial pressure (mPAP) in patients with chronic thromboembolic pulmonary hypertension (CTEPH). We investigated a total of 126 patients with CTEPH (mean age, 56 ± 12 years). They underwent echocardiography and right heart catheter examination. 2D STE-derived longitudinal strain was measured by placing 2 regions of interests (ROIs) on the RV basal free wall in RV-focused apical 4-chamber view. Peak strain (RV-PS) was acquired between the 2 ROIs. Conventional echocardiographic RV parameters (RV fractional area change, RV myocardial performance index, tricuspid annular plane systolic excursion, tricuspid annular peak systolic velocity, and tricuspid regurgitant pressure gradient) were evaluated as well. Right heart catheterization was performed on the day following of echocardiographic evaluation. Among RV echo parameters, RV-PS showed the best correlation with mPAP (r = 0.75, P < 0.0001). Receiver operating characteristic analysis revealed that a cut-off value of RV-PS -20.8% could detect mPAP ≧ 25 mmHg (sensitivity 78%, specificity 93%, area under the curve 0.90, P < 0.001). RV basal free wall strain was a useful tool for the non-invasive detection of increased mPAP in patients with CTEPH.

Two cases with past Kawasaki disease developing acute myocardial infarction in their thirties, despite being regarded as at low risk for coronary events.

Two patients after Kawasaki disease (KD) developed acute myocardial infarction in their thirties, though coronary artery follow-up were deemed unnecessary because of apparently angiographic normal coronary arteries in their children more than 1-year after acute KD. Angiographic findings of apparently normal coronary arteries in the late period after acute KD are possible to mislead their prognoses. It should be recognized that coronary aneurysms can often regress in the late period. There is ongoing controversy about the therapeutic strategy in patients whose coronary aneurysms regressed within several years after acute KD. Coronary computed tomography angiography and flow-mediated dilatation might be useful for the detection of mild sequelae of KD non-invasively.

The role of norepinephrine and estradiol in the pathogenesis of cardiac wall motion abnormality associated with subarachnoid hemorrhage.

BACKGROUND AND PURPOSE: The majority of patients with ventricular wall motion abnormality (WMA) associated with subarachnoid hemorrhage (SAH) are postmenopausal women. In addition to elevated catecholamine, the role of estrogen in the pathogenesis of WMA has recently been implicated. The objective of this study is to clarify the interrelation among catecholamine, estrogen, and WMA in patients with SAH. METHODS: A retrospective analysis was performed on the medical records of 77 patients with SAH (23 men, 54 women) whose plasma levels of epinephrine, norepinephrine, and estradiol had been measured and echocardiograms had been obtained within 48 hours of SAH onset. RESULTS: Twenty-four patients (31%) were found to sustain WMA on admission. Multivariate regression analysis revealed that decreased estradiol (P=0.018; OR, 0.902) and elevated norepinephrine levels (P=0.027; OR, 1.002) were associated with WMA. After quadrichotomization of 77 patients based on sex/WMA, plasma norepinephrine levels were markedly elevated in men with WMA, whereas estradiol levels were markedly decreased in women with WMA. Plasma norepinephrine and estradiol levels were not correlated. Fifty-four female patients with SAH were further quadrichotomized based on norepinephrine/estradiol levels with a threshold value of 1375 pg/mL for norepinephrine and 11 pg/mL for estradiol. The incidence of WMA in the high-norepinephrine/low-estradiol group was significantly higher than the low-norepinephrine/high-estradiol group. CONCLUSIONS: To our knowledge, this is the first study to evaluate the interrelation among catecholamine, estrogen, and SAH-induced WMA. Lack of estradiol in postmenopausal women may predispose them to develop WMA after poor-grade SAH. However, the precise role of multiple sex hormones in SAH-induced WMA should be evaluated in future prospective studies.

Prognostic value of left atrial volume index in patents with first acute myocardial infarction.

AIMS: We evaluated the usefulness of left atrial volume index (LAVI) and the degree of changes in LAVI (delta LAVI) during hospitalization for the prediction of prognosis after acute myocardial infarction (AMI). METHODS AND RESULTS: We investigated 205 consecutive patients with first AMI. They underwent echocardiography on admission as well as at discharge. Delta LAVI was calculated by subtracting the value on admission from that at discharge. The primary endpoints were major cardiac events (MACE): cardiac death due to heart failure and heart failure hospitalization. During a mean follow-up of 26 months, MACE occurred in 29 patients. Patients were divided into two groups according to the optimal cut-off values of LAVI (32.0 mL/m(2)) at discharge and delta LAVI (2.5 mL/m(2)) derived from receiver operating characteristic curves, respectively; Group I: LAVI ≤ 32.0 mL/m(2), Group II: LAVI > 32.0 mL/m(2) and Group A: delta LAVI ≤ 2.5 mL/m(2), Group B: delta LAVI > 2.5 mL/m(2). In comparisons of two groups, respectively, the incidence of MACE between the groups showed significant differences [Group I (3.8%) vs. Group II (32.0%): P < 0.001, log-rank, Group A (7.4%) vs. Group B (20.0%): P = 0.0079, log-rank]. In multivariate analysis, LAVI at discharge [risk ratio (RR): 1.077, 95% CI: 1.035-1.124, P = 0.0002] and delta LAVI (RR: 1.056, 95% CI: 1.012-1.108, P = 0.0109) were significant. LAVI > 32.0 mL/m(2) at discharge (sensitivity: 93%, specificity: 69%) and delta LAVI > 2.5 mL/m(2) (sensitivity: 79%, specificity: 50%) were predictors of MACE. CONCLUSION: LAVI at discharge and delta LAVI would be useful predictors for MACE after first AMI.

(123)I-BMIPP and (99m)Tc-TF discordance on myocardial scintigraphy and it's correlation with functional recovery following acute myocardial infarction: role of conventional echocardiography.

(123)I-beta-methyl-iodophenyl pentadecanoic acid (BMIPP) and (99m)Tc-Tetrofosmin (TF) mismatch designated as stunned myocardium having both systolic and diastolic components. The degree of mismatch might reflect subsequent functional improvement, and this study was designed to unravel the impact of mismatched defect score (MMDS) on recovery of both systolic and diastolic function following acute myocardial infarction (AMI). Forty patients with recent AMI were recruited, and all of them underwent emergency percutaneous coronary intervention. Echocardiography and BMIPP and TF cardiac scintigraphy were performed on 7 +/- 3 days of admission. Follow up echocardiography was performed after 3 months. MMDS were compared with the systolic [ejection fraction (EF) and wall motion score index (WMSI)] and diastolic [peak velocity of early diastolic filling of mitral inflow/peak early diastolic velocity of the mitral annulus(E/E') and left atrial volume index(LAVI)] parameters. BMIPP defect score was significantly higher than the TF defect score and there was a strong positive correlation between them (r = 0.90, P < 0.00001). Thirty-two (80%) patients showed mismatched defect and rest 8(20%) showed matched defect. Of 32 patients 24(75%), 22(69%), 19(59%), and 20(62.5%) showed improved EF, WMSI, E/E' and LAVI respectively. Conversely out of 8 only 2(25%), 1(12.5%), and 2(25%) patients showed improvement of EF, WMSI and LAVI, respectively. E/E' was not improved in patients with matched defect. MMDS were significantly correlated with the improvement of EF (r = -0.46, P = 0.002), WMSI (r = 0.41, P = 0.007), E/E' (r = 0.56, P < 0.0002), and LAVI (r = 0.44, P = 0.004). Mismatched defect score could predict the approximate amount of viable dysfunctional myocardium, and the degree of mismatch showed a significant correlation with the improvement of both systolic and diastolic function.

Long term prognosis of chronic heart failure: reduced vs preserved left ventricular ejection fraction.

BACKGROUND: Left ventricle diastolic dysfunction is attracting increasing attention of one of the etiologies of chronic heart failure (CHF). METHODS AND RESULTS: The study sample included 560 patients with CHF who were hospitalized during the 5-year period. They were classified into 2 groups according to the left ventricular ejection fraction (LVEF): reduced group (LVEF <50%, n=431); or preserved group (LVEF >or=50%, n=129). The degree of cardiac symptoms did not differ between the 2 groups; however, no difference was found between the 2 groups in the mortality rate (P=0.898), and readmission rates (P=0.674). The results of a multivariate analysis using a Cox proportional hazards model to identify predictors of the prognosis of heart failure revealed no difference in prognosis according to the presence/absence of decreased LVEF, whereas renal dysfunction and anemia were identified as significant prognostic determinants. Also, in the reduced group, the administration of angiotensin-converting enzyme inhibitors (ACE-I) and/or angiotensin II receptor blockers (ARB), beta-blockers reduced mortality. In the preserved group, ACE-I and/or ARB administration reduced mortality, whereas beta-blockers did not. CONCLUSION: In the present study, the likelihood of LVEF influencing prognosis was considered to be low, with the contribution of non-cardiac factors such as renal function and anemia concluded to be greater.

Prognostic implications of left ventricular wall motion abnormalities associated with subarachnoid hemorrhage.

Left ventricular (LV) dysfunction generally occurs early in the course of subarachnoid hemorrhage (SAH). We evaluated the prognostic value of electrocardiographic (ECG) abnormalities and echocardiographic LV dysfunction evaluated shortly after SAH. We prospectively enrolled 47 SAH patients (62 +/- 14 years, mean +/- SD) who were admitted to the neurosurgical care unit of our institute. Neurological status was rated on the day of admission. Twelve-lead ECG and 2-dimensional echocardiography were recorded 2 +/- 1 day after onset of SAH. ECG abnormalities (pathological Q-wave, ST-segment deviation, T-wave inversion, and QT prolongation) were evaluated and the incidences of global (LV ejection fraction < 50%) and segmental (regional wall motion abnormality [RWMA]) LV dysfunction were measured. During a follow-up period of 44 +/- 23 days, 17 (36%) patients died. ECG abnormalities, LV ejection fraction < 50%, and RWMA were observed in 62%, 11%, and 28% of patients, respectively. Univariate Cox proportional hazards regression analysis revealed that neurological status, rate-corrected QT interval, LV ejection fraction, and RWMA were significant predictors of death. After adjustment for these significant clinical variables, and age and sex, independent predictors of mortality were neurological status and RWMA. RWMA may provide significant prognostic information in patients with SAH.

Significance of transient left ventricular wall thickening in acute lymphocytic myocarditis.

Transient left ventricular (LV) wall thickening is observed in patients with acute lymphocytic myocarditis. The present study was undertaken to clarify the significance of transient LV wall thickening in patients with this disease. The subjects comprised 25 patients with acute lymphocytic myocarditis. Echocardiography was used to measure the thickness of the interventricular septum (IVS) and the LV posterior wall (PW) at four time points after myocarditis onset--namely, on days 1-3, 6-8, 13-15, and 28-30--to clarify the timing and frequency of wall thickening. The 25 patients were divided into a fulminant myocarditis group (n = 14) and a nonfulminant myocarditis group (n = 11), and the relationship between LV wall thickening and myocarditis severity was investigated. Left ventricular wall thickening was greatest on days 1-3 after myocarditis onset (IVS: 13.3 +/- 3.2 mm; PW: 12.1 +/- 2.6 mm), with this finding being noted in 14 of the 25 cases (56%). By days 6-8, the thickness of IVS had virtually normalized to 10.6 +/- 1.6 mm (P < 0.0001) and that of PW to 10.2 +/- 1.4 mm (P = 0.0006). The thickness of the IVS and PW on days 1-3 after myocarditis onset were 14.6 +/- 3.7 and 13.0 +/- 2.9 mm, respectively, in the fulminant group (P = 0.014), and 11.5 +/- 0.9 and 10.9 +/- 1.4 mm, respectively, in the nonfulminant group (P = 0.039). In lymphocytic myocarditis, LV wall thickening is greatest on days 1-3 after myocarditis onset and improves to near normal by days 6-8. Such transient LV wall thickening occurs in approximately 50% of cases. Left ventricular wall thickening was more marked in the fulminant compared with the nonfulminant group.

Relief of left ventricular outflow obstruction by cibenzoline in a patient with Fabry's disease--a case report.

A 46-year-old man was admitted for further evaluation of exertional chest discomfort. One family member had experienced sudden death, and 2 others had died of heart failure, including 1 known to have had Fabry's disease. The patient was also diagnosed with Fabry's disease, based on reduced leukocyte alpha-galactosidase A activity, 2.0 nmol/mg protein/hour, as well as endomyocardial biopsy findings of marked sarcoplasmic vacuolization of cardiac muscle cells by light microscopy and lamellated "zebra bodies'' in the cytoplasm shown by electron microscopy. Echocardiography disclosed marked left ventricular hypertrophy and systolic anterior motion of the mitral leaflets. On cardiac catheterization, a left ventricular peak systolic outflow gradient of 50 mm Hg was noted; this decreased to 10 mm Hg following intravenous administration of 100 mg of cibenzoline. It is imperative to recognize the existence of cases with Fabry's disease associated with left ventricular outflow obstruction.

Relationship between basal thinning of the interventricular septum and atrioventricular block in patients with cardiac sarcoidosis.

BACKGROUND: Basal thinning of the interventricular septum (IVS) and atrioventricular block (AVB) are characteristic features of cardiac sarcoidosis. Since the conduction system passes along IVS, it has been considered that a close connection exists between basal thinning of IVS and AVB. However, neither the incidence of cases showing basal thinning of IVS nor the relation between it and AVB has been clarified. We thus investigated to elucidate these two issues. METHODS: Thirty-five patients with cardiac sarcoidosis were selected for this study and underwent echocardiographic examination. The wall thickness of IVS was measured at a site 1 cm below the aortic valve inserted point of IVS. Thickness of this site < or = 5 mm was defined as thinning. Twelve-lead and Holter electrocardiograms were obtained to determine the presence/absence and degree of AVB. RESULTS: Basal thinning of IVS was noted in 7 of the 35 patients (20%). AVB was present in 4 of these 7 (57%), and was first degree in 3 (43%) and third degree in one (14%). AVB was not present in 3 patients. Basal thinning of IVS was not apparent in 28 of the 35 patients (80%). AVB was observed in 14 of the 28 patients, 3 had first degree block, 2 had second degree block, and 9 had third degree block. AVB was not observed in 14 of the 28 patients. CONCLUSIONS: These results clarified that basal thinning of IVS is not as common as previously thought in cardiac sarcoidosis, basal thinning of IVS and the presence/absence and degree of AVB are not necessarily correlated.

A case of unicuspid aortic valve associated with a single coronary artery and ventricular septal defect.

The patient was a 26-year-old man who had undergone patch closure of a ventricular septal defect at 2 years of age. After this surgery, his condition was satisfactory until he visited our hospital for treatment of paroxysmal supraventricular tachycardia in November 2000. Echocardiography revealed moderate to severe aortic valve regurgitation and dilatation of the left ventricle and ascending aorta. These echocardiographic abnormalities were attributed to a bicuspid aortic valve. Coronary angiography suggested the presence of a single coronary artery originating from the left Valsalva sinus. We performed Bentall's operation in January 2003. The intraoperative findings revealed that the aortic valve consisted of an extensively calcified single cusp, and there was a single coronary artery originating from the left Valsalva sinus. Because adult patients with a unicuspid aortic valve are rare, and no cases of unicuspid aortic valve associated with a single coronary artery have been reported, we herein report this case with a review of the literature.

Questionnaire survey on the state of routine echocardiographic examinations in Japan: second report.

We mailed questionnaires to 748 registered medical sonographers [RMSs (cardiology)] to gather information for a large-scale survey of RMSs in May 2000. We wanted to evaluate the current state of routine echocardiography in Japan. Altogether, 530 (70.9%) of these sonographers responded; 18 respondents employed by equipment manufacturers were excluded from the start of the study, and 20 others later found to be employed by equipment manufacturers were also excluded. Responses from all personnel at a single institution were treated as a single response; 436 institutions were thus included in the survey. Most or all examinations were carried out by sonographers at 77.3% of the responding institutions but were performed mainly by physicians at 11.1% of the institutions. At least 80% of sonographer or physician working hours were used for echocardiographic examination at 18.9% of the surveyed institutions, whereas up to half the working hours were devoted to echocardiographic examinations at 67.0% of the institutions. The most frequently reported examination time was 30-40 min [35.6% (n = 116) of the institutions], whereas 32.8% (n = 107) of the institutions indicated durations of 10-20 min per examination. Left ventricular (LV) dimensions and wall thickness were measured on M-mode images in all patients at 14.1% (n = 59) of the institutions and mainly on M-mode images but from two-dimensional echocardiography in problematic patients at 74.2% (n = 311) of the institutions. The LV ejection fraction was calculated from LV dimensions at 55.7% (n = 205) of the institutions and from the LV cross-sectional area at 44.3% (n = 163) of the institutions. The LV ejection fraction was estimated visually at 57.0% of the institutions. Only 5.5% (n = 22) of the facilities always scored the wall motion. Pulsed Doppler echocardiography was used to assess LV inflow in all patients at 65.9% of the institutions; regurgitation and shunting were always assessed quantitatively at only 2% (n = 8). Comments concerning image quality were reported in all cases or in cases of poor image quality at 98% of the institutions, and the sonographer was also involved in writing the diagnostic report at 94% of institutions. Echocardiography is less expensive than other diagnostic imaging methods, and its importance is thus likely to continue to increase. Echocardiographic examinations should be carried out by skilled RMSs and physician echocardiographers; and an accurate, readily comprehensible report of the findings should be provided promptly to the referring physician. More such surveys are required to ensure that these practices are adopted.

Narrowing of the left ventricular cavity associated with transient ventricular wall thickening reduces stroke volume in patients with acute myocarditis.

It has been reported that some patients with acute myocarditis have transient ventricular thickening associated with narrowing of the left ventricular cavity caused by interstitial edema. The present study investigated this phenomenon in 20 patients with acute myocarditis. Based on the sum of the interventricular septal wall thickness and left ventricular posterior wall thickness (IVST + PWT), measured by M-mode echocardiography, patients were divided into group A (IVST + PWT >/=25 mm, n=12) and group B (IVST + PWT <25 mm, n=8). The IVST + PWT was 31.8 +/-3.5 mm in group A and 21.9+/-2.7 mm in group B (p<0.0001). The left ventricular end-diastolic dimension (LVDd) was 42.3+/-6.0 mm in group A and 49.4+/-6.7 mm in group B (p<0.05). The stroke volume (SV) was 41.1+/-20.5 ml and 73.0+/-32.3 ml in groups A and B, respectively (p<0.05). The left ventricular ejection fraction (LVEF) was similar in group A (47.9+/-13.0%) and group B (56.9+/-9.0%). The SV correlated inversely with IVST + PWT (r=-0.62, p<0.01), and directly with both the LVDd (r=0.95, p<0.0001) and LVEF (r=0.64, p<0.01). The LVDd correlated inversely with IVST + PWT (r=-0.62, p<0.01). In conclusion, the reduction in SV that occurs during the acute phase of myocarditis is not only the result of systolic dysfunction, but also of the concentric left ventricular wall thickening associated with myocardial interstitial edema, which results in narrowing of the left ventricular cavity at end diastole.