Early surgery with aggressive surgical approach to improve 6-month outcomes in patients with active infective endocarditis: contribution of cerebral preoperative magnetic resonance imaging.

OBJECTIVES: We investigated the hypothesis that early surgery for infective endocarditis (IE) attenuates the rate of death or embolic events and does not increase the rate of relapse or postoperative valvular dysfunction (PVD) at 6 months. METHODS: 21 consecutive patients who underwent surgical treatment of IE were prospectively included. We assessed 6-month postoperative clinical outcomes by comparing early surgery (Group E, surgery within 72 h) and conventional treatment (Group C). Nine patients (43%) were assigned to Group E based on a combination of preoperative evaluation parameters, including the findings of cerebral magnetic resonance imaging (MRI), which was performed in all patients with left-sided IE. RESULTS: Six surgical plans (5 advancements and 1 postponement) were modified by routine MRI. Although preoperative echocardiography did not confirm all annular invasions, the rate of periannular infection, which was treated by pericardial annular patch plasty (56%) in patients with native-valve IE, was higher in Group E than C (P = 0.006). Early surgery based on MRI findings resulted in no postoperative embolic events or cerebral bleeding. The 6-month mortality rate was 0% in both groups, although the calculated 6-month IE mortality rate was 49.2 ± 25% and 28.8 ± 18%, respectively. No recurrence of IE or PVD occurred in Group E. The 6-month rate of freedom from composite events was 100% in Group E. CONCLUSIONS: Aggressive treatment (periannular resection and disuse of a prosthetic annuloplasty ring) and optimal antibiotic therapy based on intraoperative microorganisms, even in patients who underwent early surgery, reduced the 6-month relapse and PVD rates.

[A Case of a Breast Cancer Patient with Cardiac Metastasis].

The patient was a 65-year-old woman who was diagnosed with Stage III A triple-negative breast cancer(T2N2aM0)at the age of 63. AC chemotherapy(3 months)followed by paclitaxel plus bevacizumab(4 months)was administered as neoadjuvant chemotherapy. After chemotherapy, she underwent mastectomy and lymph node dissection. Pathological examination revealed a partial response. After surgery, radiotherapy with a radiation dose of 50 Gy was applied to the chest wall and supraclavicular lymph node. Multiple pulmonary metastases and mediastinal lymph node metastases were diagnosed 23 months after initial treatment, and she was treated with S-1 administration. Two months after S-1 treatment, the PET-CT showed metastasis in the right atrium. Since there were no cardiac symptoms, S-1 treatment was continued without cardiovascular treatment. However, the mediastinal lymph node metastasis progressed; and therefore, S-1 administration was stopped and chemotherapy with eribulin was initiated. Brain metastasis was diagnosed at the same time and treated with a gamma knife. Although chemotherapy with eribulin was continued, the patient died 33 months after initial treatment owing to the brain metastasis. The cardiac metastasis did not progress during chemotherapy with eribulin. There was no sign of heart failure or arrhythmia during the treatment.

Association of peripartum troponin I levels with left ventricular relaxation in women with hypertensive disorders of pregnancy.

Objective: Women with hypertensive disorders of pregnancy (HDP) show elevated risk of heart failure despite decreased circulating plasma volume compared with those with normotensive control pregnancies (NCP). This study was performed to better characterise the heart in women with HDP and determine whether high-sensitivity troponin I (hs-TnI) around childbirth predicts reduced left ventricular (LV) relaxation at 1 month postpartum. Methods: Echocardiography was performed longitudinally during the first, second and third trimesters and immediately postpartum within 1 week and 1 month postpartum in 24 women with HDP, with simultaneous determination of blood variables in comparison with 51 women with NCP. Results: Compared with NCP, HDP showed greater antepartum left atrial (LA) volume, LV mass and inferior vena cava (IVC) diameter, higher peripartum brain natriuretic peptide/N-terminal pro-B-type natriuretic peptide and hs-TnI with the highest value immediately postpartum, and lower early diastolic mitral annular velocity (e') during pregnancy/postpartum. In analyses of data on HDP and NCP, hs-TnI at the third trimester as well as that immediately postpartum was negatively correlated with later e' at 1 month postpartum. The areas under the receiver operating characteristic curves were 0.82 and 0.81 for hs-TnI at the third trimester and immediately postpartum, respectively, in the prediction of reduced LV relaxation at 1 month postpartum. Conclusion: Reduced LV diastolic function and decreased splanchnic blood reservoir may contribute to the increased third trimester IVC diameter and LA volume in women with HDP. The rise in hs-TnI around childbirth was associated with poor LV relaxation ability at 1 month postpartum.

Morphofunctional cardiac changes in pregnant women: associations with biomarkers.

Objective: This longitudinal study was performed to determine changes in echocardiography parameters in association with various biomarker levels in pregnancy/postpartum. Methods: Fifty-one healthy pregnant women underwent echocardiography with simultaneous determination of blood levels of five biomarkers at each of the first, second and third trimesters of pregnancy, immediately postpartum within 1 week after childbirth and approximately 1 month postpartum. Data on 255 echocardiography scans (five times per woman) and biomarkers were analysed. Results: Left ventricular end-diastolic dimension, left atrial (LA) volume index and left ventricular (LV) mass index increased with advancing gestation and reached the maximum immediately postpartum concomitant with the highest brain natriuretic peptide (BNP), N-terminal pro B-type natriuretic peptide (NT-proBNP), high-sensitivity troponin I (hs-TnI) and creatine kinase MB levels. The inferior vena cava diameter was significantly reduced in the third trimester compared with that in the first trimester and the peak occurred immediately after childbirth. In 255 paired measurements, hs-TnI level was significantly positively correlated with LA volume index and LV mass index; BNP and NT-proBNP were significantly positively correlated with LA volume index and estimated glomerular filtration rate (eGFR) was significantly positively correlated with the average of early diastolic septal and lateral mitral annular velocity (e'). Conclusions: Maximal cardiac changes in morphology occurred postpartum within 1 week after childbirth, not during pregnancy. BNP/NT-proBNP, hs-TnI and eGFR reflected cardiac changes in pregnancy.

A new method to estimate pulmonary vascular resistance using diastolic pulmonary artery-right ventricular pressure gradients derived from continuous-wave Doppler velocity measurements of pulmonary regurgitation.

Pulmonary vascular resistance (PVR) is an important hemodynamic parameter in patients with heart failure, especially when the pulmonary arterial pressure is lower due to reduced stroke volume. Several echocardiographic methods to estimate PVR have been proposed, but their applications in patients with organic left-sided heart diseases have been limited. The aim of the present study was to examine the usefulness of our new method to estimate PVR (PVRPR) based on the continuous-wave Doppler velocity measurements of pulmonary regurgitation in these patients. In 43 patients who underwent right heart catheterization, PVRPR was calculated as the difference between the Doppler-derived early- and end-diastolic pulmonary artery (PA)-right ventricular (RV) pressure gradients divided by the cardiac output measured in the left ventricular outflow tract by echocardiography. The PVRPR correlated well with invasive PVR (PVRCATH) (r = 0.81, p < 0.001) without any fixed bias in Bland-Altman analysis. The conventional echocardiographic PVRs showed inadequate correlations with PVRCATH, or a obvious overestimation of PVRCATH. In the receiver operating characteristic analyses to determine the patients with abnormal elevation of PVRCATH (>3 Wood units, WU), the area under the curve was the greatest for PVRPR (0.964) compared to the conventional PVRs (0.649-0.839). PVRPR had 83 % sensitivity and 100 % specificity at the optimal cut-off value of 3.10 WU in identifying patients with PVRCATH >3 WU. Our simple and theoretical PVRPR is useful for the noninvasive estimation of PVR.

Relationships of left ventricular strain and strain rate to wall stress and their afterload dependency.

Whether and how left ventricular (LV) strain and strain rate correlate with wall stress is not known. Furthermore, it is not determined whether strain or strain rate is less dependent on the afterload. In 41 healthy young adults, LV global peak strain and systolic peak strain rate in the longitudinal direction (LS and LSR, respectively) and circumferential direction (CS and CSR, respectively) were measured layer-specifically using speckle tracking echocardiography (STE) before and during a handgrip exercise. Among all the points before and during the exercise, all the STE parameters significantly correlated linearly with wall stress (LS: r = -0.53, p < 0.01, LSR: r = -0.28, p < 0.05, CS in the inner layer: r = -0.72, p < 0.01, CSR in the inner layer: r = -0.47, p < 0.01). Strain more strongly correlated with wall stress than strain rate (r = -0.53 for LS vs. r = -0.28 for LSR, p < 0.05; r = -0.72 for CS vs. r = -0.47 for CSR in the inner layer, p < 0.05), whereas the interobserver variability was similar between strain and strain rate (longitudinal 6.2 vs. 5.2 %, inner circumferential 4.8 vs. 4.7 %, mid-circumferential 7.9 vs. 6.9 %, outer circumferential 10.4 vs. 9.7 %), indicating that the differences in correlation coefficients reflect those in afterload dependency. It was thus concluded that LV strain and strain rate linearly and inversely correlated with wall stress in the longitudinal and circumferential directions, and strain more strongly depended on afterload than did strain rate. Myocardial shortening should be evaluated based on the relationships between these parameters and wall stress.

Characteristic systolic waveform of left ventricular longitudinal strain rate in patients with hypertrophic cardiomyopathy.

We analyzed the waveform of systolic strain and strain-rate curves to find a characteristic left ventricular (LV) myocardial contraction pattern in patients with hypertrophic cardiomyopathy (HCM), and evaluated the utility of these parameters for the differentiation of HCM and LV hypertrophy secondary to hypertension (HT). From global strain and strain-rate curves in the longitudinal and circumferential directions, the time from mitral valve closure to the peak strains (T-LS and T-CS, respectively) and the peak systolic strain rates (T-LSSR and T-CSSR, respectively) were measured in 34 patients with HCM, 30 patients with HT, and 25 control subjects. The systolic strain-rate waveform was classified into 3 patterns ("V", "W", and "√" pattern). In the HCM group, T-LS was prolonged, but T-LSSR was shortened; consequently, T-LSSR/T-LS ratio was distinctly lower than in the HT and control groups. The "√" pattern of longitudinal strain-rate waveform was more frequently seen in the HCM group (74 %) than in the control (4 %) and HT (20 %) groups. Similar but less distinct results were obtained in the circumferential direction. To differentiate HCM from HT, the sensitivity and specificity of the T-LSSR/T-LS ratio <0.34 and the "√"-shaped longitudinal strain-rate waveform were 85 and 63 %, and 74 and 80 %, respectively. In conclusion, in patients with HCM, a reduced T-LSSR/T-LS ratio and a characteristic "√"-shaped waveform of LV systolic strain rate was seen, especially in the longitudinal direction. The timing and waveform analyses of systolic strain rate may be useful to distinguish between HCM and HT.

Left Ventricular Global Strain for Estimating Relaxation and Filling Pressure　- A Multicenter Study.

BACKGROUND: Speckle-tracking echocardiography (STE)-derived parameters may have better correlation with left ventricular (LV) relaxation and filling pressure than tissue Doppler-derived parameters. However, it has not been elucidated which parameter - strain or strain rate - and which direction of myocardial deformation - longitudinal or circumferential - is the most useful marker of LV relaxation and filling pressure. METHODS AND RESULTS: We conducted a prospective multicenter study and compared the correlation of tissue Doppler- and STE-derived parameters with the time constant of LV pressure decay (τ) and LV mean diastolic pressure (MDP) in 77 patients. The correlation of early-diastolic mitral annular velocity (e´) with τ was weak (r=-0.32, P<0.01), and that of peak longitudinal strain (LS) was the strongest (r=-0.45, P<0.001) among the STE-derived parameters. There was a modest correlation between LVMDP and the ratio of early-diastolic inflow velocity (E) to e´ (E/e´) (r=0.50, P<0.001). In contrast, the ratio of E to LS (E/LS) correlated strongly with LVMDP (r=0.70, P<0.001). The correlation of E/LS with LVMDP was significantly better than that for E/e´ (P<0.01). Receiver-operating characteristic analysis showed that E/LS had the largest area under the curve for distinguishing elevated LVMDP (E/LS 0.86, E/e´ 0.74, E/A 0.67). CONCLUSIONS: STE-derived longitudinal parameters correlated well with LV relaxation and filling pressure. In particular, E/LS could be more accurate than E/e´ for estimating LV filling pressure. (Circ J 2016; 80: 1163-1170).

Long-term echocardiographic evaluation of valvular lesions in a patient with nonbacterial thrombotic endocarditis associated with advanced uterine cancer.

Nonbacterial thrombotic endocarditis (NBTE) is characterized by the deposition of thrombi on previously undamaged heart valves in the absence of bacteremia and predominantly affects patients with hypercoagulable state. Although the diagnosis is usually based on transthoracic echocardiography, little is known about the serial changes of the vegetation in response to treatment. We experienced a 42-year-old woman with advanced uterine cancer and asymptomatic cerebral embolization. Plasma d-dimer level was markedly elevated and echocardiography showed highly mobile masses attached to the anterior and posterior mitral leaflets with moderate regurgitation. Based on these findings, she was diagnosed as having NBTE associated with uterine cancer and intravenous administration of heparin and chemotherapy were performed. Follow-up echocardiography revealed the disappearance of the vegetation and reduction of mitral regurgitation. Uterine cancer was successfully treated by surgery and recurrence of the valvular lesion did not occur. .

Myocardial shortening in 3 orthogonal directions and its transmural variation in patients with nonobstructive hypertrophic cardiomyopathy.

BACKGROUND: Although longitudinal strain (LS) is known to be reduced in patients with hypertrophic cardiomyopathy (HCM), it has not been elucidated whether or not circumferential strain (CS) is reduced. We aimed to determine whether multidirectional and layer-specific myocardial strain is reduced in patients with nonobstructive HCM. METHODS AND RESULTS: Speckle-tracking echocardiography was performed in 41 HCM patients and 27 control subjects. Segmental and global LS and CS were measured in the inner, mid, and outer layers. Global LS was significantly lower in the HCM group than in controls in the inner (-10.3±2.9 vs. -14.8±2.0%, P<0.001), mid (-8.7±2.6 vs. -13.8±1.9%, P<0.001), and outer (-7.2±2.6 vs. -11.9±1.9%, P<0.001) layers. Global CS was preserved in the inner layer (-23.8±4.7 vs. -24.3±3.3%, P=0.69) but reduced in the mid (-10.3±3.1 vs. -13.3±2.5%, P<0.001) and outer layers (-6.7±2.3 vs. -8.6±2.3%, P=0.002). Differences in CS between the inner and outer layers correlated with segmental relative wall thickness (r=-0.20, P=0.002). Furthermore, only the absolute value of global CS in the inner layer positively correlated with left ventricular ejection fraction (r=0.32, P<0.01) among these multidirectional and layer-specific strains. CONCLUSIONS: In patients with HCM, not only the LS in all layers but also CS in the mid and outer layers was reduced, presumably reflecting impaired myocardial function. In contrast, CS in the inner layer was preserved, being associated with maintenance of chamber function.