Relationship between duration of atrial fibrillation and right heart structure remodeling as assessed by 3-dimensional transesophageal echocardiography.

BACKGROUND: Tricuspid valve (TV) remodeling occurs in patients with atrial fibrillation (AF); however, the affecting factor related to TV remodeling in AF remains to be elucidated. We sought to explore whether the AF persistence itself affects right heart remodeling. METHODS: A total of 372 lone AF patients (234 paroxysmal AF [paroxAF] and 138 persistent AF [persAF]) who underwent 3-dimensional transesophageal echocardiography (3D-TEE) was retrospectively reviewed. The duration from first-detected episode of AF to the TEE exam date was defined as AF duration. RESULTS: PersAF patients had a larger TV area index (625.4 vs 719.0 mm2/m2; P < 0.001) and a higher right atrium area-to-right ventricle end-systolic area ratio (RA/RVESA ratio, 1.7 vs 1.9; P = 0.005) than paroxAF patients. The prevalence of AF-tricuspid regurgitation was higher in persAF than in paroxAF patients (1.3% vs 12.3%; P < 0.001). In persAF patients, AF duration was moderately correlated with TV diameter and 3D-TEE-derived TV annular area but not in paroxAF. On multivariable analysis, AF duration was independently associated with TV annular dilatation even after adjustment for RA/RVESA ratio and tricuspid regurgitation severity (ß 0.37 [95% CI: 0.77-1.81]; P < 0.001). Additionally, AF duration with cutoff values of 20 months for predicting TV annular dilatation and 37 months for predicting RA/RVESA ratio > 2.1 had both high diagnostic accuracies among persAF patients (both P < 0.01). CONCLUSIONS: AF duration itself is independently associated with right heart remodeling in persAF but not in paroxAF, such as TV annular dilatation and predominant RA remodeling which may lead to subsequent TR progression and adverse outcomes.

Left Atrial Stiffness Index as a Predictor of Effort Intolerance and Hemodynamics Evaluated by Invasive Exercise Stress Testing in Degenerative Mitral Regurgitation.

In patients with degenerative mitral regurgitation (DMR), peak oxygen consumption is the significant prognostic factor, and exercise intolerance has been considered a trigger for surgical intervention. The significant mitral regurgitation (MR) induces left atrial (LA) remodeling, but the significance of LA stiffness calculated by the ratio of E/e' to LA reservoir strain in degenerative MR has not been elucidated. A total of 30 patients with asymptomatic or minimally symptomatic grade ≥III + DMR underwent the cardiopulmonary exercising test simultaneously with invasive hemodynamic assessment. LA stiffness index significantly correlated with exercise hemodynamic deterioration, including pulmonary arterial wedge pressure (r = 0.71, p <0.01), systolic pulmonary arterial pressure at peak exercise (r = 0.73, p <0.01), and pulmonary circulatory reserve (mean pulmonary arterial pressure/cardiac output slope, r = 0.45, p = 0.012). Multiple linear regression analysis revealed that the higher LA stiffness index was significantly associated with decreased percent predicted peak oxygen consumption (per 0.1 increase, ß -4.0, 95% confidence interval -6.9 to -1.3, p <0.01) independently of MR deterioration during exercise. In conclusion, increased LA stiffness was associated with exercise intolerance through hemodynamic deterioration during exercise in patients with asymptomatic or minimally symptomatic severe DMR.

First Report of Electromagnetic Interference Between Percutaneous Ventricular Assist Device and Implantable Cardioverter-Defibrillator.

Electromagnetic interference (EMI) between implantable left ventricular assist devices and cardiac implantable electronic devices has been observed. We demonstrated the first case of EMI between a percutaneous ventricular assist device and an implantable cardioverter-defibrillator, validated by an extra vivo simulation test. EMI might depend on the distance between devices. (Level of Difficulty: Advanced.).

Significant Correlates of Nocturnal Hypertension in Patients With Hypertension Who Are Treated With Antihypertensive Drugs.

BACKGROUND: Nocturnal hypertension assessed by a home blood pressure monitoring (HBPM) device is associated with an increased risk of cardiovascular events. However, it is still difficult to assess nighttime blood pressure (BP) frequently. The purpose of this cross-sectional study was to identify significant correlates of nocturnal hypertension assessed by an HBPM device in patients with hypertension who are treated with antihypertensive drugs. METHODS: We measured nighttime BP, morning BP, and evening BP by an HBPM device for 7 consecutive days in 365 medicated patients with hypertension. RESULTS: Of the 365 subjects, 138 (37.8%) had nocturnal hypertension defined as a mean nighttime systolic BP of ≥ 120 mm Hg. Receiver operating characteristic curve analyses showed that the diagnostic accuracy of morning systolic BP for subjects with nocturnal hypertension was significantly superior to that of evening systolic BP (P = 0.04) and that of office systolic BP (P < 0.001). Multivariate analysis revealed that morning systolic BP of 125-<135 mm Hg (odds ratio [OR], 2.26; 95% confidence interval [CI], 1.13-4.58; P = 0.02), morning systolic BP of ≥ 135 mm Hg (OR, 16.4; 95% CI, 8.20-32.7; P < 0.001), and a history of cerebrovascular disease (OR, 3.99; 95% CI, 1.75-9.13; P = 0.001) were significantly associated with a higher risk of nocturnal hypertension and that bedtime dosing of antihypertensive drugs was significantly associated with a lower risk of nocturnal hypertension (OR, 0.56; 95% CI, 0.32-0.97; P = 0.04). CONCLUSIONS: Morning systolic BP of ≥ 125 mm Hg, a history of cerebrovascular disease, and bedtime dosing were significant correlates of nocturnal hypertension in medicated patients with hypertension, and may help detect this risky BP condition. CLINICAL TRIALS REGISTRATION: University Hospital Medical Information Network Clinical Trials Registry (UMIN000019173).

Role of anatomical regurgitant orifice area and right ventricular contractile reserve in severe tricuspid regurgitation.

AIMS: We sought to propose a novel risk stratification system for severe tricuspid regurgitation (TR) using 3D-anatomical regurgitant orifice area (3D-AROA) and the slope of tricuspid annular plane systolic excursion vs. systolic pulmonary artery pressure (TAPSE/SPAP) and to validate its prognostic significance. METHODS AND RESULTS: Sixty-four patients with severe functional TR (52% torrential) underwent 3D echocardiography and exercise-stress echocardiography. As an estimate of regurgitation severity, 3D-AROA was measured with the customized software package. As an index of right ventricular (RV) contractile reserve, the TAPSE/SPAP slope was calculated by plotting the relationship between TAPSE and SPAP during exercise test. Haemodynamic parameters were obtained by right heart catheterization (RHC). Based on receiver operating characteristics curves, optimal cut-off values of 3D-AROA and TAPSE/SPAP slope to identify all-cause mortality were 161 mm2 and 0.046 mm/mmHg, respectively. During a median follow-up of 559 days, 20 patients (31%) died. After correcting for potential confounders, 3DAROA≥ 161 mm2 (HR 4.37; 95% CI 1.34-14.07; P = 0.015) and TAPSE/SPAP slope≤0.046 mm/mmHg (HR 4.76; 95% CI 1.46-15.53; P = 0.009) were echocardiographic parameters independently associated with all-cause mortality. The cumulative survival rate was lower in patients with 3D-AROA≥161 mm2 and TAPSE/SPAP slope≤0.046 mm/mmHg compared with their counterparts (both P<0.05). RHC confirmed higher right atrial pressure (P<0.001) and lower cardiac index (P = 0.004) in patients with both 3D-AROA≥161 mm2 and TAPSE/SPAP slope ≤0.046 mm/mmHg. CONCLUSION: Large AROA and reduced RV contractile reserve during exercise are independently associated with poor prognosis. The new grading scheme of severe TR was validated by haemodynamics and may improve risk stratification.

Impact of the distribution of epicardial and visceral adipose tissue on left ventricular diastolic function.

Although epicardial adipose tissue (EAT) and abdominal visceral adipose tissue (VAT) can contribute to left ventricular diastolic dysfunction (LVDD), the impact of these distribution has not been fully understood. A total of 235 patients who underwent cardiac computed tomography angiography and Doppler echocardiography was included in this study. We evaluated the association of indexed EAT volume and VAT area with septal and lateral early diastolic mitral annular velocity (e'). The VAT area index was significantly associated with septal and lateral e' velocity after adjusted for conventional cardiovascular risk factors and obstructive coronary artery disease (ß-estimate; - 0.015 and - 0.019, both p = 0.01). The natural logarithmic EAT volume index (ln EAT volume index) also showed a significant association with septal and lateral e' (ß-estimate; - 1.72 and - 0.99, both p < 0.01). The significant association of ln EAT volume index with septal and lateral e' was observed even after adjusting for VAT area index (ß-estimate; - 0.79 and - 1.52, both p < 0.03). In the subgroup analysis, there were significant association of ln EAT volume index with both septal and lateral e' in the lower VAT group (ß-estimate; - 1.40 and - 1.53, both p < 0.03) and with lateral e' in the higher VAT group (ß-estimate - 1.64, p = 0.006). In contrast, ln EAT volume index was not associated with septal e' in the higher VAT group (p = 0.98). EAT accumulation was significantly associated with LVDD independently of obstructive coronary artery disease and abdominal VAT. The impact of EAT on LVDD may vary depending on the amount of abdominal VAT.

Factors Influencing Cardiac Sympathetic Nervous Function in Patients With Severe Aortic Stenosis: Assessment by 123I-Metaiodobenzylguanidine Myocardial Scintigraphy.

BACKGROUND: Numerous studies have shown that 123I-metaiodobenzylguanidine (MIBG) scintigraphy, an index of cardiac sympathetic nervous (CSN) activity, is useful for predicting prognosis in patients with heart failure. However, the factors influencing the CSN activity of patients with severe aortic stenosis (AS) remain unclear. METHODS: We enrolled 91 patients with severe AS who underwent 123I-MIBG scintigraphy, coronary computed tomography (CCT), and transthoracic echocardiography. When CCT angiography (CCTA) showed an obstructive epicardial artery, invasive coronary angiography was performed within 1 week of CCTA. RESULTS: There were 21 male and 70 female patients with a mean age of 84±5 years. Eighty-five (85) patients (93%) had hypertension and 13 patients (14%) had diabetes. Two (2) patients (2%) had previous myocardial infarction and eight (9%) had a previous coronary intervention. All patients had severe AS: aortic valve area was 0.63±0.18 cm2 and the mean pressure gradient was 56±19 mmHg. Regarding 123I-MIBG parameters, early heart-to-mediastinum (H/M) ratio was 3.1±0.5, delayed H/M ratio was 2.8±0.6, and the washout rate (WR) was 35%±13%. Multivariable linear regression analysis showed that coronary artery disease (ß=-0.30, p=0.002) was an independent predictor of delayed H/M ratio, and that aortic valve area (ß=-0.20, p=0.048) was an independent predictor of WR. CONCLUSIONS: Our findings suggest that coronary artery disease is an independent predictor of delayed H/M ratio, and aortic valve area is an independent predictor of WR in patients with severe AS.

Prevalence, distribution, and determinants of pulmonary venous systolic flow reversal in severe mitral regurgitation.

AIMS: This study aimed to evaluate the prevalence and distribution of pulmonary venous systolic flow reversal (PVSFR) in patients with severe mitral regurgitation (MR), and to examine the relationship between PVSFR profile and cardiac parameters. METHODS AND RESULTS: A total of 125 patients with severe MR who had transoesophageal echocardiography (TOE) performed were reviewed. Of these, 121 (96.8%) patients showed all four pulmonary venous (PV) flows by TOE. They were categorized into three groups by the MR aetiology: degenerative MR (DMR) (n = 72), ventricular functional MR (V-FMR) (n = 20), and atrial functional MR (A-FMR) (n = 16). Eighteen (16.7%) patients had PVSFR in all four PVs. Twenty-nine (26.9%) had PVSFR in three PVs, 23 (21.3%) in two PVs, and 23 (21.3%) in one PV. PVSFR appeared at right PVs more frequently compared with left PVs. A high number of PVSFR was significantly correlated with higher pulmonary capillary wedge pressure (PCWP) and 3D vena contracta area (3D-VCA). With regard to MR aetiology, the number of PVSFRs was correlated with high 3D-VCA in patients with DMR and A-FMR, while it was correlated with high PCWP in patients with V-FMR. Laminar-type PVSFR appeared more frequently in FMR compared with DMR, and it had a relationship with higher PCWP and lower right ventricular fractional area change (RVFAC). CONCLUSION: All four PV were detected in 96.8%, and 16.8% patients had PVSFR in all four PVs. PCWP and 3D-VCA were correlated with the number of PVSFRs in severe MR patients. Laminar-type PVSFR was related to higher PCWP and lower RVFAC.

Determinants of Exercise-Induced Mitral Regurgitation Using Three-Dimensional Transesophageal Echocardiography Combined With Isometric Handgrip Exercise.

Using three-dimensional (3D) transesophageal echocardiography (TEE) and isometric handgrip exercise (IHE), we investigated the determinants of exercise-induced mitral regurgitation (MR) according to MR etiologies. Seventy-six patients with more than moderate MR, 40 patients with functional MR (FMR) and 36 patients with degenerative MR (DMR), underwent 3D TEE combined with IHE. Mitral valve (MV) geometry and 3D vena contracta area (3D VCA) were simultaneously evaluated at baseline and during IHE. With regard to exercise-induced MR, Δ3D VCA was calculated as the difference between 3D VCA at baseline and 3D VCA during IHE. IHE caused different changes in MV geometry between etiologies and led to exacerbation of 3D VCA at baseline. Larger Δ3D VCA was observed in the FMR group compared with the DMR group (15.9 ± 10.3 mm2 versus 7.3 ± 4.2 mm2; p < 0.0001). In multivariate analyses, tenting height and 3D VCA were selected as independent factors associated with Δ3D VCA in the FMR group (p = 0.0135 and p = 0.0201, respectively), while flail width was selected as an independent factor associated with Δ3D VCA in the DMR group (p = 0.0066). In conclusion, IHE alters mitral valve geometry and causes exacerbation of MR regardless of MR etiology and the determinants of exercise-induced MR differed between MR etiologies.

Higher visit-to-visit blood pressure variability and N-terminal pro-brain natriuretic peptide elevation: influence of left ventricular hypertrophy and left ventricular diastolic function.

OBJECTIVE: The issue of whether visit-to-visit blood pressure variability (VVV) is associated with higher levels of N-terminal pro-brain natriuretic peptide (NT-proBNP) has been controversial, and the underlying mechanism is not well understood. We hypothesized that (1) VVV is associated with the NT-proBNP level, and (2) this association is mediated by left ventricular (LV) hypertrophy and LV diastolic dysfunction. PATIENTS AND METHODS: A total of 72 hypertensive patients were examined. Clinic blood pressure was measured at each visit for 12 months (1×/month or every 2 months), and echocardiography was performed during this period. VVV is expressed as the SD, coefficient of variation (CV), and delta (Δ; the difference between the maximum and the minimum) in SBP and in DBP. We investigated the association between VVV and NT-proBNP and whether the LV mass index (LVMI) and the mitral early diastolic inflow velocity (E) to mitral annular early-diastolic peak velocity (e') ratio (E/e') influence this association. RESULTS: The loge NT-proBNP values were significantly correlated with the CV of SBP (r = 0.42), ΔSBP (r = 0.41), the CV of DBP (r = 0.32), and ΔDBP (r = 0.28). The CV and Δ in SBP or those in DBP were not significantly correlated with LVMI or E/e'. A multiple linear regression analysis revealed that higher CV of SBP and ΔSBP were significantly associated with loge NT-proBNP. CONCLUSION: Higher VVV was significantly associated with higher NT-proBNP independently of LV hypertrophy and diastolic function.

Disease Control Status and Safety of Telemedicine in Patients With Lifestyle Diseases　- A Multicenter Prospective Observational Study in Japan.

Background: The Japanese Ministry of Health, Labour and Welfare has tried to promote telemedicine since 2018, but faces difficulties in increasing the use of telemedicine partly due to a lack of clinical evidence. This study investigated the disease control status and safety of telemedicine, which, in Japan, is provided under the National Health Insurance system, for the treatment of lifestyle diseases under the present legal restraints. Methods and Results: This multicenter prospective observational study started in April 2018 and enrolled 34 patients with lifestyle diseases, including hypertension, dyslipidemia, and diabetes. Primary and secondary outcome measures included control status, serial changes in clinical indices, and the safety of telemedicine 6 months after implementation. Control status was assessed by the attending physician, and differences in blood pressure (BP), low density lipoprotein cholesterol (LDL-C), or HbA1c levels were evaluated. Of the 34 patients, 29 were successfully introduced to telemedicine and followed-up for 6 months. Median patient age was 77 years, 14 (48.3%) were men, 24 (82.8%) had hypertension, 17 (58.6%) had dyslipidemia, and 9 (31.0%) had diabetes. At the 6-month follow-up, no patients had experienced exacerbation of underlying diseases, with no significant changes in BP, LDL-C, or HbA1c. Moreover, no telemedicine-associated adverse events were observed. Conclusions: Telemedicine can be a safe and feasible option for managing lifestyle diseases under the present legal restraints.

H2FPEF Score for the Prediction of Exercise Intolerance and Abnormal Hemodynamics in Japanese　- Evaluation by Exercise Stress Echocardiography Combined With Cardiopulmonary Exercise Testing.

BACKGROUND: Both the H2FPEF-score and nomogram-score, which consist of simple clinical parameters, can assist in diagnosing "early" heart failure with preserved ejection fraction (HFpEF) and only exertional dyspnea, but their these usefulness in Japanese remains unclear. We sought to investigate the correlation between these scores and exercise response, including the peak oxygen uptake (V̇O2), the pulmonary artery systolic pressure (PASP), the ratio of early diastolic transmitral flow velocity to early diastolic mitral annular velocity (E/e') and stroke volume (SV) using exercise stress echocardiography (ESE) combined with cardiopulmonary exercise testing (CPET).Methods and Results:In this single-center, retrospective cross-sectional study the H2FPEF-score and nomogram-score were calculated in a total of 139 patients who underwent ESE combined with CPET. The scores correlated with peak V̇O2(r=-0.48, r=-0.44), PASP (r=0.23, r=0.29) and SV (r=-0.32, r=-0.19) at peak exercise. The nomogram-score correlated with E/e' (r=0.24). The prevalence of exercise intolerance (percent predicted peak V̇O2<75% and <50%) increased as the H2FPEF-score increased and reached 88.9% and 22.2% among the patients with high H2FPEF-score (6-9 points). CONCLUSIONS: The H2FPEF-score may be useful as the initial step to diagnosing 'early' HFpEF. The nomogram-score may be more useful in Japanese because of its more universal association with exercise response than the H2FPEF-score.

Comprehensive Evaluation of Tricuspid Regurgitation Location and Severity Using Vena Contracta Analysis: A Color Doppler Three-Dimensional Transesophageal Echocardiographic Study.

BACKGROUND: The clinical significance of three-dimensional (3D) vena contracta area (VCA) in tricuspid regurgitation (TR) is not fully elucidated. The aim of this study was to investigate the diagnostic accuracy of 3D VCA using 3D echocardiography-derived regurgitation volume as a reference standard. METHODS: One hundred sixteen patients with at least moderate TR underwent two-dimensional transthoracic and color Doppler 3D transesophageal echocardiography. The 3D vena contracta, which was located at the narrowest neck of the TR jet just above and toward the right atrial side of the flow convergence zone, was assessed for TR location and severity. RESULTS: As for TR location, patients with severe functional TR had the highest prevalence of central jet location among TR subgroups, whereas patients with severe primary TR showed a greater spatial extent of TR jet location involved compared with the moderate TR group (P < .05 for both). As for TR severity, a 3D VCA cutoff value of 0.61 cm2 discriminated severe TR with sensitivity of 78% and specificity of 97% in the total patient population (area under the curve = 0.93, P < .001). Multivariate analysis revealed that 3D VCA, a dilated right ventricle, and hepatic vein systolic reversal were independently associated with regurgitant volume (P < .001 for all). The χ2 value for the model that incorporated clinical and two-dimensional integrative parameters and 3D VCA > 0.61 cm2 to evaluate severe TR was significantly higher than that for the model that incorporated only clinical and two-dimensional integrative parameters (P = .001). CONCLUSIONS: Three-dimensional VCA has independent and incremental diagnostic value for evaluating severe TR. Comprehensive evaluation of TR location and severity using 3D vena contracta analysis may help in treatment selection for TR.

Visit-to-visit Blood Pressure Variability and Arterial Stiffness: Which Came First: The Chicken or the Egg?

Earlier studies have shown that visit-to-visit blood pressure (BP) variability (VVV) served as a significant independent risk factor of stroke, specifically, in the high-risk elderly of cardiovascular disease (CVD). Although the mechanism is not clearly understood, arterial remodeling such as carotid artery, coronary artery and large aortic artery would be a strong moderator in the relationship between VVV and CVD incidence. Recent studies have provided evidence that VVV predicted the progression of arterial stiffness. While the class of antihypertensive agents is suggested to be an important determinant of VVV, long-acting calcium channel blockers use (CCBs) is associated with the reduction of VVV, and thus, is suggested to decrease the arterial stiffness. Specifically, the relationship between VVV and coronary arterial remodeling has never been reviewed until now. This article summarizes the recent literature on these topics. In the elderly hypertensives, strict BP control using CCBs could play a pivotal role in suppressing arterial stiffening via VVV reduction.

Factors Associated with Gastric Black Spot, White Flat Elevated Mucosa, and Cobblestone-Like Mucosa: A Cross-Sectional Study.

BACKGROUND/AIMS: Previous studies have reported a possible relevance between proton pump inhibitor (PPI) use and 3 new gastric mucosal changes: black spots (BSs), white flat elevated mucosa (WFEM), and cobblestone-like mucosa (CLM). The aim of this study was to investigate the association between these mucosal changes and multiple factors including PPI use. METHODS: All subjects who underwent a routine esophagogastroduodenoscopy (EGD) were successively enrolled. Endoscopists carried out the EGD after being blinded about -information on patient PPI usage and determined the presence of these mucosal changes. The ratio of each factor was -compared in cases with and without each gastric finding. RESULTS: Out of 1,214 patients, BSs were recognized in 75 (6.2%) cases, WFEM in 59 (4.9%), and CLM in 41 (3.4%). In logistic regression analysis, PPI use was significantly correlated with all of these findings (BSs: OR 2.94; 95% CI 1.66-5.21), (WFEM: OR 3.58; 95% CI 1.94-6.61), and (CLM: OR 4.57; 95% CI 2.34-9.96), and Helicobacter pylori eradication was related to BSs (OR 3.01; 95% CI 1.73-5.24) and WFEM (OR 2.11; 95% CI 1.08-4.11). Decision-tree analyses showed that H. pylori eradication was associated with all findings. CONCLUSIONS: All of the considered findings were correlated with PPI and H. pylori eradication.

Proton Pump Inhibitor Induction of Gastric Cobblestone-like Lesions in the Stomach.

Objective The long-term use of proton pump inhibitors (PPIs) may induce adverse events in many organs, including the stomach. The chronic use of PPIs has been associated with the growth of fundic gland polyps (FGPs) and of gastric black spots. This study assessed the incidence of gastric lesions with cobblestone-like appearance in PPI users. Methods The clinical characteristics and endoscopic findings of patients who underwent upper gastrointestinal endoscopy after using PPIs for at least six months were analyzed. The biopsy specimens from patients with gastric cobblestone-like lesions (GCLLs) were examined histopathologically. Patients This study analyzed 171 patients who underwent upper gastrointestinal endoscopy after more than 6 months of PPI use in Mitsugi Public General Hospital from January 1, 2015, to March 31, 2016. Results Of the 171 patients, 60 (35.1%) had GCLLs and 111 (64.9%) did not. There were no significant between-group differences in age, sex, duration of PPI use, and receipt of Helicobacter pylori eradication therapy. Atrophic gastritis of the corpus was significantly less frequent in the GCLL than in the non-GCLL group (55.0% vs. 47.8%, p=0.0097). Among the GCLL group, histological examinations of 24 patients revealed cystic dilation of the fundic gland in 19 (79.2%), parietal cell hyperplasia in 18 (75.0%), and cytoplasmic vacuolation in 7 (29.2%). Conclusion GCLLs occurred frequently in long-term PPI users, especially in patients without atrophic gastritis. The pathological findings of GCLLs included parietal cell hyperplasia and fundic gland cysts. The clinical importance of these new lesions remains uncertain, but they should be observed carefully.