Association between an early revascularization strategy and major cardiac events based on left ventricular dyssynchrony in patients at intermediate risk of major cardiac events using the J-ACCESS risk model.

Objective This retrospective study aimed to investigate the association between therapeutic strategies and the development of major cardiac events (MCEs) in intermediate-risk patients by using the J-ACCESS risk model in combination with the stress phase bandwidth (SPBW), an index of left ventricular dyssynchrony. Methods Patients were followed-up for three years to confirm their prognosis. Based on the estimated propensity scores, the patients who underwent revascularization within the first 60 days after SPECT and those who did not were matched 1:1 (n = 367 per group). The composite endpoint was the occurrence of MCEs, consisting of cardiac death, non-fatal myocardial infarction, and severe heart failure. SPBW was calculated by a phase analysis using the Heart Risk View-F software program, and the MCE rate was compared between the two groups by applying the normal value of SPBW (38°). Patients The study included 2,053 patients with either known or suspected CAD who underwent electrocardiogram-gated single-photon emission computed tomography myocardial perfusion imaging and were at intermediate risk of MCE according to the J-ACCESS risk model. Results During follow-up, 54 of the 734 patients (7.4%) experienced MCEs. The overall incidence of MCE in intermediate-risk patients was not significantly different between the two groups. However, the incidence of MCE in patients with an abnormal SPBW was significantly lower in those who underwent early revascularization (4.8% vs. 11.9%, P = 0.0407). Conclusion The combination of the J-ACCESS risk model and the SPBW is thus considered to be an optimal treatment strategy for patients at intermediate risk of MCE, and early revascularization may lead to an improved prognosis in intermediate-risk patients with an abnormal SPBW.

Prognostic risk stratification based on left ventricular mechanical dyssynchrony in patients at low or intermediate risk of major cardiac events using the J-ACCESS risk model.

There have been no reports on prognostic prediction and risk stratification based on stress phase bandwidth (SPBW), or a left ventricular (LV) mechanical dyssynchrony index, in patients with known or suspected stable coronary artery disease (CAD) at low or intermediate risk of major cardiac events (MCEs) using the J-ACCESS risk model. We retrospectively investigated 4,996 consecutive patients with known or suspected CAD who underwent rest 201Tl and stress 99mTc-tetrofosmin electrocardiogram (ECG)-gated single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) and followed up for 3 years to confirm their prognosis. MCE risk over 3 years was estimated using an equation based on that used in the J-ACCESS study. The composite endpoint was the onset of MCEs consisting of cardiac death, non-fatal myocardial infarction (MI), and severe heart failure requiring hospitalization. SPBW was calculated by phase analysis with the Heart Risk View-F software and its normal upper limit was set to 38°. Based on the estimated 3-year incidence of MCEs obtained from the J-ACCESS risk model, 4,123 of the 4,996 consecutive patients were classified as low (n = 2,653) or intermediate risk (n = 1,470) and they were analyzed for follow-up. During the follow-up, 153 patients experienced MCEs: cardiac death (n = 38), non-fatal MI (n = 45), and severe heart failure (n = 70). The results of the multivariate analysis showed age, estimated glomerular filtration rate (eGFR), stress LV ejection fraction, and stress SPBW to be independent predictors of MCEs. The actual 3-year MCE rate in patients at intermediate risk was significantly higher than in those at low risk (6.7% vs. 2.1%, P < 0.0001). However, the actual 3-year MCE rate in patients with abnormal SPBW (> 38°) was 4.0% and 9.2% in low- and intermediate-risk patients, respectively, which corresponded to intermediate and high risk. Kaplan-Meier analysis also showed significant risk stratification by normal SPBW values for both low- and intermediate-risk patients. LV mechanical dyssynchrony assessed with ECG-gated SPECT MPI is useful for risk stratification of known or suspected stable CAD patients at low or intermediate risk of MCEs and may help identify higher risk patients who could not be identified as being at risk based on J-ACCESS risk assessment.

Prognostic value of the normalization of left ventricular mechanical dyssynchrony after revascularization in patients with coronary artery disease.

There are no reports indicating a prognostic difference based on normalization of left ventricular (LV) mechanical dyssynchrony after revascularization in patients with coronary artery disease (CAD). We retrospectively investigated 596 patients who underwent rest 201Tl and stress 99mTc-tetrofosmin electrocardiogram-gated single-photon emission computed tomography (SPECT) myocardial perfusion imaging. All patients had significant stenosis with ≥ 75% narrowing of the coronary arterial diameter detected by coronary angiography performed after confirmation of ≥ 5% ischemia by the SPECT. Patients underwent revascularization and thereafter were re-evaluated by the SPECT during a chronic phase, and followed-up to confirm their prognosis for ≥ 1 year. The composite endpoint was the onset of major cardiac events (MCEs) consisting of cardiac death, non-fatal myocardial infarction (MI), unstable angina pectoris (UAP), and severe heart failure requiring hospitalization. The stress phase bandwidth (SPBW) was calculated by phase analysis with the Heart Risk View-F software and its normal upper limit was set to 38°. During the follow-up, 64 patients experienced MCEs: Cardiac death (n = 11), non-fatal MI (n = 5), UAP (n = 26), and severe heart failure (n = 22). The results of the multivariate analysis showed the ∆summed difference score %, ∆stress LV ejection fraction, and stress SPBW after revascularization to be independent predictors of MCEs. Additionally, the results of the multivariate logistic regression analysis showed the summed rest score%, summed difference score%, stress LV ejection fraction, and perfusion defects in the left circumflex artery region before revascularization to be independent predictors for normalized SPBW after revascularization. The prognosis of patients who normalized SPBW after revascularization was similar to that of patients with a normal SPBW before revascularization, while patients who did not normalize after revascularization had the worst prognosis. In conclusion, normalization of LV dyssynchrony after revascularization assessed with nuclear cardiology may help predict future MCEs and thus a useful indicator for predicting improved prognosis in patients with CAD.

Prognostic Significance of Left Ventricular Dyssynchrony Assessed with Nuclear Cardiology for the Prediction of Major Cardiac Events after Revascularization.

Objective This retrospective study was aimed at determining whether or not stress phase bandwidth (SPBW), a left ventricular (LV) mechanical dyssynchrony index, predicts major cardiac events (MCEs) and stratifies the risk of those in patients with coronary artery disease (CAD) who undergo revascularization. Methods Patients were followed up to confirm the prognosis for at least one year. The SPBW was calculated by a phase analysis using the Heart Risk View-F software program. The composite endpoint was the onset of MCEs, consisting of cardiac death, non-fatal myocardial infarction, unstable angina pectoris, and severe heart failure requiring hospitalization. Patients The study subjects were 332 patients with CAD who underwent coronary angiography and revascularization after confirming ≥5% ischemia detected by rest 201Tl and stress 99mTc-tetrofosmin electrocardiogram-gated single-photon emission computed tomography myocardial perfusion imaging. Results During the follow-up, 35 patients experienced MCEs of cardiac death (n=5), non-fatal myocardial infarction (n=3), unstable angina pectoris (n=11), and severe heart failure requiring hospitalization (n=16). A receiver operating characteristics analysis indicated that the optimal cut-off value of the SPBW was 52° for predicting MCEs, and the MCE rate was significantly higher in the patients with an SPBW >52° than in those with an SPBW ≤52°. Results of the multivariate analysis showed the SPBW and estimated glomerular filtration rate to be independent predictors for MCEs. In addition, the cut-off value of the SPBW significantly stratified the risk of MCEs according to the results of the Kaplan-Meier analysis. Conclusion Evaluating the SPBW before revascularization may help predict future MCEs in patients with CAD who intended to undergo treatment.

Comprehensive assessment of left atrial and ventricular remodeling in paroxysmal atrial fibrillation by the cardiovascular magnetic resonance myocardial extracellular volume fraction and feature tracking strain.

Atrial fibrillation (AF) is a progressive disease that starts with structural or functional changes in the left atrium and left ventricle, and evolves from paroxysmal toward sustained forms. Early detection of structural or functional changes in the left atrium and left ventricle in the paroxysmal stage could be useful for identifying a higher risk of progression to persistent AF and future cardio-cerebrovascular events. The aim of this study was to test the hypothesis that the feature tracking (FT) left atrial (LA) strain and left ventricular (LV) extracellular volume fraction (ECV) derived from cardiovascular magnetic resonance (CMR) could detect early changes in remodeling of the left atrium and ventricle in the paroxysmal AF (PAF) stage. The participants were comprised of 106 PAF patients (age, 66.1 ± 10.7 years; 66% male) who underwent clinical CMR before pulmonary vein isolation and 20 control subjects (age, 68.3 ± 8.6 years; 55% male). The CMR-FT LA strain/phasic function and LV-ECV were compared between the PAF and control groups. The total and passive LA empty fraction (LAEF) and LA strain (corresponding to LA reservoir and conduit function) were decreased in the PAF group as compared to the control group. However, active LAEF (corresponding to the LA booster pump function) did not differ significantly between the PAF group (33.9 ± 10.9%) and control group (37.9 ± 13.3%, p = 0.15), while the active LA strain (corresponding to the LA booster pump function) was significantly decreased in the PAF group (11.4 ± 4.3 vs. 15.2 ± 5.6%, p = 0.002). The LV-ECV was significantly greater in the PAF group (28.7 ± 2.8%) than control group (26.6 ± 2.0%, p = 0.002). In the PAF group, the LV-ECV correlated significantly with the E/e' and LA volume index. Regarding the LA strain, correlations were seen between the LV-ECV and both the reservoir function and conduit function. CMR-FT LA strain in combination with the LV-ECV in a single clinical study offers a potential imaging marker that identifies LA/LV remodeling including subtle LA booster pump dysfunction undetectable by the conventional booster pump LAEF in the PAF stage.

Prognostic Value of Left Ventricular Dyssynchrony Assessed with Nuclear Cardiology in Patients with Known or Suspected Stable Coronary Artery Disease with Preserved Left Ventricular Ejection Fraction.

Left ventricular (LV) mechanical dyssynchrony assessed with phase analysis of electrocardiogram (ECG) -gated single photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) is useful for predicting major cardiac events (MCEs) in patients with cardiac dysfunction. However, there is no report on its usefulness in Japanese patients with known or suspected stable coronary artery disease (CAD) with preserved LV ejection fraction (LVEF).We retrospectively investigated 3,374 consecutive patients with known or suspected CAD who underwent rest 201Tl and stress 99mTc-tetrofosmin ECG-gated SPECT MPI and had preserved LVEF (≥ 45%), and followed them up to confirm their prognosis for three years. The composite endpoint was the onset of MCEs consisting of cardiac death, non-fatal myocardial infarction (MI), unstable angina pectoris, and severe heart failure requiring hospitalization. LV mechanical dyssynchrony was evaluated with phase analysis with the Heart Risk View-F software to obtain the phase bandwidth and standard deviation.During the follow-up, 179 patients experienced MCEs: cardiac death (n = 42); non-fatal MI (n = 34); unstable angina pectoris (n = 54); and severe heart failure (n = 49). Results of the multivariate analysis showed age, a history of MI, diabetes mellitus, summed stress score, and stress phase bandwidth to be independent predictors for MCEs. In Kaplan-Meier analysis, prognoses were significantly stratified with the tertiles of stress phase bandwidth.LV mechanical dyssynchrony assessed with ECG-gated SPECT MPI is useful for predicting a prognosis and stratifying the risk of MCEs in Japanese patients with known or suspected stable CAD with preserved LVEF.

Prognostic Significance of the Residual SYNTAX Score and Ischemic Reduction Detected with Nuclear Cardiology for Prediction of Major Cardiac Events after Revascularization.

Objective There is no report on the risk stratification of major cardiac events (MCEs) with a combination of the Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery (SYNTAX) score and ischemic reduction detected with rest 201Tl and stress 99mTc-tetrofosmin myocardial perfusion single-photon-emission computed tomography (SPECT) after revascularization in Japanese patients with coronary artery disease (CAD). Methods This was a retrospective study. The patients were followed up to confirm their prognosis for at least one year. Ischemia was evaluated based on the summed difference scores converted to the percentage of the total myocardium Safety Data Sheet (SDS%). The SYNTAX score and SDS% were calculated before and after revascularization. The endpoint was the occurrence of MCEs. Patients Study subjects were 293 patients who had a ≥75% stenotic lesion detected with coronary angiography following confirmation of ≥5% ischemia with SPECT, underwent revascularization, and thereafter received a re-evaluation with SPECT and coronary angiography. Results During the follow-up, 25 patients experienced MCEs of cardiac death (n=2), non-fatal myocardial infarction (n=3), and unstable angina pectoris (n=20). A receiver operating characteristic analysis indicated that the best cut-off values of the residual SYNTAX score and ΔSDS% were 12 and 5%, respectively, for the prediction of MCEs. The patients with a low residual SYNTAX score (<12) and high ΔSDS% (≥5%) had the best prognosis, while those with a high residual SYNTAX score (≥12) and low ΔSDS% (<5%) had the worst prognosis. Conclusion The combination of the residual SYNTAX score and ischemic reduction detected with nuclear cardiology is useful for predicting MCEs after revascularization.

Desmin-related myopathy characterized by non-compaction cardiomyopathy, cardiac conduction defect, and coronary artery dissection.

Desmin-related myopathy (DRM) is a rare heritable cardiac and skeletal muscle disease caused by mutations in the desmin gene (DES). DRM is generally characterized by skeletal muscle weakness, conduction disturbance, and dilated cardiomyopathy. However, the clinical cardiac phenotypes of DRM are not yet fully understood. Herein, we report the first case of DRM with the de novo missense DES mutation, R454W, that is characterized by left ventricular non-compaction cardiomyopathy, progressive cardiac conduction defect, spontaneous coronary artery dissection, and no skeletal muscle weakness. Our case findings suggest that clinicians should genetically test patients who have cardiomyopathy, progressive cardiac conduction defect, and coronary artery dissection, even if the patient has neither family history of DRM nor skeletal muscle symptoms.

Risk Stratification of Cardiovascular Events in Very Elderly Patients with Known or Suspected Coronary Artery Disease Who Had Normal Single-photon Emission Computed Tomographic Myocardial Perfusion Imaging Findings.

Objective We aimed to stratify the risk of major cardiovascular (MCV) events in Japanese patients with known or suspected coronary artery disease (CAD) who had normal single-photon emission computed tomographic myocardial perfusion imaging (SPECT MPI) findings and to compare the risk by generation. Methods This was a retrospective study. The composite endpoint was the occurrence of cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke. Patients The study subjects were 2,035 patients with normal SPECT MPI findings at baseline who had been followed up to confirm their prognosis for 3 years. The patients were categorized into 3 age groups: very elderly (≥80 years old, n=311), elderly (65-79 years old, n=1,097), and younger (<65 years old, n=542). Results During the follow-up, 68 patients experienced MCV events: cardiovascular death (n=29), non-fatal myocardial infarction (n=15), and non-fatal stroke (n=24). The MCV event rate was significantly higher in very elderly patients than in other patients. Multivariate predictors were age categories, the estimated glomerular filtration rate, atrial fibrillation, and stress left ventricular ejection fraction. The MCV event rate was 6.1% in very elderly patients. However, the MCV event rate in those with normal cardiac and renal functions without atrial fibrillation was 3.3%, which was similar to that in elderly and younger patients. Conclusion The MCV event rate was high in very elderly patients despite their normal SPECT MPI findings at baseline. Therefore, very elderly patients with multivariate risks should be carefully followed to avoid a poor prognosis.

Calcified Amorphous Tumor-Induced Acute Cerebral Infarction.

We report the case of a 38-year-old woman who was admitted for acute cerebral infarction linked to a cardiac calcified amorphous tumor (CAT) and related mitral annular calcification (MAC). The cardiac mass was removed, and mitral valve replacement surgery was performed. Pathological examination revealed an amorphous accumulation of degenerating material within both lesions, indicating that build-up of calcium along the mitral annulus and subsequent rupture of the fibrotic tissue may be involved in the initiation and progression of CAT.

Correlation between early revascularization and major cardiac events demonstrated by ischemic myocardium in Japanese patients with stable coronary artery disease.

BACKGROUND: There is no report on correlation between early revascularization and the occurrence of major cardiac events (MCEs) except severe heart failure in Japanese patients with stable coronary artery disease (CAD). This study aimed to determine whether early revascularization affected the incidence of MCEs in Japanese patients with stable CAD. METHODS: We retrospectively investigated 3581 stable CAD patients who underwent rest 201Tl and stress 99mTc-tetrofosmin myocardial perfusion single-photon emission computed tomography (SPECT) and provided three-year-prognostic data. The endpoint was the onset of MCEs consisting of cardiac death, non-fatal myocardial infarction, and unstable angina pectoris. On the basis of estimated propensity scores, patients who underwent revascularization within the first 60 days after the SPECT and those who did not were matched in a 1:1 ratio (n=450 per group). We compared MCE rates in relation to the amount of ischemic myocardium detected with the SPECT between the two groups. RESULTS: The overall incidence of MCEs was not significantly different between the early-revascularization and no-early-revascularization groups (6.7% vs. 8.7%, p=0.2598). Nevertheless, the incidence of MCEs in the patients with ≤5% ischemia was significantly higher in the early-revascularization group than in the no-early-revascularization group (5.8% vs. 0.8%, p=0.0226). In contrast, the incidence of MCEs in the patients with >10% ischemia was significantly lower in the early-revascularization group than in the no-early-revascularization group (7.0% vs. 16.8%, p=0.0036). The incidence of MCEs in the patients with 6-10% ischemia, however, was not significantly different between the early-revascularization and no-early-revascularization groups (6.9% vs. 4.1%, p=0.3235). CONCLUSIONS: Early revascularization possibly leads to the occurrence of MCEs related to the treatment procedure but may be a therapeutic strategy leading to improvement in prognosis in patients with moderate to severe ischemia.

Giant Thrombus Formation Immediately After Mitral Valvuloplasty.

Patients with atrial fibrillation (AF) are at risk of cardioembolism.(1,2)) Atrial thrombus formation associated with AF typically occurs in the left atrial appendage (LAA);(3)) therefore, transesophageal echocardiography (TEE) is important for detection of such a thrombus and measurement of LAA flow velocity.(4,5)) LAA closure is routinely performed during mitral valve surgery in patients with AF to prevent cardiogenic stroke.(6)) We report the case of a 65-year-old woman with severe mitral regurgitation (MR) and AF in whom a giant thrombus formed almost immediately after mitral and tricuspid valvuloplasty and concurrent LAA resection. No atrial thrombus or spontaneous echo contrast (SEC) was detected by TEE before the surgery. However, a giant intramural thrombus was detected in the left atrium 7 days after surgery. It was thought that the atrial dysfunction as well as the change in morphology of the left atrium resulting from the severe MR complicated by AF and congestive heart failure produced a thrombotic substrate. This case suggests that careful surveillance for thrombus formation and careful maintenance of anticoagulation therapy are needed throughout the perioperative period even if no SEC or thrombus is detected before surgery.