Common carotid artery kinking is a predictor of cardiovascular events: A long-term follow-up study using carotid ultrasonography.

BACKGROUND: Kinking of the internal carotid artery is a cardiovascular (CV) risk factor. However, it remains unclear as to whether kinking of the common carotid artery (CCA) can also predict CV events. We conducted a long-term follow-up study to examine whether CCA kinking as assessed by carotid ultrasonography is a predictor of CV events in asymptomatic patients with CV risk factors. METHODS: We enrolled 598 patients (mean age, 66.8 ± 11.8 years) who were divided into two groups according to CCA kinking severity: kinking of 0-29° (Group I); and kinking at ≥30° (Group II). We assessed whether CCA kinking predicts CV events during follow-up. RESULTS: A total of 91 CV events were observed during the follow-up period (median, 124 months). Hypertension (P < .0001), prior CV events (P < .0001), CCA kinking (P < .0001), intima-media thickness (P < .0001), and max plaque score (P < .0001) were significantly higher in patients with CV events than those without. The age-adjusted hazard ratio of CCA kinking for CV events was 3.42 (95% CI: 2.2-5.3) in Group II compared to Group I. Cox proportional hazard regression analysis revealed that CCA kinking (HR: 3.02, 95% CI: 1.97-4.67), prior CV events (HR: 2.53 95% CI: 1.604.00), hypertension (HR: 2.19 95% CI: 1.17-4.57), and age (HR: 1.04, 95% CI: 1.02-1.07) were independent predictors of CV events. CONCLUSION: CCA kinking is a powerful independent predictor of CV events in asymptomatic patients with CV risk factors.

Influence of Power-Weighted Center of Echo Signal Within Window Function on Local Strain Rate Distribution in Left Ventricular Wall.

OBJECTIVE: The deviation of the power-weighted center of the echo signal from the geometric center within the velocity estimation window for calculating strain rate (SR) causes an estimation error. This study aimed to confirm whether an erroneous multilayer pattern in the SR distribution of the left ventricular wall could be corrected by considering the power-weighted center of the echo signal. METHODS: The SR distributions were measured locally in the transmural direction around the pre-ejection and early diastolic phases in healthy volunteers. The estimation error related to the power-weighted center of the echo signal was corrected using a previously proposed method, and the effectiveness of the correction was confirmed based on the accuracy of the estimated myocardial displacement. RESULTS: The SR distribution in early diastole was observed as multilayers of low- and high-amplitude negative SRs. However, this multilayer pattern disappeared after correction. In the pre-ejection phase, multilayers of positive and negative SRs were observed in the SR distributions with and without correction. This correction was sufficiently effective in accurately tracking the local peak of the echo signal. CONCLUSION: The multilayer pattern of low- and high-amplitude positive or negative SRs is caused by estimation errors related to the power-weighted center of the echo signal. The multilayer pattern of positive and negative SRs might not be caused by these errors and might relate to the actual change in myocardial thickness because the estimation errors do not convert the negative (positive) SR to positive (negative) in a homogeneous negative (positive) SR distribution.

Normal values of real-time 3-dimensional echocardiographic parameters in a healthy Japanese population: the JAMP-3D Study.

BACKGROUND: The recently developed real-time 3-dimensional echocardiography (RT3DE) is a promising imaging method to quantify cardiac chamber volumes and their functions in clinical practice. However, normal reference values of RT3DE parameters have not been fully investigated in a large, healthy Japanese population. METHODS AND RESULTS: This study consisted of 410 healthy subjects aged from 20 to 69 years who had a RT3DE at one of the 23 collaborating institutions. All subjects had no history of cardiac disease and no risk factors. The mean values in men and women were as follows: 50 ± 12 ml/m(2) and 46 ± 9 ml/m(2) for left ventricular (LV) end-diastolic volume index, 19 ± 5 ml/m(2) and 17 ± 4 ml/m(2) for end-systolic volume index, 61 ± 4% and 63 ± 4% for ejection fraction, 64 ± 1 2 g/m(2) and 56 ± 11 g/m(2) for mass index, 23 ± 6 ml/m(2) and 24 ± 6 ml/m(2) for left atrial (LA) maximum volume index, 10 ± 3 ml/m(2) and 10 ± 3 ml/m(2) for minimum volume index, and 58 ± 6% and 58 ± 6% for percent volume change. LV sizes decreased with age, whereas LV mass index did not change. LA sizes slightly increased with age. CONCLUSIONS: This multicenter investigation determined normal reference values for LV and LA sizes, and their functional parameters on RT3DE in a large, healthy Japanese population. The results of the present study support the use of RT3DE for the diagnosis and management of cardiovascular disease.

The pacemaker lead dislocation.

An 88-year-old man with history of pacemaker implantation was admitted for septic shock. His first pacemaker in the left subclavian had been removed because of generator pocket infection. On presentation, the abandoned lead was fallen out of subclavian and coiled up in the right ventricle, causing moderate tricuspid regurgitation.

A normal pattern of mitral inflow predicts a better prognosis following cardiovascular events in early advanced-age patients.

Although a mitral inflow pattern usually changes from a normal pattern to an abnormal relaxation pattern as part of the aging process in healthy people, some early advanced-age individuals maintain a normal pattern. We investigated whether a normal pattern of mitral inflow predicts a better prognosis following cardiovascular (CV) events in early advanced-age patients. We enrolled 425 patients aged 60-65 years with 0.6 < E/A < 1.5. Patients were divided according to their mitral inflow pattern, i.e., a normal pattern group (E/A ≥ 1.0, n = 77) and an abnormal relaxation pattern group (E/A < 1, n = 348), and were evaluated the relationship with CV events. Multivariate regression analysis found that the normal inflow pattern was associated with odds ratios of 0.859 for body mass index (BMI; 95% confidence interval [CI]: 0.778-0.937), 0.529 for hypertension (0.303-0.924), and 0.325 for heart rate (0.228-0.463). During the follow-up period (4.9 ± 1.8 years), the adjusted-hazard ratio was significantly lower in the normal pattern group (HR: 0.119, 95% CI 0.016-0.910). Kaplan-Meier curves showed a higher event-free rate for the normal pattern group than for the abnormal relaxation pattern group (p = 0.0292). Normal inflow pattern in early advanced-age patients predicts a better prognosis following CV events.

Ratio of the false lumen to the true lumen is associated with long-term prognosis after surgical repair of acute type A aortic dissection.

Objectives: The aim of this study was to assess potential predictors of aortic events after an emergency surgery for acute type A aortic dissection, especially paying attention to the findings of computed tomography (CT) performed immediately after the surgery. Methods: Between January 2001 and December 2015, 72 patients, who were diagnosed as having Stanford type A acute aortic dissection with a patent false lumen in the descending thoracic aorta, survived the emergency operation, and had postoperative CT scan data, were included in this study (mean follow-up, 8.2 ± 3.8 years; range 0.8-17.4 years). From the CT scan data, the diameter of the false lumen (FL-D) and true lumen (TL-D) were measured, and the FL-D:TL-D ratio was calculated. Long-term outcomes of the FL-D > TL-D group (n = 30) and the FL-D < TL-D group (n = 42) were compared. Results: In the late follow-up, 17 aortic events in the downstream aorta were observed. The FL-D:TL-D ratio (P = .01) was an adjusted risk of aortic events in multivariable analysis. The rates of freedom from aortic events at 5 and 9 years were superior in the FL-D < TL-D group than in the FL-D > TL-D group (92.0% and 88.6% vs 81% and 60.7%; log rank P < .05). Conclusions: Our results suggest that the false lumen:true lumen ratio predicts long-term prognosis after surgical repair of acute type A aortic dissection.

Trends and Regional Differences in the Prevalence of Dyslipidemia before and after the Great East Japan Earthquake: A Population-Based 10-Year Study Using the National Database in Japan.

Since the Great East Japan Earthquake in March 2011, an increase in lifestyle-related diseases due to changes in living environment following the nuclear power plant accident has been reported in Fukushima Prefecture, especially among evacuees. However, no long-term studies covering the entire Fukushima Prefecture have been conducted. The study aim was to investigate the effects of post-disaster evacuation life on the prevalence of dyslipidemia in Fukushima Prefecture using a national database. The data from 3,866,674 people who underwent specific health checkups between fiscal year (FY) 2008 and FY2017 were analyzed. Fukushima Prefecture was divided into four areas, and the prevalence of dyslipidemia and related parameters were compared. The prevalence of dyslipidemia increased overall, with a particularly sharp increase after FY2011 in the evacuation area. The sex- and age-adjusted odds ratio (95% confidence intervals) of having dyslipidemia in the evacuation area compared with that in the control area was 0.951 (0.929-0.973) in FY2008-2010, which increased to 1.130 (1.105-1.155) in FY2012-2014 and 1.117 (1.092-1.143) in FY2015-2017. Since the prevalence of dyslipidemia has increased and remained high after the earthquake in Fukushima Prefecture, especially in the evacuation area, continued measures to prevent cardiovascular diseases among the residents are needed.

Permanent Pacemaker Implantation in a Patient with Takotsubo Cardiomyopathy and Complete Atrioventricular Block.

This case report presents a patient with Takotsubo cardiomyopathy (TCM) and complete atrioventricular (AV) block who was treated with permanent pacemaker implantation. A 78-year-old woman with a history of hypertension presented with a 6-month history of palpitations. On initial evaluation, her heart rate was 40 beats/minute. Electrocardiography revealed a complete AV block and T-wave inversion in these leads: I, II, aVL, aVF, and V3-6. Echocardiography showed akinesis from the midventricle to the apex and hyperkinesis on the basal segments. The patient was diagnosed with TCM and complete AV block. Because improvement of TCM may subsequently improve the AV node dysfunction associated with TCM, the patient was admitted for treatment of heart failure without pacemaker implantation. The left ventricular (LV) abnormal wall motion improved gradually; however, the AV block persisted intermittently. On hospital day 14, a pause of 5-6 seconds without LV contraction was observed, and permanent pacemaker implantation was performed. On day 92, echocardiography revealed normal LV wall motion. However, electrocardiography revealed that the pacemaker rhythm with atrial sensing and ventricular pacing remained. Although specific degree of damage that may result from AV block associated with TCM is unknown, some of these patients require pacemaker implantation, despite improvement of abnormality in LV wall motion.

Reflected wave intensity increases based on aortic diameter after endovascular aortic therapy in a goat model.

Reflected wave increases after endovascular aortic repair (EVAR) in patients with aortic aneurysm. This affects the left ventricular (LV) diastolic function and leads to a poor prognosis. This study aimed to evaluate the relationship between increased reflected wave amplitude and aortic diameter after EVAR. EVAR was performed in seven healthy goats. We assessed wave intensity (WI), aortic diameter, and stiffness parameter ß. Moreover, we evaluated the relationship between negative reflected wave (NW, reflected waves toward the heart from the periphery by WI) and other parameters after EVAR. Results showed an increase in stiffness parameter ß (3.5 ± 0.3 vs 15.9 ± 4.7, p = 0.018) and a decrease in the change of aortic diameter (6.9 ± 0.7 vs 2.7 ± 0.4%, p = 0.018) after EVAR. The NW was significantly amplified after EVAR from baseline (-589.8 ± 143.4 to - 1192.3 ± 303.7 mmHg-m/sec3, p = 0.043). The NW showed a significant correlation with maximum aortic diameter (R = 0.707, p = 0.038) and minimum aortic diameter (R = 0.724, p = 0.033). The reflected wave was enhanced after EVAR and was correlated to the aortic diameter at the stent-graft site. It is important to consider that patients with smaller aortic diameters in landing zone who undergo EVAR may develop LV dysfunction.

Long-term results of modified bentall procedures: 18-year experience of the flanged technique.

OBJECTIVES: To evaluate the early and late outcomes of the modified Bentall procedure with the flanged technique. METHODS: We reviewed the medical records of 63 patients who had undergone root replacement by the modified Bentall procedure at our institute between January 2001 and December 2018. In most cases, we adopted a composite graft constructed with a mechanical valve or bioprosthesis and a Dacron graft by the flanged technique. Since 2011, we have used Valsalva grafts. RESULTS: Mean age 57 ± 16 years, range 16-80, male 43 cases. The mean follow-up was 75 ± 56 months (range 0-216). Through April 1, 2020, we could follow up on 61 cases (97%) within a six-month period. Hospital mortality was 7.9% (4.8% in elective cases). In late follow-up, eight deaths were observed. In the bio-Bentall group (n=26), no deaths or major adverse valve-related events (MARVEs) occurred. In the mechanical Bentall group (n=37), seven cases of MARVEs, including two cerebral hemorrhages and one cerebral embolism, were observed. All patients were free from MARVEs at 5 years post procedure in the bio-Bentall group, and 93.8% and 76.8% were event-free at 5 years and 10 years, respectively, in the mechanical Bentall group. CONCLUSIONS: The 18-year results of the modified Bentall procedure were acceptable, providing excellent outcomes in the bio-Bentall group. The flanged technique enabled the use of a larger prosthesis, which may have resulted in good durability with the bio-Bentall procedure.

Blood concentration of tacrolimus and age predict tacrolimus-induced left ventricular dysfunction after bone marrow transplantation in adults.

PURPOSE: Tacrolimus (TAC) is used for the prophylaxis and treatment of acute graft-versus-host disease after bone marrow transplantation (BMT). However, few have reported on TAC-induced left ventricular hypertrophy. This study aimed to assess the relationship between blood concentration of TAC and development of TAC-induced left ventricular (TI-LV) dysfunction in adult BMT patients with hematologic malignant diseases, and to evaluate whether TAC concentration can predict TI-LV dysfunction occurrence in these patients. METHODS: We enrolled 16 consecutive patients (mean age 44.6 ± 13.0 years) who received TAC after BMT. Echocardiography was performed before and after BMT, and blood concentrations of TAC were evaluated in terms of AUC15 (area sum of TAC > 15 ng/ml during follow-up). We assessed the relationship between AUC15 and development of TI-LV dysfunction after TAC. RESULTS: During the follow-up period (mean duration 47.6 ± 13.7 days), interventricular septum thickness (IVST, P = 0.001) and posterior wall thickness (PWT, P < 0.001) increased, and E' decreased (P = 0.006). AUC15 was associated with post-IVST (R = 0.627, P = 0.009), post-PWT (R = 0.669, P = 0.005), and post-E' (R = - 0.767, P = 0.001). In multivariate analysis, AUC15 and age independently predicted the increase in IVST and PWT and decrease in E' after BMT. The combination of AUC15 and older age predicted post-PWT with a sensitivity of 77.8% and specificity of 71.4%. CONCLUSION: TAC concentrations should be maintained at < 15 ng/ml and age should be considered in patients undergoing BMT to avoid TI-LV dysfunction.

The results of an entry-oriented strategy for acute type A aortic dissection in octogenarians: an 18-year experience.

OBJECTIVES: The aim of this study was to evaluate the 18-year results of emergency operations for acute type A aortic dissection, especially in octogenarians. METHODS: We reviewed 199 patients who underwent surgical aortic repair of an acute type A aortic dissection from January 2001 to December 2018. If the primary entry existed in the ascending aorta, we limited the extent of the replacement to within the ascending aorta. We analysed the early and late outcomes and identified the predictive factors for in-hospital death and difficulty of direct discharge to home. RESULTS: The hospital mortality was 16%. The causes of death were postoperative bleeding (n = 8, 4%), intestinal ischaemia (n = 6, 3%), respiratory failure (n = 5, 3%), systemic inflammatory response syndrome (n = 4, 2%), low output syndrome (n = 3, 2%), sudden death (n = 3, 2%), myonephrotic metabolic syndrome (n = 2, 1%) and stroke (n = 1, 1%). Multivariable analysis revealed that an estimated glomerular filtration rate <30 (P = 0.006), malperfusion (P = 0.001), rupture (P < 0.001) and cross-clamping time (P = 0.003) were independent predictive factors of in-hospital death. Age was not a significant factor for predicting in-hospital death. Ascending aorta replacement (P = 0.013), advanced age (P = 0.002) and prolonged extracorporeal circulation time (P = 0.009) were independent predictive factors of difficulty in direct discharge to home. In the late follow-up period, the 5-year survival and aortic event-free rates were 62.2% and 88.9% in octogenarians, respectively. CONCLUSIONS: From the perspective of saving lives, the results of emergency surgery for octogenarians were acceptable. Avoiding the postoperative decline in activities of daily living in octogenarians is a consideration going forward.

Participation of mast cells in angiogenesis in the border zone of myocardial infarction in rats.

BACKGROUND: We hypothesized that mast cells may participate in coronary angiogenesis in acute myocardial infarction, contributing to myocardial salvage. METHODS: The left coronary artery was occluded in control (n = 30) and Ws rats (n = 30), which genetically lacked c-kit, resulting in a mast cell deficiency. Four weeks later, the infarct area, i.e., infarct core and surrounding infarct areas, and the non-infarct area were assessed histopathologically. The mast cell and small vessel densities were assessed using toluidine blue and alkaline phosphatase staining. Myocardial perfusion was assessed by myocardial contrast echocardiography (MCE). RESULTS: In Ws rats, the percentage infarct core area increased (p < 0.05) compared with the controls, whereas the percentage surrounding infarct area decreased (p < 0.01). Mast cell density increased most in the surrounding infarct area (p < 0.01) in control rats, whereas mast cells were absent in Ws rats. Compared with the controls, coronary microvessel density decreased in the surrounding infarct area in Ws rats (p < 0.01). MCE showed that the percentage infarct core area, i.e., perfusion defect, increased (p < 0.05) and the percentage surrounding infarct area, i.e., reduced perfusion area, decreased (p < 0.01) in Ws rats. CONCLUSION: Mast cells may participate in promoting coronary angiogenesis in the infarct area surrounding the infarct core, contributing to attenuation of left ventricular dysfunction.

Acute and chronic effects of mokuboito in a patient with heart failure due to severe aortic regurgitation.

Medical treatment for heart failure is still limited in patients with symptomatic aortic regurgitation (AR). Here we report the effects of mokuboito used in combination with standard medical therapy for heart failure in an inoperable patient with symptomatic severe AR. We observed acute effects of mokuboito in decreasing systemic vascular resistance and increasing cardiac output, as well as its chronic effects in improving New York Heart Association class, plasma brain natriuretic peptide levels, and left ventricular diastolic function. Given its efficacy, the use of mokuboito might be an additional treatment for patients with heart failure.

Late Gadolinium Enhancement Predicts Improvement in Global Longitudinal Strain after Aortic Valve Replacement in Aortic Stenosis.

Myocardial fibrosis, as detected by late gadolinium enhancement (LGE) magnetic resonance imaging (MRI), is related to mortality after aortic valve replacement (AVR). This study aimed to determine whether LGEMRI predicts improvement in global longitudinal strain (GLS) after AVR in patients with severe aortic stenosis (AS). Twenty-nine patients with severe AS who were scheduled to undergo AVR were enrolled. Two-dimensional echocardiography and contrast-enhanced MRI were performed before AVR. GLS and LGEcore (g: > 5 SD of normal area), LGEgray (g: 2-5 SD), and LGEcore+gray (g) were measured. One year after AVR, GLS were examined by echocardiography to assess improvement in LV function. Preoperatively, GLS correlated with LGEcore (g) (r2 = 0.14, p < 0.05), LGEgray (g) (r2 = 0.32, p < 0.01) and LGEcore+gray (g) (r2 = 0.36, p < 0.01). LGEcore was significantly lower in patients with improved GLS after AVR (GLS1year ≥ -19.9%) compared to those with no improvement (1.34 g vs. 4.70 g, p < 0.01). LGE predicts improvement in LV systolic function after AVR.

Assessment of deformation of the mitral valve complex during off-pump coronary artery bypass surgery using three-dimensional echocardiography in a porcine model.

BACKGROUND: This study aimed to assess the deformation of the mitral valve complex during the displacement of the beating heart by using three-dimensional echocardiography in a porcine off-pump coronary artery bypass grafting (OPCAB) model. METHODS: In nine healthy swine, we positioned the beating heart as an OPCAB model, i.e. control, left anterior descending artery (LAD), right coronary artery (RCA), and left circumflex artery (LCX) positions. In each position, three-dimensional echocardiography was performed to assess the mitral valve complex with hemodynamic parameters. We analyzed the deformation of the mitral valve and the three-dimensional coordinates of the papillary muscles. RESULTS: There was a significant increase in maximum tenting length and tenting volume (control 0.70±0.30, LAD 0.65±0.27, RCA 0.79±0.23, LCX 0.95±0.34cm3, p<0.05) in the LCX position compared with the other positions. The posterior papillary muscle (PPM) angle had a significant relationship with the tenting volume (r=-0.643, p<0.001). The PPM was displaced to the medial side in the LAD and LCX positions (p<0.01). CONCLUSIONS: The prime cause of the deformation of the mitral leaflets is suggested to be the displacement of the PPM associated with the change in geometry of the left ventricle in a porcine model.

A case of left ventricular aneurysm caused by localized myocardial infarction.

A 73-year-old man was hospitalized for unstable angina pectoris with no history of myocardial infarction. After undergoing percutaneous coronary intervention, left ventriculography incidentally revealed a cavity in the anterior wall, and echocardiography found the cavity wall to be dyskinetic. Myocardial contrast echocardiography revealed that the wall of the cavity was surrounded by myocardial tissue with low perfusion. Furthermore, radial strain in the wall of the cavity was low. Myocardial scintigraphy showed a localized defect on the anterior wall. The patient was finally diagnosed as true aneurysm after asymptomatic and localized myocardial infarction, and has since been followed up by echocardiography in the outpatient clinic.