Chisato Izumi

Initial Surgical Versus Conservative Strategies in Patients With Asymptomatic Severe Aortic Stenosis.

BACKGROUND Current guidelines generally recommend watchful waiting until symptoms emerge for aortic valve replacement (AVR) in asymptomatic patients with severe aortic stenosis (AS). OBJECTIVES The study sought to compare the long-term outcomes of initial AVR versus conservative strategies following the diagnosis of asymptomatic severe AS. METHODS We used data from a large multicenter registry enrolling 3,815 consecutive patients with severe AS (peak aortic jet velocity >4.0 m/s, or mean aortic pressure gradient >40 mm Hg, or aortic valve area <1.0 cm(2)) between January 2003 and December 2011. Among 1,808 asymptomatic patients, the initial AVR and conservative strategies were chosen in 291 patients, and 1,517 patients, respectively. Median follow-up was 1,361 days with 90% follow-up rate at 2 years. The propensity score-matched cohort of 582 patients (n = 291 in each group) was developed as the main analysis set for the current report. RESULTS Baseline characteristics of the propensity score-matched cohort were largely comparable, except for the slightly younger age and the greater AS severity in the initial AVR group. In the conservative group, AVR was performed in 41% of patients during follow-up. The cumulative 5-year incidences of all-cause death and heart failure hospitalization were significantly lower in the initial AVR group than in the conservative group (15.4% vs. 26.4%, p = 0.009; 3.8% vs. 19.9%, p < 0.001, respectively). CONCLUSIONS The long-term outcome of asymptomatic patients with severe AS was dismal when managed conservatively in this real-world analysis and might be substantially improved by an initial AVR strategy. (Contemporary Outcomes After Surgery and Medical Treatment in Patients With Severe Aortic Stenosis Registry; UMIN000012140).

Normal values and clinical relevance of left atrial myocardial function analysed by speckle-tracking echocardiography: multicentre study

AIMS The aim of this multicentre study was to determine the normal range and the clinical relevance of the myocardial function of the left atrium (LA) analysed by 2D speckle-tracking echocardiography (2DSTE). METHODS AND RESULTS We analysed 329 healthy adult subjects prospectively included in 10 centres and a validation group of 377 patients with left ventricular diastolic dysfunction (LVDD). LA myocardial function was analysed by LA strain rate peak during LA contraction (LA-SRa) and LA strain peak during LA relaxation (LA-Strain). The range of values of LA myocardial function in healthy subjects was LA-SRa -2.11 ± 0.61 s(-1) and LA-Strain 45.5 ± 11.4%, and the lowest expected values of these LA analyses (calculated as -1.96 SD from the mean of healthy subjects) were LA-SRa -0.91 s(-1) and LA-Strain 23.1%. Concerning the clinical relevance of these LA myocardial analyses, LA-SRa and LA-Strain detected subtle LA dysfunction in patients with LVDD, even though LA volumetric measurements were normal. In addition, in these patients we found that the functional class (dyspnoea-NYHA classification) was inversely related to both LA-Strain and LA-SRa. CONCLUSION In the present multicentre study analysing a large cohort of healthy subjects and patients with LVDD, the normal range and the clinical relevance of the myocardial function of the LA using 2DSTE have been determined.

Guidelines from the Japanese Society of Echocardiography: Guidance for the management and maintenance of echocardiography equipment

Echocardiography plays a pivotal role as an imaging modality in modern cardiology practice. Information derived from echocardiography is definitely helpful for patient care. The Japanese Society of Echocardiography has promoted echocardiography in routine clinical and research use. One of the missions of the Society is to provide information that is useful for high-quality examinations. To ensure this, we believe that equipment in good condition and a comfortable environment are important for both patient and examiner. Here, the Guideline Preparation Committee of the Japanese Society of Echocardiography has established brief guidance for the routine use of echocardiography equipment.

Multidirectional Global Left Ventricular Systolic Function in Normal Subjects and Patients with Hypertension: Multicenter Evaluation

BACKGROUND The aim of this multicenter study was to determine the normal ranges and the clinical relevance of multidirectional systolic parameters to evaluate global left ventricular (LV) systolic function. METHODS Three hundred twenty-three healthy adult subjects prospectively included at 10 centers and a cohort of 310 patients with hypertension were analyzed. Multidirectional global LV systolic function was analyzed using two-dimensional speckle-tracking echocardiography by means of two indices: longitudinal-circumferential systolic index (the average of longitudinal and circumferential global systolic strain) and global systolic index (the average of longitudinal, circumferential, and radial global systolic strain). RESULTS The ranges of values of the multidirectional systolic parameters in healthy subjects were -21.22 ± 2.22% for longitudinal-circumferential systolic index and 29.71 ± 5.28% for global systolic index. In addition, the lowest expected values of these multidirectional indices were determined in this population (calculated as -1.96 SDs from the mean): -16.86% for longitudinal-circumferential systolic index and 19.36% for global systolic index. Concerning the clinical relevance of these measurements, these indices indicated the presence of subtle LV global systolic dysfunction in patients with hypertension, even though LV global longitudinal systolic strain and LV ejection fraction were normal. Moreover, in these patients, functional class (dyspnea [New York Heart Association classification]) was inversely related to both the longitudinal-circumferential index and the global systolic index. CONCLUSIONS In the present multicenter study analyzing a large cohort of healthy subjects and patients with hypertension, the normal range and the clinical relevance of multidirectional systolic parameters to evaluate global LV systolic function have been determined.

Unexpectedly High Prevalence of Acquired von Willebrand Syndrome in Patients with Severe Aortic Stenosis as Evaluated with a Novel Large Multimer Index

AIM Severe gastrointestinal bleeding sometimes occurs in patients with aortic stenosis (AS), known as Heydes syndrome. This syndrome is thought to be caused by acquired von Willebrand syndrome and is characterized by reduced large von Willebrand factor (vWF) multimers. However, the relationship between the severity of AS and loss of large vWF multimers is unclear. METHODS We examined 31 consecutive patients with severe AS. Quantitative evaluation for loss of large vWF multimers was performed using the conventional large vWF ratio and novel large vWF multimer index. This novel index was defined as the ratio of large multimers of patients to those of controls. RESULTS Loss of large vWF multimers, defined as the large vWF multimer index ＜80%, was detected in 21 patients (67.7%). The large vWF multimer ratio and the large vWF multimer index were inversely correlated with the peak aortic gradient (R = -0.58, p=0.0007, and R=-0.64, p＜0.0001, respectively). Anemia defined as hemoglobin ＜9.0 g/dl was observed in 12 patients (38.7%), who were regarded as Heydes syndrome. Aortic valve replacement was performed in 7 of these patients, resulting in the improvement of anemia in all patients from a hemoglobin concentration of 7.5±1.0 g/dl preoperatively to 12.4±1.3 g/dl postoperatively (p＜0.0001). CONCLUSIONS Acquired von Willebrand syndrome may be a differential diagnosis in patients with AS with anemia. The prevalence of AS-associated acquired von Willebrand syndrome is higher than anticipated.

Relation of risk factors with response to carvedilol in heart failure with preserved ejection fraction – A report from the Japanese Diastolic Heart Failure Study (J-DHF)

BACKGROUND The Japanese Diastolic Heart Failure Study (J-DHF) has suggested beneficial effects of the standard-dose prescription of carvedilol in heart failure with preserved ejection fraction (HFPEF). However, it is unclear whether any risk factors modulate the effects of the standard-dose carvedilol. METHODS AND RESULTS Data from 245 patients with HFPEF in J-DHF were evaluated. Decreased body mass index, diabetes mellitus, and left atrial (LA) dilatation were independent risk factors for both of the primary outcomes (cardiovascular death and unplanned hospitalization for heart failure) and another major composite outcome (cardiovascular death and unplanned hospitalization for any cardiovascular causes) in multivariable analysis. In patients with LA diameter≥the median value (43.2mm), standard-dose carvedilol was associated with unadjusted hazard ratio (HR) 0.263 [95% confidence interval (CI): 0.080-0.859] and covariate adjusted 0.264 (0.080-0.876) for the primary outcome. In those with LA diameter<43.2mm, unadjusted and adjusted HRs were 1.123 (0.501-2.514) and 1.067 (0.472-2.412). A p-value for interaction was 0.046 (unadjusted) and 0.058 (adjusted). The similar effects of LA diameter were observed regarding another major composite outcome. The other risk factors in univariate or multivariable analyses did not influence the response to the standard-dose carvedilol. CONCLUSIONS The standard-dose carvedilol may exert greater reduction of the incidence of clinical outcomes in the patients with HFPEF and advanced rather than mild diastolic dysfunction.

Increased thrombin–antithrombin III complex during an episode of paroxysmal atrial fibrillation

Thrombin-antithrombin III complex (TAT) is a marker of thrombin generation, indicating increased coagulability. To investigate whether paroxysmal atrial fibrillation (PAf) is associated with an increased coagulation system, we measured TAT within 24 h after the documentation of PAf in 50 patients with structurally normal hearts. The mean age of the study population was 62 years old. In 32 patients, PAf was documented during routine physical examinations, electrocardiograms or echocardiograms and in the remaining 18 patients, it was reproducibly documented on more than two Holter electrocardiograms. Group I consisted of 38 TAT data sets from 38 patients who did not receive anticoagulant therapy during PAf episodes. At least one week after starting anticoagulant therapy, TAT was measured again in ten patients in whom there was evidence of PAf on the day of measurement. In the remaining 12 patients, PAf occurred while the patients were receiving anticoagulation. Group II consisted of 22 TAT data sets from 22 patients who received anticoagulation during PAf episodes. The average TAT value was 5.8 ng/ml in group I, while it was 2.8 ng/ml in group II (P<0.0001). TAT was greater than 5 ng/ml in 15 of the 38 patients in group I, and in four of the 22 patients in group II. In 20 symptomatic patients, we measured TAT again when the patients maintained sinus rhythm under the same anticoagulant therapy; four patients were receiving and 16 patients were not receiving anticoagulation therapy. TAT decreased from 6.4 to 2.3 ng/ml on average when PAf disappeared and sinus rhythm was maintained (P=0.0009). Increase in the coagulation system occurred transiently during or shortly after PAf episodes in about 40% of PAf patients. As patients with prior anticoagulation had a relatively low TAT value, anticoagulant therapy might be useful in patients with PAf.

Rapid growth of a left atrial myxoma. Serial two-dimensional echocardiographic observation over eighteen months.

We encountered a patient with rapid progressing left atrial myxoma in whom two-dimensional echocardiography was serially obtained over eighteen months. The horizontal and longitudinal diameters showed a linear 2.5 fold increase, while the size of the base attached to the left atrial wall remained unchanged. Therefore, the last echocardiogram obtained just before surgery showed the characteristic pendular motion of left atrial myxoma.

Predictors of Rapid Progression and Clinical Outcome of Asymptomatic Severe Aortic Stenosis.

BACKGROUND The optimal timing of aortic valve replacement (AVR) is controversial in patients with asymptomatic severe aortic stenosis (AS) except when very severe. Prediction of progression of severe AS is helpful in deciding on the timing of AVR. The purpose of this study was to clarify the predictors of progression rate and clinical outcomes of severe AS. METHODSANDRESULTS We retrospectively investigated 140 consecutive patients with asymptomatic severe AS (aortic valve area [AVA], 0.75-1.0 cm(2)). First-year progression rate and annual progression rate of AVA and of aortic jet velocity (AV-Vel) were calculated. Cardiac events were examined and the predictors of rapid progression and cardiac events were analyzed. The median follow-up period was 36 months. The median annual progression rate was -0.05 cm(2)/year for AVA and 0.22 m/s/year for AV-Vel. Dyslipidemia, moderate-severe calcification, and first-year AV-Vel progression ≥0.22 m/s/year were independent predictors of cardiac events. Cardiac event-free rate was lower in patients with AV-Vel first-year progression rate ≥0.22 m/s/year than in those with a lower rate. Diabetes and moderate-severe calcification were related to first-year rapid progression. CONCLUSIONS The annual progression rate of severe AS was -0.05 cm(2)/year for AVA and 0.22 m/s/year for AV-Vel. Patients with first-year rapid progression or severely calcified aortic valve should be carefully observed while considering an early operation. (Circ J 2016; 80: 1863-1869).

Five-Year Clinical Outcome of Asymptomatic vs. Symptomatic Severe Aortic Stenosis After Aortic Valve Replacement

BACKGROUND There is discordance regarding the effect of symptom status before aortic valve replacement (AVR) on long-term outcome after AVR in severe aortic stenosis (AS).Methods and Results:The CURRENT AS registry is a multicenter retrospective registry enrolling 3,815 consecutive patients with severe AS. Among 1,196 patients managed with the initial AVR strategy, long-term clinical outcomes were compared between the symptomatic patients (n=905), and asymptomatic patients (n=291). Median follow-up interval was 1337 days with a 91% follow-up rate at 2 years. AVR was performed in 886 patients (98%) in the symptomatic group and in 287 patients (99%) in the asymptomatic group. Symptomatic patients were older and more often had comorbidities than asymptomatic patients with similar echocardiographic AS severity. The cumulative 5-year incidences of all-cause death and heart failure (HF) hospitalization were significantly higher in symptomatic patients than in asymptomatic patients (25.6% vs. 15.4%, P=0.001, and 14.2% vs. 3.8%, P<0.001, respectively). On landmark analysis at 30 days after AVR, the differences in mortality and HF hospitalization between the 2 groups were mainly observed beyond 30 days. CONCLUSIONS When managed with the initial AVR strategy, the long-term outcomes of symptomatic severe AS were worse than those of asymptomatic severe AS. Early AVR strategy might be recommended in some selected asymptomatic severe AS patients with reasonable operative risk.