Eiichi Hyodo

Usefulness of a combination of systolic function by left ventricular ejection fraction and diastolic function by E/E' to predict prognosis in patients with heart failure.

Left ventricular (LV) ejection fraction (EF) was known as a conventional predictor of heart failure (HF). However, early transmitral flow velocity (E)/early diastolic velocity of mitral annulus (E) correlated well with LV end-diastolic pressure, and E/E ratio >15 was an excellent predictor of adverse outcomes in patients with HF. This study was designed to determine the prognostic value of a new combined index, E/E ratio and LVEF, in patients with HF. One hundred twenty-six consecutive patients hospitalized with HF underwent comprehensive echocardiographic-Doppler study when ready for discharge. Patients were divided into the 4 groups of group I (LVEF >40% and E/E ratio <15), group II (EF >40% and E/E ratio >or=15), group III (EF <or=40% and E/E ratio <15), and group IV (EF <or=40% and E/E ratio >or=15). The ability of this index to determine the primary end point (rehospitalization for HF or cardiac death) was assessed. Patients with significant valvular disease were excluded. Of 126 patients, 110 met the inclusion criteria. Follow-up was complete for 108 of 110 patients at 351 +/- 252 days after discharge. There were 27, 30, 21, and 30 patients in groups I, II, III, and IV, respectively. There were 52 patients with the primary end point. On univariate analysis, E/E ratio, group IV, E, and age were significant predictors. In multivariable analysis, the most powerful independent prognostic indicator of events was group IV (hazard ratio 12.6, 95% confidence interval 2.2 to 74.2, p = 0.005). In conclusion, a new index, a combination of LVEF and E/E ratio, allowed the identification of patients at higher risk of readmission and cardiac death in patients with HF.

Prognostic Value of Aortic Valve Area Index in Asymptomatic Patients With Severe Aortic Stenosis

Recently, an aortic valve area (AVA) index (AVAI) <0.6 cm(2)/m(2) was proposed as an indicator of severe aortic stenosis. The purpose of the present study was to clarify the prognostic value of the AVAI. We identified 103 consecutive asymptomatic patients (mean age 72 ± 11 years) with severe aortic stenosis, defined by an AVA of <1.0 cm(2), who had not undergone aortic valve replacement on initial evaluation. During follow-up (median 36 ± 27 months), 31 aortic valve replacements and 20 cardiac deaths occurred. Multivariate analysis revealed that an AVAI <0.6 cm(2)/m(2) (hazard ratio 2.6, 95% confidence interval 1.1 to 6.3; p = 0.03) and peak aortic jet velocity (Vp) >4.0 m/s (hazard ratio 2.6, 95% confidence interval 1.2 to 5.8; p = 0.02) were associated with cardiac events but that an AVA <0.75 cm(2) was not. The event-free survival of patients with an AVAI of ≥0.6 cm(2)/m(2) was better than that for those with an AVAI <0.6 cm(2)/m(2) (86% vs 41% at 3 years, p <0.01). Furthermore, patients with an AVAI of ≥0.6 cm(2)/m(2) and Vp of ≤4.0 m/s showed an excellent prognosis, but those without these findings had poorer outcomes. In conclusion, AVAI is a powerful predictor of adverse events in asymptomatic patients with severe aortic stenosis. Furthermore, the combination of AVAI and Vp provides additional prognostic information. Watchful observations are required for timely aortic valve replacement in patients with an AVAI of <0.6 cm(2)/m(2) or a Vp >4.0 m/s.

Detection of restenosis after percutaneous coronary intervention in three major coronary arteries by transthoracic Doppler echocardiography.

BACKGROUNDnThe aim of this study was to evaluate the diagnostic potential of coronary flow velocity reserve (CFR) measurement by transthoracic Doppler echocardiography (TTDE) to detect restenosis in the 3 major coronary arteries: the left anterior descending coronary artery, right coronary artery, and left circumflex coronary artery.nnnMETHODSnThe lesions of 175 patients who were scheduled for follow-up coronary angiography and TTDE 6 months after undergoing stents implantation were studied. CFR was assessed by TTDE in the targeted arteries into which stents had been implanted.nnnRESULTSnCoronary stents were implanted in a total of 238 angiographic lesions in 175 patients. Doppler recordings of coronary flow in the 3 major arterial lesions were obtained in 211 of the 238 angiographic lesions (89% feasibility). CFR was significantly lower in lesions with restenosis than those without restenosis (1.70 +/- 0.32 vs 2.65 +/- 0.66, P < .01). A CFR value < 2.0 was 89% sensitive and 91% specific for detecting restenosis in the 3 major coronary arteries. Sensitivity and specificity were 86% and 91%, respectively, in the left anterior descending coronary artery (95% feasibility); 92% and 92%, respectively, in the right coronary artery (85% feasibility); and 91% and 92%, respectively, in the left circumflex coronary artery (81% feasibility).nnnCONCLUSIONnCFR assessment by TTDE is an accurate method for monitoring restenosis, not only in the left anterior descending but also in the right and left circumflex coronary arteries in patients previously subjected to percutaneous coronary intervention.

Parathyroid hormone and systolic blood pressure accelerate the progression of aortic valve stenosis in chronic hemodialysis patients

BACKGROUNDnAortic valve stenosis (AS) is a frequent complication contributing to poor prognosis in chronic hemodialysis (CHD) patients. However, little is known regarding the risk factors affecting AS progression. The purpose of this study was to define risk factors affecting AS progression in CHD patients.nnnMETHODSnWe retrospectively investigated 34 consecutive CHD patients with asymptomatic AS (mild in 9, moderate in 20, severe in 5; aortic valve area (AVA), 1.31±0.31cm(2); mean age, 69±8years) who underwent followed-up paired transthoracic echocardiography with period of at least six months apart (22±9months). AS progression was evaluated using the absolute reduction in AVA per year.nnnRESULTSnCHD patients were divided into 20 patients with rapid progression (AVA reduction, >0.1cm(2) per year) and 14 with slow progression (AVA reduction, ≤ 0.1cm(2) per year). Serum parathyroid hormone (PTH) level was significantly higher in patients with rapid progression than in those with slow progression [343±489pg/ml vs. 76±80pg/ml, P<0.05]. In univariate analysis, AS progression by absolute AVA reduction per year was associated with age, PTH level, initial AVA, systolic blood pressure (SBP), diastolic blood pressure, total cholesterol, and left ventricular diameter at end-diastole and end-systole. Multiple regression analysis indicated that serum PTH level and SBP remained independently associated with AS progression.nnnCONCLUSIONSnAS progression was accelerated in the presence of high PTH and SBP. Careful monitoring and intensive treatment of these parameters may have a beneficial effect on secondary prevention in CHD patients.

Quantitative Intravenous Myocardial Contrast Echocardiography Predicts Recovery of Left Ventricular Function After Revascularization in Chronic Coronary Artery Disease

Background: Quantitative intravenous myocardial contrast echocardiography (MCE) has been shown to measure regional myocardial blood flow velocity noninvasively.

Simultaneous assessment of endothelial function and morphology in the brachial artery using a new semiautomatic ultrasound system

The accuracy of measurements of the intima–media thickness (IMT) and flow-mediated dilatation (FMD) of the brachial artery made using a new semiautomated ultrasound system and the relationships among those parameters and the Framingham Risk Score (FRS) as a predictor of coronary heart disease (CHD) are unknown. We enrolled 70 subjects, including 47 patients with cardiovascular risk factors and 23 normal healthy volunteers. IMT and FMD were simultaneously measured using a new semiautomated ultrasound system, and the measurements were compared with those obtained manually as a reference standard (study 1). In addition, we enrolled 200 consecutive patients with risk factors but no CHD to examine the relationships among IMT, FMD and the FRS. The optimal cutoff values of FMD and IMT were determined in 200 patients without CHD, and the subjects were classified into four groups. The 10-year Framingham risks for each group were compared (study 2). FMD and IMT measurements made using the new semiautomated ultrasound system showed a good correlation with the measurements determined manually (study 1). Furthermore, FMD and IMT showed a significant correlation with the FRS. The 10-year Framingham risk was markedly higher in group D (FMD <5.5% and IMT >0.3u2009mm; 19.0±11.3%; study 2). In conclusion, the measurements made using a new semiautomated ultrasound system provided reliable and simultaneous evaluations of IMT and FMD. The combination of IMT and FMD measurements of the brachial artery may be beneficial for risk stratification of patients with cardiovascular risk factors but no CHD.

The utility of fully automated real-time three-dimensional echocardiography in the evaluation of left ventricular diastolic function

BACKGROUNDnA novel real-time three-dimensional echocardiography (RT3DE) system allows fully automated quantification of the left ventricular (LV) volume throughout a cardiac cycle. This study aimed to investigate whether an LV time-volume curve, obtained using fully automated RT3DE, is useful in the evaluation of LV diastolic function.nnnMETHODSnFirst, 15 patients underwent simultaneous standard two-dimensional echocardiography (2DE), RT3DE, and cardiac catheterization to measure the time constant of the isovolumic-pressure decline (τ). From the LV time-volume curve obtained using RT3DE, peak early filling rate (PFR) during diastole was generated and indexed for LV end-systolic volume. Next 570 patients, who were scheduled for both 2DE and RT3DE examinations, were enrolled to investigate the association between PFR index and 2DE-evidenced diastolic dysfunction and clinical characteristics.nnnRESULTSnOf the 585 patients, RT3DE analysis was adequate in 542 patients (feasibility 93%). In the 15 patients, PFR index showed significant correlation with τ (r=-0.65, p=0.009). In the remaining 527 patients, PFR index was related to age (r=-0.24, p<0.001) and e (r=0.41, p<0.001). PFR index decreased in proportion to the grade of 2DE-evidenced diastolic dysfunction. All patients with normal diastolic function had a PFR index greater than 2.0.nnnCONCLUSIONSnThis study demonstrated that a novel, fully automated RT3DE-derived PFR index was the diagnostic tool of choice for the assessment of LV diastolic function.

PROGNOSTIC IMPLICATION OF EPICARDIAL AND PERICARDIAL FAT ACUTELY AFTER MYOCARDIAL INFARCTION

Recent studies have shown that increased accumulation of fat around the heart, i.e. epicardial adipose tissue (EPI) and pericardial adipose tissue (PERI), is associated with cardiovascular disease and metabolic disease. However, which cardiac fat is more appropriate for cardiovascular risk

Quantitative intravenous myocardial contrast echocardiography predicts recovery of left ventricular function after revascularization in chronic coronary artery disease

BACKGROUNDnQuantitative intravenous myocardial contrast echocardiography (MCE) has been shown to measure regional myocardial blood flow velocity noninvasively.nnnPURPOSEnTo determine whether quantitative intravenous MCE could be used clinically to predict functional recovery after revascularization in patients with chronic coronary artery disease.nnnMETHODSnTwenty-eight patients with chronic stable coronary artery disease and resting regional left ventricular dysfunction were included in this study. The study permits myocardial perfusion analysis by intravenous MCE before revascularization with continuous infusion of Levovist and intermittent ultrasonic exposure. Wall motion assessment by echocardiography at rest was repeated after long-term follow-up period (7 +/- 2 months). In dysfunctional segments, we analyzed myocardial perfusion quantitatively by fitting to an exponential function, Y = A(1 - e-betat) to obtain the rate of rise (beta) of background-subtracted intensity, which represented myocardial blood flow velocity.nnnRESULTSnOf the 101 revascularized dysfunctional segments, MCE was adequately visualized in 91 (90%) segments, and wall motion was recovered in 45 (49%) segments. The value of beta in the recovery segments was significantly higher than that in nonrecovery segments (0.80 +/- 0.50 vs 0.39 +/- 0.24, P < 0.001). The value of beta > 0.5 predicted recovery of segmental function with a sensitivity of 71%, specificity of 78%.nnnCONCLUSIONnQuantitative intravenous MCE can predict functional recovery after revascularization in patients with chronic coronary artery disease.