Eiji Kuwahara

Mechanism of Recurrent/Persistent Ischemic/Functional Mitral Regurgitation in the Chronic Phase After Surgical Annuloplasty Importance of Augmented Posterior Leaflet Tethering

Background— Surgical annuloplasty can potentially hoist the posterior annulus anteriorly, exaggerate posterior leaflet (PML) tethering, and lead to recurrent ischemic/functional mitral regurgitation (MR). Characteristics of leaflet configurations in late postoperative MR were investigated. Methods and Results— In 30 patients with surgical annuloplasty for ischemic MR and 20 controls, the anterior leaflet (AML) and PML tethering angles relative to the line connecting annuli, posterior and apical displacement of the coaptation and the MR grade were measured by echocardiography before, early after, and late after surgery. Early after surgery, grade of MR and AML tethering generally decreased (P<0.01), whereas PML tethering significantly worsened (P<0.01). Nine of the 30 patients showed recurrent/persistent MR late after surgery. Compared with patients without late MR, those with the MR showed similar reduction in the annular area, significant re-increase in posterior displacement of the coaptation, and progressive worsening in PML tethering (P<0.05) late after surgery in comparison to the early phase. Both preoperative MR and late postoperative MR were significantly correlated with all tethering variables in univariate analysis. Although apical displacement of the coaptation was the primary determinant of preoperative MR (r2=0.60, P<0.0001), increased PML tethering was the primary determinant of late MR (r2=0.75, P<0.0001). Conclusions— Whereas both leaflets tethering is related to preoperative ischemic MR, both leaflets tethering but with predominant contribution from augmented and progressive PML tethering is related to recurrent/persistent ischemic/functional MR late after surgical annuloplasty.

Left ventricular global systolic dysfunction has a significant role in the development of diastolic heart failure in patients with systemic hypertension

Regional left ventricular (LV) systolic dysfunction has been identified in diastolic heart failure (DHF). However, the relationship between regional or global LV systolic function and heart failure symptoms in DHF has not been evaluated in detail. The present study evaluates such relationships in patients with systemic hypertension (HT) and DHF. We assessed LV systolic and diastolic function in 220 consecutive patients with systemic HT and in 30 normal individuals (Control) using Doppler echocardiography. Patients with HT were assigned to groups with DHF, asymptomatic diastolic dysfunction (ADD) and no diastolic dysfunction (Simple HT). Ejection fraction in DHF was significantly decreased (63±8%) compared with the Control, Simple HT and ADD groups (67±5, 66±7 and 68±8%, respectively). Isovolumetric contraction time in DHF (70±30 msec) was significantly increased compared with those in the ADD, Simple HT and Control groups (31±17, 31±15 and 30±19 msec, respectively). Mitral annular systolic velocities were significantly decreased in the DHF and ADD groups (6.4±1.5 and 7.2±1.3 cm sec−1, respectively) compared with those in the Simple HT and Control groups (8.5±1.8 and 8.4±3.0 cm sec−1, respectively), and in the DHF group compared with the ADD group. LV global systolic dysfunction has a significant role in the development of heart failure symptoms associated with DHF in patients with systemic HT.

Transient late-onset ischemic mitral regurgitation following Dor’s procedure

A 60-year-old man developed anteroseptal acute myocardial infarction with subsequent left hemiplegia. Echocardiography detected apical aneurysm with thrombus. Coronary artery bypass grafting with Dor’s procedure were performed. Chronic heart failure (CHF) developed three months after the surgery. CHF with mitral regurgitation (MR) continued for more than two months and then disappeared. When surgical intervention is considered for late MR after Dor’s procedure, it is important to consider that late-onset MR after Dor’s procedure can be transient with full medication, which may require four or more months to achieve its full effects.

Prosthetic tricuspid valve dysfunction assessed by three-dimensional transthoracic and transesophageal echocardiography

A 39-year-old male who had undergone tricuspid valve replacement for severe tricuspid regurgitation was admitted with palpitation and general edema. Two-dimensional (2D) echocardiography showed tricuspid prosthetic valve dysfunction. Additional three-dimensional (3D) transthoracic and transesophageal echocardiography (TEE) could clearly demonstrate the disabilities of the mechanical tricuspid valve. Particularly, 3D TEE demonstrated a mass located on the right ventricular side of the tricuspid prosthesis, which may have caused the stuck disk. This observation was confirmed by intra-operative findings.

Non-Circular Shape of Right Ventricular Outflow TractClinical Perspective: A Real-Time 3-Dimensional Transesophageal Echocardiography Study

Background—The shape of right ventricular outflow tract (RVOT) has been assumed to be circular. The aim of this study was to assess RVOT morphology using 3-dimensional transesophageal echocardiography (3D TEE). Methods and Results—This prospective study included 114 patients who underwent 3D TEE. Two-dimensional (2D) TEE measured maximum and minimum RVOT diameters (RVOTD max and min) during a cardiac cycle. 3D TEE determined RVOT area (RVOTA) max and min, RVOT fractional area change, and RVOT shape index (RVOTSI; vertical/horizontal RVOTD). Cardiac output (CO) was calculated using 2D TEE, 3D TEE, and a Swan-Ganz catheter in 23 patients. All patients were classified into group 1 (RVOTSI ⩽1) or group 2 (RVOTSI >1) based on the RVOT shapes. The mean RVOTSIs were 0.84±0.21(max) and 0.82±0.20 (min). Only 17 patients (14.9%) had circular RVOT (RVOTSI: 0.95–1.05); 82 patients (71.9%) were categorized into group 1 and 32 patients (28.1%) into group 2. 2D TEE, compared with 3D TEE, underestimated RVOTA max and min (both P<0.001). CO with 3D TEE had better agreement with CO with a catheter than CO with 2D TEE (r=0.83 and 0.53, respectively). Conclusions—3D TEE revealed that RVOT geometry was not generally circular but oval with 2 different types. Because of the detailed morphological information of RVOT, 3D TEE could provide more accurate assessment of CO than 2D TEE.Background— The shape of right ventricular outflow tract (RVOT) has been assumed to be circular. The aim of this study was to assess RVOT morphology using 3-dimensional transesophageal echocardiography (3D TEE). Methods and Results— This prospective study included 114 patients who underwent 3D TEE. Two-dimensional (2D) TEE measured maximum and minimum RVOT diameters (RVOTD max and min) during a cardiac cycle. 3D TEE determined RVOT area (RVOTA) max and min, RVOT fractional area change, and RVOT shape index (RVOTSI; vertical/horizontal RVOTD). Cardiac output (CO) was calculated using 2D TEE, 3D TEE, and a Swan-Ganz catheter in 23 patients. All patients were classified into group 1 (RVOTSI ≤1) or group 2 (RVOTSI >1) based on the RVOT shapes. The mean RVOTSIs were 0.84±0.21(max) and 0.82±0.20 (min). Only 17 patients (14.9%) had circular RVOT (RVOTSI: 0.95–1.05); 82 patients (71.9%) were categorized into group 1 and 32 patients (28.1%) into group 2. 2D TEE, compared with 3D TEE, underestimated RVOTA max and min (both P <0.001). CO with 3D TEE had better agreement with CO with a catheter than CO with 2D TEE ( r =0.83 and 0.53, respectively). Conclusions— 3D TEE revealed that RVOT geometry was not generally circular but oval with 2 different types. Because of the detailed morphological information of RVOT, 3D TEE could provide more accurate assessment of CO than 2D TEE.

Non-Circular Shape of Right Ventricular Outflow TractClinical Perspective

Background—The shape of right ventricular outflow tract (RVOT) has been assumed to be circular. The aim of this study was to assess RVOT morphology using 3-dimensional transesophageal echocardiography (3D TEE). Methods and Results—This prospective study included 114 patients who underwent 3D TEE. Two-dimensional (2D) TEE measured maximum and minimum RVOT diameters (RVOTD max and min) during a cardiac cycle. 3D TEE determined RVOT area (RVOTA) max and min, RVOT fractional area change, and RVOT shape index (RVOTSI; vertical/horizontal RVOTD). Cardiac output (CO) was calculated using 2D TEE, 3D TEE, and a Swan-Ganz catheter in 23 patients. All patients were classified into group 1 (RVOTSI ⩽1) or group 2 (RVOTSI >1) based on the RVOT shapes. The mean RVOTSIs were 0.84±0.21(max) and 0.82±0.20 (min). Only 17 patients (14.9%) had circular RVOT (RVOTSI: 0.95–1.05); 82 patients (71.9%) were categorized into group 1 and 32 patients (28.1%) into group 2. 2D TEE, compared with 3D TEE, underestimated RVOTA max and min (both P<0.001). CO with 3D TEE had better agreement with CO with a catheter than CO with 2D TEE (r=0.83 and 0.53, respectively). Conclusions—3D TEE revealed that RVOT geometry was not generally circular but oval with 2 different types. Because of the detailed morphological information of RVOT, 3D TEE could provide more accurate assessment of CO than 2D TEE.Background— The shape of right ventricular outflow tract (RVOT) has been assumed to be circular. The aim of this study was to assess RVOT morphology using 3-dimensional transesophageal echocardiography (3D TEE). Methods and Results— This prospective study included 114 patients who underwent 3D TEE. Two-dimensional (2D) TEE measured maximum and minimum RVOT diameters (RVOTD max and min) during a cardiac cycle. 3D TEE determined RVOT area (RVOTA) max and min, RVOT fractional area change, and RVOT shape index (RVOTSI; vertical/horizontal RVOTD). Cardiac output (CO) was calculated using 2D TEE, 3D TEE, and a Swan-Ganz catheter in 23 patients. All patients were classified into group 1 (RVOTSI ≤1) or group 2 (RVOTSI >1) based on the RVOT shapes. The mean RVOTSIs were 0.84±0.21(max) and 0.82±0.20 (min). Only 17 patients (14.9%) had circular RVOT (RVOTSI: 0.95–1.05); 82 patients (71.9%) were categorized into group 1 and 32 patients (28.1%) into group 2. 2D TEE, compared with 3D TEE, underestimated RVOTA max and min (both P <0.001). CO with 3D TEE had better agreement with CO with a catheter than CO with 2D TEE ( r =0.83 and 0.53, respectively). Conclusions— 3D TEE revealed that RVOT geometry was not generally circular but oval with 2 different types. Because of the detailed morphological information of RVOT, 3D TEE could provide more accurate assessment of CO than 2D TEE.

Mechanisms of Acute Mitral Regurgitation in Patients With Takotsubo CardiomyopathyClinical Perspective

Background—Recent studies have suggested acute mitral regurgitation (MR) as a potentially serious complication of takotsubo cardiomyopathy (TTC); however, the mechanism of acute MR in TTC remains unclear. The aim of this study was to elucidate the mechanisms of acute MR in patients with TTC. Methods and Results—Echocardiography was used to assess the mitral valve and left ventricular outflow tract (LVOT) pressure gradient in 47 patients with TTC confirmed by coronary angiography and left ventriculography. Mitral valve assessment included coaptation distance, tenting area at mid systole in the long-axis view, and systolic anterior motion of the mitral valve (SAM). Of the study patients, 12 (25.5%) had significant (moderate or severe) acute MR. In patients with acute MR versus those without acute MR, we found lower ejection fraction (31.3±6.2% versus 41.5±10.6%, P=0.001) and higher systolic pulmonary artery pressure (49.3±7.4 versus 35.5±8.9 mm Hg, P<0.001). Moreover, 6 of the 12 patients with acute MR had SAM, with peak LVOT pressure gradient >20 mm Hg (average peak LVOT pressure gradient, 81.3±35.8 mm Hg). The remaining 6 patients with acute MR revealed significantly greater mitral valve coaptation distance (10.9±1.6 versus 7.8±1.4 mm, P<0.001) and tenting area (2.1±0.4 versus 0.95±0.25 cm2, P<0.001) than those without acute MR. A multivariate analysis revealed that SAM and tenting area were independent predictors of acute MR in patients with TTC (all P<0.001). Conclusions—SAM and tethering of the mitral valve are independent mechanisms with differing pathophysiology that can lead to acute MR in patients with TTC.

Mechanisms of Acute Mitral Regurgitation in Patients With Takotsubo CardiomyopathyClinical Perspective: An Echocardiographic Study

Background—Recent studies have suggested acute mitral regurgitation (MR) as a potentially serious complication of takotsubo cardiomyopathy (TTC); however, the mechanism of acute MR in TTC remains unclear. The aim of this study was to elucidate the mechanisms of acute MR in patients with TTC. Methods and Results—Echocardiography was used to assess the mitral valve and left ventricular outflow tract (LVOT) pressure gradient in 47 patients with TTC confirmed by coronary angiography and left ventriculography. Mitral valve assessment included coaptation distance, tenting area at mid systole in the long-axis view, and systolic anterior motion of the mitral valve (SAM). Of the study patients, 12 (25.5%) had significant (moderate or severe) acute MR. In patients with acute MR versus those without acute MR, we found lower ejection fraction (31.3±6.2% versus 41.5±10.6%, P=0.001) and higher systolic pulmonary artery pressure (49.3±7.4 versus 35.5±8.9 mm Hg, P<0.001). Moreover, 6 of the 12 patients with acute MR had SAM, with peak LVOT pressure gradient >20 mm Hg (average peak LVOT pressure gradient, 81.3±35.8 mm Hg). The remaining 6 patients with acute MR revealed significantly greater mitral valve coaptation distance (10.9±1.6 versus 7.8±1.4 mm, P<0.001) and tenting area (2.1±0.4 versus 0.95±0.25 cm2, P<0.001) than those without acute MR. A multivariate analysis revealed that SAM and tenting area were independent predictors of acute MR in patients with TTC (all P<0.001). Conclusions—SAM and tethering of the mitral valve are independent mechanisms with differing pathophysiology that can lead to acute MR in patients with TTC.