Go Hashimoto

Midwall ejection fraction for assessing systolic performance of the hypertrophic left ventricle

BackgroundIn patients with left ventricular hypertrophy (LVH), LV midwall fractional shortening (FS) is used as a measure of LV systolic performance that is more physiologically appropriate than conventional FS. For evaluation of LV volume and ejection fraction (EF), 2-dimensional (2D) echocardiography is more accurate than M-mode echocardiography. The purpose of this study was to assess systolic performance by midwall EF using 2D speckle tracking echocardiography (STE).MethodsSixty patients were enrolled in the study. Patients were divided into two groups with LVH (n = 30) and without LVH (control group, n = 30). LV systolic function was compared between the two groups and the relationships of left ventricular mass index (LVMI) with LV systolic parameters, including midwall EF, were investigated.ResultsMidwall EF in the LVH group was significantly lower than that in the control group (42.8±4.4% vs. 48.1±4.1%, p <0.0001). Midwall FS was also significantly lower in the LVH group (13.4±2.8% vs. 16.1±1.5%, p <0.0001), but EF did not differ significantly between the two groups. There were significant correlations between midwall EF and LVMI (r=0.731, p <0.0001) and between midwall FS and LVMI (r=0.693, p <0.0001), with midwall EF having the higher correlation.ConclusionsThese results show that midwall EF can be determined using 2D STE. Midwall EF can be used to monitor LV systolic dysfunction, which is not possible with conventional EF. Evaluation of midwall EF may allow assessment of new parameters of LV systolic function in patients with LV geometric variability.

A case of bicuspid aortic valve with two raphes

A 60-year-old woman was referred to our hospital for exertional shortness of breath. She was made aware of a heart murmur as a high school student. She had exertional dyspnea and chest pain. Her symptoms were getting worse over the previous year. On admission, her blood pressure was 160/54 mmHg, heart rate was 72 bpm, and grade 3/6 regurgitant murmur over the precordium was present. She was diagnosed with severe aortic regurgitation by transthoracic echocardiography and the other clinical examination. Transthoracic echocardiography showed severe aortic regurgitation with normal left ventricular systolic function. Two raphes of the aortic valve were not diagnosed by transthoracic echocardiography because of poor quality echo images. Two-dimensional transesophageal echocardiograms showed a bicuspid aortic valve (BAV) with fused cusps between the two components of the right and noncoronary cusps (Fig. 1). Furthermore there were two raphes on the fused cusps. Real-time three-dimensional echocardiograms showed two commissures and two raphes on the fused area in systole and diastole (Fig. 2a, b). The perioperative findings were exactly the same as the information obtained by three-dimensional transesophageal echocardiography (Fig. 2c). Discussion

Impact of Cilostazol on Left Ventricular Geometry and Function: Assessment by Tissue Doppler Imaging and Two-Dimensional Speckle-Tracking Echocardiography

Objectives: Cilostazol, a type III phosphodiesterase inhibitor, is an antiplatelet agent with vasodilating properties. Positive inotropic and chronotropic effects are frequently observed with cilostazol, but there are few reports on the influence of cilostazol on left ventricular function. The aim of this study was to assess this effect using tissue Doppler imaging (TDI) and two‐dimensional speckle‐tracking echocardiography (2D‐STE). Methods: Thirty‐five patients with normal left ventricular ejection fraction were enrolled in the study. Left ventricular cardiac function was assessed by TDI and 2D‐STE before and after oral administration of cilostazol. Peak strain was defined using the peak radial strain (PRS), peak circumferential strain (PCS) and peak longitudinal strain (PLS). Time to peak strain was defined based on the times to PRS, PCS, and PLS, as T‐PRS, T‐PCS, and T‐PLS, respectively. Results: After cilostazol administration, there were significant decreases in the left ventricular end‐diastolic and end‐systolic diameters (47.3 ± 5.2 vs. 43.3 ± 4.9 mm, P < 0.0001; 29.3 ± 6.4 vs. 26.0 ± 5.5 mm, P < 0.0001, respectively), and significant increases in the left ventricular ejection fraction (70.6 ± 9.5 vs. 72.7 ± 7.8%, P = 0.0381) and peak systolic annular velocity (7.9 ± 1.7 vs. 9.5 ± 3.1 cm/sec, P < 0.0001). PRS, PCS, and PLS all increased significantly and T‐PRS, T‐PCS, and T‐PLS all decreased significantly after cilostazol administration. Conclusion: Positive inotropic and chronotropic effects of cilostazol were found based on assessment by TDI and 2D‐STE. We suggest that periodic echocardiographic assessment should be performed before and after oral administration of cilostazol. (Echocardiography 2011;28:431‐437)

Percutaneous Antegrade Mitral Paravalvular Leak Closure Through Porcelain Atrial Septum – First Percutaneous Paravalvular Leak Closure in Japan –

Received August 24, 2014; revised manuscript received December 21, 2014; accepted December 23, 2014; released online January 26, 2015 Time for primary review: 29 days Division of Cardiovascular Medicine, Toho University Ohashi Medical Center, Tokyo (H.H., G.H., T.A., Y.N., K.Y., M.T., Y.E., F.H., Y.Y., R.I., M.S., K.S., M.N.); Department of Cardiovascular Surgery, National Hospital Organization Kanazawa Medical Center, Kanazawa (Y.M.), Japan; and Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (T.M., S.K.), USA Mailing address: Hidehiko Hara, MD, PhD, Division of Cardiovascular Medicine, Toho University Ohashi Medical Center, 2-17-6 Ohashi, Meguro-ku, Tokyo 153-8515, Japan. E-mail: harahide@oha.toho-u.ac.jp ISSN-1346-9843 doi: 10.1253/circj.CJ-14-0940 All rights are reserved to the Japanese Circulation Society. For permissions, please e-mail: cj@j-circ.or.jp Percutaneous Antegrade Mitral Paravalvular Leak Closure Through Porcelain Atrial Septum – First Percutaneous Paravalvular Leak Closure in Japan –

Prediction of Development of Critical Limb Ischemia in Hemodialysis Patients

Hemodialysis (HD) patients with critical limb ischemia (CLI) suffer chronic inflammation and repeated infection, require intervention, and may have a protracted hospital stay. Therefore, early prediction is particularly important for management of CLI in patients with suspected peripheral artery disease. The purpose of this study is to develop a simple score for predicting the incidence of CLI in HD patients with suspected peripheral artery disease. The subjects were 139 asymptomatic patients receiving maintenance HD and with ABI <1.0. Multivariate logistic regression analysis was used to identify factors associated with development of CLI. These factors were subsequently weighted and integrated into a scoring system for the prediction of onset of CLI. Twenty‐five patients had onset of CLI. Five factors selected from the multivariate model were weighted proportionally using their respective odds ratio (OR) for incidence of CLI (history of cerebral vascular disease, OR 6.42 [3 points]; diabetes, OR 3.92 [2 points]; hypoesthesia, OR 4.21 [2 points]; left ventricular ejection fraction <50%, OR 3.89 [2 points]; serum albumin <3.5 g/dL, OR 4.39 [2 points]). Three strata of risk were defined (low risk, 0 to 3 points; intermediate risk, 4 to 6 points; and high risk 7 to 11 points) with excellent prognostic accuracy for progression to CLI using the Kaplan–Meier method. Five factors were identified that increased the risk of progression to CLI in HD patients with suspected peripheral artery disease. A combination of those factors permitted establishment of three risk strata for accurate prediction of onset of CLI.

Transcatheter atrial septal defect closure in a patient with paradoxical brain emboli: who should treat it and who should be treated?

This report presents the case of a 51-year-old female who was admitted to a local hospital because of a persistent headache. A diagnosis of multiple cerebral infarctions was thereafter made, but there was no evidence of either atherosclerosis or atrial fibrillation. The case was thought to be a cryptogenic stroke, however, Doppler ultrasonography of the lower extremities showed venous insufficiency. Transesophageal echocardiography revealed a secundum atrial septal defect (ASD) with a left to right shunt. Therefore, the final diagnosis was paradoxical brain emboli, and transcatheter ASD closure was successfully performed by cardiologists without any sequelae.

A pericardial tumor with a unique presentation

ISSN 1748-2941 print/ISSN 1748-295X online

Congenital Absence of Left Atrial Appendage Diagnosed by Multimodality Imaging

A 70-years-old male with a history of hypertension and drug resistant paroxysmal atrial fibrillation (AF) presented to our hospital for catheter ablation to his symptomatic AF. He had no prior surgical or percutaneous procedure to close or exclude the left atrial appendage (LAA). A transesophageal echocardiography (TEE) was performed to rule out intra-cardiac thrombus prior to the ablation procedure. Although the TEE imaging at multiple acquisition angles was obtained, the LAA could not be visualized and an absence of the LAA was suspected. An absence of the LAA was confirmed using cardiac computed tomography (CT), which included 3D reconstruction. Additionally, the LAA was not visualized with left atrium (LA) angiography. During the ablation procedure, 3D voltage mapping in LA was created and no low voltage area or abnormal potential was recorded around the usual root location of the LAA. Successful electrical pulmonary vein isolation was achieved with no major complications. After six months of follow-up, the patient remained in sinus rhythm without any antiarrhythmic drugs and showed no related clinical symptoms. He stopped his anticoagulation therapy due to lack of evidence of AF recurrence and an absence of LAA. Multimodality imaging allowed us to identify the congenital absence of LAA.

Paget-Schroetter Syndrome Resulting from Thoracic Outlet Syndrome and KAATSU Training

A 29-year-old woman who worked as a KAATSU (a type of body exercise that involves blood flow restriction) instructor visited our emergency room with a chief complaint of swelling and left upper limb pain. Chest computed tomography (CT) showed non-uniform contrast images corresponding to the site from the left axillary vein to the left subclavian vein; vascular ultrasonography of the upper limb revealed a thrombotic obstruction at the same site, leading to a diagnosis of Paget-Schroetter syndrome (PSS). We herein report our experience with a case of PSS derived from thoracic outlet syndrome (TOS), in a patient who was a KAATSU instructor.

COMBINED ASSESSMENT OF CAROTID INTIMA-MEDIA THICKNESS AND LEFT VENTRICULAR CONCENTRIC HYPERTROPHY PREDICT CARDIOVASCULAR DEATH IN HEMODIALYSIS PATIENTS

The purpose of this study is to analysis the usefulness of combination of common carotid artery intima-media thickness (IMT) thickening and left ventricular (LV) hypertrophy with concentric geometry for predicting the cardiovascular death (CVD) in hemodialysis (HD) patients. Two hundred twenty-nine