Hirofumi Maeba

Different Time Course of Changes in Tricuspid Regurgitant Pressure Gradient and Pulmonary Artery Flow Acceleration After Pulmonary Thromboendarterectomy

BACKGROUND Pulmonary artery pressure (PAP) is reduced dramatically after pulmonary thromboendarterectomy in patients with chronic thromboembolic pulmonary hypertension (CTEPH). However, it is unclear whether pulmonary artery compliance increases in conjunction with the reduction in PAP. Pulmonary artery compliance may affect right ventricular afterload and prognosis. METHODS AND RESULTS In 33 patients with CTEPH (9 men, 22-76 years), changes in the tricuspid regurgitation pressure gradient (TRPG) and the acceleration time (ACT) of pulmonary artery flow (a surrogate parameter of pulmonary artery compliance) were examined before and after pulmonary thromboendarterectomy using echocardiography to clarify factors affecting the changes. At 6 months, both TRPG and ACT normalized (<or=30 mmHg, >or=100 ms, respectively) in 25 patients (group A) but not in 8 (group B). In group B, there were 5 with normal TRPG and shortened ACT at 6 months that normalized at 17+/-3 months. Group A patients showed shorter disease period and shorter period without anticoagulation than group B patients (p=0.04, 0.02 respectively). All patients in group A had the proximal type, and 2 patients of group B had the distal type (p=0.05). Clinical improvement was more remarkable in group A. CONCLUSIONS The recovery of PAP and the ACT of pulmonary artery flow was not always concordant after pulmonary thromboendarterectomy, suggesting a presence of a time lag in the recovery between pressure and compliance in some patients. A long period of CTEPH, a long period without anticoagulation and the distal embolism type may be predictive factors of an unfavorable operative result with reduced pulmonary artery compliance, and hence poor recovery of clinical performance.

'Takotsubo' cardiomyopathy in a maintenance hemodialysis patient.

Abstract:  An 84‐year‐old woman undergoing maintenance hemodialysis presented with chest discomfort lasting several days and electrocardiographic abnormalities. She had stopped smoking 2 weeks earlier and was experiencing irritability. Upon admission, electrocardiography showed ST‐segment elevation in leads I, II, aVF, and V2‐6 and an abnormal Q wave in leads II, III, and aVF. Ultrasound cardiography showed left ventricular anteroapical akinesia and basal hyperkinesia. The chest discomfort disappeared without specific therapy. During hospital days 1–5, the ST‐segment elevation gradually improved. Giant negative T waves then developed. The left ventricular asynergy resolved by day 8. Radionuclide imaging with iodine‐123‐beta‐methyl‐p‐iodophenyl pentadecanoic acid, but not with technetium‐99 m‐sestamibi, showed an apical defect. Elective coronary angiography showed no stenosis. ‘Takotsubo’ cardiomyopathy was diagnosed. After discharge, the patient continued regular dialysis without cardiac symptoms. We concluded that endogenously activated sympathetic nerve action in hemodialysis patients, especially those under emotional or physical stress, might be a causative factor for Takotsubo cardiomyopathy.

Obesity as an independent risk for left ventricular diastolic dysfunction in 692 Japanese patients

SUMMARY BACKGROUND Both obesity and left ventricular (LV) diastolic dysfunction are associated with an increased risk of cardiovascular morbidity and mortality. There is a paucity of data as to whether obesity is independently associated with LV diastolic dysfunction. METHODS Adult patients with sinus rhythm referred for a transthoracic echocardiography between July, 2007, and December, 2007, were prospectively included. Exclusion criteria were patient who had a history of congenital or valvular heart disease, treatment with pacemaker implantation or implantable cardioverter defibrillator, myocardial infarction, or impaired LV systolic function. Diastolic function was classified by an algorithm incorporating data from mitral and pulmonary venous flow indices, and Doppler tissue imaging. Body mass index (BMI) was evaluated as a categorical variable (normal weight <25.0 kg/m(2); overweight 25.0 to <30.0 kg/m(2); and obese ≥30 kg/m(2)). Logistic models were used to assess the risk of abnormal LV diastolic function associated with BMI categories. RESULTS Of a total number of 692 patients who met all study criteria (mean 59 ± 15 year-old; 50% women, 48% hypertension, 16% diabetes, 26% overweight, 8% obese), 538 (78%) had abnormal LV diastolic function. In multivariate analyses adjusting for age, sex, and cardiovascular risk factors, obesity was independently associated with LV diastolic dysfunction (odds ratio [OR]: 2.98, 95% confidence interval [CI]: 1.12-7.88; P = 0.03) compared to normal weight. LV mass did not weaken this association (OR: 2.88, 95% CI: 1.08-7.68; P = 0.04). Overweight was not independently associated with LV diastolic dysfunction. CONCLUSION Obesity was associated with LV diastolic dysfunction independent of cardiovascular risk factors and LV mass.

Non-invasive detection of ischemic left ventricular dysfunction using rest gated SPECT: expectation of simultaneous evaluation of both myocardial perfusion and wall motion abnormality

ObjectiveAlthough the accurate detection of ischemic etiology is important in the management of patients with severe left ventricular (LV) dysfunction, it is difficult to determine using a non-invasive strategy. The present study investigates whether perfusion and regional functional abnormalities identified by quantitative electrocardiographic gated single-photon emission computed tomography (QGS) at rest can detect ischemic LV dysfunction in patients with severe LV dysfunction.MethodsRest QGS with 99mTc-tetrofosmin was performed on 54 consecutive patients with LV ejection fraction of ≤40%. Ischemic LV dysfunction (n = 32) was defined according to the established standard. Regional perfusion and wall motion were calculated using a 14-segment model (six mid-ventricular and eight apical segments) and compared with a normal control group.ResultsThe numbers of reduced [mean −1 standard deviation (SD) of normal individuals] and severely reduced (mean −2 SD) wall motion segments were similar between patients with ischemic and non-ischemic LV dysfunction (13.5 ± 1.1 vs. 13.6 ± 0.9 and 10.6 ± 2.0 vs. 9.9 ± 3.0 segments, respectively). The number of hypoperfused (mean −1 SD) segments was significantly greater in patients with ischemic LV dysfunction than in those with non-ischemic LV dysfunction (9.3 ± 3.8 vs. 2.0 ± 2.8 segments, P < 0.0001). The analysis of the receiver operating characteristics showed that a cut-off value of 4 hypoperfused segments among 14 segments provided the best separation between ischemic and non-ischemic LV dysfunction (sensitivity = 88% and specificity = 91%). Furthermore, patients with non-ischemic LV dysfunction had no severely hypoperfused (mean −2 SD) segments in any of the segments, whereas patients with ischemic LV dysfunction had 4.4 ± 0.2 segments.ConclusionsThe QGS strategy at rest can accurately differentiate patients with ischemic LV dysfunction from those with severe LV dysfunction by simultaneous regional evaluation of wall motion and myocardial perfusion.

Direct correlation between regional systolic function and regional washout rate of ⁹⁹mTc-sestamibi in patients with idiopathic dilated cardiomyopathy.

ObjectiveAlthough a higher washout of 99mTc-sestamibi (MIBI) from the ischemic myocardium was reported, little is known about it in idiopathic, nonischemic dilated cardiomyopathy (DCM). Using a quantitative electrocardiographic-gated single-photon emission computed tomography strategy, regional myocardial function may be obtained in conjunction with regional tracer perfusion. The aim of this study was to investigate the significance of regional washout of MIBI compared with regional systolic function in patients with DCM. MethodsRest quantitative electrocardiographic-gated single-photon emission computed tomography was performed in 20 patients with DCM who had no significant coronary stenosis on coronary angiogram and in five normal volunteers. single-photon emission computed tomography imaging was observed at 30 min and 4 h after 740 MBq of MIBI injection, and the regional washout rate (WR) was calculated using a 20-segment model. ResultsThe mean global ejection fraction was 28.2±12.4% and the mean end-diastolic volume was 177±78 ml. The myocardial segments were divided into three groups on the basis of the mean WR of normal volunteers: group A (n=164): WR≥25.4% (=mean+SD); group B (n=138): 19.6%⩽WR<25.4%; group C (n=98): WR<19.6% (=mean−SD). The regional wall thickening of group A segments was significantly less than that of the other groups (11.6±0.7 vs. 14.0±0.9 and 14.9±0.7%, respectively, P<0.05). The global left ventricular ejection fraction showed significant negative correlation to the extent of group A segments per patient (R=−0.65, P<0.005), indicating that higher washout was the result of decreased systolic function in DCM hearts. ConclusionRegional higher WR of MIBI may indicate a significant marker for myocardial damage in asymptomatic to mildly symptomatic patients with DCM.

Real Time Three‐Dimensional Transesophageal Echocardiographic Images of Platypnea‐Orthodeoxia Due to Patent Foramen Ovale

A 74-year-old man with a patent foramen ovale was admitted with dyspnea and cyanosis that had become progressively worse along with dehydration. Transthoracic echocardiography (iE33, Philips Medical Systems, Andover, MA, USA) revealed a normal ventricular size and function and no evidence of intracardiac shunting by Doppler color interrogation. Neither chest x-ray nor chest computed tomography (Aquilion 64, Toshiba Medical Systems, Otawara, Japan) revealed any apparent pulmonary disease that could cause his dyspnea. A right and left heart catheterization demonstrated normal coronaries with a mean right atrial pressure of 3 mmHg and a normal mean pulmonary artery pressure of 13 mmHg. Careful history taking revealed that he developed dyspnea in a sitting position, whereas the symptoms were relieved in a supine position. The transesophageal echocardiographic images taken in the supine position showed the foramen ovale was closed (Fig. 1 right), and no apparent right-to-left shunt by Doppler color flow (Fig. 1 left). The images taken in the sitting position showed the foramen ovale was wide open (Fig. 2 right, Fig. 3), with a massive rightto-left shunt across the patent foramen ovale by Doppler color flow (Fig. 2 left), caused hypoxemia and dyspnea. The patient was given the diagnosis of platypnea-orthodeoxia syndrome. Platypnea-orthodeoxia, a syndrome character-

Effect of eicosapentaenoic acid on regional arterial stiffness: Assessment by tissue Doppler imaging

AIM To evaluate the effects of eicosapentaenoic acid (EPA) on regional arterial stiffness assessed by strain rate using tissue Doppler imaging. METHODS Nineteen eligible patients were prospectively studied (mean age 62 ± 8 years, 68% men). Subjects with large vessel complications and/or diabetes mellitus were excluded. The strain rate of the ascending aorta was measured by tissue Doppler imaging as an index of regional arterial stiffness, and brachial-ankle pulse wave velocity (baPWV) was measured as an index of degree of systemic arteriosclerosis. These indices were compared before and after administration of EPA at 1800 mg/d for one year. RESULTS The plasma concentration of EPA increased significantly after EPA administration (3.0% ± 1.1% to 8.5% ± 2.9%, P < 0.001). There were no significant changes in baPWV (1765 ± 335 cm/s to 1745 ± 374 cm/s), low-density lipoprotein cholesterol levels (114 ± 29 mg/dL to 108 ± 28 mg/dL), or systolic blood pressure (131 ± 16 mmHg to 130 ± 13 mmHg) before and after EPA administration. In contrast, the strain rate was significantly increased by administration of EPA (19.2 ± 5.6 s(-1), 23.0 ± 6.6 s(-1), P < 0.05). CONCLUSION One year of administration of EPA resulted in an improvement in regional arterial stiffness which was independent of blood pressure or serum cholesterol levels.

Scintigraphic prediction of left ventricular functional recovery early after primary coronary angioplasty using single-injection quantitative electrocardiographic gated SPECT.

ObjectiveThe clinical usefulness of characterizing reperfused myocardium by perfusion/thickening assessment using electrocardiographic gated single photon emission computed tomography (SPECT) has not been investigated. We evaluated whether single-injection gated SPECT with 99mTc tetrofosmin early after primary percutaneous coronary intervention (PCI) can predict left ventricular (LV) functional recovery. MethodsGated SPECT was performed 3 days after primary PCI in 45 patients with acute myocardial infarction and revascularized segments were classified into perfusion/thickening mismatched segments, matched normal and matched abnormal segments. Gated SPECT was repeated 3 months later to evaluate the changes in LV ejection fraction (ΔLVEF). ResultsAmong 332 revascularized segments, there were 83 mismatched segments, 163 matched abnormal segments and 86 matched normal segments. In all the patients, LVEF increased significantly from 3 days to 3 months after primary PCI (52±13 to 57±14%, P<0.0001). Patients were divided into two groups according to ΔLVEF: 24 patients with LV functional recovery (ΔLVEF ≥5%) and 21 patients without LV functional recovery. The number of mismatched segments in patients with LV functional recovery was significantly greater than that in patients without (2.7±1.7 vs. 0.8±1.4, P<0.0003) despite no differences in the number of matched abnormal and matched normal segments. There was a significant correlation between ΔLVEF and the number of mismatched segments (r=0.56, P<0.0001) and LVEF at 3 months after primary PCI was related to the number of matched abnormal segments (r=−0.78, P<0.0001). ConclusionSingle-injection gated SPECT early after primary PCI can predict LV functional recovery.

Pseudoaneurysm with left-to-right shunt in a patient with myocardial infarction: evaluation by three-dimensional echocardiography

It is often difficult to noninvasively differentiate a post-infarction left ventricular (LV) pseudoaneurysm from a post-infarction true aneurysm. A 66-year-old woman with a past history of inferior acute myocardial infarction was admitted to our hospital because of acute decompensated heart failure. Two-dimensional transthoracic echocardiography showed an aneurysm with a narrow orifice in the inferoposterior basal area. The pulmonary to systemic flow ratio (Qp/Qs) was 2.2:1, which corresponded to moderate left–right shunting. Three-dimensional transesophageal echocardiography (3D-TEE) showed the orifice in the perforated right ventricular basal area with a color jet through the orifice from the LV to the right ventricle. Collectively, based on the 3D-TEE findings, we diagnosed the case as inferoposterior pseudoaneurysm with a left-to-right shunt caused by myocardial infarction.

Efficacy of Oxycodone for Dyspnea in End-stage Heart Failure with Renal Insufficiency

A 67-year-old man with dilated cardiomyopathy and renal insufficiency was admitted to our hospital with dyspnea secondary to end-stage heart failure. We introduced oxycodone for medically refractory dyspnea instead of morphine because of the patients renal insufficiency. After the administration of oxycodone, his dyspnea was alleviated without any adverse opioid effects, such as respiratory depression. After treating his heart failure, he was able to leave the intensive care unit. Oxycodone may therefore be a reliable agent for the treatment of dyspnea in patients with end-stage heart failure and renal insufficiency.