Junichi Imanishi

Association of Apical Longitudinal Rotation with Right Ventricular Performance in Patients with Pulmonary Hypertension: Insights into Overestimation of Tricuspid Annular Plane Systolic Excursion

Current guidelines recommend the routine use of tricuspid annular plane systolic excursion (TAPSE) as a simple method for estimating right ventricular (RV) function. However, when ventricular apical longitudinal rotation (apical‐LR) occurs in pulmonary hypertension (PH) patients, it may result in overestimated TAPSE.

Bi-ventricular contractile reserve offers an incremental prognostic value for patients with dilated cardiomyopathy

AIMS Right ventricular (RV) as well as left ventricular (LV) function has been recognized as an important prognostic factor for heart failure patients. Our objective was thus to investigate the prognostic significance of combined assessment of bi-ventricular functional reserve for patients with dilated cardiomyopathy (DCM). METHODS AND RESULTS We studied 104 DCM patients with ejection fractions (EF) of 32 ± 9%, and speckle-tracking echocardiography was used to assess both RV and LV contractile reserve under dobutamine stress (20 µg/kg/min). RV contractile function was measured as peak global longitudinal strain (GLS) from the RV free wall (RV-free), and LV function as global circumferential strain (GCS) and GLS, respectively. Event-free survival was then tracked for 17 months. Twenty-one patients (20%) developed cardiovascular events. A multivariate Cox proportional-hazards analysis revealed that the baseline EF, E/A, and the relative change in EF (ΔEF), in GCS (ΔGCS), and in RV-free (ΔRV-free) during dobutamine stress were the independent predictors of cardiovascular events (P < 0.001, <0.05, <0.01, <0.05, and <0.01, respectively). A Cox model based on baseline clinical and echocardiographic variables (χ(2) = 23.6) was improved by the addition of LV contractile reserve parameters (plus ΔGCS and ΔEF) (χ(2) = 49.1; P < 0.001) and further improved by adding RV contractile reserve (plus ΔRV-free) (χ(2) = 60.3, P < 0.001). CONCLUSION Assessment of RV contractile reserve during dobutamine stress offers a significantly better prognostic value for patients with DCM. Bi-ventricular contractile reserve may be required for a favourable outcome, so that estimation of RV contractile reserve should be considered part of a comprehensive functional assessment of these patients.

Association of Left Atrial Booster‐Pump Function with Heart Failure Symptoms in Patients with Severe Aortic Stenosis and Preserved Left Ventricular Ejection Fraction

Identification of heart failure (HF) symptoms in patients with severe aortic stenosis (AS) and preserved left ventricular (LV) ejection fraction (EF) is clinically important, but assessment of HF symptoms is challenging. It was recently reported that resting left atrium (LA) functions are related to exercise performance and are also important prognostic markers for patients with HF. The aim of this study was to assess the association of the HF symptoms with LA function in patients with severe AS and preserved LVEF.

Preliminary Observations of Prognostic Value of Left Atrial Functional Reserve during Dobutamine Infusion in Patients with Dilated Cardiomyopathy

BACKGROUND The importance of left atrial (LA) functional reserve in patients with depressed left ventricular function remains unclear. Thus, the aim of this study was to test the hypothesis that diminished augmentation of LA function during dobutamine stress might be associated with cardiovascular events in patients with dilated cardiomyopathy. METHODS Eighty-four patients with dilated cardiomyopathy with a mean ejection fraction of 34 ± 9% were retrospectively recruited, and LA strain was determined as the averaged global speckle-tracking longitudinal strain from apical four-chamber and two-chamber views during dobutamine stress (20 μg/kg/min). The systolic component of LA strain was considered to reflect reservoir function, whereas the passive and active emptying components were considered to reflect passive and active emptying function, respectively. Event-free survival was tracked for 17 months. RESULTS Multivariate Cox proportional-hazards analysis identified LA volume index (hazard ratio [HR], 1.060; P < .001) and β-blocker use (HR, 0.048; P < .05) as the independent variables associated with cardiovascular events among the baseline parameters and changes in systolic LA strain (HR, 0.971; P = .02), in passive emptying LA strain (HR, 0.942; P < .001), and in left ventricular early diastolic strain rate (HR, 0.986; P = .03) under dobutamine as the variables among the functional reserve parameters. In sequential Cox models, a model based on clinical variables (χ(2) = 9.3) was improved by conventional echocardiographic parameters (χ(2) = 19.2, P = .012) and LA strain parameters at rest (χ(2) = 40.1, P = .005) and further improved by the addition of changes in LA strain parameters under dobutamine (χ(2) = 61.6, P < .001). CONCLUSIONS The assessment of LA reservoir and passive emptying function during dobutamine stress provides important incremental prognostic value in patients with dilated cardiomyopathy.

Utility of combined assessment of baseline dyssynchrony and its acute improvement to predict long-term outcomes after cardiac resynchronization therapy.

Although left ventricular (LV) mechanical dyssynchrony can predict the response to cardiac resynchronization therapy (CRT), the presence of baseline LV dyssynchrony might not be the only determinant of the response to CRT. The objectives of the present study were to test the hypothesis that a combined assessment of baseline LV dyssynchrony and its acute improvement can produce a more accurate prediction of the long-term outcomes after CRT. We studied 121 patients with heart failure undergoing CRT. LV dyssynchrony was determined by measuring the anteroseptal-to-posterior wall time delay using the speckle-tracking radial strain (≥130 ms was predefined as significant) and was assessed at baseline and 7 ± 3 days after CRT. Long-term unfavorable outcome events were tracked for 5 years. Acute improvement in LV dyssynchrony of ≥33% was predictive of the long-term outcome with an area under the curve of 0.67 (p = 0.0024). Using this cutoff value, the Kaplan-Meier curve showed that patients with acute improvement in LV dyssynchrony experienced fewer cardiovascular events than those without (log-rank p = 0.0002). The event-free survival of patients whose baseline LV dyssynchrony was ≥130 ms and whose acute improvement in LV dyssynchrony was ≥33% was greater than that of the patients with baseline LV dyssynchrony of ≥130 ms but with acute improvement in LV dyssynchrony of <33% (88% vs 65%, p = 0.012). In conclusion, the combined assessment of baseline LV dyssynchrony and its acute improvement after CRT produced a more accurate prediction of long-term outcomes after CRT.

Impact of Right Ventricular Geometry on Mitral Regurgitation After Transcatheter Closure of Atrial Septal Defect

Worsening of mitral regurgitation (MR) is sometimes observed after closure of an atrial septal defect (ASD). However, since the mechanism of this deterioration remains unclear, the aim of our study was to investigate the effect of left (LV) and right ventricular (RV) geometry on MR after transcatheter closure of ASD.We studied 27 patients with ASD who underwent transcatheter closure. Echocardiography was performed before and 6 ± 2 months after the procedure. In addition to conventional echocardiographic parameters, full volume data of the whole LV and RV heart was obtained with 3-dimensional echocardiography. MR was quantified by measuring the width of the vena contracta, and was graded as mild (< 3.0 mm), moderate (3.0 to 6.9 mm), or severe (≥ 7.0 mm).Ten patients (37%) were classified as having worsening MR and the remaining 17 (63%) as not having worsening MR. The two groups showed similar baseline characteristics, except for patients with worsening MR being more likely to be older (P = 0.009) and having a larger left-to-right shunt of pulmonary and systemic blood flow ratio (P = 0.02). It is noteworthy that the horizontal-to-vertical ratio of basal-RV at end-systole for patients with worsening MR was significantly smaller than that for patients without worsening MR (1.0 ± 0.2 versus 1.4 ± 0.2, P < 0.0001). Furthermore, multivariate analysis showed that the horizontal-to-vertical ratio of basal-RV at end-systole was the independent predictor of worsening MR during follow-up (P < 0.001).RV geometry may affect MR after closure of ASD. The pre-operative horizontal-to-vertical ratio of basal-RV is considered useful for predicting worsening of MR after closure of ASD.

An Unusual Case of Inferior Vena Cava Thrombosis in a Healthy Male Bodybuilder

Inferior vena cava (IVC) thrombosis is very rare, particularly in the absence of an apparent congenital caval abnormality or hypercoagulable state. We herein report an unusual case of a healthy and active 62-year-old male bodybuilder with a mass-like IVC thrombus. We placed an IVC filter and began treatment with rivaroxaban. The patient recovered successfully, and the IVC thrombus completely disappeared three months later. This case suggested that extrinsic compression of IVC by a tightened weightlifting belt around the abdomen is a triggering factor of IVC thrombosis, and rivaroxaban, a new oral anticoagulant, may be a useful option for treatment.

Dasatinib-Induced Pulmonary Arterial Hypertension Treated with Upfront Combination Therapy

Pulmonary arterial hypertension (PAH) is a rare complication of dasatinib that was approved as a first-line therapy for chronic myelocytic leukemia (CML). A 24-year-old man presenting dyspnea at rest and leg edema was admitted to our hospital. He had been diagnosed with CML and prescribed dasatinib for 4 years. Chest X-ray showed significant bilateral pleural effusion and heart enlargement. Echocardiography revealed interventricular septal compression and elevated peak tricuspid regurgitation pressure gradient of 66.7 mmHg indicating severe pulmonary hypertension. After the other specific diseases to provoke PAH were excluded, he was diagnosed with dasatinib-induced PAH. Despite discontinuation of dasatinib and intravenous administration of diuretic for two weeks, World Health Organization (WHO) functional class was still II and mean pulmonary arterial pressure (PAP) was high at 37 mmHg. Therefore, we administered sildenafil and bosentan together as an upfront combination therapy three weeks after dasatinib discontinuation. Six months later, his symptoms improved to WHO functional class I and mean PAP was decreased to 31 mmHg. Although PAH is a rare complication of dasatinib, symptomatic patients prescribed with dasatinib should have an echocardiogram for PAH screening. Moreover, the upfront combination therapy would be a useful option for symptomatic patients after discontinuation of dasatinib.

ASSOCIATION OF APICAL LONGITUDINAL ROTATION WITH TRICUSPID ANNULAR PLANE SYSTOLIC EXCURSION IN PATIENTS WITH PULMONARY HYPERTENSION

The assessment of right ventricular (RV) function plays an important role in the management of patients with pulmonary hypertension (PH). The current guidelines recommendation has been routinely to use tricuspid annular plane systolic excursion (TAPSE) as a simple method of estimating RV function.

ENDOCARDIAL DYSFUNCTION IN PATIENTS WITH PRESERVED EJECTION FRACTION AFTER ANTHRACYCLINE THERAPY AS ASSESSED BY 3D SPECKLE-TRACKING AREA STRAIN

Anthracyclines cause dose-dependent cardiomyopathy, but it remains difficult to detect subtle left ventricular (LV) myocardial dysfunction in patients with preserved ejection fraction (EF) after anthracyclines therapy. Three-dimensional (3-D) speckle-tracking can quantify endocardial function from