Koji Kurosawa

Left Atrial Strain Provides Incremental Value for Embolism Risk Stratification over CHA2DS2-VASc Score and Indicates Prognostic Impact in Patients with Atrial Fibrillation

BACKGROUND The aim of this study was to investigate whether left atrial (LA) strain has incremental value over the CHA2DS2-VASc score for stratifying the risk for embolism in patients with atrial fibrillation (AF) and whether LA strain predicts poststroke mortality. METHODS Consecutive patients with paroxysmal or persistent AF with acute embolism (82 patients) or without (204 controls) were prospectively enrolled. Global peak LA longitudinal strain during ventricular systole (LAS) was assessed during AF rhythm. Global LAS was compared between the groups in the first cross-sectional study. Then, the 82 patients with acute embolism were prospectively followed during the second prospective cohort study. RESULTS Global LAS was lower in patients with acute embolism than in controls (P < .001). Global LAS < 15.4% differentiated patients with acute embolism from controls, with an area under the curve of 0.83 (P < .0001). In multivariate analysis, global LAS was independently associated with acute embolism (odds ratio, 0.74; 95% confidence interval, 0.67-0.82; P < .001) and had an incremental value over the CHA2DS2-VASc score (P < .0001). Furthermore, 26 patients with acute embolisms died during a median follow-up period of 425 days. Global LAS independently predicted mortality after embolism. CONCLUSIONS In this observational study, LA strain provided incremental diagnostic information over that provided by the CHA2DS2-VASc score, suggesting that LA strain analysis could improve the current risk stratification of embolism in patients with AF. LA strain can also predict poststroke mortality.

Practical guidance in echocardiographic assessment of global longitudinal strain

there has been increasing interest in the measurement of global myocardial strain because it is a sensitive and robust index to detect subclinical myocardial dysfunction, with a defined normal range [(1)][1]. Numerous commercially-available versions of speckle tracking software are available for

Effect of Sex Differences on the Association Between Stroke Risk and Left Atrial Anatomy or Mechanics in Patients With Atrial FibrillationCLINICAL PERSPECTIVE

Background—Embolic stroke in atrial fibrillation is more prevalent in women than in men, yet the basis for this difference remains unclear. This study seeks to elucidate whether there are any sex differences in the relationships between stroke risk (CHADS2 score, CHA2DS2-VASc score without a sex category, and estimated stroke rate) and left atrial (LA) anatomy or mechanics in patients with atrial fibrillation. Methods and Results—LA emptying fraction and global peak atrial longitudinal strain were assessed in 414 subjects with paroxysmal or persistent atrial fibrillation (156 women and 258 men). Linear regression models with an interaction term were performed to test the effect of sex difference on associations between the embolic risk and LA function or anatomy. Sensitivity analyses were performed in 228 age, heart rate, and rhythm-matched subjects (114 women and men). Women were older and had larger LA volumes and lower LA mechanics than men. Significant negative association between the CHADS2 score and LA emptying fraction was only demonstrated in women with a significant interaction between sexes. Similar significant interactions were found in global peak atrial longitudinal strain but not in LA volume. These findings were corroborated in the comparisons against CHA2DS2-VASc score without a sex category and the estimated stroke rate. Sensitivity analyses in the matched subgroup also confirmed the robustness of these sex differences in LA emptying fraction, but less so in global peak atrial longitudinal strain. Conclusions—Significant sex interactions on the association between global LA function and risk stratification schemes exist, which may be a reason for the higher prevalence of embolic stroke in women.

Comparison of different interdialytic intervals among hemodialysis patients on their echocardiogram-based cardiovascular parameters.

BACKGROUND Although cardiovascular events in hemodialysis (HD) patients are the most frequent on the day after a long (2 days) interdialytic interval (IDT), it has been uncertain whether accumulation or elimination of large extracellular fluid volume, electrolyte, and/or uremic substances is the culprit for this. We sought to test our hypothesis that the long IDT alters echocardiographic parameters at rest and during exercise in stable maintenance HD patients compared with other IDTs. METHODS We performed a cross-sectional comparison using 1-way repeated analysis of variance or Friedman test of echocardiograms at 3 different IDTs, just after HD, after short IDT (1 day), and after long IDT, among 80 stable Japanese outpatients (age 61 ± 9 years, 60 males) on thrice weekly maintenance. End-systolic elastance (Ees), arterial elastance (Ea), and pressure-volume area (PVA) were estimated using a noninvasive single-beat technique. Ventricular-arterial coupling was assessed by Ea/Ees ratio. Measurements were repeated after 2-minute handgrip stress to evaluate cardiac reserve. RESULTS Resting left ventricular end-diastolic volume index and stroke volume index were significantly larger after a 1-day IDT compared with just after HD and even more after a 2-day IDT. Although Ees, Ea, and Ea/Ees ratio at rest remained similar between short and long intervals, stroke work (SW) and PVA were higher after the long interval. During handgrip stress, a significant increase in Ea without corresponding rise in Ees was observed only after long IDT, resulting in decreased stroke volume index, SW, and SW/PVA efficiency. CONCLUSIONS In a selective Japanese outpatient population on maintenance HD, there were no differences in resting cardiovascular function measured by echocardiography at 3 different IDTs. However, exercise-induced afterload mismatch assessed by the changes in Ea, SV, SW, and SW/PVA efficiency was most pronounced in individuals after the long IDT compared with other IDTs. Our findings report potential pathophysiologic echocardiographic parameters that attempt to explain why cardiovascular events are highest on the day after the long IDT compared to other IDTs in dialysis patients.

Infective Endocarditis Complicated by Mycotic Aneurysm of a Coronary Artery With a Perforated Mitral Valvular Aneurysm

Mycotic aneurysms are well-documented complications of infective endocarditis and occur frequently in the intracranial arteries. However, mycotic aneurysms of the coronary arteries are very rare, and there are few reports of the management of these lesions. The authors report the case of a 72-year-old woman with coagulase-negative staphylococcal endocarditis involving a perforated aortic valve, a perforated mitral valve aneurysm, and a large mycotic coronary artery aneurysm. After antimicrobial therapy, the patient underwent open-heart surgery with mitral and aortic valve replacement, coronary artery bypass, and resection of the mycotic coronary aneurysm. The authors present detailed serial echocardiograms of the mycotic coronary artery aneurysm, which was subsequently confirmed intraoperatively and pathologically.

The Seabed-like Appearance of Atherosclerotic Plaques: Three-Dimensional Transesophageal Echocardiographic Images of the Aortic Arch Causing Cholesterol Crystal Emboli

Cholesterol crystal embolism (CCE) is a rare but important complication of endovascular procedures or anticoagulation therapy. An 84-year-old man was referred to the Gunma University Graduate School of Medicine with the diagnosis of acute myocardial infarction. After successful emergency coronary angioplasty, his serum creatinine level increased continuously. A subsequent skin biopsy confirmed that the patient had CCE. Transesophageal echocardiography (TEE) clearly demonstrated the mobile mass protruding from the complex atheroma. Three-dimensional TEE provides more precise and attractive volumetric images of the atherosclerotic plaque than two-dimensional TEE. In addition, the findings of this case revealed contrast media-induced nephropathy and CCE as possible causes of renal dysfunction after endovascular procedures.

Incremental Prognostic Value of Ventricular-Arterial Coupling over Ejection Fraction in Patients with Maintenance Hemodialysis

Background: Left ventricular ejection fraction (LVEF) is a predictor of adverse outcomes in hemodialysis patients. LVEF is, however, an integral parameter determined by contractility, loading condition, and coupling. We sought to determine whether these components would better predict adverse outcomes and have incremental prognostic value over a validated clinical score and EF. Methods: Two hundred thirty‐four hemodialysis patients were prospectively followed up for primary composite endpoint: all‐cause death, nonfatal myocardial infarction, and hospitalization due to worsening heart failure (HF). Load‐independent contractility (end‐systolic elastance [Ees] and preload recruitable stroke work [PRSW]) and arterial afterload (arterial elastance [Ea]) were noninvasively estimated. Ventricular‐arterial coupling was assessed using the Ea/Ees ratio. LV global longitudinal strain (GLS) and mitral E‐wave over annular velocity E′ ratio (E/E′) were also measured. Results: During a median follow‐up of 776 days, 30 patients developed the primary endpoint. Ees, PRSW, GLS, S′, Ea/Ees, E/E′, and EF were independently associated with the outcome after adjusting for the clinical score and prior HF hospitalization, whereas end‐diastolic volume index or arterial afterload parameters were not. The nested Cox models indicated that Ea/Ees had independent and incremental predictive value over the model based on the score and either EF or E/E′. Furthermore, Ea/Ees continued to have predictive value after adjusting for GLS. The classification and regression analysis stratified event rates ranging from 4.2% to 68.8%. Conclusions: LV contractility and Ea/Ees were independently associated with adverse outcome in hemodialysis patients. Ea/Ees had an incremental prognostic value over the clinical score and EF.

Left intraventricular dyssynchrony caused by a false tendon

Left ventricular (LV) false tendons are usually benign, intraventricular myocardial structures, which may cause functional malfunction or deformation of the LV cavity due to mechanical stretching and dilatation of the LV wall. We present a case of non‐ischemic cardiomyopathy complicated with intraventricular dyssynchrony that was caused by complete left bundle branch block and the mechanical pressure exerted by the stiff false tendon on the weakened mid‐septum during systole.

Pulmonary hypertension with extensive calcification in small pulmonary vessels and alveolar capillary wall in a chronic hemodialysis patient

We report a case of a 41-year-old male with end-stage renal disease receiving chronic hemodialysis who was referred to this hospital because of dyspnea. He had been on a regular dialysis for 20 years due to chronic glomerulonephritis. His transthoracic echocardiography revealed severe pulmonary hypertension (PH), and cardiac catheterization confirmed this diagnosis. From clinical examination and review of the chest X-ray and computed tomography images, we thought PH was due to multifactorial mechanisms typical of hemodialysis patients. However, microscopic examination of lung tissue from autopsy specimen revealed extensive calcium deposits not only in alveolar septal wall but also in alveolar capillaries and small vessels, which had diffuse intimal thickening causing the narrowing of the lumens. These pathological findings suggest that pulmonary vascular calcification contributed to the PH in this patient. <Learning objective: Pulmonary hypertension (PH) is prevalent and associated with mortality in patients with end-stage renal disease (ESRD). However, the pathogenesis of PH with ESRD remains uncertain. Here we report a PH case receiving long-term hemodialysis, and whose pathological findings revealed extensive calcification in small pulmonary vessels and alveolar capillaries. This case will provide evidence indicating the causative role of pulmonary calcification for the development of PH in dialysis patients.>.

Reduced variability of visual left ventricular ejection fraction assessment with reference images: The Japanese Association of Young Echocardiography Fellows multicenter study

BACKGROUND Visual estimation of left ventricular ejection fraction (LVEF) is widely applied to confirm quantitative EF. However, visual assessment is subjective, and variability may be influenced by observer experience. We hypothesized that a learning session might reduce the misclassification rate. METHODS Protocol 1: Visual LVEFs for 30 cases were measured by 79 readers from 13 cardiovascular tertiary care centers. Readers were divided into 3 groups by their experience: limited (1-5 years, n=28), intermediate (6-11 years, n=26), and highly experienced (12-years, n=25). Protocol 2: All readers were randomized to assess the effect of a learning session with reference images only or feedback plus reference images. After the session, 20 new cases were shown to all readers following the same methodology. To assess the concordance and accuracy pre- and post-intervention, each visual LVEF measurement was compared to overall average values as a reference. RESULTS Experience affected the concordance in visual EF values among the readers. Groups with intermediate and high experience showed significantly better mean difference (MD), standard deviation (SD), and coefficient of variation (CV) than those with limited experience at baseline. The learning session with reference image reduced the MD, SD, and CV in readers with limited experience. The learning session with reference images plus feedback also reduced proportional bias. Importantly, the misclassification rate for mid-range EF cases was reduced regardless of experience. CONCLUSION This large multicenter study suggested that a simple learning session with reference images can successfully reduce the misclassification rate for LVEF assessment.