Naoko Mizukami

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.

Intracardiac thrombus, superior vena cava syndrome, and pulmonary embolism in a patient with Behçet's disease: a case report and literature review

A 26-year-old woman with intermittent fever was admitted to our hospital, and gradually developed facial edema. Examinations including computed tomography, transesophageal echocardiography, digital subtraction angiography, and pulmonary perfusion scintigraphy revealed intracardiac thrombus, superior vena cava syndrome, and pulmonary embolism. Clinical findings and laboratory data led us to make a diagnosis of Behçets disease. Combination of intracardiac thrombus, superior vena cava syndrome, and pulmonary embolism are rare complications in Behçets disease. Behçets disease should be considered in the differential diagnosis of intracardiac mass of the right heart, and early diagnosis and treatment are essential for the management of Behçets disease especially with large-vessel manifestations. In addition to a case report, we review the literature and report the characteristics of intracardiac thrombus in Behçets disease.

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.

No reflow-like pattern in intramyocardial coronary artery suggests myocardial ischemia in patients with hypertrophic cardiomyopathy.

BACKGROUND AND PURPOSE To evaluate intramyocardial coronary flow velocity pattern by transthoracic Doppler echocardiography and its clinical significance in patients with hypertrophic cardiomyopathy (HCM). METHODS AND RESULTS In 48 patients with HCM who had angiographically normal coronary artery, coronary flow velocity in the left anterior descending coronary artery (LAD) and intramyocardial coronary artery (IMCA) derived from LAD were evaluated using transthoracic Doppler echocardiography. Two clearly different flow patterns in the IMCA were observed in patients with HCM. Twenty-seven HCM patients (group A) had slow deceleration slope in the IMCA flow (average diastolic deceleration time, 989+/-338; range, 585-1680) and the remaining 21 patients (group B) had steep deceleration slope with diastolic deceleration time <300 ms, resulting in a no reflow-like pattern in the IMCA flow (average diastolic deceleration time, 166+/-67; range, 55-280). There were no significant differences in the clinical characteristics and LAD flow velocity profiles between the two groups. The incidence of cardiovascular symptoms (chest pain or syncope) was significantly higher in group B than in group A (67% vs. 26%, p<0.01). Additionally, exercise-induced ischemia as detected by thallium-201 scintigraphy was significantly more frequent in group B than in group A (6 of 9 (67%) vs. 0 of 9 (0%), p<0.01). CONCLUSIONS Two different intramyocardial coronary flow velocity patterns are observed in patients with HCM using transthoracic Doppler echocardiography. No reflow-like pattern in the IMCA is strongly related to myocardial ischemia in the absence of epicardial coronary artery stenosis, suggesting that coronary microvascular dysfunction may be a causative mechanism.

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.

Application of a novel ultrasound transducer for continuous monitoring treadmill exercise stress echocardiography: Utility in the detection of coronary artery stenosis

Background: The clinical usefulness of rescue coronary angioplasty (PCI) in patients with acute myocardial infarction (AMI) is still under discussion. In particular, no data are available on the effects of late infarct-related artery (IRA) reopening on microvascular perfusion. Echocardiographic assessment of microvascular integrity is now feasible by intravenously injected contrast agents and real time myocardial contrast echocardiography (It-MCE). Previous MCE studies showed the efficacy of primary PCI in reducing microvascular damage. We sought to determine if even rescue PCI may improve tissue level perfusion. Method: We studied 46 patients with first anteroseptal AMI, undergoing primaly PCI within 6 hours from symptoms onset (Group A. n=26 pts) or, on the basis of clinical symptoms, rescue PCI within 12 h after thrombolysis (Group B, n=20 pts). MCE was periormed using real-time imaging (Philips Sonos 55W or CnTl Esaote) during continuous infusion of SonoVueB (Bracco) with a prototype (Bracco Imaging) rotating infusion pump at 120-160 ml/h infusion rate. In both groups the endocardial length of contrast defect in apical 45and 2-chamber views, the contrast score index, left ventricular ejection fraction and the wall motion score index were calculated before and after PCI. TIMI grade flow and myocardial blush after PCI were also calculated. Results: The mean time to IRA reopening was significantly lower I” the first group (al.5 vs 10+1.5 hours, respectively, p>O.OOl). Despite the different time to IRA reopening, similar changes in contrast score index (-11% YS -IO%, ns), length of contrast defect (-64% vs 61%. ns), ejection fraction (~10% vs +4%, ns), and wall motion score index (-11% YS lo%, ns) were observed. There was no statistical differences among groups in TIMI grade flow and myocardial blush after coronary procedure (2.510.4 vs 2.4s.4, and I.22 0.3 YS 1.19.2, respectively, ns) Conclusions: Our results suggest that even rescue PCI in still unstable patients after thrombolysis may be effective in reducing microvascular damage. JACC March 19,2003