Norihito Kageyama

Detection of coronary arterial microvascular disorders using 99mTc-tetrofosmin uptake increase during exercise and coronary blood flow velocity patterns obtained by magnetic resonance imaging

This study reports an evaluation of coronary arterial blood flow patterns in patients with diabetes mellitus and healthy subjects using magnetic resonance coronary angiography (MRCA). Twenty patients with diabetes mellitus (DM group) and 20 healthy subjects (N group) were studied using MRCA and myocardial SPECT images using 99mTc-tetrofosmin (TF). The rate of change in myocardial TF uptake was measured during a 1-day protocol of exercise and rest. Initial and delayed exercise single photon emission computed tomography (SPECT) images were acquired 30 min and 3 h after injection (370 MBq of TF) (TF1 and TF2, respectively). Thereafter, 740 MBq of TF was administered intravenously, again, and resting SPECT images (TF3) were acquired 30 min later. The myocardial counts of these three points of acquisition were defined, and the rate of change of myocardial TF uptake between exercise and rest was determined. The % increase in uptake was significantly lower in the DM group than in the N group in all myocardial segments. The average coronary arterial diastolic velocity determined using MRCA was slightly lower in the DM group than in the N group, and the average systolic peak velocity (ASPV) was slightly greater in the DM group than in the N group, although these values were not statistically significant. The diastolic/systolic velocity ratio (DSVR) in the DM group was significantly lower than that in the N group (P ≪ 0.05). There was a significant correlation between DSVR and % uptake increase (r = 0.605, P ≪ 0.05). These results indicate that the measurements made using MRCA and the % uptake increase measured using TF myocardial scintigraphy represent a potentially useful noninvasive method for diagnosing microvascular dysfunction in diabetic patients.

Intravenous nicorandil for treatment of the urgent phase acute heart failure syndromes: A randomized, controlled trial.

Background: Vasodilators, such as nitroglycerin, have long been first-line treatments for acute heart failure syndromes (AHFS). Nicorandil is a vasodilator with dual potassium channel opening and nitrate properties. However, there are no randomized controlled studies of intravenous nicorandil safety and efficacy in the urgent phase AHFS. We examined the symptomatic, hemodynamic, and echocardiographic effects and safety, and 60-day clinical outcomes of intravenous nicorandil, in addition to standard therapy, in patients with AHFS in the urgent phase. Methods: In this prospective, randomized controlled trial, 106 AHFS patients were randomized within one hour of arrival to receive either standard therapy (control group, n=56) or standard therapy plus simultaneous intravenous nicorandil (0.2 mg/kg bolus followed by 0.2 mg/kg/h for 24 h; nicorandil group, n=50). Outcomes were assessed at 60 days. Results: Patients in the nicorandil group exhibited greater improvement of dyspnea as measured by change in a five-point Likert scale compared to those in the control group (after 1 h infusion: p=0.006, 6 h; p<0.001). The nicorandil group also showed significantly improved E/e′, an estimate of left ventricular filling pressure, at 1 and 24 h (p=0.001 and p=0.004, respectively). In addition, intravenous nicorandil therapy was safe and did not cause side effects such as excessive hypotension or reflex tachycardia. However, it did not reduce all-cause mortality and readmission rates at 60 days. Conclusions: Addition of intravenous nicorandil to standard therapy for urgent phase AHFS improved dyspnea and left ventricular diastolic function but not 60-day outcome.

Left ventricular obstruction caused by a large hiatal hernia

A 76‐year‐old man was admitted to our emergency department owing to chest pain, which started immediately after lunch. Although electrocardiogram revealed ST‐segment elevation with hyperacute T‐wave changes in the anterior lead tracings, emergency coronary angiography revealed normal coronary arteries. Echocardiography revealed left ventricular (LV) compression with left ventricular obstruction (LVO) caused by an echogenic mass. Computed tomography clearly revealed compression of both left atrial (LA) and LV by a large hiatal hernia. A large hiatal hernia can induce cardiac symptoms resulting from cardiac compression. This case highlights a possible association between chest pain and LVO caused by a hiatal hernia.

A patient responding to combined therapy with pirmenol and midodrine for refractory neurally mediated syncope complicated by prostatic hypertrophy

A 67-year-old man with neurally mediated syncope (NMS) complicated by prostatic hypertrophy responded well to combined therapy with pirmenol and midodrine. In 2003, syncope occurred while the patient was driving a car. Results of head-up tilt-table testing (HUT) suggested a mixed type of NMS. Oral administration of disopyramide provided severe urinary obstruction. Pirmenol treatment was not associated with syncope during ordinary HUT, but nausea, sweating, and syncope occurred during HUT with provocative administration of isosorbide dinitrate. Combined therapy with pirmenol and midodrine avoided syncope during HUT, and has prevented attacks since discharge from the hospital.

Longitudinal myocardial displacement and strain rate in the hypertrophied heart evaluated by tissue strain imaging with doppler angle correction and tissue tracking technique

S Noninvasive Imaging 455A JACC March 19,2003 and MVP was analyzed off-line. Results : 1) Wall motion score index (WMSI) assessed by PDE decreased significantly in 9 of 12 patients (75%) reflecting improvement of regional wall motion abnormality. 2) In contrast, in 11 of 12 patients (92%) the peak systolic myocardial velocity (1.17 vs 4.97cm!s, p 40%. We considered also age, NYHA functional class, QRS narrowing and mitral regurgitation for multivariate analysis. Results The highest mortality rate (100%) was observed in IIIB electrical-mechanical pattern and LVEF 30-40%, while the lowest mortality rate (25%) was related to IIA TDI pattern with LVEF ~30% (100% vs 25%, p< 0.01). The multivariate analysis show that the electromechanical pattern is a strong predictor for mortality indipendently from age. NYHA functional class, QRS narrowing, mitral regurgitation (x2= 0; df=l). Conclusions TDI is an useful method to assess the severity of LV asincrony. The electromechanical pattern is a strong predictor on mortality, rndipendently from LVEF, rn HF patients. 1189-38 Longitudinal Myocardial Displacement and Strain Rate in the Hypertrophied Heart Evaluated by Tissue Strain imaging With Doppler Angle Correction and Tissue Tracking Technique Tomotsuau Tabata, Hideji Tanaka, Eriko Kimura, Kenji Harada, Tetsuzo Wakatsuki, Takashi Yamamoto, Akihiro Saito, Kozo Uehara, Norihito Kageyama. Hirotsugu Yamada, Takashi Oki. The University of Tokushima, Tokushima, Japan, The National HigashiTokushima Hospital, Tokushima, Japan Background: The left ventricular (LV) systolic function in the long-axis direction has been evaluated by pulsed tissue Doppler mitral annular motion velocity. However, it could not avoId the effect of cardiac translation. A prototype software (ApliQ, Toshiba Corp.) was recently developed to obtain tissue strain imaging (TSI). In this program. the center of contraction was set in the LV cavity and velocity was automatically angle-corrected. The velocity values from the same region of moving myocardium were automatically defined and interrogated over time to yield displacement by 2D tissue Doppler tracking technique. TSI was finally obtained as a spatial derivative of the tissue displacement. Purpose To evaluate longrtudinal LV myocardial contractile characteristics in hypertrophied heart using TSI. Methods Subjects consisted of 20 normal (N), 20 hypertensive hypertrophy (HHD) and 12 asymmetric septal hypertrophy (ASH). Color tissue Doppler image was recorded from apical four chamber view and the TSI at the base of ventricular septum was analyzed off-line. Results Peak systolic displacement (Dp) and peak systolic strain rate (SRp) decreased and time to Dp prolonged in hypertrophied heart (table). Conclusions: Longitudinal myocardial fiber contraction was depressed in hypertrophied ventricular septum especially in asymmetric hypertrophy. TSI with Doppler angle correction and tissue trackrng can quantitatively evaluate longitudinal LV contractility regardless of cardiac translation.