Shinichi Minagoe

Isolated annular dilation does not usually cause important functional mitral regurgitation: comparison between patients with lone atrial fibrillation and those with idiopathic or ischemic cardiomyopathy.

OBJECTIVES We sought to test whether isolated mitral annular (MA) dilation can cause important functional mitral regurgitation (MR). BACKGROUND Mitral annular dilation has been considered a primary cause of functional MR. Patients with functional MR, however, usually have both MA dilation and left ventricular (LV) dilation and dysfunction. Lone atrial fibrillation (AF) can potentially cause isolated MA dilation, offering a unique opportunity to relate MA dilation to leaflet function. METHODS Mid-systolic MA area, MR fraction, LV volumes and papillary muscle (PM) leaflet tethering length were compared by echocardiography among 18 control subjects, 25 patients with lone AF and 24 patients with idiopathic or ischemic cardiomyopathy (ICM). RESULTS Patients with lone AF had a normal LV size and function but MA dilation (isolated MA dialtion) significant and comparable to that of patients with ICM (MA AREA: 8.0 +/- 1.2 vs. 11.6 +/- 2.3 vs. 12.5 +/- 2.9 cm(2) [control vs. lone AF vs. ICM]; p < 0.001 for both lone AF and ICM). However, patients with lone AF had only modest MR, compared with that of patients with ICM (MR fraction: -3 +/- 8% vs. 3 +/- 9% vs. 36 +/- 25%; p < 0.001 for patients with ICM). Multivariate analysis identified PM tethering length, not MA dilation, as an independent primary contributor to MR. CONCLUSIONS Isolated annular dilation does not usually cause moderate or severe MR. Important functional MR also depends on LV dilation and dysfunction, leading to an altered force balance on the leaflets, which impairs coaptation.

Repeated Sauna Treatment Improves Vascular Endothelial and Cardiac Function in Patients With Chronic Heart Failure

OBJECTIVES The purpose of this study was to determine the mechanism by which 60 degrees C sauna treatment improves cardiac function in patients with chronic heart failure (CHF). BACKGROUND We have previously reported that repeated 60 degrees C sauna treatment improves hemodynamic data and clinical symptoms in patients with CHF. We hypothesized that the sauna restores endothelial function and then improves cardiac function. METHODS Twenty patients (62 plus minus 15 years) in New York Heart Association (NYHA) functional class II or III CHF were treated in a dry sauna at 60 degrees C for 15 min and then kept on bed rest with a blanket for 30 min, daily for two weeks. Ten patients with CHF, matched for age, gender and NYHA functional class, were placed on a bed in a temperature-controlled (24 degrees C) room for 45 min as the nontreated group. Using high-resolution ultrasound, we measured the diameter of the brachial artery at rest and during reactive hyperemia (percent flow-mediated dilation, %FMD: endothelium-dependent dilation), as well as after sublingual administration of nitroglycerin (%NTG: endothelium-independent dilation). Cardiac function was evaluated by measuring the concentrations of plasma brain natriuretic peptide (BNP). RESULTS Clinical symptoms were improved in 17 of 20 patients after two weeks of sauna therapy. The %FMD after two-week sauna treatment significantly increased from the baseline value, whereas the %NTG-induced dilation did not. Concentrations of BNP after the two-week sauna treatment decreased significantly. In addition, there was a significant correlation between the change in %FMD and the percent improvement in BNP concentrations in the sauna-treated group. In contrast, none of the variables changed at the two-week interval in the nontreated group. CONCLUSIONS Repeated sauna treatment improves vascular endothelial function, resulting in an improvement in cardiac function and clinical symptoms.

Repeated thermal therapy improves impaired vascular endothelial function in patients with coronary risk factors

OBJECTIVES We sought to determine whether sauna therapy, a thermal vasodilation therapy, improves endothelial function in patients with coronary risk factors such as hypercholesterolemia, hypertension, diabetes mellitus and smoking. BACKGROUND Exposure to heat is widely used as a traditional therapy in many different cultures. We have recently found that repeated sauna therapy improves endothelial and cardiac function in patients with chronic heart failure. METHODS Twenty-five men with at least one coronary risk factor (risk group: 38 +/- 7 years) and 10 healthy men without coronary risk factors (control group: 35 +/- 8 years) were enrolled. Patients in the risk group were treated with a 60 degrees C far infrared-ray dry sauna bath for 15 min and then kept in a bed covered with blankets for 30 min once a day for two weeks. To assess endothelial function, brachial artery diameter was measured at rest, during reactive hyperemia (flow-mediated endothelium-dependent dilation [%FMD]), again at rest and after sublingual nitroglycerin administration (endothelium-independent vasodilation [%NTG]) using high-resolution ultrasound. RESULTS The %FMD was significantly impaired in the risk group compared with the control group (4.0 +/- 1.7% vs. 8.2 +/- 2.7%, p < 0.0001), while %NTG was similar (18.7 +/- 4.2% vs. 20.4 +/- 5.1%). Two weeks of sauna therapy significantly improved %FMD in the risk group (4.0 +/- 1.7% to 5.8 +/- 1.3%, p < 0.001). In contrast, %NTG did not change after two weeks of sauna therapy (18.7 +/- 4.2% to 18.1 +/- 4.1%). CONCLUSIONS Repeated sauna treatment improves impaired vascular endothelial function in the setting of coronary risk factors, suggesting a therapeutic role for sauna treatment in patients with risk factors for atherosclerosis.

Mechanism of Persistent Ischemic Mitral Regurgitation After Annuloplasty Importance of Augmented Posterior Mitral Leaflet Tethering

Background—We hypothesized that surgical annuloplasty for ischemic mitral regurgitation (MR) that displaces the posterior annulus anteriorly can potentially augment posterior leaflet (PML) tethering, leading to persistent MR. Relationships between leaflet configurations and persistent ischemic MR after the annuloplasty were investigated. Methods and Results—In 31 patients with surgical annuloplasty for ischemic MR and 20 controls, posterior and apical displacement of the leaflet coaptation, the anterior leaflet (AML) and PML tethering angles relative to the line connecting annuli, coaptation length (CL), and the MR grade were quantified before and early after surgery in echocardiographic left ventricular long-axis views. Six of the 31 patients showed persistent MR despite annuloplasty. Compared with patients without persistent MR, those with MR showed no improvement in the left ventricular ejection fraction and systolic volume, similar reduction in the annular area, significant increase in posterior displacement of the coaptation (P<0.01), no improvement in AML tethering, greater worsening in PML tethering (P<0.01), and no increase in the CL. All tethering variables were significantly correlated with both preoperative and postoperative MR in univariate analysis, and reduced CL was the primary independent determinant of both preoperative and postoperative MR. Although increased AML tethering was the primary determinant of the preoperative CL (r2=0.46, P<0.0001), increased PML tethering was the primary determinant afterward (r2=0.60, P<0.0001). Conclusion—Although tethering of both leaflets is the major determinant of ischemic MR before surgical annuloplasty, both leaflets tethering but with predominant and augmented PML tethering is related to persistent ischemic MR after the annnuloplasty.

Pseudonormalized Doppler total ejection isovolume (Tei) index in patients with right ventricular acute myocardial infarction.

The Doppler total ejection isovolume (Tei) index is useful for estimating global cardiac function. However, the relation between the right ventricular (RV) Tei index and RV infarction has not been investigated. The relation between the RV Tei index and severity of RV infarction was evaluated in 25 patients with inferior wall acute myocardial infarction (13 with and 12 without RV infarction). RV infarction was diagnosed when right atrial pressure was > or = 10 mm Hg or when right atrial pressure/pulmonary capillary wedge pressure was >0.8 by catheterization. The RV Tei index was significantly increased in patients with RV infarction compared with those without (0.53 +/- 0.15 vs 0.38 +/- 0.14, p <0.05). The RV Tei index in patients with severe RV infarction (right atrial pressure > or = 15 mm Hg) was significantly smaller compared with those with mild/moderate RV infarction (right atrial pressure <15 mm Hg) and showed no significant difference in patients with myocardial infarction but without RV infarction (0.44 +/- 0.09 vs 0.61 +/- 0.16 vs 0.38 +/- 0.14, severe RV infarction vs mild/moderate RV infarction vs no RV infarction, p <0.01). The RV Tei index is generally increased in patients with RV infarction; however, severe RV infarction can be manifested with limited or no increase in the Tei index (pseudonormalization).

The Effects of Repeated Thermal Therapy for Patients with Chronic Pain

Background: It has been reported that local thermal therapy with a hot pack or paraffin relieves pain. We hypothesized that systemic warming may decrease pain and improve the outcomes in patients with chronic pain. The purpose of this study was to clarify the effects of systemic thermal therapy in patients with chronic pain. Methods: Group A (n = 24) patients with chronic pain were treated by a multidisciplinary treatment including cognitive behavioral therapy, rehabilitation, and exercise therapy, whereas group B (n = 22) patients were treated by a combination of multidisciplinary treatment and repeated thermal therapy. A far-infrared ray dry sauna therapy and post-sauna warming were performed once a day for 4 weeks during hospitalization. We investigated the improvements in subjective symptoms, the number of pain behavior after treatment and outcomes 2 years after discharge. Results: The visual analog pain score, number of pain behavior, self-rating depression scale, and anger score significantly decreased after treatment in both groups. After treatment, the number of pain behavior was slightly smaller (p = 0.07) and anger score was significantly lower in group B than those in group A (p = 0.05). Two years after treatment, 17 patients (77%) in group B returned to work compared with 12 patients (50%) in group A (p < 0.05). Conclusion: These results suggest that a combination of multidisciplinary treatment and repeated thermal therapy may be a promising method for treatment of chronic pain.

Repeated Thermal Therapy Diminishes Appetite Loss and Subjective Complaints in Mildly Depressed Patients

Objective: We observed that repeated thermal therapy improved appetite loss and general well-being in patients with chronic heart failure. The purpose of this study is to clarify the effects of repeated thermal therapy in mildly depressed patients with appetite loss and subjective complaints. Methods: Twenty-eight mildly depressed inpatients with general fatigue, appetite loss, and somatic and mental complaints were randomly assigned to thermal therapy group (n = 14) or nonthermal therapy group (n = 14). Patients in the thermal therapy group were treated with 60°C far-infrared ray dry sauna for 15 minutes and were then kept at bed rest with a blanket for 30 minutes once a day, 5 days a week for a total of 20 sessions in 4 weeks. Results: Four weeks after admission, somatic complaints, hunger, and relaxation scores significantly improved (p < .001, p < .0001, p < .0001, respectively) and mental complaints slightly improved (p = .054) in the thermal therapy group compared with the nonthermal therapy group. Furthermore, the plasma ghrelin concentrations and daily caloric intake in the thermal therapy group significantly increased compared with the nonthermal therapy group (p < .05). Conclusions: These findings suggest that repeated thermal therapy may be useful for mildly depressed patients with appetite loss and subjective complaints. ICD = International Classification of Disease; BMI = body mass index; CMI = Cornell Medical Index; SDS = Self-Rating Depression Scale; VAS = visual analog scale.

Noninvasive evaluation of coronary reperfusion by transthoracic Doppler echocardiography in patients with anterior acute Myocardial Infarction before coronary intervention

Background—Transthoracic Doppler echocardiography (TTDE) enables evaluation of distal left anterior descending coronary artery (LAD) flow. The purpose of this study was to test whether TTDE can differentiate coronary reperfusion with Thrombolysis in Myocardial Infarction (TIMI) grade 3 from TIMI grade ≤2 in patients with anterior acute myocardial infarction (AMI). Methods and Results—In 46 consecutive patients with a first anterior AMI in the acute phase before emergent coronary intervention, the presence of antegrade distal LAD flow and its diastolic peak velocity were evaluated by color and pulsed TTDE and compared with TIMI grades by subsequent coronary angiography performed 29±12 minutes later. Nineteen patients had TIMI 0 reperfusion, 4 had TIMI 1, 10 had TIMI 2, and 13 had TIMI 3. Visual antegrade distal LAD flow was present in 22 of the 46 patients. TIMI 2 and 3 reperfusions were both generally visualized by color TTDE. However, peak distal LAD flow velocity by pulsed TTDE was significantly greater in patients with TIMI 3 compared with those with TIMI 2 (40±10 vs 20±6 cm/s, P <0.0001). The diagnosis of TIMI 3 based on diastolic peak distal LAD flow velocity ≥25 cm/s by TTDE had a sensitivity, specificity, and accuracy of 77%, 94%, and 89%, respectively. Conclusion—TTDE enables noninvasive differentiation of TIMI 3 from TIMI ≤2 coronary reperfusion in patients with AMI in the acute phase before emergent coronary intervention.

Real-time cross-sectional echocardiographic evaluation of the interatrial septum by right atrium-interatrial septum-left atrium direction of ultrasound beam.

Real-time cross-sectional echocardiography was performed to record the interatrial septal echogram by right atrium-interatrial septum-left atrium (ASA) direction of the ultrasound beam by positioning the transducer to the right of the sternum. The configuration of the interatrial septum (IAS) and the change of the configuration through each cardiac cycle were studied in 10 normal subjects and 29 patients with left or right atrial overloading.In normal subjects the IAS was slightly convex toward the right atrium (RA) in end-systole and slightly convex toward the left atrium (LA) in end-diastole, respectively. In patients with mitral stenosis, the IAS protruded archwise toward the RA both in end-systole and in end-diastole, and showed only minimum difference through each cardiac cycle. In patients with acute mitral regurgitation, the IAS was markedly convex toward the RA in end-systole and slightly convex toward the LA in end-diastole; thus, the difference of the configuration of the IAS was increased. In patients with chronic mitral regurgitation, the IAS was moderately convex toward the RA in end systole and flat or slightly convex toward the RA in end-diastole. In patients with tricuspid regurgitation, the interatrial septal echogram showed several patterns. However, the change in the configuration of the IAS throughout the cardiac cycle showed a characteristic pattern, i.e., it was more convex toward the LA or less convex toward the RA in end-systole than in end-diastole.The observation of the change in the interatrial septal configuration may be useful in the diagnosis of right or left atrial overloading. The mechanism by which the configuration is altered seems to be the interatrial pressure gradient through each cardiac cycle.

Value of acceleration flow signals proximal to the leaking orifice in assessing the severity of prosthetic mitral valve regurgitation

To test the value of acceleration flow signals proximal to the leaking orifice in assessing the severity of prosthetic mitral valve regurgitation, 39 consecutive patients undergoing left ventriculography were examined by Doppler color flow imaging. Acceleration flow signals proximal to the regurgitant orifice were detected in 27 of the 31 patients who had prosthetic mitral regurgitation by left ventriculography (sensitivity 87%). All four patients without acceleration flow signals had mild prosthetic mitral regurgitation by angiography. No acceleration flow signals were detected in any patient without prosthetic regurgitation by left ventriculography (specificity 100%). Individual values of the maximal area of acceleration flow signals obtained from three orthogonal planes in seven patients with mild prosthetic mitral regurgitation by angiography ranged from 0 to 17 mm2 (mean 4 +/- 6). In 8 patients with moderate prosthetic mitral regurgitation by angiography, the maximal area of acceleration flow signals ranged from 21 to 58 mm2 (mean 33 +/- 15), whereas the maximal area of acceleration flow signals in 16 patients with severe prosthetic regurgitation ranged from 20 to 173 mm2 (mean 102 +/- 41). The maximal area of the acceleration flow signals from three planes correlated well with the angiographic grade of prosthetic mitral regurgitation. There was a significant difference in the maximal area of acceleration flow signals between mild and moderate (p less than 0.001), moderate and severe (p less than 0.001) and mild and severe (p less than 0.001) prosthetic mitral regurgitation. Thus, measurement of acceleration flow signals by Doppler color flow imaging is useful in assessing the severity of prosthetic mitral regurgitation.