Takenori Otsuka

Left ventricular diastolic dysfunction in the early stage of chronic kidney disease

BACKGROUND The disadvantageous effect of kidney dysfunction on left ventricular (LV) diastolic function is still unknown. METHODS Forty non-chronic kidney disease (CKD) patients and 202 CKD patients, aged 40-89, were examined by standard echocardiography and the new modality of tissue Doppler imaging. All subjects were divided into 5 groups depending on their estimated glomerular filtration rate (GFR: ml/min/BSA). Classifications by GFR were defined as follows: group 1 (more than 90: normal subjects), group 2 (60-89), group 3 (30-59), group 4 (15-29) and group 5 (less than 15). RESULTS There were no significant differences in LV systolic function among the groups. Mitral E velocity was significantly lower in groups 1-4 (p<0.01-0.02) compared with group 5. Mitral A velocity was higher in groups 2-5 (p<0.01-0.04) compared with group 1. The ratio of mitral E and A velocities (E/A) was significantly higher in group 1 (p<0.02-0.05) compared with groups 2-5. Deceleration time was significantly shorter in groups 1 and 2 (p<0.01-0.02) compared with groups 4 and 5. Furthermore, it was significantly lower in group 5 (p<0.01) compared with group 4. Early diastole velocity of mitral annulus (Ea) by tissue Doppler was also higher in group 1 (9.1+/-2.5; p<0.01-0.04) compared with group 2 (7.9+/-1.7), group 3 (7.9+/-1.6), group 4 (7.5+/-2.1), and group 5 (7.6+/-2.0). Severity of the kidney dysfunction appears to parallel with the rise of E/Ea significantly (p<0.02). A, E/A and Ea could differentiate between groups 1 and 2 with early stage of CKD. CONCLUSIONS These data suggest that LV diastolic dysfunction was observed even in patients with early stages of chronic kidney dysfunction. Doppler indices combined with conventional and tissue Doppler methods could detect the subtle changes of diastolic function due to kidney dysfunction.

Differences in left ventricular dyssynchrony between high septal pacing and apical pacing in patients with normal left ventricular systolic function.

BACKGROUND AND PURPOSE Permanent right ventricular apical pacing can result in heart failure due to ventricular mechanical dyssynchrony. The purpose of the study was to define differences in left ventricular dyssynchrony between high septal pacing and apical pacing using tissue Doppler imaging (TDI) and two-dimensional (2D) speckle-tracking echocardiography (STE). METHODS The subjects were 60 patients with normal left ventricular systolic function who underwent implantation of a permanent pacemaker. Patients were divided into two groups with high septal pacing (n=36) and conventional right apical pacing (n=24). Left ventricular dyssynchrony was measured using TDI and 2D-STE. The time difference (TD) between the earliest and latest activated segments obtained from each systolic velocity curve by TDI was defined as TD-TDI. The time differences obtained from systolic strain curves obtained by 2D-STE were defined as TD-RS for radial strain, TD-CS for circumferential strain, and TD-LS for longitudinal strain. RESULTS The high septal pacing group had significantly shorter TD-TDI (20.0+/-24.3ms vs. 59.7+/-43.0ms, p<0.0001), TD-RS (13.5+/-19.9ms vs. 45.8+/-24.6ms, p<0.0001), and TD-LS (42.7+/-22.0ms vs. 66.6+/-26.8ms, p=0.001) values compared to the apical pacing group. There was no significant difference in TD-CS between the two groups. CONCLUSION Left ventricular dyssynchrony was smaller in patients with high septal pacing. The results show that 2D-STE is useful for detection of differences in left ventricular mechanical dyssynchrony in patients with permanent pacemaker implantation, in addition to TDI.

Midwall ejection fraction for assessing systolic performance of the hypertrophic left ventricle

BackgroundIn patients with left ventricular hypertrophy (LVH), LV midwall fractional shortening (FS) is used as a measure of LV systolic performance that is more physiologically appropriate than conventional FS. For evaluation of LV volume and ejection fraction (EF), 2-dimensional (2D) echocardiography is more accurate than M-mode echocardiography. The purpose of this study was to assess systolic performance by midwall EF using 2D speckle tracking echocardiography (STE).MethodsSixty patients were enrolled in the study. Patients were divided into two groups with LVH (n = 30) and without LVH (control group, n = 30). LV systolic function was compared between the two groups and the relationships of left ventricular mass index (LVMI) with LV systolic parameters, including midwall EF, were investigated.ResultsMidwall EF in the LVH group was significantly lower than that in the control group (42.8±4.4% vs. 48.1±4.1%, p <0.0001). Midwall FS was also significantly lower in the LVH group (13.4±2.8% vs. 16.1±1.5%, p <0.0001), but EF did not differ significantly between the two groups. There were significant correlations between midwall EF and LVMI (r=0.731, p <0.0001) and between midwall FS and LVMI (r=0.693, p <0.0001), with midwall EF having the higher correlation.ConclusionsThese results show that midwall EF can be determined using 2D STE. Midwall EF can be used to monitor LV systolic dysfunction, which is not possible with conventional EF. Evaluation of midwall EF may allow assessment of new parameters of LV systolic function in patients with LV geometric variability.

A case of bicuspid aortic valve with two raphes

A 60-year-old woman was referred to our hospital for exertional shortness of breath. She was made aware of a heart murmur as a high school student. She had exertional dyspnea and chest pain. Her symptoms were getting worse over the previous year. On admission, her blood pressure was 160/54 mmHg, heart rate was 72 bpm, and grade 3/6 regurgitant murmur over the precordium was present. She was diagnosed with severe aortic regurgitation by transthoracic echocardiography and the other clinical examination. Transthoracic echocardiography showed severe aortic regurgitation with normal left ventricular systolic function. Two raphes of the aortic valve were not diagnosed by transthoracic echocardiography because of poor quality echo images. Two-dimensional transesophageal echocardiograms showed a bicuspid aortic valve (BAV) with fused cusps between the two components of the right and noncoronary cusps (Fig. 1). Furthermore there were two raphes on the fused cusps. Real-time three-dimensional echocardiograms showed two commissures and two raphes on the fused area in systole and diastole (Fig. 2a, b). The perioperative findings were exactly the same as the information obtained by three-dimensional transesophageal echocardiography (Fig. 2c). Discussion

Impact of Cilostazol on Left Ventricular Geometry and Function: Assessment by Tissue Doppler Imaging and Two-Dimensional Speckle-Tracking Echocardiography

Objectives: Cilostazol, a type III phosphodiesterase inhibitor, is an antiplatelet agent with vasodilating properties. Positive inotropic and chronotropic effects are frequently observed with cilostazol, but there are few reports on the influence of cilostazol on left ventricular function. The aim of this study was to assess this effect using tissue Doppler imaging (TDI) and two‐dimensional speckle‐tracking echocardiography (2D‐STE). Methods: Thirty‐five patients with normal left ventricular ejection fraction were enrolled in the study. Left ventricular cardiac function was assessed by TDI and 2D‐STE before and after oral administration of cilostazol. Peak strain was defined using the peak radial strain (PRS), peak circumferential strain (PCS) and peak longitudinal strain (PLS). Time to peak strain was defined based on the times to PRS, PCS, and PLS, as T‐PRS, T‐PCS, and T‐PLS, respectively. Results: After cilostazol administration, there were significant decreases in the left ventricular end‐diastolic and end‐systolic diameters (47.3 ± 5.2 vs. 43.3 ± 4.9 mm, P < 0.0001; 29.3 ± 6.4 vs. 26.0 ± 5.5 mm, P < 0.0001, respectively), and significant increases in the left ventricular ejection fraction (70.6 ± 9.5 vs. 72.7 ± 7.8%, P = 0.0381) and peak systolic annular velocity (7.9 ± 1.7 vs. 9.5 ± 3.1 cm/sec, P < 0.0001). PRS, PCS, and PLS all increased significantly and T‐PRS, T‐PCS, and T‐PLS all decreased significantly after cilostazol administration. Conclusion: Positive inotropic and chronotropic effects of cilostazol were found based on assessment by TDI and 2D‐STE. We suggest that periodic echocardiographic assessment should be performed before and after oral administration of cilostazol. (Echocardiography 2011;28:431‐437)