Tomoko Tamada

Influence of chronic tethering of the mitral valve on mitral leaflet size and coaptation in functional mitral regurgitation.

OBJECTIVES The purposes of this study were to examine whether tethering of the mitral leaflets affects coaptation in patients with functional mitral regurgitation (FMR) and to assess the interaction between the mitral coaptation and mitral regurgitation severity. BACKGROUND Functional mitral regurgitation causes restriction of leaflet closure as a result of enhanced tethering of the mitral leaflets and papillary muscle (PM) displacement. METHODS Three-dimensional transesophageal echocardiography was performed in 44 patients with FMR related to the bilateral PM displacement and in 56 controls. The distance between the tip of the anterior or posterior PM and the intervalvular fibrosa were measured as the lateral or medial tethering length (TL) in midsystole. To evaluate the degree of coaptation, coaptation length (CL) at medial, middle, and lateral sites of mitral valve and an estimate of coaptation area (CA) were measured. RESULTS The FMR group showed the significantly decreased CA (1.3 ± 0.4 cm(2) vs. 1.6 ± 0.4 cm(2), p = 0.005) and CL (medial 3.2 ± 0.9 mm vs. 4.8 ± 0.6 mm, middle 3.8 ± 1.3 mm vs. 5.8 ± 0.7 mm, lateral 3.3 ± 0.9 mm vs. 4.8 ± 0.6 mm; all p < 0.0001) compared with the controls. Each CL correlated negatively and significantly with both medial and lateral TL (all p < 0.0001). Annular area (p = 0.004) was significantly smaller and leaflet-to-annular area ratio (p < 0.0001) was significantly larger in patients with nonsignificant FMR than in the patients with significant (moderate to severe) FMR. Significant correlations were found between effective regurgitant orifice area and CA or each CL (all p < 0.0001). CONCLUSIONS Coaptation decreased significantly in patients with FMR. The CL at each region was related to PM displacement and the indexes of coaptation were associated with mitral regurgitation severity.

Impact of right ventricular involvement on the prognosis of takotsubo cardiomyopathy

BACKGROUND Previous studies showed that patients with takotsubo cardiomyopathy had a higher long-term mortality rate than the general population and the incidence of in-hospital complications was higher in takotsubo cardiomyopathy with than without right ventricular (RV) involvement. This study was performed to investigate the long-term prognostic impact of RV involvement in takotsubo cardiomyopathy. METHODS AND RESULTS The clinical data of 113 patients (72.7 ± 11.4 years old, 84 females) with takotsubo cardiomyopathy were studied retrospectively. The patients were divided into two groups according to the presence (biventricular group, n = 21, 18.6%) or absence (classical group, n = 92, 81.4%) of RV involvement assessed by initial echocardiography. The end point was a composite of all-cause death, re-hospitalization due to heart failure, and recurrence of takotsubo cardiomyopathy. The in-hospital mortality rate was significantly higher in the biventricular group than the classical group (14.3 vs. 1.1%, respectively, P = 0.02). Kaplan-Meier analysis indicated a significantly lower event-free survival rate in the biventricular group than the classical group (log-rank, P < 0.001). On multivariate analysis, RV involvement was the only independent predictor of the end point (HR: 2.73, P = 0.026). CONCLUSION The rates of in-hospital and long-term events were significantly higher in takotsubo cardiomyopathy with than without RV involvement, and RV involvement was the independent predictor of the poor prognosis.

In vivo assessment of vasa vasorum neovascularization using intravascular ultrasound: A comparison between acute coronary syndrome and stable angina pectoris

BACKGROUND Previous studies have suggested that vasa vasorum (VV) neovascularization plays an important role in the progression and vulnerability of coronary atherosclerotic plaque. METHODS A total of 130 patients with coronary artery disease including 75 acute coronary syndrome (ACS) cases and 55 stable angina pectoris (SAP) cases were studied. By using intravascular ultrasound (IVUS), VV was defined as a small (<1mm) tubular or vesicular, low-echoic structure observed exterior to the media. Prevalence and maximal number of VV were compared between patients with ACS versus SAP. RESULTS The prevalence of VV at the culprit lesion was similar between the 2 groups (97% vs. 93%, p=0.216). On the other hand, it was significantly higher in ACS than SAP at both reference sites (proximal: 93% vs. 81%, p=0.047 and distal: 88% vs. 60%, p<0.001, respectively). The maximum number of VV was significantly higher in ACS than in SAP (at the culprit lesion: 2.8±1.3 vs. 1.8±1.0, p<0.001, at the proximal reference: 1.9±1.1 vs. 1.3±0.9, p=0.003 and distal reference: 1.7±1.1 vs. 1.1±1.1, p=0.003, respectively). CONCLUSIONS VV neovascularization of coronary arteries was more enhanced in patients with ACS than in those with SAP, supporting its relation to plaque vulnerability. VV detected by widely used IVUS could be an adequate surrogate marker for plaque vulnerability in vivo.

A case of ventricular septal defect detected after myomectomy by intra-operative transesophageal echocardiography in patient with situs inversus and double-chambered right ventricle

A 48-year-old man was referred to our hospital because of exertional dyspnea. He had a history of situs inversus since his childhood. During physical examination, systolic murmur was audible at high right sternal border (Levine VI/ VI). Twelve-lead electrocardiography showed normal sinus rhythm with right ventricular (RV) hypertrophy and poor R wave progression in leads V3–6. The right-sided precordial leads showed RV hypertrophy and normalized R wave progression. Transthoracic echocardiography (TTE) showed normal left ventricular (LV) ejection fraction, biventricular hypertrophy, and aortic root was deviated to the right. It was diagnosed as I, L, and IN types (situs inversus, l-loop, and inverted normal) according to the guidelines for the clinical examinations for decision making of diagnosis, pathophysiology, and therapy in congenital heart disease [1]. In addition, TTE-showed anomalous muscle bundles divided the right ventricle (Fig. 1a, arrow: abnormal muscle band) and a muscular separation inside this chamber causing obstruction with a peak gradient of 63 mmHg and tricuspid valve regurgitation pressure gradient of 136 mmHg (Fig. 1b). He was performed cardiac catheterization. Right ventriculography showed stenosis of RV outflow tract (Fig. 1c). LV systolic pressure was 143 mmHg, and RV systolic pressure was 137 mmHg. He was diagnosed with situs inversus with double-chambered right ventricle (DCRV). He underwent RV myomectomy. After RV myomectomy, intra-operative transesophageal echocardiography (TEE) showed that pressure gradient between proximal and distal chamber into the right ventricle decreased from 63 to 23 mmHg. Shunt through from left ventricle to right ventricle was detected by intra-operative TEE (Fig. 1d). He, additionally, underwent VSD closure soon after the detection of VSD. Finally, he was diagnosed with situs inversus with DCRV and perimembranous type of VSD.

Coronary bifurcation bench test using multimodality imaging: Impact of stent strut link location on stent deformity and jailed side-branch orifices during re-proximal optimizing technique

The purpose of this study was to compare the stent deformation, obstruction of stent struts at a jailed side branch (SB) ostium, and stent strut malapposition after a repetitive proximal optimizing technique (re‐POT) sequence between bifurcation lesions with and without stent links at SB ostia in ex vivo experimental setting.

Bilateral atrial appendage thrombus formation in a patient with atrial fibrillation

A 60-year-old Japanese man without obvious past medical history was referred to our hospital because of dyspnea. An electrocardiogram revealed atrial fibrillation (AF) without ST-T change, and a chest X-ray showed mild pulmonary congestion and bilateral pleural effusion. Two-dimensional transthoracic echocardiography (2D TTE) on admission showed markedly reduced left ventricular systolic function (LVEF) of 19 % and enlarged heart chambers (Fig. 1a, b). We detected a left atrial appendage thrombus (Fig. 1c). 2D transesophageal echocardiography (2D TEE) was additionally performed to prepare for electrical cardioversion, and incidentally identified mobile thrombi in both the left atrial appendage (LAA) and right atrial appendage (RAA) (Fig. 2a–d). The patient underwent emergency prophylactic surgical resection of bilateral thrombi in order to prevent systemic and pulmonary embolism. The surgical procedure removed both LAA and RAA with thrombi. In addition, the ‘‘Maze’’ procedure was performed for the treatment of atrial fibrillation. Pathological findings showed a mixture of old and freshly organized thrombus in the LAA. On the other hand, the RAA thrombus mainly consisted of fresh thrombus (Fig. 3). In the present case, we were able to visualize both left and right appendage thrombi using 3D TEE. This is the first report of 3D TEE images of bilateral atrial thrombi. Thrombus formation in LAA is a common complication in patients with AF, and its incidence is quoted as 12–15 %. In contrast, the formation of a RAA thrombus is relatively rare, at 0.8–6 % [1–4], and few cases of bilateral appendage thrombosis have been reported [1]. In our case, the size of the RAA thrombus (3.39 9 2.01 cm) was larger than that of the LAA thrombus (2.53 9 1.26 cm), and this finding coincides with the previous report [1]. In addition, LV systolic dysfunction (reduced LVEF) is a risk factor for LV and LAA thrombus formation. A previous report suggested that LV end-diastolic diameter was correlated with LAA thrombus formation [5]. On the other hand, moderate to severe mitral regurgitation (MR) has been recognized as a negative predictor for the development of a left atrial thrombus [6, 7]. The severity of MR was mild in our case. We should pay attention to thrombus formation in not only the left but also the right atrial appendage, especially in patients with AF and reduced LV systolic function. Recently, real-time three-dimensional (3D) TEE has been a

New Echo Window to Quantify Eccentric Mitral Regurgitation Using a Transgastric Approach on Transesophageal Echocardiography

Received October 8, 2014; accepted October 22, 2014; released online November 20, 2014 Time for primary review: 13 days Division of Cardiology, Kawasaki Medical School, Kurashiki (T.T., H.O.); Division of Cardiology, Sakakibara Heart Institute of Okayama, Okayama (K.Y.), Japan Mailing address: Hiroyuki Okura, MD, Division of Cardiology, Kawasaki Medical School, 577 Matsushima, Kurashiki 701-0192, Japan. E-mail: hokura@fides.dti.ne.jp ISSN-1346-9843 doi: 10.1253/circj.CJ-14-1103 All rights are reserved to the Japanese Circulation Society. For permissions, please e-mail: cj@j-circ.or.jp New Echo Window to Quantify Eccentric Mitral Regurgitation Using a Transgastric Approach on Transesophageal Echocardiography

ECHOCARDIOGRAPHIC FINDINGS IN TAKOTSUBO CARDIOMYOPATHY: BEYOND APICAL BALLOONING

Takotsubo cardiomyopathy (TC) is characterized by acute and transient left ventricular (LV) wall motion abnormalities triggered by emotional and/or physical stress. Although, it was named after the unique “Takotsubo like” wall motion, recent studies have shown possible variants of TC such as “

QUANTIFICATION OF THE MITRAL VALVE APPARATUS BY THREE-DIMENSIONAL TRANSESOPHAGEAL ECHOCARDIOGRAPHY: AN IN VITRO VALIDATION STUDY COMPARING TWO DIFFERENT ANALYSIS SYSTEMS

Background Two commercial software systems have become available for quantitation of mitral leaflet and annulus geometry based on three-dimensional (3D) transesophageal echocardiographic (3DTEE) images. The aim of this study is to investigate the accuracy and compatibility of the three-dimensional (3D) measurements by Real View® and MVQ®.