Yasuhide Mochizuki

Comprehensive Functional Assessment of Right-Sided Heart Using Speckle Tracking Strain for Patients with Pulmonary Hypertension.

Right ventricular (RV) systolic function is one of the most important determinants of outcome for pulmonary hypertension (PH) patients, but the factors influencing prognosis vary widely. Elevated right atrial (RA) pressure is reported to be one of these prognostic factors, but its functional importance has scarcely been assessed.

Association of Apical Longitudinal Rotation with Right Ventricular Performance in Patients with Pulmonary Hypertension: Insights into Overestimation of Tricuspid Annular Plane Systolic Excursion

Current guidelines recommend the routine use of tricuspid annular plane systolic excursion (TAPSE) as a simple method for estimating right ventricular (RV) function. However, when ventricular apical longitudinal rotation (apical‐LR) occurs in pulmonary hypertension (PH) patients, it may result in overestimated TAPSE.

Bi-ventricular contractile reserve offers an incremental prognostic value for patients with dilated cardiomyopathy

AIMS Right ventricular (RV) as well as left ventricular (LV) function has been recognized as an important prognostic factor for heart failure patients. Our objective was thus to investigate the prognostic significance of combined assessment of bi-ventricular functional reserve for patients with dilated cardiomyopathy (DCM). METHODS AND RESULTS We studied 104 DCM patients with ejection fractions (EF) of 32 ± 9%, and speckle-tracking echocardiography was used to assess both RV and LV contractile reserve under dobutamine stress (20 µg/kg/min). RV contractile function was measured as peak global longitudinal strain (GLS) from the RV free wall (RV-free), and LV function as global circumferential strain (GCS) and GLS, respectively. Event-free survival was then tracked for 17 months. Twenty-one patients (20%) developed cardiovascular events. A multivariate Cox proportional-hazards analysis revealed that the baseline EF, E/A, and the relative change in EF (ΔEF), in GCS (ΔGCS), and in RV-free (ΔRV-free) during dobutamine stress were the independent predictors of cardiovascular events (P < 0.001, <0.05, <0.01, <0.05, and <0.01, respectively). A Cox model based on baseline clinical and echocardiographic variables (χ(2) = 23.6) was improved by the addition of LV contractile reserve parameters (plus ΔGCS and ΔEF) (χ(2) = 49.1; P < 0.001) and further improved by adding RV contractile reserve (plus ΔRV-free) (χ(2) = 60.3, P < 0.001). CONCLUSION Assessment of RV contractile reserve during dobutamine stress offers a significantly better prognostic value for patients with DCM. Bi-ventricular contractile reserve may be required for a favourable outcome, so that estimation of RV contractile reserve should be considered part of a comprehensive functional assessment of these patients.

Impaired Mechanics of Left Ventriculo-Atrial Coupling in Patients With Diabetic Nephropathy

BACKGROUND Diabetic nephropathy is independently associated with longitudinal systolic dysfunction of the left ventricle (LV) in asymptomatic diabetes mellitus (DM) patients with preserved LV ejection fraction (LVEF). However, the effect of diabetic nephropathy on left atrial (LA) function remains unknown. METHODSANDRESULTS We studied 198 asymptomatic DM patients (LVEF ≥50%). Diabetic nephropathy was defined as a protein level higher than for micro-albuminuria. LV global longitudinal strain (GLS) and LA strain were analyzed by 2D speckle-tracking; 69 age-, sex-, and LVEF-matched controls were also studied. GLS and LA strain in systole (LAS-s) decreased significantly from normal controls to DM patients without (n=137) and with nephropathy (n=61), in that order. Furthermore, GLS, LAS-s, and LA strain in late diastole (LAS-a) were significantly lower in DM patients with macro-albuminuria (n=19) than in those with micro-albuminuria (n=42). Although 1 multivariate regression analysis identified albuminuria as an independent determinative factor of LAS-s among other relevant clinical background factors (β=-0.16, P=0.002), another multivariate regression model for LAS-s+GLS (β=0.40, P<0.001) showed that albuminuria was not a significant factor (β=-0.02, P=0.68). Similarly, another multivariate regression model including GLS (β=0.32, P<0.001) demonstrated that clinical features relevant for LAS-a, except for age, were not independent determinants of LAS-a. CONCLUSIONS The cross-linked association of LA strain with GLS and albuminuria may be important for better understanding the development of diabetic cardiomyopathy. (Circ J 2016; 80: 1957-1964).

Association of Left Atrial Booster‐Pump Function with Heart Failure Symptoms in Patients with Severe Aortic Stenosis and Preserved Left Ventricular Ejection Fraction

Identification of heart failure (HF) symptoms in patients with severe aortic stenosis (AS) and preserved left ventricular (LV) ejection fraction (EF) is clinically important, but assessment of HF symptoms is challenging. It was recently reported that resting left atrium (LA) functions are related to exercise performance and are also important prognostic markers for patients with HF. The aim of this study was to assess the association of the HF symptoms with LA function in patients with severe AS and preserved LVEF.

Impact of left ventricular longitudinal functional mechanics on the progression of diastolic function in diabetes mellitus

Left ventricular (LV) diastolic dysfunction and longitudinal systolic dysfunction were identified in patients with diabetes mellitus (DM). This study’s aim was to investigate the impact of LV longitudinal systolic function on LV diastolic function in DM patients with preserved LV ejection fraction (LVEF). We studied 177 DM patients with preserved LVEF (all ≥50%), and 82 age-, gender- and LVEF-matched healthy volunteers as control. Global longitudinal strain (GLS) was defined as the average peak strain of 18 segments from standard apical views, GLS <18% as subclinical LV systolic dysfunction (LVSD), and LV dispersion as the standard deviation of time-to-peak strain from the same views. For DM patients with LVSD (n = 74), E/A and E’ were lower, and E/E’ and isovolumic relaxation time (IVRT) were greater than for DM patients without LVSD (n = 103) and normal controls (n = 82). Moreover, these parameters were lower for DM patients without LVSD than for normal controls. Multivariate analysis revealed that GLS was a strong determinative factor for E’ and E/E’ (β = 0.30, p < 0.001 and β = −0.25, p < 0.001, respectively), as was LV dispersion for E-wave deceleration time and IVRT (β = 0.21, p = 0.002 and β = 0.30, p < 0.001, respectively) independently of age. For normal subjects, however, only age was associated with all LV diastolic parameters. In conclusions, in contrast to age-related LV diastolic dysfunction in normal subjects, in DM patients with preserved LVEF, LV diastolic function was associated with LV longitudinal systolic function and LV dispersion independently of age. Our findings have obvious clinical implications for the management of DM patients.

Risk Stratification of Future Left Ventricular Dysfunction for Patients with Indications for Right Ventricular Pacing due to Bradycardia

Although right ventricular (RV) pacing is the only effective treatment for patients with symptomatic bradycardia, it creates left ventricular (LV) dyssynchrony, which can induce LV dysfunction and heart failure. The current criterion for consideration of cardiac resynchronization therapy (CRT) is LV ejection fraction (LVEF) ≤ 35%, but indication for CRT in patients required for RV pacing with LVEF > 35% remains unclear.We studied 40 patients, all LVEF ≥ 35%, who had undergone implantable cardioverter-defibrillator implantation with RV pacing < 5%. Echocardiography was performed at baseline and during RV pacing. LV dyssynchrony was defined as anteroseptal-to-posterior wall delay from the mid-LV short-axis view using two-dimensional speckle-tracking radial strain (significant: ≥ 130 ms). Patients were divided into two groups based on baseline LVEF: normal LVEF ( ≥ 50%; n = 20) and mildly reduced LVEF (35-50%; n = 20).LVEF and LV dyssynchrony in patients with mildly reduced LVEF deteriorated significantly during RV pacing compared to those in patients with normal LVEF. Moreover, changes in LV dyssynchrony during RV pacing significantly correlated with changes in LVEF (r = -0.44, P < 0.01). Multivariate logistic regression analysis showed that baseline LVEF was the only independent predictor and baseline LVEF < 48% predictive of significant LV dyssynchrony during RV pacing.The extent of RV pacing-induced LV dysfunction may be associated with baseline LV function. These adverse effects on patients with mildly reduced LVEF of 35-50% and indications for RV pacing due to bradycardia can thus be prevented by CRT.

Left ventricular dyssynergy and dispersion as determinant factors of fatal ventricular arrhythmias in patients with mildly reduced ejection fraction

AIMS Current guidelines recommend implantation of prophylactic implantable cardioverter-defibrillators (ICD) in patients with left ventricular (LV) ejection fraction (EF) <35%. We explored the prognostic factors of fatal ventricular arrhythmias for heart failure (HF) patients with LVEF ≥35%. METHODS AND RESULTS We retrospectively studied 72 patients with LVEF of 52 ± 12% (all ≥35%) who had undergone ICD implantation. Heterogeneity of LV regional myocardial contraction was defined as standard deviation of peak strain (dyssynergy index) and time-to-peak strain (dispersion index) from 18 LV segments determined by speckle tracking. Fatal ventricular arrhythmias with appropriate ICD therapy occurred in 34 patients (47%) during a median follow-up of 17 months. Receiver operating characteristic curve analysis identified dispersion index ≥101 ms and dyssynergy index ≥6.1% as predictors of fatal ventricular arrhythmias (P = 0.004 and P = 0.0001, respectively). In addition, the combination of dispersion index ≥101 ms and dyssynergy index ≥6.1% was the most predictive of fatal ventricular arrhythmias with a sensitivity of 77%, specificity of 79%, and area under the curve of 0.795 (P < 0.0001). A sequential Cox model based on clinical and conventional echocardiographic variables including age, gender, HF aetiology, and LVEF (χ(2) = 4.8) was improved, but not statistically significant (χ(2) = 4.9; P = 0.82), by addition of global longitudinal strain, whereas improvement by the addition of the dispersion index (χ(2) = 8.9; P = 0.04) and further improvement by the addition of the dyssynergy index (χ(2) = 20.2; P < 0.005). CONCLUSION Combined assessment of LV dyssynergy and dispersion can enhance predictive capability for fatal ventricular arrhythmias in patients with LVEF ≥35% and may have potential for better management of such patients.

Infective endarteritis associated with aortic dissection underlying bacterial meningitis

A 74-year-old male without a history of immunological disorders was transferred to our hospital for further evaluation of persistent high fever in spite of having received optimal antibiotics administration for 13 days. He was diagnosed with bacterial meningitis, and streptococcus agalactiae was identified by the findings of both cerebrospinal fluid culture and blood culture studies at the local hospital. A contrast …

Unusual rapid progression of non-bacterial thrombotic endocarditis in a patient with bladder cancer despite undergoing intensification treatment with rivaroxaban for acute venous thromboembolism

A 65-year-old man was referred to our department for evaluation of bilateral femoral swelling after total cystectomy and ureterostomy for advanced bladder cancer. Contrast-enhanced computed tomography detected a small pulmonary thromboembolism and a deep vein thrombus (Panels A and B). Transthoracic echocardiography showed normal mitral valve (Panel C; Supplementary material online, Video S1). The patient was pathophysiologically diagnosed with venous thromboembolism (VTE) associated with active cancer. Anticoagulant therapy with rivaroxaban was initiated at a dose of 30 mg for 3 weeks. However, 17 days after anticoagulant therapy, he presented to our hospital due to sudden onset of right lower limb paraesthesia, dysarthria, and agnosia. Brain magnetic resonance imaging showed acute sporadic infarction of left parietal lobe and subacute infarction of the left angular gyrus (Panel D). Transthoracic (Panel E; Supplementary material online, Video S2) and transoesophageal (Panel F) echocardiography at second admission demonstrated mobile and fragile vegetations (yellow arrow) 20 mm in diameter on the mitral valve, which was not observed 17 days before. According to urgent vegetectomy, non-bacterial vegetations were easily peeled off because the boundary between the vegetations and the mitral valve was relatively clear. Pathological images demonstrated that vegetation was composed of fibrin and red blood cells, whereas inflammatory cells and bacterial invasion were not observed (Panels G and H). This case was extremely rare due to the unusual and rapid progression of cancer-associated VTE not only in the venous system but also in the arterial system despite receiving adequate anticoagulation therapy with an adequate dose of rivaroxaban.