Yuichi Sato

Short-term effects of low-dose tolvaptan on hemodynamic parameters in patients with chronic heart failure

BACKGROUNDnWe evaluated the short-term effects of low-dose tolvaptan treatment on hemodynamic parameters in patients with chronic heart failure (HF).nnnMETHODSnWe studied 22 patients (69 ± 10 years) with chronic HF and excess fluid retention despite receiving appropriate medical therapy, including loop and/or thiazide diuretics. The therapeutic effects of low-dose (7.5mg) once-daily tolvaptan on hemodynamics associated with changes in fluid balance and neurohumoral activations were investigated after a seven day treatment period.nnnRESULTSnAfter the treatment period, body weight decreased (-2.7 ± 2.3 kg) associated with increases in daily urine output. Whereas plasma arginine-vasopressin levels, serum aldosterone concentration, and plasma renin activity mildly increased, plasma levels of B-type natriuretic peptide and atrial natriuretic peptide significantly decreased after tolvaptan treatment. Serum electrolytes were not adversely affected by tolvaptan treatment. Although cardiac index and systemic vascular resistance index remained unchanged, mean pulmonary artery wedge pressure (22 ± 7 mmHg vs. 17 ± 7 mmHg, p<0.05), mean right atrial pressure (12 ± 5 mmHg vs. 9 ± 5 mmHg, p<0.05), mean pulmonary artery pressure (32 ± 9 mmHg vs. 25 ± 7 mmHg, p<0.05), and pulmonary vascular resistance index (332 ± 207 dynes/cm(-5)/m(2) vs. 245 ± 110 dynes/cm(-5)/m(2), p<0.05) significantly decreased after tolvaptan treatment. The extent of the reduction in pulmonary vascular resistance index after tolvaptan treatment strongly correlated with baseline values.nnnCONCLUSIONSnShort-term treatment with low-dose tolvaptan improved hemodynamic parameters and correlated with significant fluid removal in patients with chronic HF.

Interrelationship between haemodynamic state and serum intact parathyroid hormone levels in patients with chronic heart failure

Objective To assess the impact of serum intact parathyroid hormone (PTH) levels on haemodynamic state and their relations by comparing plasma B-type natriuretic peptide (BNP) levels. Design Cross-sectional study in molecular epidemiology. Setting Mie University Hospital, Tsu, Japan. Patients Consecutive 105 patients with chronic heart failure (CHF). Main outcome measures Serum intact PTH and plasma BNP levels were assessed simultaneously with right heart catheterisation. Results Although serum intact PTH levels (46±25u2005pg/ml) were within the normal range (<65u2005pg/ml) in 87% of patients, log-transformed intact PTH levels significantly correlated with pulmonary capillary wedge pressure (PCWP: 15±9u2005mmu2005Hg, r=0.55, p<0.05) and heart rate (73±14/min, r=0.40, p<0.05), whereas log-transformed intact PTH levels were inversely correlated with stroke volume index (SVI: 38±11u2005ml/m2, r=−0.52, p<0.05) and cardiac index (2.6±0.7u2005l/min/m2, r=−0.41, p<0.05) in all patients. PCWP and SVI were independent determinants of log-transformed intact PTH levels (β=0.40 and −0.37, p<0.05, respectively) after adjusting for variables associated with PTH. Conversely, after adjusting for variables associated with CHF, log-transformed intact PTH levels were an independent determinant of PCWP, SVI, heart rate and cardiac index (β=0.38, −0.33, 0.32, and −0.25, p<0.05, respectively), and might be defined as a superior determinant of SVI and cardiac index compared with log-transformed BNP levels using stepwise multivariate regression analyses. Conclusions Increased PCWP and decreased SVI independently contribute to elevated intact PTH in patients with CHF.

Biventricular pacing worsened dyssynchrony in heart failure patient with right-bundle branch block

The use of a biventricular pacing system for patients with complete right-bundle branch block (CRBBB) is still controversial. Although cardiac resynchronization therapy-defibrillator (CRT-D) was implanted in a heart failure patient with CRBBB, dyssynchrony worsened and stroke volume decreased, and this patient was re-admitted due to exacerbated heart failure. Therefore, evaluation of dyssynchrony and cardiac function after implantation of a biventricular pacing system may be needed in patients with atypical indications for CRT.

Recurrent inflammatory aortic aneurysms in chronic mucocutaneous candidiasis with a gain-of-function STAT1 mutation

a Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Japan b Department of Pediatrics, Mie University Graduate School of Medicine, Tsu, Japan c Department of Thoracic and Cardiovascular Surgery, Mie University Graduate School of Medicine, Tsu, Japan d Department of Hematology and Oncology, Mie University Graduate School of Medicine, Tsu, Japan e Department of Pathology and Matrix Biology, Mie University Graduate School of Medicine, Tsu, Japan f Department of Cell Transplantation, Mie University Graduate School of Medicine, Tsu, Japan g Mie University Research Center for Matrix Biology, Tsu, Japan

Quantifying longitudinal right ventricular dysfunction in patients with old myocardial infarction by using speckle-tracking strain echocardiography

BackgroundWe investigated longitudinal right ventricular (RV) function assessed using speckle-tracking strain echocardiography in patient with myocardial infarction (MI), and identified the contributing factors for RV dysfunction.MethodsWe retrospectively studied 71 patients with old MI (the OMI group) and 45 normal subjects (the Control group) who underwent a transthoracic echocardiography. Global and free wall RV peak systolic strains (PSSs) in the longitudinal direction were measured by using speckle-tracking strain echocardiography. Left ventricular (LV) PSSs were measured in the longitudinal, radial and circumferential directions. Cardiac hemodynamics including peak systolic pulmonary artery pressure was also assessed non-invasively. Plasma brain natriuretic peptide (BNP) levels were measured in all patients.ResultsIn the OMI group, 73% of the patients had a normal estimated peak systolic pulmonary artery pressure of less than 35u2009mmHg. Global and free wall RV PSS were impaired in the OMI group compared with the Control group, and these RV systolic indices were significantly associated with heart rate, logarithmic transformed plasma BNP, greater than 1 year after onset of MI, Doppler-derived estimated pulmonary vascular resistance, LV systolic indices, LV mass index, infarcted segments within a territory of the left circumflex artery and residual total occlusion in the culprit right coronary artery. Multivariable linear regression analysis indicated that reduced longitudinal LV PSS in the 4-chamber view and BNP levels ≥500 pg/ml were independently associated with reduced global and free wall RV PSS. Moreover, when patients were divided into 3 groups according to plasma BNP levels (BNP <100 pg/ml; n = 31, 100 ≤BNP <500 pg/ml; n = 24, and BNP ≥500 pg/ml; n = 16), only patients with BNP ≥500 pg/ml had a strong correlation between RV PSS and longitudinal LV PSS in the 4-chamber view (r = 0.78 for global RV PSS and r = 0.71 for free wall RV PSS, p <0.05).ConclusionLongitudinal RV systolic strain depends significantly on longitudinal LV systolic strain especially in patients with high plasma BNP levels, but not on estimated peak systolic pulmonary artery pressure. These results indicate that process of RV myocardial dysfunction following MI may be governed by neurohormonal activation which causing ventricular remodeling rather than increased RV afterload.

Combination of Urinary Sodium/Creatinine Ratio and Plasma Brain Natriuretic Peptide Level Predicts Successful Tolvaptan Therapy in Patients With Heart Failure and Volume Overload

To evaluate the short-term clinical and hemodynamic effects of tolvaptan therapy and to identify predictors of the therapeutic outcomes, we retrospectively recruited 60 consecutive hospitalized heart failure (HF) patients (70 ± 11 years) with volume overload. The subjects were divided into two groups on the basis of the changes in HF symptom scores and hemodynamic status assessed by right heart catheterization after tolvaptan therapy (median: 7 days). The majority of patients were successfully treated (group 1). However, 22% of patients (group 2) were unsuccessfully treated, in whom 1) the HF symptom score worsened or 2) there was a stationary HF symptom score ≥ 6 points, and mean PCWP > 18 mmHg and mean RAP > 10 mmHg, after tolvaptan therapy. HF symptom scores, hemodynamic parameters, and plasma brain natriuretic peptide (BNP) level improved in group 1, but all of these parameters remained unchanged in group 2. Lower urine sodium/creatinine ratio (UNa/UCr) and higher BNP level at baseline were independently associated with unsuccessful tolvaptan therapy, and UNa/UCr best predicts unsuccessful tolvaptan therapy with a cut-off value of 46.5 mEq/g·Cr (AUC 0.847, 95% CI: 0.718-0.976, sensitivity 77%, specificity 81%, P < 0.01). Double-positive results of UNa/UCr < 46.5 mEq/g·Cr and plasma BNP level > 778 pg/mL predicted unsuccessful tolvaptan therapy with high diagnostic accuracy (sensitivity 54%, specificity 100%, positive predictive value 100%, negative predictive value 89%, and accuracy 90%). In summary, short-term tolvaptan therapy ameliorated HF symptoms and provided hemodynamic improvement in the majority of patients, and UNa/UCr and BNP level strongly predicted the therapeutic outcomes.

Effect of Anemia on Cardiovascular Hemodynamics, Therapeutic Strategy and Clinical Outcomes in Patients With Heart Failure and Hemodynamic Congestion

BACKGROUNDnWe investigated the effect of anemia on cardiovascular hemodynamics, therapeutic strategies and clinical outcomes in heart failure (HF) patients.Methodsu2004andu2004Results:We divided 198 consecutive HF patients who underwent right heart catheterization before in-hospital HF treatment into 2 groups according to the presence or absence of hemodynamic congestion (HC: mean pulmonary capillary wedge pressure ≥15 mmHg and/or mean right atrial pressure ≥10 mmHg). The hemoglobin level correlated with the cardiac index (CI) and systemic vascular resistance index (SVRI) (r=-0.34 and 0.42, P<0.05, respectively), and was the strongest contributor of SVRI only in the HC group. Anemic patients more frequently required intravenous inotropic support despite having higher CI and lower SVRI than non-anemic patients in the HC group. The novel hemodynamic subsets based on mean right atrial pressure and estimated left ventricular stroke work index but not Forrester subsets appropriately predicted the need for intravenous inotropic support. The probability of hospitalization for worsening HF during 2-year follow-up period was significantly higher in anemic patients than in non-anemic patients in the HC group.nnnCONCLUSIONSnAnemia had a direct effect on cardiovascular hemodynamics and thus can confound therapeutic planning in HF patients with HC. The novel hemodynamic subsets can be applied in daily clinical practice regardless of the presence or absence of anemia.

Calcified amorphous tumor of the heart in a hemodialysis patient

We report a case of calcified amorphous tumor (CAT) of the heart in a 60‐year‐old Japanese man on hemodialysis. Because the masses in the mitral annulus developed during two‐year echocardiographic follow‐up, he underwent surgical resection with mitral valve replacement. Histological examination showed that the tumor contained multiple calcified nodules, which confirmed the diagnosis of CAT. This case report reinforces the need to deeply and periodically investigate for cardiac involvement of CAT in all patients on hemodialysis.

Effect of Sitagliptin on Coronary Flow Reserve Assessed by Magnetic Resonance Imaging in Type 2 Diabetic Patients With Coronary Artery Disease

BACKGROUNDnThe present study was conducted to assess the cardiovascular effects of dipeptidyl peptidase-4 inhibitors (DPP4i) on coronary flow reserve (CFR), left ventricular (LV) function and endothelial function of the peripheral artery by comparison with those of α-glucosidase inhibitors (αGI) in patients with type 2 diabetes mellitus (T2DM) and coronary artery disease (CAD).Methodsu2004andu2004Results:We randomly assigned 30 patients with T2DM and CAD to receive either sitagliptin or voglibose, and 28 patients (age 69±9 years, 75% male, hemoglobin A1c [HbA1c] 6.62±0.48%) completed the study (14 in each group). CFR and LV function, assessed by cardiac magnetic resonance imaging, and endothelial function, assessed by reactive hyperemia peripheral arterial tonometry (RH-PAT), were measured at baseline and 24 weeks after treatment. Clinical and laboratory parameters, including HbA1c level, plasma active glucagon-like peptide-1 concentrations, and biomarkers of inflammation, were unchanged in both groups after 24 weeks of treatment. CFR were unchanged in both the αGI group (3.01±0.98 at baseline and 3.06±0.8 after treatment, P=NS) and the DPP4i group (4.29±2.04 at baseline and 3.63±1.31 after treatment, P=NS), with no interaction effect. LV functional parameters and the reactive hyperemia index also remained unchanged after the 24-week treatment.nnnCONCLUSIONSnDPP4i did not improve CFR, LV function or endothelial function of the peripheral artery in patients with relatively well-controlled T2DM and CAD.

A novel method for the quantitative evaluation of diurnal respiratory instability in patients with heart failure: A pilot study

BACKGROUNDnThere is no established method to quantitatively measure the presence and the severity of respiratory instability (RI). The purpose of this pilot study was to propose a novel index of diurnal RI as a surrogate measure of clinical severity of heart failure (HF).nnnMETHODS AND RESULTSnWe prospectively enrolled 60 patients with symptomatic HF [70±14 years, 75% male, and New York Heart Association (NYHA) functional classes II-IV] who underwent right heart catheterization (RHC), and recorded diurnal respiration using a nasal pressure sensor during bed rest while awake within 2 days before or after RHC. Non-uniformity of the breath-by-breath respiratory slopes during 15min calculated as the ratio of peak expiratory amplitude to corresponding peak-to-peak interval was assessed by histogram-based frequency distribution measurement, and was defined as the RI-index. The RI-index was significantly different among NYHA functional classes and was highest in NYHA class IV. The presence of atrial fibrillation (β coefficient: 0.300, p=0.01) and stroke volume index (β coefficient: -0.462, p<0.01) were independently associated with RI index among hemodynamic parameters. Furthermore, the high RI index above the median value was the independent predictor of the composite outcome of death from any cause, a life-threatening arrhythmia, and an unplanned hospitalization for worsening HF.nnnCONCLUSIONSnThe RI index stratified functional severity of HF well, and was a significant independent predictor of poor outcomes.