Yukina Hirata

Optimal Analysis of Left Atrial Strain by Speckle Tracking Echocardiography: P‐wave versus R‐wave Trigger

Left atrial (LA) strain analysis using speckle tracking echocardiography is useful for assessing LA function. However, there is no established procedure for this method. Most investigators have determined the electrocardiographic R‐wave peak as the starting point for LA strain analysis. To test our hypothesis that P‐wave onset should be used as the starting point, we measured LA strain using 2 different starting points and compared the strain values with the corresponding LA volume indices obtained by three‐dimensional (3D) echocardiography.

Prognostic Implications of Non-Invasive Vascular Function Tests in High-Risk Atherosclerosis Patients

BACKGROUND The aim of this study was to assess the role of clinically available vascular function tests as predictors of cardiovascular events and decline in kidney function. METHODSANDRESULTS One hundred and fourteen patients who had at least 2 cardiovascular risk factors were recruited for vascular function assessment including ankle-brachial blood pressure index (ABI), brachial-ankle pulse wave velocity (baPWV), cardio-ankle vascular index (CAVI) and flow-mediated vasodilatation (%FMD). During a median period of 51 months, 35 patients reached the primary endpoint (29 cardiovascular events and 6 cardiac deaths), and 30 patients reached the secondary endpoint (decline in kidney function: defined as a 5% per year decline of estimated glomerular filtration rate). In sequential Cox models, a model on the basis of the Framingham risk score, hemoglobin, and high-sensitivity C-reactive protein (chi-squared, 16.6) was improved by the ABI (chi-squared: 21.5; P=0.047). The baPWV (hazard ratio: 1.42 per 1 SD increase; P=0.025) and the CAVI (hazard ratio: 1.52 per 1 SD increase; P=0.040) were associated with the secondary endpoint. The %FMD was only slightly associated with the primary and secondary endpoints. CONCLUSIONS Both ABI and baPWV are significantly associated with future cardiovascular events in high-risk patients with cardiovascular disease. The predictive capabilities of these parameters are greater than that of other parameters in this cohort.

Comparison of Tricuspid Annular Plane Systolic Excursion in Patients With Atrial Fibrillation Versus Sinus Rhythm.

Echocardiography now plays a central guiding role in the management of patients with atrial fibrillation (AF). However, the current guidelines mention little about the presence AF during the assessment of echocardiographic variables in the clinical setting. AF itself may impact on tricuspid annular plane systolic excursion (TAPSE) as a right ventricular systolic function compared with sinus rhythm (SR). The aim of this study was to compare and assess the echocardiographic parameters including TAPSE in patients with AF and SR. From January 1, 2013, to September 30, 2014, patients with AF without any cardiovascular disease were retrospectively evaluated using echocardiography. Age-, gender-, and left ventricular ejection fraction-matched patients with SR were selected from our database on the basis of a comprehensive history, physical examination, and echocardiographic findings. During the study period, we identified 239 patients with AF (74 ± 9 years; 65% men) and without any cardiac disease who underwent echocardiography. We also included 281 patients in the SR group (74 ± 8 years; 67% men). In all study subjects, TAPSE in AF was smaller than in SR regardless of age (17 ± 3 vs 20 ± 3 mm, p <0.001). In the stepwise multiple regression model, TAPSE was strongly associated with the presence of AF (standardized β = -0.362, p <0.001) and stroke volume index (standardized β = 0.173, p <0.001) after adjustment for age, gender, heart rate, left ventricular ejection fraction, and tricuspid regurgitant grade. In conclusions, patients with AF had lower TAPSE than those with SR regardless of age. When we assess TAPSE in the clinical setting, we must pay attention to the presence of AF.

Echocardiographic Epicardial Adipose Tissue Thickness Is Associated with Symptomatic Coronary Vasospasm during Provocative Testing

Background: Epicardial adipose tissue (EAT) is the ectopic visceral fat surrounding the heart, which plays an important role in atherosclerosis of the coronary arteries via endothelial damage. Several studies have also suggested that vasospasm with angina (VSA) causes endothelial dysfunction in the coronary arteries. The aim of this study was to evaluate the thickness of EAT in the anterior interventricular groove (EAT‐AIG) using echocardiography in patients who had no obstructive coronary artery disease and were suspected of having VSA. Methods: Sixty‐five patients who underwent intracoronary acetylcholine provocation testing for clinical indications were prospectively enrolled. VSA was diagnosed by coronary artery stenosis increase of >90% and the presentation of chest pain with ischemic changes on electrocardiography. Results: Subjects were divided into two groups, with and without significant coronary spasm (VSA group, 30 patients; non‐VSA group, 35 patients), consistent with acetylcholine provocation testing. EAT‐AIG thickness was significantly greater in the VSA group than in the non‐VSA group (8.2 ± 2.7 vs 6.1 ± 2.5 mm, P = .002). By receiver operating characteristic analysis, EAT‐AIG thickness had a high C statistic (area under the curve = 0.81, P < .001) after adjustment for conventional risk factors (smoking, diabetes mellitus, and dyslipidemia). EAT‐AIG thickness had incremental diagnostic value over other conventional risk factors (area under the curve = 0.81 vs 0.64, P for comparison = .020). Conclusions: EAT‐AIG thickness, which is noninvasively and easily measured using transthoracic echocardiography, can be one of multiple clinical variables associated with VSA. HighlightsTo the best of our knowledge, this is the first report of echocardiographic EAT‐AIG thickness to help diagnose VSA in patients with chest pain or discomfort.EAT‐AIG thickness is noninvasively and easily measured using transthoracic echocardiography and can be one of multiple clinical variables associated with VSA.EAT‐AIG thickness may be useful as a risk factor and for follow‐up of patients with presumptive VSA.

Preload Stress Echocardiography Predicts Outcomes in Patients With Preserved Ejection Fraction and Low-Gradient Aortic StenosisCLINICAL PERSPECTIVE

Background— The projected aortic valve area (AVAproj) at a normal transvalvular flow rate using dobutamine is helpful to determine the actual severity of aortic stenosis (AS) and to predict risk of adverse events in low-gradient AS cases with unclear surgical indication. Our study aimed to identify the independent and incremental value of preload stress echocardiography-derived AVAproj to predict outcomes in patients with preserved ejection fraction and low-gradient AS. Methods and Results— We prospectively performed echocardiographic studies in 79 patients with low-gradient AS (age, 77±7 years; 30% men) with preload stress echocardiography using leg positive pressure. AVAproj was calculated using AVA and transvalvular flow rate at baseline and during leg positive pressure. The primary end point was the decision for aortic valve surgery or cardiac death. During a median period of 19 months, 23 patients had the decision for aortic valve surgery, and none died during follow-up. In a stepwise multivariable analysis, indexed AVAproj (AVAiproj; hazard ratio, 2.00 per 0.1 cm2/m2 decrease; 95% confidence interval, 1.36–2.96; P<0.001) was associated with the primary end point. Using a receiver operating characteristic curve analysis, the best cutoff value of AVAiproj for predicting cardiac events was <0.72 cm2/m2. By incorporating AVAiproj into AVAi at baseline, continuous net reclassification index for cardiac events was 0.48 (P=0.04). Conclusions— In patients with low-gradient AS, indexed AVAproj derived from preload stress echocardiography can be useful to predict risk of adverse events. The present article should be considered as a proof of concept study, and we think that larger multicenter studies are warranted.

Noninvasive Quantitative Tissue Characterization of Carotid Plaques Using Color-Coded Mapping Based on Ultrasound Integrated Backscatter.

Ultrasound imaging of carotid artery plaques not only identifies the existence and size of the plaques but also provides information on the histological features of the plaques such as lipid pools and fibrous or calcified tissue. We attempted to develop a novel system to obtain the characteristics

Prognostic Value of Frailty and Diastolic Dysfunction in Elderly Patients

BACKGROUND High prevalence of frailty and of diastolic dysfunction (DD) in heart failure and high mortality in frail adults have been noted. We characterized frailty by quantifying differences on echocardiography, and assessed the added prognostic utility of frailty and DD grade in an elderly population. METHODS AND RESULTS One hundred and ninety-one patients ≥65 years who had at least 1 cardiovascular risk factor were prospectively recruited for clinically indicated echocardiography at the present institute. Weight loss, exhaustion, and deficits in physical activity, gait speed, and handgrip strength were used to categorize patients as frail (≥3 features), intermediately frail (1 or 2 features), or non-frail (0 features). DD grade ≥2 was defined as severe. Frailty was associated with larger left atrial volume, smaller stroke volume, and worse DD grade after adjustment for age. In a period of 14 months, 29 patients (15%) had cardiovascular events. The addition of frailty score and severe DD significantly improved the prognostic power of a model containing male gender (model 1, male gender, χ2=6.4; model 2, model 1 plus frailty score, χ2=16.7, P=0.004; model 3, model 2 plus severe DD, χ2=25.5, P=0.015). CONCLUSIONS Both frailty and DD grade were significantly associated with future cardiovascular events in an elderly population with preserved ejection fraction and ≥1 risk factor of cardiovascular disease.

Effect of the Epicardial Adipose Tissue Volume on the Prevalence of Paroxysmal and Persistent Atrial Fibrillation

BACKGROUND Although increasing evidence suggests that epicardial adipose tissue volume (EATV) is associated with atrial fibrillation (AF), it is controversial whether there is a dose-response relationship of increasing EATV along the continuum of AF. We evaluated the effect of the EATV on the prevalence of paroxysmal AF (PAF) and persistent AF (PeAF) and the relationships with cardiac structure and functional remodeling.Methods and Results:Subjects who underwent multidetector computed tomography (MDCT) coronary angiography because of symptoms suggestive of coronary artery disease were divided into sinus rhythm (SR) (n=112), PAF (n=133), and PeAF (n=71) groups. The EATV index (EATV/body surface area, mL/m2) was strongly associated with the prevalence of PAF and PeAF on the model adjusted for known AF risk factors. The effect of the EATV index on the prevalence of PeAF, but not on that of PAF, was modified by the left atrial (LA) dimension, suggesting that extension of the LA dimension is related to EATV expansion in PeAF. The cutoff value of the EATV index for the prevalence was higher in PeAF than in PAF (64 vs. 55 mL/m2, P<0.01). CONCLUSIONS The EATV index is associated with the prevalence of PAF and PeAF, and its cutoff values are predictive for PAF and PeAF development independently of other AF risk factors.

Provocation of clinically significant left ventricular outflow tract obstruction by postural change in patients with sigmoid septum

A 89-year-old man had occasional palpitations with dizziness at rest for past few years. Two-dimensional echocardiography showed hypertrophy of basal left interventricular septum with a thickness of 16 mm, which we diagnosed as sigmoid septum (Fig. 1a). Although his left ventricular outflow tract (LVOT) seemed narrow, there was no systolic anterior motion of the mitral valve leaflets (SAM). During a Valsalva maneuver, the peak continuous wave Doppler flow velocity of the LVOT increased from 1.5 to 2.0 m/s (Fig. 1b, c). When we tried the same procedure in the supine position, prominent SAM occurred and the LVOT velocity dramatically increased to > 5.0 m/s during a Valsalva maneuver (Fig. 1d, e).

Age-related changes in morphology of left atrial appendage in patients with atrial fibrillation

The purpose of this study was to evaluate the relationship between age and frequency of left atrial appendage (LAA) morphology in patients with atrial fibrillation (AF) compared with sinus rhythm (SR). We enrolled 145 AF patients, and 199 SR patients for the control group without any cardiovascular disease. LAA volume index (LAAVi) and morphology were assessed by electrocardiogram-gated computed tomography angiography. LAA morphology was classified into “chicken wing” or “non-chicken wing” according to the previously described classification. There was no significant trend in frequency of non-chicken wing morphology among ages in the SR group (p = 0.36 for trend), whereas the frequency was negatively related to age in the AF group (p = 0.002 for trend). In multivariable logistic regression, age > 65 (odds ratio [OR] 0.42, p = 0.002) and duration of AF (OR 0.53, p = 0.010) and LAAVi (OR 0.62, p = 0.017) were independent factors of non-chicken wing LAA morphology in the AF group. LAA morphology is affected by age, especially in patients with AF. When we utilize non-chicken wing LAA morphology as a stroke risk factor in patients with AF, we should pay attention to their age.