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Sleep-disordered breathing is one of the complications commonly seen in patients with adult congenital heart disease (ACHD) due to multiple causes including complex underlying cardiac defects, cardiomegaly, previous thoracotomies, obesity, scoliosis, and paralysis of the diaphragm. It is often hard to determine its main cause and predict the efficacy of each treatment in its management. We herein report a 30-year-old woman after biventricular repair of pulmonary atresia with intact ventricular septum diagnosed as sleep-related hypoventilation disorder. Simultaneous treatment targeting obesity, paralysis of the diaphragm, and cardiomegaly followed by respiratory muscle reinforcement through non-invasive ventilation resolved her sleep-related hypoventilation disorder. Such management for each factor responsible for the hypoventilation is expected to provide synergetic therapeutic efficacy and increase daily activity in a patient with ACHD.

An elderly patient was admitted to our hospital for acute heart failure soon after receiving influenza vaccination. On admission, chest radiography revealed pulmonary edema. An electrocardiogram showed poor R progression, and echocardiography showed diffuse hypokinesis and myocardial edema. The serum troponin level was elevated. A histopathological evaluation indicated active myocarditis with lymphocyte-predominant infiltrates. A drug-induced lymphocyte stimulation test (DLST) was positive. The patient rapidly recovered from heart failure after treatment with conventional heart failure drugs, such as intravenous diuretics and vasodilators. These experimental data and the clinical course suggest that influenza vaccination was responsible for heart failure due to acute lymphocyte myocarditis.

Background: Sleep disordered breathing (SDB) is prevalent and associated with increased mortality in patients both with and without cardiovascular disease (CVD). Many portable monitoring devices, including peripheral arterial tonometry (PAT)-based devices, have been developed. Although previous studies have demonstrated that the apnea-hypopnea index (AHI) determined by PAT devices (pAHI) is strongly correlated with AHI determined by polysomnography (AHI-PSG), no data have been reported from a Japanese patient population or patients with CVD. In this study we compared the parameters determined by PAT-based devices with those determined by polysomnography in Japanese patients with CVD. Methods and Results: We enrolled 120 patients undergoing overnight polysomnography at 6 Japanese centers. A PAT-based device was used simultaneously with polysomnography. Polysomnography recordings were scored centrally by a technician in a blinded manner. PAT-based device recordings were scored using an automatic algorithm. There was a strong correlation between pAHI and AHI-PSG (r=0.896; P

Pulse transit time (PTT), which refers to the travel time between two arterial sites within the same cardiac cycle, has been developed as a novel cuffless form of continuous blood pressure (BP) monitoring. The aim of this study was to investigate differences in BP parameters, including BP variability, between those assessed by beat-to-beat PTT-estimated BP (eBPBTB) and those assessed by intermittent PTT-estimated BP at fixed time intervals (eBPINT) in patients suspected of having sleep disordered breathing (SDB). In 330 patients with SDB (average age, 66.8 ± 11.9 years; 3% oxygen desaturation index [ODI], 21.0 ± 15.0/h) from 8 institutes, PTT-estimated BP was continuously recorded during the nighttime. The average systolic eBPBTB, maximum systolic and diastolic eBPBTB, standard deviation (SD) of systolic and diastolic eBPBTB, and coefficient variation (CV) of systolic and diastolic eBPBTB were higher than the respective values of eBPINT (all P BTB and eBPINT in average systolic BP and SD and CV of systolic BP, while there were disagreements in both minimum and maximum values of eBPBTB and eBPINT in patients with high systolic BP (P BTB and eBPINT (all P BTB and eBPINT. In patients with suspected SDB, the difference between eBPBTB and eBPINT was minimal, and there were disagreements regarding both the minimum and maximum BP. However, there were agreements in regard to the index of BP variability between eBPBTB and eBPINT.

Lung to finger circulation time (LFCT) has been used to estimate cardiac function. We developed a new LFCT measurement device using a laser sensor at fingertip. We measured LFCT by measuring time from re-breathing after 20 seconds of breath hold to the nadir of the difference of transmitted red light and infrared light, which corresponds to percutaneous oxygen saturation. Fifty patients with heart failure were enrolled. The intrasubject stability of the measurement was assessed by the intraclass correlation coefficient (ICC). The ICC calculated from 44 cases was 0.85 (95% confidence interval:0.77-0.91), which means to have “Excellent reliability.” By measuring twice, at least one clear LFCT value was obtained in 89.1% of patients and the overall measurability was 95.7%. We conducted all LFCT measurements safely. High ICCs were obtained even after dividing patients according to age, cardiac index (CI), and New York Heart Association (NYHA) classification; 0.85 and 0.84 (≥ 75 or < 75 years group, respectively), 0.81 and 0.84 (N=28, ≥ or < 2.2 L/min/M2), 0.82 and 0.94 (NYHA Class I-II or Class III). These results show that our new method to measure LFCT is highly stable and feasible for any type of heart failure patients.

Background: Respiratory stability index (RSI), a semi-quantitative measure of respiratory instability, was found to reflect congestive and other clinical status of acutely decompensated heart failure in the PROST study. Given that the association between RSI and another important factors affecting respiration, such as peripheral oxygen saturation (SpO2), and the influence of oxygen inhalation on this association were undetermined, and that the association between common sleep-disordered breathing (SDB) parameters and RSI was unknown, we performed a subanalysis using PROST data. Methods and Results: Correlation analyses were performed to evaluate the relationships between RSI, SpO2, and other SDB parameters (3% oxygen desaturation index [3%ODI], respiratory disturbance index [RDI]) using Spearman's rank correlation. RSI and overnight mean SpO2 were not significantly correlated either after admission (n=38) or before discharge (n=36; r=0.27, P=0.10 and r=0.05, P=0.76, respectively). This correlation was also not affected by presence or absence of oxygen inhalation. 3%ODI, RDI and RSI were significantly and inversely correlated both after admission and before discharge. Conclusions: RSI and blood oxygen level were not significantly correlated irrespective of oxygen inhalation, while the SDB parameters were significantly correlated, suggesting that RSI reflects lung congestion independently of blood oxygen concentration and, thus, can be a useful indicator of the non-invasive assessment of lung congestion.

Lung to finger circulation time (LFCT) has been used to estimate cardiac function. We developed a new LFCT measurement device using a laser sensor at fingertip. We measured LFCT by measuring time from re-breathing after 20 s of breath hold to the nadir of the difference of transmitted red light and infrared light, which corresponds to percutaneous oxygen saturation. Fifty patients with heart failure were enrolled. The intrasubject stability of the measurement was assessed by the intraclass correlation coefficient (ICC). The ICC calculated from 44 cases was 0.85 (95% confidence interval: 0.77–0.91), which means to have “Excellent reliability.” By measuring twice, at least one clear LFCT value was obtained in 89.1% of patients and the overall measurability was 95.7%. We conducted all LFCT measurements safely. High ICCs were obtained even after dividing patients according to age, cardiac index (CI); 0.85 and 0.84 (≥ 75 or 2). These results show that our new method to measure LFCT is highly stable and feasible for any type of heart failure patients.

Mandibular advancement device (MAD) is an alternative therapeutic option for CPAP to treat obstructive sleep apnea (OSA). While MAD showed the better adherence, patients with over moderate OSA have been treated more frequently with CPAP despite increasing positive evidence on the cardiovascular outcome with MAD, even in severe patients. Thus, more information is needed regarding the cardiovascular and symptomatic outcome of MAD treatment objectively compared to CPAP. Forty-five supine-dependent OSA patients (apnea-hypopnea index 20-40/h) were randomized to either CPAP or MAD and treated for 8 weeks and switched to another for 8 weeks. The primary endpoint was improvement in the endothelial function, indexed by the flow-mediated dilatation (FMD), and the secondary endpoint was the sleep-time blood pressure (BP). The duration of MAD use was evaluated objectively by an implanted adherence monitor. Treatment efficacy was also evaluated by home sleep monitor and a questionnaire about the symptoms. The adherence was not significantly different (CPAP vs. MAD: 274.5 ± 108.9 min/night vs. 314.8 ± 127.0 min/night, p = 0.095). FMD and sleep-time mean BP were not markedly changed from the baseline with either approach (CPAP vs. MAD: FMD, + 0.47% ± 3.1% vs. + 0.85% ± 2.6%, p = 0.64; BP, - 1.5 ± 5.7 mmHg vs. - 1.2 ± 7.5 mmHg, p = 0.48), although sleepiness, nocturia, and sleep-related parameters were similarly improved and more patients preferred MAD. As MAD and CPAP showed similar effects on cardiovascular outcome and symptomatic relief even with a comparable length of usage, we might expect MAD as an alternative treatment option for CPAP in this range of OSA group.

BACKGROUND The respiratory instability frequently observed in advanced heart failure (HF) is likely to mirror the clinical status of worsening HF. The present multicenter study was conducted to examine whether the noble respiratory stability index (RSI), a quantitative measure of respiratory instability, reflects the recovery process from HF decompensation. Methods and Results: Thirty-six of 44 patients hospitalized for worsening HF completed all-night measurements of RSI both at deterioration and recovery phases. Based on the signs, symptoms, and laboratory data during hospitalization, the Central Adjudication Committee identified 22 convalescent patients and 14 patients with less extent of recovery in a blinded manner without any information on RSI or other respiratory variables. The all-night RSI in the convalescent patients was increased from 27.8±18.4 to 34.6±15.8 (P

Background People with Down syndrome (DS) often have sleep-disordered breathing (SDB). Unusual sleep postures, such as leaning forward and sitting, are observed in people with DS. This study aimed to clarify the prevalence of unusual sleep postures and their relationships with SDB-related symptoms (SDB-RSs), such as snoring, witnessed apnoea, nocturnal awakening and excessive daytime sleepiness. Methods A questionnaire, including demographic characteristics and the presence of unusual sleep postures, as well as SDB-RSs, was completed by 1149 parents of people with DS from Japan. Results Unusual sleep postures were recorded in 483 (42.0%) people with DS. These participants were significantly younger and had a history of low muscle tone more frequently than people without unusual sleep postures. In all ages, the leaning forward posture was more frequent than sitting. People with DS with unusual sleep postures suffered from SDB-RSs. Those who slept in the sitting posture had more frequent SDB-RSs than did those who slept with the leaning forward posture. Snoring, witnessed apnoea and nocturnal awakening were observed in 73.6, 27.2 and 58.2% of participants, respectively. Snoring increased with aging. Witnessed apnoea was more common in males and in those with hypothyroidism than in females and in those without hypothyroidism. Conclusions Our study shows that there is a close relationship between unusual sleep postures and SDB-RSs. We recommend that all people with DS with unusual sleep postures should be checked for the presence of SDB.

Cardiopulmonary polygraphy (PG) demonstrates not only parameters for sleep disordered breathing (SDB) but also hemodynamics. We previously developed a software that detects lung to fingertip circulation time (LFCT) derived from PG dataset and reported that those LFCT reflected the cardiac output. The purpose of this study is to investigate how the LFCT changes during clinical course and whether reflects the impact of in-hospital treatment on cardiac function. Consecutive patients (N = 89) who admitted to the cardiovascular division, underwent PG at the early and late phase of admission. Parameters for SDB and LFCT were compared between an acute decompensated heart failure (ADHF) group (n = 51) and non-ADHF group (n = 38). ADHF group was further divided into subgroups: preserved ejection fraction (pEF) (EF > 40%) and reduced EF (rEF) (EF ≤ 40%). Using our original algorithm, we obtained LFCT values from all of the patients, though 29.4% of ADHF and 44.7% of non-ADHF had no or mild SDB. LFCT significantly shortened in the ADHF-rEF group, in contrast to ADHF-pEF group or non-ADHF group (ADHF-rEF group: 26.9 ± 7.6 to 24.2 ± 6.1 s, p = 0.01; ADHF-pEF group: 25.3 ± 7.3 to 25.3 ± 6.9 s, p = 0.98; non-ADHF group: 21.5 ± 5.5 to 21.9 ± 5.0 s, p = 0.65). The respiratory disorder index in the ADHF group improved after treatment, irrespective of EF (pEF: 26.9 ± 16.1 to 15.8 ± 11.9/h, p

Introduction: The severity of obstructive sleep apnea (OSA) is assessed by the apnea-hypopnea-index (AHI) determined from polysomnography (PSG). However, PSG requires a specialized facility with well-trained specialists and takes overnight. Therefore, simple tools, which could distinguish severe OSA, have been needed before performing PSG. Objectives: We propose the new index using cine-MRI as a screening test to differentiate severe OSA patients, who would need PSG and proper treatment. Methods: Thirty-six patients with suspected OSA (mean age 54.6 y, mean AHI 52.6 events/hour, 33 males) underwent airway cine-MRI at the fourth cervical vertebra level during 30 seconds of free breathing and PSG. The minimum airway ellipticity (AE) in 30 seconds duration was measured, and was defined as the severity of OSA. Patients were divided into severe OSA, not-severe OSA, and normal groups, according to PSG results. The comparison of AE between any two of the three groups was performed by Wilcoxon rank-sum test. Receiver-operating-characteristic (ROC) curve analysis was performed to determine the optimal cut-off of AE for identifying severe OSA patients. Results: The minimum AE for severe OSA was significantly lower than that for not-severe OSA and normal (severe, 0.17 ± 0.16; not-severe, 0.31 ± 0.17; normal, 0.38 ± 0.19, p

Introduction Obstructive sleep apnea (OSA) is common sleep disorder characterized by repetitive episodes of airway closure which usually occurs in the retropalatal region of the oropharynx. It has been known that upper airway mucosa in OSA patients is described as edematous, but not fully clarified. Objectives This study aimed to investigate and establish magnetic resonance imaging (MRI) parameter to estimate tissue water content at retropalatal level and its relationship with sleep parameters in OSA patients. Methods Forty-eight subjects with OSA underwent overnight polysomnography and cervical MRI with 1.5-tesla [mean (SD) age 55 (14) years and apnea-hypopnea index (AHI) 45.2 (26.1) events/hour, 79.2% male]. On the axial T2-weighted images from epipharynx to oropharynx, the signal intensities of masseter muscle and peripharyngeal mucosa [T2 mucous-to-masseter intensity ratio (T2MMIR)], was used as water content estimation in the retropalatal region. Partial correlation analysis was performed to examine the correlation between T2MMIR and polysomnography parameters. Results We found that there were strong and positive correlations between the T2MMIR and AHI (r = 0.545, P

Sleep-disordered breathing (SDB) has a big impact on autonomic nervous activity and thus induces or deteriorates various cardiovascular diseases. We here describe a typical but rarely documented case which clearly indicates a strong link between SDB and cardiovascular disease. A 68-year-old woman complaining of frequent palpitations was referred to our institute. An electrocardiogram (ECG) at a previous clinic had shown atrial fibrillation, although it had already returned to sinus rhythm on arrival at our institute. Her body mass index was 32.5kg/m 2 and she had a history of loud snoring. Simultaneous examinations of Holter ECG monitoring and ambulatory polysomnography (PSG) showed onset of paroxysmal atrial fibrillation following marked oxygen desaturation at midnight. In-hospital PSG revealed severe obstructive sleep apnea. A new device with desaturation triggered ambulatory blood pressure monitoring system performed 1 week later again showed a midnight onset of paroxysmal atrial fibrillation coincided with surge of blood pressure with marked desaturation. Her recurrence of palpitations had obviously decreased by continuous positive airway pressure therapy thereafter. Learning objective: A clinician should suspect sleep-disordered breathing (SDB) behind cardiac arrhythmia, especially if it is nocturnal. Nocturnal hypertension especially in obese patients may indicate SDB. Successful therapy for SDB by such as continuous positive airway pressure therapy attenuates sympatho-excitation and would improve the result of treatment of the arrhythmia.>

Sleep disordered breathing (SDB) has been recognized as one of the important causes or factors of worsening for various cerebro- and cardiovascular diseases. On the other hand, a recent large randomized study and meta-analysis about the effect of continuous positive airway pressure (CPAP) indicated no or only minor effects to improve the outcome of SDB patients. Accumulating evidence has indicated that the key factor of the link between SDB and cardiovascular diseases might be hypoxia caused during repetitive long apneic episodes. Hypertension and atrial fibrillation (AF) are two important cardiovascular diseases that relate to SDB and the therapeutic consequences by CPAP treatment have been studied. As for the mechanism that elevates blood pressure during night, stimulation of chemoreceptors by hypoxia and the resultant increase in sympathetic nervous activity is the first step and repetitive hypoxic stimulation changes the characteristics of chemoreceptors and baroreceptors resulting in daytime hypertension. Pathological changes in the atrial muscle in SDB patients might be a result of repetitive hypoxia and atrial expansion. As for triggering AF, several animal studies revealed that the changes in autonomic nervous system caused by hypoxia and negative intra-thoracic pressure might be crucial. However, a recent observational study could not show the relation between SDB and AF. The difference between the previous studies and this negative study seems to exist in the difference of the severity of SDB or the degree of hypoxia. Such a difference might be also one of the reasons why a recent randomized trial to prove the effect of CPAP in cardio- or cerebrovascular patients failed to improve the patient prognosis. Hence, in this review, the relationship between hypoxia and onset or continuation of hypertension and AF will be reconsidered to understand the fundamental and robust relationship between SDB and these cardiovascular diseases.

Background falls by inpatients often result in serious injuries and deterioration in a patient's physical abilities and quality of life, especially among older individuals. Although various factors have been found to be associated with falls, the combined effects of behavioural and ambient factors are not fully evaluated. Objective we investigated the influence of both behavioural and ambient factors on inpatient falls, focusing on seasonal and diurnal variations. Design retrospective study. Methods we surveyed the incident reports related to falls from April 2010 to March 2014 and examined the relationship between the incidents and seasonal and diurnal variations in behavioural and ambient factors, including the sunrise time, the night-time length and temperature. Results we identified 464 fallers from 3,037 incident reports. The average fall-rate of the study population was 1.4 ± 0.5/1,000 occupied bed-days. The seasonal and diurnal variations in falls were compared. The number of falls around dawn in October-February was higher than that in April-September. Toileting was the behaviour most frequently related to the falls (56.9%, n = 264), and 57.1% of the falls occurred at night. A multivariate analysis showed that the night-time length was significantly related to an increase in night-time falls (P = 0.047). Conclusion these results suggested that the inpatient falls increased in the early morning from November to March and tended to be related to toileting activities. Considering these results, additional attention and support during the higher risk hours and seasons, especially in relation to toileting activities, might help to reduce the incidence of falls. Clinical trial name, url and registration number N/A (Because of retrospective nature).

OBJECTIVE We assessed the prevalence of sleep disordered breathing (SDB) and characteristics among patients who visited a urology clinic complaining of nocturia (URO group) and those who visited a sleep apnea (SA) clinic complaining of excessive daytime sleepiness (EDS) (SA group). Additionally, we evaluated the effects of continuous positive airway pressure (CPAP) therapy in the URO group patients with nocturia and SDB resistant to conventional therapy for nocturia. METHODS Questionnaires were used to assess EDS, nocturia and lower urinary tract symptoms in 34 URO group patients and 49 age-matched SA group patients. We also compared these factors in the male patients in both groups and the male and female patients in the SA group. Significant SDB was diagnosed as a 3% oxygen desaturation index (3%ODI) on pulse oximeter of >5/h. The treatment response was analyzed in six URO group patients treated with CPAP after not responding to the conventional medical treatment. RESULTS SDB was found in 91.8% of the SA group patients and 70.6% of the URO group patients. The level of EDS and lower urinary tract symptoms were similar in both groups. The SA group showed higher 3%ODI values, while the frequency of urination during bedtime was higher in the URO group. The frequency of nocturnal urination was reduced after CPAP in the subjects resistant to conventional therapy. CONCLUSION SDB is as prevalent in patients who visit a urology clinic complaining of nocturia as in those who visit a sleep apnea clinic. Patients who complains of nocturia must be assessed for SDB before starting therapy for nocturia.

The Ambulatory Blood Pressure Control and Home Blood Pressure (Morning and Evening) Lowering By N-Channel Blocker Cilnidipine (ACHIEVE-ONE) trial is a large-scale clinical study on blood pressure (BP) and pulse rate (PR) in the real world with use of cilnidipine, a unique L/N-type Ca channel blocker, possessing a suppressive action on increased sympathetic activity in patients with essential hypertension. The effects of cilnidipine on morning hypertension were examined. The authors examined 2319 patients treated with cilnidipine for 12 weeks. Clinic systolic BP (SBP) decreased by 19.6 mm Hg from 155.0 mm Hg, whereas morning SBP decreased by 17.0 mm Hg from 152.9 mm Hg after 12-week cilnidipine treatment. Cilnidipine reduced both morning SBP and PR more markedly in patients with higher baseline morning SBP (-3.2 mm Hg and -1.3 beats per minute in the first quartile of morning SBP, -30.9 mm Hg and -3.2 beats per minute in the fourth quartile), and also reduced both morning PR and SBP more markedly in patients with higher baseline morning PR (0.6 beats per minute and -15.6 mm Hg in

Background Recent studies have reported the clinical usefulness of positive airway pressure ventilation therapy with various kinds of pressure support compared with simple continuous positive airway pressure (CPAP) for heart failure patients. However, the mechanism of the favorable effect of CPAP with pressure support can not be explained simply from the mechanical aspect and remains to be elucidated. Methods and Results In 18 stable chronic heart failure patients, we performed stepwise CPAP (4, 8, 12 cm H 2 O) while the cardiac output and intracardiac pressures were continuously monitored, and we compared the effects of 4 cm H 2 O CPAP with those of 4 cm H 2 O CPAP plus 5 cm H 2 O pressure support. Stepwise CPAP decreased cardiac index significantly in patients with pulmonary arterial wedge pressure (PAWP) −1 m −2 ( P = .001) compared with CPAP alone, regardless of basal filling condition or cardiac index. Conclusions Our results suggest that CPAP plus pressure support is more effective than simple CPAP in heart failure patients and that the enhancement might be induced by neural changes and not simply by alteration of the preload level.

Background Previous studies have shown a higher prevalence of obstructive sleep apnea (OSA) in patients with coronary artery disease than in control subjects. However, the association between coronary spastic angina pectoris (CSA) and OSA has not been investigated. Accordingly, we examined this association. Methods and results We performed overnight polysomnography in 42 consecutive patients with CSA confirmed by an acetylcholine or ergonovine provocation test and in 20 age- and gender-matched control subjects. OSA was classified into the following three groups: mild OSA (5 ≤ apnea–hypopnea index [AHI]

AIMS Complex fractionated atrial electrogram (CFAE) has been reported to relate to maintain atrial fibrillation (AF). The aims of this study were to investigate the relationship between CFAE and background conditions during sinus rhythm (SR). METHODS AND RESULTS Electroanatomical mapping using an EnSite Array was performed in 20 patients (paroxysmal AF:persistent AF = 16:4) who underwent pulmonary vein antrum isolation (PVAI). Contact bipolar electrograms were recorded before PVAI, during SR, and subsequently during induced AF. Peak-to-peak voltages and morphologies of the electrograms during SR were compared between sites with and without CFAE during AF. Among 1947 points obtained during SR, 974 (50%) were included in CFAE sites and 973 (50%) in non-CFAE sites. Electrogram amplitude during SR was higher at the CFAE sites than at the non-CFAE sites (2.4 +/- 1.7 vs. 1.9 +/- 1.9 mV; P < 0.0001), whereas fractionated or double electrograms were found in a similar range between the two areas (2 vs. 3%; P = 0.21). When analysed further in terms of AF termination by PVAI followed by confirmation of non-inducibility, the voltage of electrograms at the CFAE sites was lower (2.1 +/- 1.7 vs. 2.6 +/- 1.8 mV; P = 0.0001) and the morphology was more complex in patients without AF termination compared with those with AF termination. CONCLUSION Our results suggest that in paroxysmal and persistent AF with minimally damaged LA, the CFAE sites in patients with AF termination by PVAI alone represent healthy atrial tissue with rapid electrical activity in response to an AF driver located in the pulmonary vein. However, in patients without AF termination, they represent more damaged tissue responsible for maintaining AF.

AIMS It is unclear how the amplitude of bipolar electrogram relates to the local conduction velocity (CV) in patients with atrial fibrillation (AF). For 50 AF patients (paroxysmal/persistent AF: 40/10 patients), contact bipolar voltage maps of the left atrium (LA) were constructed during sinus rhythm using EnSite version 6.0J in a point-by-point recording fashion. Patients were divided into Groups A (n = 16), B (n = 19), and C (n = 15) according to the level of the lowest electrogram amplitudes

Background: Recognizing the relative location of the esophagus to the left atrial posterior wall (LAPW) is required to avoid esophageal injury during atrial fibrillation ablation. Methods and Results: The 24 patients undergoing circumferential pulmonary vein isolation (CPVI) each had the geometry of their left atrium (LA) and esophagus constructed by a noncontact mapping system with EnSite version 6.0J. The esophageal course relative to the LAPW was found to be to the left in 12, middle in 8, right in 2, and obliquely left-to-right in 2 patients, and in 13 patients (54%) it was located on or near either the left or right CPVI line. The mean distance between the esophagus and LAPW was shorter at the bottom line of the LAPW connecting both inferior pulmonary veins (3 ±3 mm) than at the LA roof line connecting both superior pulmonary veins (6 ±6 mm, P

BACKGROUND Metabolic syndrome (MetS) is involved in the increased risk of atherosclerotic cardiovascular diseases. We have previously reported that the prevalence of MetS is more than 2-fold greater in patients with chronic heart failure (CHF) than in the general population in Japan. However, the prognostic impact of MetS in CHF patients remains to be elucidated. METHODS AND RESULTS In the present nationwide, large-scale clinical study in Japan, we enrolled 4,762 patients with Stage C/D CHF. The prevalence of MetS by the definition of the Japanese Committee for the Diagnostic Criteria in 2005 was 41.3% (50.6% in males, 21.5% in females). MetS was characterized by higher prevalence of males, obesity and lifestyle-related comorbidities, including glucose intolerance, dyslipidemia and hypertension. Multivariate Cox hazard analysis showed that MetS was associated with increased incidence of the composite of all-cause death and atherosclerotic events in males (hazard ratio [HR] 1.28; 95% confidence interval [CI] 1.06-1.54, P=0.011) but not in females (HR 1.23, 95% CI 0.87-1.75, P=0.241). Among the components of MetS, over waist circumference and glucose intolerance were significantly associated with increased incidence of the composite endpoint (HR 1.23, P=0.038, and HR 1.29, P

To examine the effect of controlled-release nifedipine (nifedipine CR) given at bedtime on morning hypertension and to compare its effect with that of α-adrenergic blocker, doxazosin, given at bedtime, we performed a cross-over study in ten (5 males, 5 females) hypertensive patients with morning hypertension. After control measurements, the patients were assigned to either nifedipine CR (20-40 mg) first or doxazosin (1-2 mg) first. After 4 weeks of the treatment, measurements were repeated and medication was switched to another drug for another 4 weeks. Systolic and diastolic blood pressure (BP) and heart rate were measured using a 24-hour ambulatory BP monitoring system. While BP at evening and early nighttime (16 : 00-3 : 00) were the same in the three conditions (control, nifedipine CR, and doxazosin), nifedipine CR significantly suppressed BP at the latest nighttime (5 : 00-6 : 00) (systolic BP/diastolic BP : control 128.4±12.0/85.1±10.6 mmHg, doxazosin 124.5±11.6/81.4±10.7 mmHg, nifedipine CR 111.2±16.0/77.7±11.2 mmHg, p

A case of extensive inferior myocardial infarction complicated by a large ventricular aneurysm is presented. Magnetic resonance (MR) imaging 4 days after the onset showed a small protrusion from the necrotic inferior myocardium, which expanded 10 days after onset with a marked pericardial effusion. The follow-up examination by MR and CT imaging 6 months after the onset revealed a large ventricular aneurysm from the inferior cardiac wall. After the aneurysmectomy, the histological study revealed that the aneurysm wall was made up of 2 different types of walls; the peripheral part was a false-pseudo aneurysm and the central part was a pseudo aneurysm. From the serial MR imaging, it is considered that such an aneurysm is primarily formed from a small discontinuation of the LV wall followed by oozing type rupture. Finally, the ruptured central part of the LV wall, which was covered by the pericardium, formed a pseudo aneurysm and the stretched peripheral area, which contains myocardium, formed a false-pseudo aneurysm afterward and then they extended together. Thus, MR imaging provided the important information for the understanding of the formation process of the pseudo and false pseudo LV aneurysm.

Background: Metabolic syndrome (MetS) is a pathological condition with a clustering of metabolic components and is substantially associated with increased risk of atherosclerotic cardiovascular diseases. However, prognostic impacts of MetS in patients with chronic heart failure (CHF) remain to be fully elucidated. Methods and Results: From the database of our nationwide, multicenter observational study with 10,464 CHF patients in stage A/B/C/D in Japan, 4,764 patients with Stage C/D CHF were enrolled. The prevalence of MetS, according to the Japanese standard diagnostic criteria, was 39.6% (48.7% in males and 20.5% in females), which was almost twice higher as compared with the general population in Japan. CHF patients with MetS were characterized by higher prevalence of male, obesity and lifestyle-related diseases, including diabetes mellitus, hypertension and hyperlipidemia. Although univariate Cox proportional hazard analysis revealed that MetS was not associated with increased incidence of composite of all-cause death and atherosclerotic cardiovascular events (unadjusted HR 0.92; 95% CI 0.81-1.04, P=0.177), multivariate analysis adjusted with body mass index (BMI) alone or fully adjusted with clinical backgrounds showed that MetS was associated with increased incidence of the composite endpoint (BMI-adjusted HR 1.33; 95% CI 1.15-1.55, P2 , but not in those with BMI≥25.0kg/m 2 ( Table ). Conclusions: These results indicate that MetS is associated with worse prognosis in patients with Stage C/D CHF, particularly in male patients without obesity.

Obstructive sleep apnea (OSA) is common sleep disorder characterized by repetitive episodes of airway closure which usually occurs in the retropalatal region of the oropharynx. It has been known that upper airway mucosa in OSA patients is described as edematous, but not fully clarified.This study aimed to investigate and establish magnetic resonance imaging (MRI) parameter to estimate tissue water content at retropalatal level and its relationship with sleep parameters in OSA patients.Forty-eight subjects with OSA underwent overnight polysomnography and cervical MRI with 1.5-tesla [mean (SD) age 55 (14) years and apnea-hypopnea index (AHI) 45.2 (26.1) events/hour, 79.2% male]. On the axial T2-weighted images from epipharynx to oropharynx, the signal intensities of masseter muscle and peripharyngeal mucosa [T2 mucous-to-masseter intensity ratio (T2MMIR)], was used as water content estimation in the retropalatal region. Partial correlation analysis was performed to examine the correlation between T2MMIR and polysomnography parameters.We found that there were strong and positive correlations between the T2MMIR and AHI (r = 0.545, P 0.05), supine AHI (r = 0.553, P 0.05) and REM AHI (r = 0.640, P 0.01) by partial correlation analysis. Besides, in patients with less efficient sleep who had more stage 1 sleep, significantly higher T2MMIR was noted (r = 0.357, P 0.05).This study confirmed that peripharyngeal T2MMIR can be a simple parameter representing peripharyngeal tissue water contents related to severe OSA.

BACKGROUND Sleep-disordered breathing (SDB) is associated with repeated intermittent hypoxemia, and it is known as one of the risk factors for cardiovascular diseases. Previous studies assessing the effects of frequency and depth of hypoxemia on cardiovascular diseases have shown conflicting results. The aim of the current study was to clarify what SDB-related parameters most predict endothelial dysfunction to better understand the pathogenesis of endothelial dysfunction in patients with SDB. METHODS We conducted polysomnography (PSG) and measured flow-mediated vasodilation response (%FMD) in 50 outpatients suspected of SDB. Evaluated indices included: apnea-hypopnea index (AHI), 3% oxygen desaturation index (3%ODI), averaged arterial oxygen saturation (averaged SpO2), lowest arterial oxygen saturation (lowest SpO2), ratio of arterial oxygen saturation

Objective It is well known that people with Down's syndrome (DS) frequently complicate with congenital heart diseases (CHDs). Patients with heart diseases often have sleep-disordered breathing as a co-morbidity (SDB) which worsens the heart diseases. However, the relationship between SDB and CHDs in DS people has not yet been fully elucidated. The aim of this study was to establish the association between SDB and CHDs in DS people using data from a large nationwide questionnaire survey in Japan. Methods We conducted a cross-sectional questionnaire survey of a randomly selected sample of 2,000 DS people and their caregivers throughout Japan to examine the associations between observed signs of SDB and CHDs in DS people. The questionnaire included the presence of SDB symptoms (snoring, apnea, arousal, nocturia, and napping) and CHDs (the presence and types of CHDs). Results Of the 1,222 replies received from the caregivers, 650 reported complications of some type of CHDs. The observed apnea tended to be higher among DS people with CHDs than those without CHDs (OR=1.28, 95% CI=0.97-1.70, p=0.09). DS people with tetralogy of Fallot reported significantly more frequent apnea than those without CHDs (OR=3.10, 95% CI=1.36-7.05, p Conclusion SDB prevailed among DS people with severe CHDs, such as tetralogy of Fallot. Careful attention to the signs of SDB in such patients may lead to earlier clinical intervention removing the vicious cycle between SDB and CHDs.

Sympathetic activation and sleep apnea are present in most patients with symptomatic systolic heart failure (HF). Acutely, obstructive and central apneas increase muscle sympathetic activity (MSNA) during sleep by eliciting recurrent hypoxia, hypercapnia, and arousal. In obstructive sleep apnea patients with normal systolic function, this increase persists after waking. Whether coexisting sleep apnea augments daytime MSNA in HF is unknown. We tested the hypothesis that its presence exerts additive effects on MSNA during wakefulness. Overnight sleep studies and morning MSNA recordings were performed on 60 subjects with ejection fraction P =0.005; 58±2 versus 50±3 bursts/min, P =0.037), irrespective of its etiology (the mean difference for central sleep apnea was 17 bursts per 100 heartbeats; n=14; P =0.006; and for obstructive sleep apnea, 11 bursts per 100 heartbeats; n=29; P =0.032). In a subgroup (n=8), treatment of obstructive sleep apnea lowered MSNA by 12 bursts per 100 heartbeats ( P =0.003). Convergence of independent excitatory influences of HF and sleep apnea on central sympathetic neurons results in higher MSNA during wakefulness in HF patients with coexisting sleep apnea. This additional stimulus to central sympathetic outflow may accelerate the progression of HF; its attenuation by treatment of sleep apnea represents a novel nonpharmacological opportunity.

BACKGROUND Because the conventional evaluation of autonomic nervous system (ANS) function inevitably uses long-lasting uncomfortable electrocardiogram (ECG) recording, a more simplified and comfortable analysis system has been sought for this purpose. The feasibility of using a portable micro-electromechanical system (MEMS) blood flowmeter to analyze heart rate variability (HRV) for evaluating ANS function was thus examined. METHODS AND RESULTS Measurements of the R-R interval (TRR) derived from an ECG, simultaneously with the pulse wave interval (TPP) derived from a MEMS blood flowmeter, in 8 healthy subjects was performed and resultant HRV variables in time and frequency domains were compared. The TRR- and TPP-derived variables were strongly correlated (coefficients of regression for low frequency (LF), high frequency (HF), and LF/HF of 1.1, 0.66, and 0.35, respectively; corresponding coefficients of determination of 0.92, 0.63, and 0.91, respectively (P

Summary We report a 30-year-old man with severe obesity hypoventilation syndrome (OHVS) complicated by right-sided heart failure. Polysomnography revealed severe obstructive sleep apnea with apnea–hypopnea index (AHI) 70.4/h and gradual decrease in minimum oxygen saturation (SpO 2 ) from 86% before sleep to 36% during sleep. Cardiac output (CO) was suppressed from 3.9L/min before sleep to 2.5L/min during sleep. Noninvasive positive pressure ventilation (NPPV) treatment drastically restored CO to the level before sleep, and improved AHI to 9.4/h and minimum SpO 2 to 87%. NPPV may provide rapid and powerful symptom relief in patients with OHVS complicated with right sided heart failure.

Background The Yo/Yin concept is fundamental to making a Kampo (sho) diagnosis and may be deeply related to the autonomic nervous system. There is, however, little objective data to confirm the validity of these concepts. Methods and results After diagnosis using standardized Kampo techniques, 20 men and 67 women (mean age, 52.4 years) for whom the prescribed Kampo medication was effective were judged to be correctly classified as Yo- (n=49) or Yin-sho (n=38) and enrolled. Autonomic nervous function was assessed at first visit using HRV obtained from 24-h Holter ECG. Nocturnal ultra low frequency-1 (ULF-1, 0.0001-0.0003 Hz) and ULF-2 (0.0003-0.003 Hz) were significantly higher in the Yin-sho than in the Yo-sho group (P=0.030, P=0.016), suggesting a higher variation of autonomic nervous activity according to sleep stage. On multivariate analysis BMI (≥ 23.0 kg/m(2)) and ULF-1 (≥ 1,150 ms(2)) were identified as independent factors associated with a differential diagnosis of Yo- or Yin-sho (odds ratio [OR], 11.63, P=0.002; OR, 0.30, P=0.038, respectively). When the sleep period was divided into 3 phases, the ULF-1 of the Yin-sho group was significantly higher than that of the Yo-sho group in the late phase of sleep (P=0.023). Conclusions On heart rate variability analysis there was a sleep stage-related difference in the autonomic nervous activity of patients treated with standard Yo- and Yin-sho Kampo medicines.